**2. Brief history of population policies and family planning programs**

An abundant literature covers the history of population policies and family planning programs in the world since 1950. A synthesis book edited by the World Bank summarizes the major stages of these programs, focusing mainly on Asia and America Latin [9]. A review published by the Rand Corporation provides a detailed analysis of family planning programs and their problems [10]. A recent article presents the challenges for the 21st century [11]. This section presents the main stages of this construction, important for understanding the African context.

#### **2.1. Awareness and organization**

couples. To give a classic example, that of Sweden, the level of fertility has not exceeded 4.7 children per woman since the 18th century, began to decline rapidly around 1870, reaching 2 children per woman around 1930, a date that can be taken as that of the end of fertility transition. After this date, fertility followed several cycles, up and down, around this average level. The fertility transition itself lasted about 60 years or two generations. The number of births balanced approximately the number of deaths by 1800 and this balance was practically restored around 1980, about 50 years after the end of the fertility transition. This model is fairly general for European countries, with the notable exception of France, where fertility decline occurred much earlier, beginning in the 18th century, and was very slow, since it lasted nearly two centuries. Historical demographic studies in Europe showed that the fertility transition was virtually unrelated to short-term socio-economic indicators and that it affected different countries at different levels of development, as measured by income per

Russia presents a different case because the state has begun to play an active role in the decline in fertility in this country. Available evidence suggests a small decline in fertility at the end of the 19th century, probably restricted to large cities. Then, after the troubled period of the Bolshevik revolution, fertility reached a peak in 1924. After this date, fertility started a steady decline, reaching a level of 2 children per woman in 1970, some 45 years after the beginning of the transition, after which it fluctuated upwards and downwards. What is important in the case of Russia is the voluntarist policy of the Soviet state, which authorized medical abortion as early as 1921, induced abortion being the main form of birth control in the USSR until 1990. This policy was above all a social and feminist policy aimed at ensuring greater freedom for women and encouraging them to work in industrial and agricultural production, and not a policy of population control in the Western sense. It was however interrupted at the time of

In the Third World, fertility decline began most often after 1960, and is mainly the result of public policies, that is family planning programs. According to United Nations estimates, fertility in Asia fell from 5.67 to 2.24 children per woman between 1960 and 2010 and in Latin America from 5.95 to 2.20 children per woman during the same period, thus realizing the essential part of the transition of fertility in half a century. In sub-Saharan Africa as a whole, fertility declined only slightly during the same period of time, from 6.62 to 5.26 children per woman between 1960 and 2010 [6]. Africa is the last continent where the transition was delayed and remained largely unfinished by 2010. The consequences of this persistent high fertility are incalculable and will lead some countries to situations very difficult to manage,

The purpose of this study is to trace the history of family planning policies and programs and their impact on fertility and contraception in Africa, to highlight what worked and what did not work, and to document the reasons of successes and failures. The emphasis here is on rural areas, because demographic dynamics are different in urban areas which are much more advanced in the fertility transition. This study is intended for social scientists and policy makers, and therefore provides only few details on the demographic and statistical techniques that underlie the tables and graphs. These technical details are amply covered in other publi-

capita, level of education level or level of urbanization [1, 2].

the Second World War, in this case for demographic purposes [3–5].

especially countries located in the Sahel and in Central Africa [7, 8].

cations cited in text.

120 Family Planning

The first voluntarist movements of birth planning, initially private initiatives, appeared in the United States and in England at the beginning of the 20th century, with activist women, most notably Margaret and Ethel Sanger and Marie Stopes, who installed the first clinics promoting birth control in New York City (1916) and in London (1921).

Awareness of the world population problem dates back to the years following the end of the Second World War, especially in the United States and in some European countries (England, Sweden), and it was from 1950 on that concerted efforts to develop and disseminate contraception and limit population growth were made.

Initially, extensive research was funded to develop modern contraceptives with maximum efficacy and minimal side effects, and best suited to the needs of couples. This research produced a long series of important technological innovations: contraceptive pills (1960), Intra-Uterine Devices or IUDs (1958, 1962, 1968), spermicides (numerous products), injectable hormonal contraceptives (1969), implants (1983), abortion pills (1988), morning-after-pills (1999), non-surgical sterilization (2002), etc. These innovations enabled the development of family planning programs and the spread of modern contraception worldwide. These new methods complemented previously known methods (abstinence, interrupted coitus or withdrawal, condom, diaphragm, sterilization, induced abortion, etc.) and facilitated the adoption of new behaviors. It should be noted here that these new contraceptive methods are the most widely used methods in Africa: five modern methods (injectable, pill, implant, IUD, condom) account for 90% of contraceptive methods used, among which almost half (42% of total) are injectables (source: Demographic and Health Surveys, or DHS).

It was also during this period that were founded the leading organizations responsible for disseminating modern contraception and monitoring its effects, such as the Population Council (1952), the International Planned Parenthood Federation (IPPF, 1952), the PathFinder Fund (1957), as well as the specialized programs of large American foundations (Ford, Rockefeller, Hewlett-Packard, etc.) and of the American government (USAID). At the level of international organizations, the United Nations created in 1967 an agency specialized in population issues: the United Nations Fund for Population Activities (UNFPA). Other UN agencies will also participate in this movement in various ways: World Health Organization (WHO), UNICEF, World Bank, etc.

With the development of major family planning programs worldwide, many consulting firms and consulting groups, mostly American and financed by USAID, were created since the 1970s, which played an important role in the establishment, management and evaluation of family planning programs, such as: Family Health International, Futures Group, PSI, JSI, MSH, Abt Associates, World Vision, etc. The programs were monitored mainly through demographic sample surveys, firstly the Contraceptive Prevalence Surveys (CPS) in the 1960s, then through more elaborate surveys: the World Fertility Surveys, or WFS (1972-1984), and especially the Demographic and Health Surveys (DHS), which have been in place since 1985 to date.

a minority represented by some Third World countries like Algeria and Argentina and some communist countries, supported the slogan: "the best pill is development." Their argument was that economic development was a prerequisite for declining fertility, that is, economic growth must create the necessary and sufficient conditions for fertility control. In the following years, the experience of many Third World countries showed the opposite, that is that family planning programs could work well in very poor countries with low economic growth. However, this meeting resulted in the adoption of a global action plan (World Population Action Plan), a reference document used extensively thereafter. This very comprehensive document contains 109 recommendations covering all aspects of population, health and development policies which were later implemented in the world, including technical details such as

Family Planning and Fertility Decline in Africa: From 1950 to 2010

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123

• The International Conference on Population held in Mexico in 1984: this conference was the first to express an almost unanimous consensus on the need to limit the number of births globally, and received the strong support of Western countries for family planning programs. On one hand, this meeting was an important step forward, because African countries endorsed the "Kilimanjaro Declaration," which affirmed their support for family planning programs in the continent. On the other hand, the United States of President Ronald Reagan expressed opposition to induced abortion and to programs supporting

• The International Conference on Population and Development (ICPD) held in Cairo in 1994, emphasized the public health aspects of contraception, introduced the concepts of "Reproductive Health" and "Sexual Health", in the context of the fight against HIV/AIDS and other sexually transmitted infections. The conference insisted on the rights of women to control their reproduction and on their autonomy of decision. By focusing on the individual, this approach was closer to that of the pioneers of contraception, and avoided the pitfalls of the so-called population control approach that was dominant in the 1950s.

• The International Parliamentarians' Conference on the Implementation of the ICPD, held in Strasbourg in 2004, continued along the same lines and saw a solemn commitment by parliamentarians from all over the world to continue to implement the ICPD Plan of Action.

• The Family Planning Summit held in London in 2012, under the aegis of the British government and the Gates Foundation, proposed to continue along the same lines, and to focus efforts on the lagging countries (69 countries were selected, including the poorest countries and many African countries), with the goal of universal access to contraception by year 2020.

• This conference was followed 5 years later (10–11 July 2017), also in London, by a new sum-

Of course, these large international meetings were complemented by a myriad of small con-

The development of modern contraception and family planning in Africa follows overall the

mit with the same actors, focusing on the needs of adolescent girls.

