J: You work on family planning is in a broader context of a reproductive health philosophy, but your doctorate is in political science. How did you get into reproductive health?

    Simmons: It all started in India in the late 60s when I began helping my husband George, who was in the population field, evaluate the introduction of the intrauterine contraceptive device. At that time the IUD was considered to be the panacea for India's population problem. George's dissertation was focused on population and he became interested in the question of this new technology and how people were responding to it.

    What we discovered in that research was instrumental in shaping the way I looked at family planning programs later. We experienced the tensions that were created when women began using the IUD. Although some women were eager to control their fertility and were looking toward a new technology with open eyes, they were completely unprepared for the health and social consequences of this method.

    Nobody had counseled women to expect the changes in bleeding patterns which are typically associated with IUD use, and they received no support from the health clinics with their problems. Because in traditional Hindu culture menstruation is associated with a variety of social taboos, prolonged menstrual bleeding produced conflicts within families. The whole idea of fertility regulation was still extremely new in this setting and many husbands and other family members were angry when they found out that women had decided on their own to use the method and had gone to the clinic in secret. We began to learn the extent to which this new technology affected people's lives and how policy makers and donor agencies who argued for its immediate and widespread diffusion had never considered the operational and social implications of IUD introduction into a rural, traditional society.

    Another perspective I gained was to look at the context in which contraceptive services are organized. Bureaucratic systems are not set up to be what we refer to as human service organizations. They were established to collect revenue and maintain law and order and they used a law and order approach in providing family planning services.

    J: What, in general, did you learn from this experience that influenced your later work?

    Simmons: It taught me that a focus on people's health and well-being must be the core of family planning research and policy. This may seem self-evident, but the realities of program implementation in third world countries has often shown that the health and well-being of individuals is not a priority. Governments have a legitimate concern with slowing population growth. But often this has been attempted with little concern for the individuals most affected.

    J: You also worked on a major program of work with the World Health Organization.

    Simmons: I have been working with the World Health Organization since 1989 in an effort to redefine approaches to contraceptive introduction. This has given me the opportunity to insist that strategies for research and policy development must simultaneously address people's needs, the capacity of programs to provide good quality of care, and the range of technological options available.

    We have emphasized the importance of applied action research because it allows evidence-based policy and program development and a focus on learning. We are also committed to using a participatory approach in which local people, local program managers and providers, local researchers, women's health activists, and national decision-makers play the leading role. International "experts" from technical assistance agencies or universities can make important contributions, but they certainly don't have all the answers. When ownership is local and national, and various stakeholders work together, program innovations have a greater chance to take root and survive.

    When we started implementing the methodology, we discovered how revolutionary it was.

    J: Why?

    Simmons: High level policy makers and program managers do not normally listen to the voices of local people, local providers and local program managers when they make decisions about contraceptive introduction or other aspects of program development in reproductive health.

    A remarkable thing is the response from national government officials and others who have participated in this approach. For example, someone who heads the maternal and child health division of a ministry of health normally has no opportunity to travel to local communities. If he or she does, travel is highly orchestrated and meetings are ceremonial. People hear the good news but never what the real issues are because to talk about problems is problematic.

    If instead policy makers and program managers participate in an interdisciplinary assessment team, make informal visits to local families and have in-depth conversations with local providers and health authorities, the real needs and complex challenges of organizing good reproductive health services become apparent.

    The first country that implemented this participatory program of assessment, research and policy development was Brazil. I was one of the outsiders who provided support to the initiative. After conducting a national assessment, a pilot project was organized in one municipality. We wanted to see how access to care can be expanded and service quality can be improved when one uses a participatory approach to program development. We showed that major changes become possible if you work in a participatory manner, listen to local people, diagnose what the problems are, provide training and identify where there are opportunities for mobilizing local resources to take action. In time leaders from other municipalities expressed interest in replication and the project succeeded in expanding innovations to three other areas. All of this was accomplished with relatively limited external resources but with a great deal of dedication on the part of my Brazilian colleagues.

    J: How did the WHO project lead to applying to the Gates Foundation?

    Simmons: From WHO's perspective the project was over because we had successfully completed the three stages of the new approach to contraceptive introduction. But my colleagues and I felt that we were not done. We had worked in four municipalities but there are more than 5,000 in Brazil. Change on a larger scale was needed. We also felt that there is an important intellectual question that needs to be addressed. There are hundreds, even thousands of remarkable pilot or experimental projects in all fields - in agriculture, health, education. But where do these pilots take us? Do they lead to change on a broader scale? If not, how can we ensure that they have broader impact?