**2.5. Development of family planning policies and programs**

same patterns in most countries, with some local variants:

ferences, seminars, scientific and political meetings on the subject since 1950.

data collection, assessment, training and research.

abortion (Global Gag Rule).

#### **2.2. Major international programs**

The first population intervention trial was conducted in the 1950s, in the form of a clinical trial with an intervention area and a control area, in the Punjab province of India, around the village of Khanna, in 1954–1959 [12]. India was the first country to officially adopt a family planning program in 1952. Following this trial, many family planning programs were implemented in most Third World countries, in Asia, Latin America, the Middle-East, North Africa and later in sub-Saharan Africa.

#### **2.3. African family planning programs**

With respect to modern contraception, very little was happening in Africa during the colonial period, that is, before 1960. At that time, the dominant doctrine was that the continent was under-populated, and that demographic growth, already strong at that time, though little documented, was conducive to economic development.

Awareness of the population problem began to change in the 1960s and 1970s with the emergence of the first population censuses, which showed an extremely high population growth, often between 30 and 40 per 1000, which clearly could not last for a long time. Let us recall that with a growth of 35 per 1000, a population doubles every 20 years, producing a multiplication by 32 within a century. The first population projections made by the United Nations Population Division (UNPD) and subsequent studies of the Futures Group (RAPID project) made it possible to ring the bell: it was clear that the continent would run to catastrophe if fertility remained at a very high level, or even increased, while mortality declined rapidly. Let us recall here that it takes almost a century to stop the devil engine of population growth. It was at this time that the first family planning programs were set up in Africa [13].

#### **2.4. Major international conferences**

Another factor that led to awareness and changes in the attitude of governments from pronatalist to neo-Malthusian was the holding of major international population conferences, held approximately every 10 years by the United Nations agencies, by major American foundations, or by other organizations [14, 15].

a minority represented by some Third World countries like Algeria and Argentina and some communist countries, supported the slogan: "the best pill is development." Their argument was that economic development was a prerequisite for declining fertility, that is, economic growth must create the necessary and sufficient conditions for fertility control. In the following years, the experience of many Third World countries showed the opposite, that is that family planning programs could work well in very poor countries with low economic growth. However, this meeting resulted in the adoption of a global action plan (World Population Action Plan), a reference document used extensively thereafter. This very comprehensive document contains 109 recommendations covering all aspects of population, health and development policies which were later implemented in the world, including technical details such as data collection, assessment, training and research.

which played an important role in the establishment, management and evaluation of family planning programs, such as: Family Health International, Futures Group, PSI, JSI, MSH, Abt Associates, World Vision, etc. The programs were monitored mainly through demographic sample surveys, firstly the Contraceptive Prevalence Surveys (CPS) in the 1960s, then through more elaborate surveys: the World Fertility Surveys, or WFS (1972-1984), and especially the

The first population intervention trial was conducted in the 1950s, in the form of a clinical trial with an intervention area and a control area, in the Punjab province of India, around the village of Khanna, in 1954–1959 [12]. India was the first country to officially adopt a family planning program in 1952. Following this trial, many family planning programs were implemented in most Third World countries, in Asia, Latin America, the Middle-East, North Africa

With respect to modern contraception, very little was happening in Africa during the colonial period, that is, before 1960. At that time, the dominant doctrine was that the continent was under-populated, and that demographic growth, already strong at that time, though little

Awareness of the population problem began to change in the 1960s and 1970s with the emergence of the first population censuses, which showed an extremely high population growth, often between 30 and 40 per 1000, which clearly could not last for a long time. Let us recall that with a growth of 35 per 1000, a population doubles every 20 years, producing a multiplication by 32 within a century. The first population projections made by the United Nations Population Division (UNPD) and subsequent studies of the Futures Group (RAPID project) made it possible to ring the bell: it was clear that the continent would run to catastrophe if fertility remained at a very high level, or even increased, while mortality declined rapidly. Let us recall here that it takes almost a century to stop the devil engine of population growth. It

Another factor that led to awareness and changes in the attitude of governments from pronatalist to neo-Malthusian was the holding of major international population conferences, held approximately every 10 years by the United Nations agencies, by major American foun-

• The International Conference on Family Planning Programs held in Geneva in 1965 was the first to show the impact of modern contraception on fertility trends in some Asian countries

• The World Population Conference held in Bucharest in 1974: this conference was the first arena of struggle between supporters and opponents of family planning policies. The opponents,

was at this time that the first family planning programs were set up in Africa [13].

Demographic and Health Surveys (DHS), which have been in place since 1985 to date.

**2.2. Major international programs**

122 Family Planning

and later in sub-Saharan Africa.

**2.3. African family planning programs**

**2.4. Major international conferences**

dations, or by other organizations [14, 15].

(South Korea, Taiwan), and to seek consensus on the issue.

documented, was conducive to economic development.

Of course, these large international meetings were complemented by a myriad of small conferences, seminars, scientific and political meetings on the subject since 1950.

#### **2.5. Development of family planning policies and programs**

The development of modern contraception and family planning in Africa follows overall the same patterns in most countries, with some local variants:

John-Paul-II (1981), and speech of Pope Benedict-XVI (2008). The position of the Catholic Church is essentially philosophical, therefore subject to adjustments, such as for example about the use of condoms. However, the Catholic Church allows certain forms of traditional contraception, defined as "observing the natural rhythms of woman's fertility", such as:

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*The position of certain Islamist groups*: Islam generally favors contraception for two reasons: to improve the health of mother and children, and to take account of economic constraints of the family. However, many Muslim schools of thought are opposed to sterilization and abortion. Moreover, some highly politicized groups are hostile to any population policy aimed at reducing the number of Muslims. These positions vary widely between countries, schools of thought, and periods [17].

The spread of modern contraception and the introduction of family planning programs raised many ethical issues around the world, which have evolved considerably over the years [10]. The most important debates have been on induced abortion, on male and female sterilization, and on the side effects of hormonal contraceptives (pills and injectables in particular). These debates were fierce in countries where population policies were restrictive or even coercive (China, Indonesia), and in countries where financial incentives for sterilization were important relative to income levels (India, Bangladesh). These issues have little affected African countries, because induced abortion is still largely illegal (except in South Africa and Ghana) and because sterilization is still rare, whereas it is the most frequent method in Asia. In Africa, questions have been raised about injectable contraceptives (Depo-Provera), because they

Furthermore, the 1960s and 1970s saw many debates and polemics on the question of the role of the developed countries, in particular the United States, in the promotion of family planning in the countries of the Third World. These actions were sometimes perceived as a form of "imperialist plot" or "cultural intrusion" in Asia, Latin America and Africa. These discussions virtually disappeared after the 1984 conference, the adoption of a broad consensus at the

This section revisits previous studies and provides a general overview of fertility trends in African countries, separating urban and rural areas, because their population dynamics are different. There are even countries in Africa where fertility continued to increase in rural

It should first be recalled that no country in sub-Saharan Africa maintains a complete civil registration of births and deaths necessary for monitoring precisely changes in birth and death rates. For the purpose of estimating fertility levels and trends, sample demographic surveys,

areas, while it was declining in urban areas for decades, such as Congo-Kinshasa.

periodic abstinence, cervical mucus, temperature method, etc.

increase the susceptibility to the HIV virus causing AIDS [18, 19].

global level, and the paradigm shift toward reproductive health in 1994.

**3. Trends in fertility and family planning in Africa**

**2.7. Ethical and political debates**

**3.1. Data and methods**

Thus, there is a wide range of situations in African countries, from countries who adopted a population policy and developed a family planning program early on, who were successful in funding and managing their programs, and who reached the whole population thanks to a good coverage of the fixed posts and of the mobile teams, to countries who started later, who invested little in the program or who mismanaged it, and who reached only a fraction of the national population. There is therefore a wide range of situations in fertility declines, which are presented below.

#### **2.6. Legal and religious barriers**

There are many ideological, legal and political obstacles to family planning programs, as will be illustrated in the case studies presented below. But there are a few specific obstacles that need to be mentioned with respect to African countries:

*The French law of 1920*: This law, passed on July 31, 1920, following the First World War and the demographic deficit that followed, prohibited "any propaganda on contraception or against the birthrate" and severely repressed induced abortion and its promotion. It was voted in the hope of raising the birthrate in order to have more soldiers in case of war, and to regain the numerical superiority of France as in the previous centuries. This law applied not only in metropolitan France but also in Algeria and in all the French colonies, where it remained in application after independence. This law was abolished only on December 28, 1967 in France (*Loi Neuwirth*). In Africa, countries concerned had to revoke this law before undertaking information and awareness campaigns on family planning. In many francophone African countries, it was not until the 1980s or 1990s that this law was abolished. The project to harmonize legislations in Francophone West Africa came even later. The model law on Sexual and Reproductive Health was adopted at the Abidjan Symposium on June 9, 1999 and subsequently implemented in the 10 countries concerned [16].

*The position of the Catholic Church*: in response to the secular movements and to the positions taken by the Anglican Church, the Catholic Church condemned modern contraception very early on, and on several occasions: encyclical *Casti Connubii* of Pope Pius-XI (1930), encyclical *Humanae Vitae* of Pope Paul-VI (1968), apostolic exhortation *Familiaris Consortio* of Pope John-Paul-II (1981), and speech of Pope Benedict-XVI (2008). The position of the Catholic Church is essentially philosophical, therefore subject to adjustments, such as for example about the use of condoms. However, the Catholic Church allows certain forms of traditional contraception, defined as "observing the natural rhythms of woman's fertility", such as: periodic abstinence, cervical mucus, temperature method, etc.

*The position of certain Islamist groups*: Islam generally favors contraception for two reasons: to improve the health of mother and children, and to take account of economic constraints of the family. However, many Muslim schools of thought are opposed to sterilization and abortion. Moreover, some highly politicized groups are hostile to any population policy aimed at reducing the number of Muslims. These positions vary widely between countries, schools of thought, and periods [17].

#### **2.7. Ethical and political debates**

• Arrival of modern contraceptives, first in pharmacies and among private doctors.

opening of the first specialized clinics.

women at home.

124 Family Planning

cation), etc.

**2.6. Legal and religious barriers**

need to be mentioned with respect to African countries:

• Establishment of private family planning associations, generally affiliated to IPPF, and

• Establishment of a national family planning program, first in urban areas and then in rural areas, usually supported by a strong international technical and financial assistance. At the beginning, these programs are based on fixed structures (hospitals, clinics, family planning centers), then on mobile teams that make home visits or even distribute contraceptives to

• Official adoption of a population policy, often with precise objectives (maximum number

• Development of programs as needed: development of integrated reproductive health programs, development of contraceptive mix, awareness campaigns (information, education, communication, or IEC), sex education in schools, adolescent awareness (peer group edu-

Thus, there is a wide range of situations in African countries, from countries who adopted a population policy and developed a family planning program early on, who were successful in funding and managing their programs, and who reached the whole population thanks to a good coverage of the fixed posts and of the mobile teams, to countries who started later, who invested little in the program or who mismanaged it, and who reached only a fraction of the national population. There is therefore a wide range of situations in fertility declines, which are presented below.

There are many ideological, legal and political obstacles to family planning programs, as will be illustrated in the case studies presented below. But there are a few specific obstacles that

*The French law of 1920*: This law, passed on July 31, 1920, following the First World War and the demographic deficit that followed, prohibited "any propaganda on contraception or against the birthrate" and severely repressed induced abortion and its promotion. It was voted in the hope of raising the birthrate in order to have more soldiers in case of war, and to regain the numerical superiority of France as in the previous centuries. This law applied not only in metropolitan France but also in Algeria and in all the French colonies, where it remained in application after independence. This law was abolished only on December 28, 1967 in France (*Loi Neuwirth*). In Africa, countries concerned had to revoke this law before undertaking information and awareness campaigns on family planning. In many francophone African countries, it was not until the 1980s or 1990s that this law was abolished. The project to harmonize legislations in Francophone West Africa came even later. The model law on Sexual and Reproductive Health was adopted at the Abidjan Symposium on June 9, 1999 and subsequently implemented in the 10 countries concerned [16].

*The position of the Catholic Church*: in response to the secular movements and to the positions taken by the Anglican Church, the Catholic Church condemned modern contraception very early on, and on several occasions: encyclical *Casti Connubii* of Pope Pius-XI (1930), encyclical *Humanae Vitae* of Pope Paul-VI (1968), apostolic exhortation *Familiaris Consortio* of Pope

of children per couple, prevalence of contraception above a threshold, etc.).

The spread of modern contraception and the introduction of family planning programs raised many ethical issues around the world, which have evolved considerably over the years [10]. The most important debates have been on induced abortion, on male and female sterilization, and on the side effects of hormonal contraceptives (pills and injectables in particular). These debates were fierce in countries where population policies were restrictive or even coercive (China, Indonesia), and in countries where financial incentives for sterilization were important relative to income levels (India, Bangladesh). These issues have little affected African countries, because induced abortion is still largely illegal (except in South Africa and Ghana) and because sterilization is still rare, whereas it is the most frequent method in Asia. In Africa, questions have been raised about injectable contraceptives (Depo-Provera), because they increase the susceptibility to the HIV virus causing AIDS [18, 19].

Furthermore, the 1960s and 1970s saw many debates and polemics on the question of the role of the developed countries, in particular the United States, in the promotion of family planning in the countries of the Third World. These actions were sometimes perceived as a form of "imperialist plot" or "cultural intrusion" in Asia, Latin America and Africa. These discussions virtually disappeared after the 1984 conference, the adoption of a broad consensus at the global level, and the paradigm shift toward reproductive health in 1994.


**1. Introduction**

Nap-of-the-earth (NOE) is a very low-altitude flight route utilized by military plane to keep- away from enemy detection and assault in the high-threat environment. This mode is the slowest

1International civil aviation organization (ICAO), United Kingdom civil aviation (UKCA), civil aviation authority (CAA) and federal aviation authority (FAA)

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**Figure 1.** Nap-of-the-earth flight.-

but exciting. When flying at the nap of the earth, the pilot flies at varying airspeed, altitude, and- remains as close to the earth's floor as feasible. Geographical functions used during NOE flight,- and this keeps below enemy radar coverage [1]. NOE used to reduce detection through an antagonistic plane, ground-based radar, or onslaught targets. Doppler radar can decide NOE flight, but the aircraft that comes closer to has to be inside radar range within the first area, and- low flight minimizes this opportunity because of the impact of terrain protecting [2].

The lowest NOE flying is by helicopters because they have lower speeds and more maneuverability than fixed-wing aircraft, mainly in the fast-jets. Only helicopters can fly at treetop levels or even below height of surrounding trees where there are clear areas (such as in river gullies), flying under wires (such as electricity cables). Attack helicopters can hide behind trees or buildings, popping up just enough to use their (rotor mast-mounted) radar or other sensors and then minimally exposing themselves to launch weapons. Then further NOE flying can make the escape [2].

**Figure 1** represents the nap of the earth operation. In this, the high-level route and the lowdegree route of the flight served. The high-level path identified by using the radar device from the base, while the low-level flight direction used to fly below the radar. They have their flight course, which avoids the collision with terrain.