    In the late 60s, 70s and possibly early 80s, social scientists were interested in researching the diffusion of innovation and studying the link between applied research and policy and program development. Recently there has been less interest in these issues and we feel that this interest must be rekindled. That is the intellectual reason for wanting to continue the work in Brazil. Our practical purpose is to facilitate expansion of service innovations on a larger scale to improve access to, and the quality of reproductive health care. We are very grateful to have received support from the Bill and Melinda Gates Foundation to continue our work.

    J: How far along on the project are you now?

    Simmons: We're three-quarters of a year into the five-year project. So we have some time. A longer time perspective is needed because we face a daunting task both in an intellectual and practical sense. Brazil is a big country and we will be working in other countries as well. One of the things we have learned in the first year is that if you want to scale-up, the first thing you have to do is to expand your own team. We hope to work closely with the leaders from the pilot municipalities in this process of expansion - strengthening their capacity to train and support others.

    On the other hand, it is almost overwhelming to see the response from people who have participated in this project. During my last trip to Brazil I visited one of the pilot municipalities. It was moving to listen to health providers and program managers talk about how this project had affected their orientation toward their work and even toward their lives. It had put them in touch with what had initially motivated them when they went into public health. We were very lucky to get this support. We felt that the Gates Foundation looked at our track record and our publications and decided that "this is persuasive; this needs to be done. Let's see what they can do."

    J: Where else will you be working besides Brazil?

    Simmons: Bolivia will be the second country because we have worked there previously in connection with the WHO program. Chile and Paraguay have also been discussed. We are trying to discover where this approach could have the greatest possibility of large-scale impact. We have to choose wisely and see where there is greatest interest and need.

    J: Are there any aspects of this work that can be brought back to Michigan?

    Simmons: If we succeed in learning more about how to expand program innovations from pilot projects so that they have broader program impact, this should be very relevant for public health initiatives in Michigan and elsewhere in the US. For example, my colleagues from the Department of Health Behavior and Health Education are working on participatory public health initiatives in Michigan, and there is much that we can learn from each other. In fact it is essential that we strengthen efforts to learn from each other, and stop considering public health in the third world and in the U.S. as separate intellectual and practical endeavors.

    J: What sort of outcome would you like to see when the Latin American project is completed?

    Simmons: We will not be able to answer all our questions, but we can address many and can disseminate not only our findings but also our conviction that "scaling-up" is an intellectual problem worth investigating. We hope to organize team residencies and a conference bringing together professionals from Latin America and from other groups around the world who are also focusing on this issue. We want to bring them together so we can learn from each other, and then widely publicize our conclusions. I would like to see policy makers and international donor agencies realize that it is not enough to give money for demonstration projects. From the very beginning plans should be made for the scaling-up of successful innovations.

    It will give me immense satisfaction if we can demonstrate large improvements in the quality and availability of reproductive health care in several Latin American countries, and can show that innovations are sustainable over time. When we conducted focus group interviews in the first municipality in Brazil before initiating the pilot project, a woman commented: Getting an appointment in the public sector municipal health services is like "winning the lottery." I would like to make it possible for many women and men in Latin America to win the lottery and receive the type of reproductive health services they so urgently need.

    Ruth Simmons Professor, School of Public Health, Department of Health Behavior and Education


    Ruth Simmons, a professor in the School of Public Health's Department of Health Behavior and Health Education, was awarded a $5 million five-year grant from the Bill and Melinda Gates Foundation to improve and expand public sector reproductive health services in Latin America. The project is a collaboration with the Population Council of Brazil and Reprolatina, a private non-profit reproductive health organization in southern Brazil. Simmons works closely with the World Health Organization in emphasizing quality of care in research and policy related to contraceptive introduction. She also continues her Ford Foundation funded collaborations with the State Family Planning Commission of China and the Population Council to improve the quality of services in the Chinese family planning program. Simmons began her work in women's health and family planning three decades ago in India. She has also worked in Bangladesh, Bolivia, South Africa, Vietnam, Indonesia and Ghana. She has published extensively in Studies in Family Planning , The Journal of Women's Health and The Journal of Health Management . Journal editor Bonnie Brereton interviewed Simmons at her home this fall between her travels to Latin America and Asia.