Core and Shell Materials

**3**

**Chapter 1**

**Abstract**

polymers

**1. Introduction**

Encapsulating Wall Materials for

Wall materials play a vital role in the development of micro-/nanocapsules to protect the bioactive compounds against external factors. The encapsulation process and the type of polymers exert a direct impact on the development of bioactive micro-/nanocapsules, which greatly reflect in encapsulation efficiency, solubility, stability, surface permeability, and release profile of desired bioactive compounds. Among the polymers, biodegradable polymeric materials have been the focus for various applications in food, pharmaceutical, and cosmetic industries. Thus, this chapter focuses on different encapsulation techniques and the importance of biodegradable polymers employed as wall materials for developing stable and safe micro-/nanocapsules. Among the natural polymers, protein- and polysaccharide-based polymers are widely used. Similarly, the most commonly used synthetic polymers are polycaprolactone, poly(lactic-co-glycolic acid), and polyethylene glycol. Synthetic polymers have been classified based on their exogenous and endogenous responsive natures. At the end, we have also discussed on the applications of biodegradable polymers employed in the development of micro-/ nanocapsules. To compile this chapter and to provide adequate information to the readers, we have explored various sources, such as reviews, research articles, books, and

**Keywords:** biodegradable polymers, microcapsules, nanocapsules, responsive

Encapsulation is a process in which tiny particles or droplets are surrounded by a coating to form capsules. Microcapsules and nanocapsules are small spheres with a uniform wall around it. The material inside the capsule is referred as the core, internal phase, or fill, whereas the wall is called as the shell, coating, or membrane. The core material may be liquid or solid, active constituents, stabilizers, diluents,

Encapsulation can be done for multiple reasons. The primary purpose of encapsulation is either for sustained or prolonged drug release. For orally delivered drugs, this method has been widely used for masking taste and odor to improve patient compliance, reduce toxicity, and gastrointestinal irritation. This method can be used to convert liquid drugs to a free flowing powder form, prevent vaporization of volatile drugs, alter the site of absorption, and to prevent incompatibility among the drugs. The drugs which are sensitive to oxygen, moisture, light, or pH changes can

Micro-/Nanocapsules

*Shaluah Vijeth, Geetha B. Heggannavar,*

*Mahadevappa Y. Kariduraganavar*

book chapters including Google sites.

excipients, and release-rate retardants or accelerators.


**7. Genetic explanations**

One of the most persuasive explanations is that a genetic predisposition may lead to abnor‐ mal neurological development, which in turn may manifest in various different aberrant be‐ haviors and developmental delays. As autism, ADHD and dyslexia and other developmental conditions are all highly heritable, so they all have a large genetic compo‐ nent, the theory seems plausible. The same genetic anomaly may lead to several disorders or psychiatric conditions. In other words one genotype may lead to several (related) pheno‐ types. This is known as 'pleiotropy'. Researchers have suggested that co-occurrence of au‐ tism and ADHD (and other developmental disorders) may reflect such common genetic causes (Reierson et al, 2008). In this model, the origins of both sets of difficulties are due to common genetic anomalies that predispose children to delayed or atypical neurological de‐ velopment. Certainly, specific genetic anomalies have been associated with a range of psy‐ chopathologies in adulthood. However, the genetic picture is complex and exact pathways are not established. It is estimated there are more than a thousand gene variations which could disrupt brain development enough to result in social delays (Sanders et al., 2012).

Such a genetic predisposition is almost certainly complex and multi factorial. So far, over 100 candidate genes have been associated with ASD, most of which encode proteins in‐ volved in neural development, but exact mutations within the candidate genes have yet to be identified (Freitag, 2007). Furthermore, different individuals may have mutations in dif‐ ferent sets of genes and most of the discovered gene variations are likely to have a low pene‐ trance, thus not all carriers will develop the disorder. There may be interactions among mutations in several genes, e.g. between regulatory genes and coding regions, or between the environment and mutated genes, altering their expression. The effect of a mutation or deletion can depend on processes relating to gene expression and regulation as well as the subsequent effects on the expression of other genes.

The advent of genomics and the emphasis placed on this has led to much research to identi‐ fy genetic predispositions to ASD. The field of psychiatry as a whole has been 'geneticised' according to some social theorists. This refers to the potential reclassification of psychiatric conditions in the light of findings from molecular biology. For example, a particular sub-cat‐ egory of DSM-IV schizophrenia has been linked to a substitution of a single base in the se‐ quence of DNA of a particular gene localised to a precise place on a particular chromosome, leading to a substitution of one amino-acid for another in an enzyme involved in neuro‐ transmission. Hedgecoe (2001) provides a discussion of the geneticisation of schizophrenia. The debate as to whether the old psychiatric systems of classification should be overhauled in the light of new genomic knowledge which illuminates genetic aetiologies is ongoing (Ericson & Doyle, 2003).


**1. Introduction**

Public–private partnerships (PPPs) are a form of cooperation in which public organizations and private organizations combine to provide public goods or services [1]. Compared with traditional procurement, PPPs can allow the public and private sectors' complementary advantages to complement each other, thereby improving infrastructure efficiency and quality [2]. Since 1982 when Britain first adopted PPPs in public infrastructure, PPPs have been developed and applied on a large scale all over the world [3,4]. In 2014, China experienced the beginning of a new round of PPPs. The State Council, the National Development and Reform Commission, and the Ministry of Finance successively issued more than 100 relevant policy documents to encourage and guide private enterprises in participating in PPPs. Since the implementation of the Belt and Road Initiative, the promotion of the Rural Revitalization Strategy, and the acceleration of the construction of "new infrastructure and urbanization initiatives", China's public infrastructure projects operating through PPPs are showing unprecedented levels of construction, and private enterprises are embracing the strong development opportunities [5]. However, after more than seven years of implementation, according to data released by the Ministry of Finance, the participation rate of private enterprises is not high [6], and the phenomenon of "the state-owned enterprises enter into, but the private enterprises exit" can be seen [7]. As of 20 May 2022, the cumulative investment of PPP projects nationwide was 21.1 trillion yuan,

**Citation:** Zhang, Y.; Yi, H.; Xie, H.; Zheng, J.; Wang, Y. How Private Enterprises' Participation Behaviors Evolve with Incentive Modes in PPPs: An Evolutionary Game View. *Buildings* **2022**, *12*, 709. https:// doi.org/10.3390/buildings12060709

Academic Editors: Yongjian Ke, Jingxiao Zhang and Simon P. Philbin

Received: 23 April 2022 Accepted: 23 May 2022 Published: 24 May 2022

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and the number of transactions was 12,853. Of these figures, investments by private enterprises accounted for 15.92% of the total, and the number of private enterprises accounted for 32.50% of the total. As it is well-known that the capital needs of PPPs are gigantic, since state-owned enterprises have ample funds and a strong ability to take risks when it comes to cash flow streams, they are more suitable to participating in PPPs. Currently, state-owned enterprises are indeed involved in 70% of PPPs. However, if the number of state-owned enterprises participating in PPPs is too large, this does not help to share the financial pressure of the government. Worse, in Chinese PPPs, state-owned businesses frequently use the benefits of control and relational relationships based on mutual confidence and shared values to implement tunneling behavior, which harms the projects' overall interests and is even detrimental to the long-term development of PPP schemes [8]. Therefore, improving the participation rate of private enterprises is an essential prerequisite for the effective implementation of PPPs.

Scholars who have examined PPPs have found that the low participation rate of private enterprises in PPPs is caused by external environmental risk factors such as the economy, the system, the society, and the project itself [9]. Osei-Kyei and Chan also found that the three critical factors in attracting private companies to participate in PPPs are government support and recognition, positive government attitudes, and political stability [10]. In addition, other critical factors or barriers inhibiting the involvement of the participation of private sectors were also explored, such as project changes [11], government attention and intervention [6], and delivery modes [12]. In fact, the balance of risk and return is among the most important factor for private enterprises participating in PPPs [13]. Generally, governments procure infrastructure PPPs through tendering processes and select potential participants. The successful bidder then creates a special purpose vehicle (SPV), which is in charge of developing the project [13,14]. According to Dixon et al. [15], there is a direct relationship between PPP project risks assumed by the SPV and the cost of finance. From a private sector perspective, a PPP project is an investment opportunity with a long-term contract and some related risks [14]. When the project is granted, a comparison can be drawn between the project's internal rate of return and the price the public sector pays for the risks transferred to the private sector. In the survey conducted by Demirag et al. [16], three-quarters of respondents to the specific question of target returns reported rates between 9 and 15%. However, in China, the average rate of return is only 6.5% in PPPs [17]. There has been relatively little research into the relationship between the expected profit and the participation behavior of private enterprises during the decision stage of PPPs. More importantly, the existing literature have rarely been concerned with the interaction between incentive modes of the public and strategic behaviors of private enterprises. Specifically, private sectors care about the expected returns under specific incentive or compensation modes. For instance, they may compare target returns with potential risks based on the incentive strategies of public organizations. If the expected return is higher than the risk reward, they would then participate in the PPP project. If the expected return is lower than the risk reward, they would not participate in the PPP project. When taking risk management into consideration, the returns are directly linked to incentive patterns. In this process, since the information about returns and risks is incomplete and strategic interaction between the public and the private is dynamic, the process of strategy selection can be perceived as an evolutionary game.

To increase the willingness of private enterprises to participate in the decision stage of PPP projects, this study aimed to quantify the returns under different incentive modes, taking the return as the criterion for whether private enterprises would participate in PPPs. Furthermore, it analyzed how the behaviors of both parties evolved dynamically with the differences. The remainder of this article is organized as follows. First, a comprehensive literature review concerning cooperation and decision-making in PPPs is presented, along with an account of evolutionary game theory and the participation behavior of private enterprises. Next, an evolutionary game model and the related model solution are constructed and conducted. The dynamic evolution of equilibrium positions and the probability of

participation through government incentives are then discussed. Subsequently, the factors and their sensitivities are explained through a numerical example. Finally, the article concludes by stating the implications of the research for private enterprises' participation in PPPs.

#### **2. Theoretical Background**

#### *2.1. Cooperation and Participation in PPPs*

Infrastructure projects can provide a range of societal, environmental, and economic benefits for many entities. In China, PPPs are common ways of handling such projects for two reasons. First, limitations to public funding have led governments to encourage the private sector to engage in various long-term arrangements for capital-intensive projects. Second, a comprehensive approach for the whole area may be more efficient and profitable than piecemeal development via individual owners' interventions [18]. Thus, a key characteristic of PPPs is that the three tasks of financing, building a facility, and subsequently operating it are bundled and delegated to a group of private partners. Such a group associated with a bidding consortium is selected as preferred participants through tendering processes [14]. The group of private partners then create the SPV and are the main equity investors that manage and develop the PPP project [13], and the main investors assume the risks of financing, building, and operating an infrastructure asset in exchange for suitable economic returns [19]. However, due to the uncertain, asset-specific, and complex issues associated with PPPs, private sectors grouped in SPVs are also vulnerable to multiple long-term returns and risks challenges [20]. Thus, diverse strategies, including whether to adopt a specific PPP or the traditional contracting approach for a specific project [21], how the decision of bundling the financing, building, and operating stages affects the incentives in PPP [22], and how to allocate risk among participants involved in PPP projects [23,24], might result in the distinct economic returns of the participants. Additionally, the risk preference, profit sharing, government attention, and delivery modes would affect the involvement of the private sectors. Therefore, the cooperation of the public and private sectors requires them to negotiate conflicting goals, and each participant in the system would adopt strategic interactions due to differences in their excepted returns.

#### *2.2. Evolutionary Game Theory*

In general, game theory is used to analyze strategy selection in terms of expected payoffs [25]. From the point of view of economic optimization, this theory provides a mathematical framework to model strategic behavior and demonstrate resulting decisions [26]. Therefore, game theory is the most effective theory of decision-making. It is an economic tool for studying cooperation, conflict, and strategic interaction in the decision-making process [27].

Furthermore, evolutionary game theory (EGT) explains the process by which entities learn, compete, and adapt to each other in biological evolution [28]. Unlike traditional game theory that focuses on perfect rationality, in EGT, participants are assumed to possess bounded rationality and be under the conditions of imperfect information. The theory emphasizes the dynamic process of changing strategies, rather than static equilibrium. The EGT can fully reflect the relationship between strategy change and payoff fluctuation, and this advantage has led the EGT to be applied in different research fields [29]. It has penetrated many areas of research that deal with social and economic systems [30]. The potential is great in economic applications, especially [31].

Economic conflicts and strategic interactions are common in terms of PPP applications, and private enterprises are not always entirely rational. Simultaneously, they attempt to maximize expected payoffs, but information and risks are not complete. This is especially true in complicated market competition, in which decision-makers seek evolutionarily stable strategies (ESS) through constant trial and error, imitation, and learning [32,33]. Therefore, the EGT is suitable for analyzing the cooperation strategies of the leading participants in PPPs. In the next section, we describe the model and its assumptions.

#### **3. Modeling**

#### *3.1. Description of the Model*

PPPs are a way of financing projects and an innovative way to marketize the supply of public services. PPPs allow all participants to cooperate to form a complementary decision-making mechanism. They break the double puzzles of government failure and market failure in public projects. They promote reforms to the supply side of the social structure in the field of public services. Participants in PPPs have different goals, especially given that those participants can be government departments and private enterprises. They must constantly interact and play games when they participate in PPPs. To maximize their expected payoffs, they may choose cooperation or non-participation strategies, and their behavioral choices will show bounded rationality under uncertain situations. The evolutionary game model can be used to analyze the decision-making mechanisms of governments and private enterprises as they cooperate in PPPs.

#### *3.2. Assumptions and Parameters*

The assumptions are hypothesized as follows: Assumption 1. The game environment for public organizations and private enterprises is one of incomplete information. Both parties are bounded rational decision-makers, and each party independently and dynamically chooses their behavior strategy. Both parties make decisions or take actions to maximize their profits based on past experiences or practices [31].

Assumption 2. The set of strategies of the private enterprises is (*E*1, *E*2) = (Participation, Non-participation), in which the probability of adopting the "participation" strategy is *x* (0 ≤ *x* ≤ 1) and the probability of adopting the "non-participation" strategy is 1 − *x*. The set of strategies of the public organizations is (*P*1, *P*2) = (Incentive, Neutrality), in which the probability of adopting the "incentive" strategy is *y* (0 ≤ *y* ≤ 1), and the probability of adopting the "neutrality" strategy is 1 − *y*.

Assumption 3. To encourage private enterprises to participate in PPPs, when a public organization chooses the "incentive" strategy, it will give private enterprises preferential policies such as tax exemptions and reduced interest. If the incentive cost for the public organization is *CI*, then the economic incentive for the private company is *λCI*, which is the incentive intensity. At the same time, let the public benefit of the PPP be *R*; that is, under the encouragement of the public sector, private enterprises can provide better public services, and the public benefit at this time is *RH*. If the public sector maintains a neutral attitude towards private enterprises participating in PPPs or has potential thresholds such as "glass doors" or "revolving doors", which increase the institutional transaction costs of a private enterprise participating in a PPP, the public benefit is then *RL*, *RL* < *RH*, and the public sector will suffer certain losses of reputation.

Assumption 4. Under a given contract, it is reasonable to anticipate that the private sector will adopt a cost-cutting strategy while retaining an acceptable level of participation to avoid high-risk damage [34]. It is assumed that the total investment of private enterprises in PPP projects is *VE*, the investment return rate is *r*1, the financing cost rate is *r*2, the project risk cost is *CR*, and the basic income of private enterprises is (*r*1 − *r*2)*VE* − *CR*. If the public sector chooses the "incentive" strategy, private enterprises will increase their income *λCI*. Currently, the private sector's net income is (*r*1 − *r*2)*VE* − *CR* + *λCI*, and the government's net income is *RH* − *CI*. If the public sector chooses the strategy of "neutrality", the institutional transaction costs of private sectors, *CC*, will increase. Currently, the net income of private enterprises is (*r*1 − *r*2)*VE* − *CR* − *CC*, and the government's net income is *RL* − *S*.

#### *3.3. Basic Model*

The payoff matrix can be obtained based on the preceding assumptions and analyses, as shown in Table 1.

**Table 1.** Payoff matrix between the public and private enterprises.

1. The expected payoffs of private enterprise (*E*)

The payoffs of private enterprise adopting the strategy of "active participation" are:

$$\mathcal{U}\_{E1} = y[(r\_1 - r\_2)V\_E - \mathcal{C}\_R + \lambda \mathcal{C}\_I] + (1 - y)[(r\_1 - r\_2)V\_E - \mathcal{C}\_R - \mathcal{C}\_C] \tag{1}$$

The payoffs of private enterprise adopting the "non-participation" strategy are:

$$
\mathcal{U}\_{E2} = 0 \tag{2}
$$

The expected payoffs of private enterprise (*E*) adopting a mixed strategy are:

$$
\overline{\mathcal{U}}\_E = \mathfrak{x} \mathcal{U}\_{E1} + (1 - \mathfrak{x}) \mathcal{U}\_{E2} \tag{3}
$$

According to the Malthusian dynamic equation principle, the speed of the dynamic change of strategy of a private enterprise can be expressed by a dynamic differential equation, and the replication dynamic equation of the private enterprise can be obtained as follows:

$$\begin{array}{l} f\_{\rm E}(\mathbf{x}) = \frac{d\mathbf{x}}{dt} \\ \mathbf{ } \end{array} = \begin{array}{l} \mathbf{x} \left( \mathcal{U}\_{\rm E1} - \overline{\mathcal{U}}\_{\rm E} \right) = \mathbf{x} (1 - \mathbf{x}) \left( \mathcal{U}\_{\rm E1} - \mathcal{U}\_{\rm E2} \right) \\ = \mathbf{x} (1 - \mathbf{x}) \left[ (\lambda \mathcal{C}\_{I} + \mathcal{C}\_{\rm C}) \mathcal{Y} + (r\_{1} - r\_{2}) V\_{\rm E} - \mathcal{C}\_{\rm R} - \mathcal{C}\_{\rm C} \right] \end{array} \tag{4}$$

2. The expected payoffs for the public organization (*P*)

The payoffs of the public organization adopting the "incentive" strategy are:

$$
\mathcal{U}\_{P1} = \mathcal{x}[\mathcal{R}\_H - V\_P - \mathcal{C}\_I] + (1 - \mathcal{x})(-\mathcal{C}\_I) \tag{5}
$$

The payoffs of the public organization adopting the "neutral" strategy are:

$$
\mathcal{U}\_{P2} = \mathcal{x} (R\_L - V\_P - S) \tag{6}
$$

The expected payoffs of the public organization adopting a mixed strategy are:

$$
\mathcal{U}\_P = y \mathcal{U}\_{P1} + (1 - y) \mathcal{U}\_{P2} \tag{7}
$$

The replication dynamic equation of the public (*P*) is:

$$f\_P(y) = y\left(\mathcal{U}\_{P1} - \overline{\mathcal{U}}\_P\right) = y(1-y)(\mathcal{U}\_{P1} - \mathcal{U}\_{P2}) = y(1-y)[(\mathcal{R}\_H - \mathcal{R}\_L + \mathcal{S})\mathbf{x} - \mathcal{C}\_I] \tag{8}$$

#### *3.4. Model Solution: Replicator Dynamics*

To sum up, a two-dimensional dynamic system can be obtained. By solving two duplicate dynamic equations *dx dt* = 0 and *dy dt* = 0 simultaneously, we learn that (0,0), (0,1), (1,0), (1,1), and (*x*∗, *y*∗) are the five local equilibrium points of this two-dimensional dynamic system, among which:

$$\chi\_{\ast} = \frac{\mathbb{C}\_{I}}{R\_{H} - R\_{L} + S} \tag{9}$$

$$y\* = \frac{(r\_2 - r\_1)V\_E + \mathcal{C}\_R + \mathcal{C}\_\mathbb{C}}{\lambda \mathcal{C}\_I + \mathcal{C}\_\mathbb{C}} \tag{10}$$

#### **4. Model Analysis**

#### *4.1. Dynamic Evolution Analysis of Equilibrium Points*

According to the local stability analysis method proposed by Freedman [35], the stability of equilibrium points for an evolutionary system can be calculated using a Jacobian matrix. The specific method of judging is as follows: if the determinant of the Jacobian matrix of the equilibrium point is *Det*(*J*) > 0 and the trace is *Tr*(*J*) < 0, it can be judged that the corresponding equilibrium point has asymptotic stability. This is called the ESS point. If *Det*(*J*) > 0 and *Tr*(*J*) > 0, it can be assumed that the related equilibrium point is unstable. If *Det*(*J*) < 0, it can be judged that the corresponding equilibrium point is a saddle point. Therefore, according to the replicated dynamic Equations (4) and (8), the Jacobian matrix of participatory decision-making in PPPs is shown by Equation (11):

$$J(\mathbf{x}, y) = \begin{pmatrix} \frac{\partial f\_E(\mathbf{x})}{\partial \mathbf{x}} & \frac{\partial f\_E(\mathbf{x})}{\partial y} \\ \frac{\partial f\_P(y)}{\partial \mathbf{x}} & \frac{\partial f\_P(y)}{\partial y} \end{pmatrix} = \begin{pmatrix} v\_1 & v\_2 \\ v\_3 & v\_4 \end{pmatrix} \tag{11}$$

where *v*1 = (1 − 2*x*)[(*λCI* + *CC*)*y* + (*r*1 − *r*2)*VE* − *CR* − *CC*]; *v*2 = *x*(1 − *x*)[*λCI* + *CC*]; *v*3 = *y*(1 − *y*)[*RH* − *RL* + *S*]; *v*4 = (1 − 2*y*)[(*RH* − *RL* + *S*)*x* − *CI*].

As for Equation (11), its determinant equation is *Det*(*J*) = *v*1*v*4 − *v*2*v*3, and the trace of this Jacobian matrix is *Tr*(*J*) = *v*1 + *v*4. The determinants and traces of the four equilibrium points (0,0), (0,1), (1,0), and (1,1) are shown in Table 2.

**Table 2.** Determinants and traces of Jacobian matrix at the equilibrium points of participation behavior decision in PPPs.

Through an analysis of the equilibrium points of private enterprises' participation behavior, the local stability of the equilibrium point can be obtained, as shown in Table 3. The local stability of the equilibrium point is closely related to the initial state of each parameter. In other words, the strategy of private enterprises' participation changes based on changes in the expected income and cost.

**Table 3.** Local stability analysis of equilibrium points of participation behavior.

#### *4.2. Discussion of Influencing Factors*

When *r*1*VE* < *r*2*VE* + *CR* + *CC* and *RH* + *S* > *RL* + *CI*, the evolutionary system has five equilibrium points, which are (0,0), (0,1), (1,0), (1,1), and (*x*∗, *y*∗). The group replication dynamics between the public and private enterprises are shown in Figure 1, and there are two stable points: *A*1 (0,0) and *A*4 (1,1). The broken line *A*2*A*5*A*3 in Figure 1 divides the plane area *SA*1*A*2*A*4*A*3 into two parts: the cooperation area *A*2*A*4*A*3*A*5 (Participation, Incentive) and the non-cooperation area (Non-participation, Neutrality). If the initial state of the public organization P and the private enterprise E falls in the cooperation area *A*2*A*4*A*3*A*5, the strategic choice of both parties will eventually converge to *A*4 (1,1). In contrast, if the initial state of the public organization P and the private enterprise E falls in the non-cooperative zone *A*1*A*2*A*5*A*3, both parties' strategies will then eventually evolve to *A*1 (0,0). The parameters of the initial state directly affect the final convergence results of both strategies. Each influence factor will be analyzed in detail below.

**Figure 1.** Dynamic of group replication between the public and enterprises.

1. The impact of the incentive intensity of the public sector *λ*

From the geometric meaning of probability in Figure 1, it can be seen that the probability that the initial state of the private enterprise E and the public organization P after negotiation falls within the (Participation, Incentive) area *A*2*A*4*A*3*A*5 is equal to its area *SA*2*A*4*A*3*A*5 (shaded part in Figure 1), namely:

$$\begin{array}{l} P = S\_{A\_2A\_4A\_3A\_5} \\ = 1 - \frac{C\_I}{2(R\_H - R\_L + S)} - \frac{1 - \left(\frac{X\*}{2} + \frac{Y\*}{2}\right)}{2(R\_H - R\_L + S)} \end{array} \tag{12}$$

For the *SA*2*A*4*A*3*A*5 first-order derivative *λ*, there are:

$$\frac{d\mathcal{S}\_{A\_2A\_4A\_3A\_5}}{d\lambda} = \frac{(r\_2 - r\_1)V\_\mathcal{E} + \mathcal{C}\_\mathcal{R} + \mathcal{C}\_\mathcal{C}}{2\lambda^2\mathcal{C}\_I} \Rightarrow \left\{ \begin{array}{c} > 0, r\_1V\_\mathcal{E} < r\_2V\_\mathcal{E} + \mathcal{C}\_\mathcal{R} + \mathcal{C}\_\mathcal{C} \\ < 0, r\_1V\_\mathcal{E} > r\_2V\_\mathcal{E} + \mathcal{C}\_\mathcal{R} + \mathcal{C}\_\mathcal{C} \end{array} \right. \tag{13}$$

It can be concluded that the correlation between the incentive intensity *λ* (through tax reduction or limits on interest) and the region *SA*2*A*4*A*3*A*5 is related to whether the expected income of private enterprises can cover the expected cost. This is specifically true when other parameter scenarios are fixed, for example, when *r*1*VE* < *r*2*VE* + *CR* + *CC* (the income of private enterprises does not cover the cost), *λ* is larger, and the probability that the initial state falls within the region *A*2*A*4*A*3*A*5 is greater. This means that the probability is greater that the public organization P adopts the "incentive" strategy, and the private enterprise E adopts the "participation" strategy. Additionally, when *r*1*VE* > *r*2*VE* + *CR* + *CC* (the income of private enterprises is greater than the cost), *λ* is larger, and the probability of the initial state falling within the region *A*2*A*4*A*3*A*5 is smaller. This means that the probability is smaller that the public organization P adopts the "incentive" strategy, and the private enterprise E adopts the "active participation" strategy.

2. The impact of the investment return rate of a private enterprise *r*1

For the *SA*2*A*4*A*3*A*5 first-order derivative *r*1, there are:

$$\frac{d\mathcal{S}\_{A\_2A\_4A\_3A\_5}}{dr\_1} = \frac{V\_E}{2(\lambda \mathcal{C}\_I + \mathcal{C}\_\mathcal{C})} > 0\tag{14}$$

It can be concluded that the investment return rate *r*1 is positively correlated with the region *SA*2*A*4*A*3*A*5 . When other parameter scenarios are fixed and *r*1 is large, a public organization is more likely to adopt the "incentive" strategy. At the same time, the probability of a private enterprise adopting participation behavior increases.

3. The impact of the financing cost of a private enterprise *r*2

For the *SA*2*A*4*A*3*A*5 first-order derivative *r*2, there are:

$$\frac{dS\_{A2A\_4A\_3A\_5}}{dr\_2} = \frac{-V\_E}{2(\lambda \mathcal{C}\_I + \mathcal{C}\_\mathbb{C})} < 0\tag{15}$$

Therefore, the financing cost of private enterprises *r*2 is negatively correlated with the region *SA*2*A*4*A*3*A*5 . When other parameter scenarios are fixed and *r*2 is large, a public organization is more inclined to adopt the "incentive" strategy. At the same time, the probability of a private enterprise adopting participation behavior decreases.

4. The impact of the cost of risk for the project *CR*

For the *SA*2*A*4*A*3*A*5 first-order derivative *CR*, there are:

$$\frac{d\mathcal{S}\_{A\_2A\_4A\_3A\_5}}{d\mathcal{C}\_R} = \frac{-1}{2(\lambda\mathcal{C}\_I + \mathcal{C}\_\mathbb{C})} < 0\tag{16}$$

It can be concluded that the risk cost *CR* is negatively correlated with the area *SA*2*A*4*A*3*A*5 . When other parameter scenarios are fixed and *CR* is large, a public organization is more inclined to adopt the "incentive" strategy. At the same time, the probability of a private enterprise adopting participation behavior decreases.

### *4.3. Sensitivity Analysis of Influencing Factors*

There are many parameters involved in the above model. To better reflect the influencing factors and the effects of private enterprises' participation in PPPs, this study took an infrastructure PPP project in a high-tech part of a city as an example. It analyzed the influence of the mode of incentive, the cooperation costs, and the risk costs. There were three parts to the PPP: municipal road construction, landscape engineering, and an underground utility tunnel. Private enterprises invested capital *VE* = 100 million; the investment return rate was *r*1= 0.6; the financing cost rate was *r*2= 0.3; the risk cost was *CR* = 30 million; the institutional transaction cost was *CC*= 50 million; the benefits for the public were *RH* = 60 million and *RL*= 40 million; the incentive intensity was *λ* = 1.0; the incentive cost was *CI*= 20 million; and the public loss was *S* = 20 million. In this scenario, the initial state of the private enterprises participating in the PPP is shown in Figure 2a. In this scenario, it was assumed that the probability of each strategy chosen by the public and private enterprises was 0.5. The sensitivity of each influencing factor is discussed in turn.

#### 1. The sensitivity of the incentive intensity *λ*

From the scenario in Figure 2a *r*1*VE* < *r*2*VE* + *CR* + *CC*, the incentive intensity was set to *λ* = 0.3, *λ* = 1.5, and *λ* = 2.5, and the other parameters remained unchanged. The dynamic evolution of private enterprises choosing the strategy of "Participation" is shown in Figure 2b. When *r*1*VE* < *r*2*VE* + *CR* + *CC*, the incentive intensity was greater, and the private enterprises were more likely to select the strategy of "Participation" more quickly

**Figure 2.** Sensitivity of key factors of private enterprises' participation behavior.

2. The sensitivity of the investment return rate *r*1

From the scenario in Figure 2a, the investment return rates of private enterprises were set as *r*1 = 0.1, 0.4, 0.6, 0.8, 1.0, 1.5. The other parameters were unchanged. The dynamic evolution of private enterprises choosing the strategy of "participation" is shown in Figure 2c. It can be seen from Figure 2c that the greater the investment return rate of private enterprises, the greater the probability that private enterprises would choose the strategy of "participation", and the faster the evolution would be. This result further proves that there is a positive correlation between investment return rate and private enterprises' adoption of the "participation" strategy.

3. The sensitivity of the financing cost rate *r*2

From the scenario in Figure 2a, the financing cost rates of private enterprises were set as *r*2 = 0.1, 0.3, 0.5, 0.7, 0.9, 1.5. The other parameters were unchanged. The dynamic evolution of private enterprises choosing to participate is shown in Figure 3a. The higher the financing cost ratio, the lower the probability that private enterprises would choose "participation". The final result of the evolution was that groups chose not to participate in PPPs. This further proves that there is a negative correlation between the financing cost rate and private enterprises' "participation" strategy choices.

**Figure 3.** Sensitivity of key factors of participation behavior.

4. The sensitivity of the risk cost *CR*

From the scenario in Figure 2a, the risk costs were set at *CR* = 1, 2, 3, 4, 5, and 6. The other parameters were unchanged. The dynamic evolution of private enterprises choosing to participate is shown in Figure 3b. This shows that the greater the risk cost, the less likely private enterprises were to choose the "participation" strategy. With the continuous increase *CR*, the evolution accelerated and finally converged on groups choosing not to participate in PPPs. The result further proves that the risk cost of a project is negatively correlated with a private enterprise's decision to participate in PPPs.

5. A comparative analysis of the sensitivity of key factors

From the sensitivity chart of each influencing factor (see Figure 3c), it can be seen that although the incentive intensity, the investment return rate of private enterprises, and the participation probability of private enterprises are all positively correlated, the influence effect of investment return rate of private enterprises is the most sensitive. In contrast, the financing cost rate, the risk cost, and the participation probability of private enterprises are negatively correlated, and the effect of the risk cost is the most sensitive.

#### **5. Conclusions and Implications**

To encourage private enterprises to actively participate in PPPs, this study constructed a decision-making model of participation behavior for private enterprises in PPPs based on evolutionary game theory. It analyzed the influencing factors and their sensitivity, and it verified the relevant conclusions regarding the theoretical model through simulation. Through the above discussion and analysis, it can be concluded that: First, the incentive intensity and investment return rate are positively correlated with the probability of private enterprises choosing the "participation" strategy, and the influencing effect of the investment return rate of private enterprises is the most sensitive. Second, the financing cost rate, the risk cost, and the probability of private enterprises selecting the "participation" strategy are negatively correlated, and the influencing effect of the risk cost is the most sensitive.

The implications for management that can be taken from the above conclusions is the following:

the expected benefits. This can help them to increase their market share, leading to a win-win situation.

**Author Contributions:** Conceptualization and methodology, Y.Z.; formal analysis, H.Y.; writing original draft preparation, Y.Z. and H.Y.; writing—review and editing, H.X. and J.Z.; supervision and funding acquisition, Y.W. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by the Applied Basic Project of Yunnan Province (Grant Nos. 202101AT070088 and 2019FB084), the Youth Program of Humanities and Social Sciences, Ministry of Education (Grant No. 19YJCZH260), the National Natural Science Foundation of China (Grant Nos. 71761021 and 71701083), and Guangxi Philosophy and Social Science Planning Project (Grant No. 20FJL001).

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author.

**Conflicts of Interest:** The authors declare no conflict of interest.


**3. Conclusion**

In conclusion, biomarkers were indicators of normal physiological processes, disease progression and response to treatment. Although many biomarkers for asthma have been mentioned in recent studies for the diagnosis of asthma, the identification of different phenotypes and efficacy evaluation, none of them have been approved for clinical practice so far, mainly due to their limited sensitivity and specificity. With the development of biomedicine, asthma research is moving from clinical symptoms, clinical phenotypes, lung function and medication response to genomics, proteomics, epigenetics, etc. More key molecules and biomarkers will be discovered in the future. Combined detection of multiple markers can more comprehensively analyze the patient's condition, thus providing more valuable clinical information for the diagnosis, classification and treatment of asthma, and ultimately achieving accurate diagnosis and treatment of asthma patients.


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David A. Schwartz David A. Schwartz Additional information is available at the end of the chapter

[68] Depe Y, Ayten Ş. Views and behaviors of men about family planning. Republican Uni-

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Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.72377

#### **Abstract**

Latin America has some of the strictest abortion rules in the world, where the procedure is criminal in cases of rape, incest, or even to save the life of the mother. More than 97% of women in Latin America and the Caribbean live in countries where access to abortion is either restricted or banned altogether. As a result, unsafe abortion is widespread and causes 10% of all maternal deaths in the region. With the onset of the Zika virus pandemic in 2015, and the identification of the virus as causing poor pregnancy outcomes including fetal infection, microcephaly, and other malformations, there became an increased demand for abortions in Latin American countries. The response of many Latin American governments to Zika infection during pregnancy was to recommend that women avoid or postpone their pregnancies. These recommendations were not possible for many women at risk in the affected countries, especially those who were uneducated or living in poverty. As a result of the Zika pandemic, there has been an increased demand for abortion in many of the affected countries that, because of the clandestine and illegal nature of the procedure, carries the heightened risk for additional maternal morbidity and mortality.

**Keywords:** Zika virus, congenital Zika syndrome, unsafe abortion, unmet need, family planning, pregnancy, illegal abortion, microcephaly, Latin America, Central America, South America, abortion, human rights, reproductive rights, reproductive health, viral infection, public health, contraception

#### **1. Introduction**

The accessibility and utilization of family planning methods in Central and South America have historically been limited by several factors, including availability, affordability, and education, especially when comparing indigenous with nonindigenous women, the poor

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

and the wealthy, and rural and urban dwellers. Throughout Latin America, multiple studies have demonstrated a variety of ethnic, financial, and social risk factors for unintended and unwanted pregnancies, unmet need for family planning, and unsafe abortion. These include widespread poverty, lower education levels, high fertility rates, early age at first intercourse, adolescent and teen pregnancy, rural areas of residence, cultural and language barriers in health-care facilities which are especially prevalent among indigenous women, sexual violence, and insubordination [1, 2]. Because the predominant religion in these countries is Roman Catholicism, religious doctrine has significantly impacted the use of family planning methods. In particular, abortion is unlawful in almost all Latin American countries, except under certain circumstances that are determined by national laws. Because of widespread unmet need for contraception, poverty, stigmatization, and unacceptably large numbers of adolescent and teenage pregnancies, women have historically sought to terminate unwanted pregnancies by means of unlawful abortion in these countries. With the advent of the Zika virus pandemic in 2015 and its spread throughout Latin America, this situation has increased. With the recognition that girls and women who become infected with the Zika virus while pregnant are at risk for developing such poor obstetrical outcomes as spontaneous abortion, stillbirth, infants with microcephaly, and other forms of fetal malformation, even if they exhibit no symptoms during gestation, the demand for abortion has increased. More than 97% of women in Latin America and the Caribbean live in countries where access to abortion is either restricted or banned altogether. In six Latin American countries, abortion is not permitted for any reason, including rape or to save the life of the mother [3]. As a result, they must often seek terminating their pregnancies through less-than-legal means, including performance of abortions in an environment lacking even minimal medical and sanitary standards and often performed clandestinely by persons lacking the necessary medical skills. The potential health consequences of unsafe abortion to the mother are well known [4]—just prior to the advent of the Zika pandemic in 2014, a minimum of 10% of all maternal deaths in Latin American and Caribbean countries, representing almost 900 girls and women, resulted from complications of unsafe abortions [5]. About 760,000 women in the region are treated annually for complications from unsafe abortion [3]. The ongoing public health problem of unsafe abortion was to be unexpectedly exacerbated when a newly emergent virus, the Zika virus, began to spread through South America in 2015 [6]. As it became known that the virus was responsible for the occurrence of microcephaly and other fetal malformations, it left those women at risk in endemic areas without a viable alternative to carrying a potentially infected fetus through to delivery. As a result, there has been an increased demand for abortion, even though it is illegal in most Latin American countries and, in some cases, can result in the incarceration of both the mother and abortionist, nurse, or physician. Penalties can be extreme—up to 10 years in prison for mothers having abortions in Paraguay and Honduras.

**2. Legal status of abortion in Latin America**

of the mother [3, 8–10].

The countries which compose Central and South America have the most restrictive and harsh penalties for performance of an abortion of any region in the world (**Figure 1**). In four Latin American countries—Suriname, El Salvador, Honduras, and Nicaragua—abortion is not permitted legally for any reason whatsoever, including in cases of rape, incest, or to save the life

Pregnant and Out of Options: The Quest for Abortion in Latin America Due to the Zika Virus…

http://dx.doi.org/10.5772/intechopen.72377

53

Chile had been included in the list of countries that completely prohibit abortion, with penalties of up to 5 years in prison, until the government lifted the ban in 2017 [11, 12]. In Guyana, abortion is legal in the first 8 weeks of pregnancy, after which it can only be legally performed when it endangers the health of the mother or fetus. The legality of abortion in Mexico is determined by each individual state—in Mexico City, abortion was decriminalized in 2007 only if performed during the first 12 weeks of gestation; however, the rest of Mexico has much stricter regulations [13]. Two countries in Central and South America permit legal abortion

**Figure 1.** The status of abortion law in Latin America, United Nations 2013 report. In some cases, this map may not accurately depict the content of this article. Legal on request; restricted to cases of maternal life, mental health, health, rape, fetal defects, and/or socioeconomic factors; restricted to cases of maternal life, mental health, health, rape, and/or fetal defects; restricted to cases of maternal life, mental health, health, and/or rape; restricted to cases of maternal life, mental health, and/or health; restricted to cases of maternal life; illegal with no exceptions. After

Wikipedia, Abortion Law. Available from: https://en.wikipedia.org/wiki/Abortion\_law.

This chapter discusses the legal, medical, and social issues surrounding the dilemma among the predominantly poor women of Latin America who are impacted by the emergence of the Zika virus pandemic, its effect on the unborn fetus, and their fears of having a malformed infant.