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Family Planning: The Unfinished Revolution

Author(s):
International Monetary Fund. External Relations Dept.
Published Date:
January 1992
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Voluntary family planning programs in the developing world help reduce population growth and contribute to better maternal and child health and to poverty alleviation. Despite the notable success of family planning programs in a number of regions, population growth remains high in many areas. The challenge lies in the better design and implementation of programs—whether new or ongoing—to ensure wider reach.

Family planning makes a difference. In 1960, Ethiopia’s population was 10 percent smaller than that of the Republic of Korea. Over the next three decades, Ethiopia recorded almost two-and-a-half times as many deaths as Korea, but by 1990, Ethiopia’s population was 20 percent larger. At least as significant, by 1990 each Korean of working age (15-64 years) had 0.44 dependents to support, whereas each Ethiopian of working age had 1.04—more than twice as many—dependents to support. Ethiopia had 26 million people in the dependent ages, compared with only 13 million in Korea.

Partly responsible for the contrasting demographic trends was an effective family planning program that Korea started in the early 1960s. Contraceptive prevalence (the proportion of married women 15-49 using contraception) climbed from under 10 percent to over 70 percent—a level comparable to that in developed countries—and fertility fell correspondingly. Almost within a generation, Korean parents went from having six children to having barely enough, and lately not quite enough, to replace themselves in the population. This substantial secular decline in fertility, which paralleled but was faster than earlier changes in developed countries, is often referred to as the fertility transition.

In countries spread over every region of the world, family planning is seen as a means of reducing high rates of population growth and of helping to improve the living conditions of individuals and families. Family planning has contributed to lower fertility, and at the same time to better child survival, lower maternal mortality, and reduced burdens for parents. The spread of family planning has now reached a tipping point: half of all couples in developing countries—about 365 million—are using contraception.

Family planning programs have especially benefited the poor. They typically have larger families, and commercial contraceptives are often priced beyond their reach. Contraceptive pills and condoms cost more than 5 percent of per capita GNP in the majority of sub-Saharan African countries, as well as in at least a few countries in every other region. This makes it difficult for poor women to avoid pregnancy. That they want to do so is suggested by the substantial unmet need for contraception, which ranges from 10 percent to as high as 70 percent of women of reproductive age.

Program experience

Family planning programs started slowly in the early 1950s, expanded rapidly in the 1970s and 1980s, and now exist in almost one hundred developing countries around the world (see table). These programs basically provide contraceptive services and counseling on the use of a variety of contraceptive methods. Communication campaigns to reach potential users, which explain the benefits of smaller families and ease concerns about contraceptive technology, are an essential part. Some programs also provide, or are linked with, a variety of other services, such as maternal and child health services and income generation activities.

Family planning programs, in country after country, have encountered similar obstacles: initial skepticism that a social program can change highly personal behavior; shortages of resources, particularly skilled management staff; ideological opposition, sometimes religious and sometimes political, as the program becomes more visible; jurisdictional quarrels between health providers and family planners, or between ministries and nongovernmental organizations, or among various donors eager to put their mark on a program; stalls in performance if programs focus narrowly on particular client groups; and an increasing concern with costs, as the number served grows and donors turn their attention elsewhere.

At the same time, the fundamental viability of a family planning program in any culture and at any level of socioeconomic development has been increasingly established, as shown by the experience in selected countries in two regions—East and Southeast Asia and sub-Saharan Africa. The experience of these countries demonstrates the elements of program successes, as well as the obstacles that frequently prevail.

Room for improvement Strength of family planning program, 1989
StrongModerateWeakVery weak or none
BangladeshChileKorea, PDRAfghanistanMadagascarCambodia
BotswanaColombiaLebanonAlgeriaMaliChad
ChinaCosta RicaMalaysiaAngolaMauritaniaGabon
El SalvadorCubaMoroccoArgentinaMozambiqueIraq
IndiaDominicanNepalBeninNigerCôte d’ Ivoire
IndonesiaRepublicPakistanBhutanNigeriaKuwait
Korea, Republic ofEcuadorPanamaBoliviaPapua NewLao PDR
MauritiusEgyptPeruBrazilGuineaLiberia
MexicoGhanaPhilippinesBurkina FasoParaguayLibya
Sri LankaGuatemalaSouth AfricaBurundiRwandaMalawi
Taiwan Province of ChinaGuyanaSingaporeCameroonSenegalMyanmar
ThailandHondurasVenezuelaCentral AfricanSierra LeoneNamibia
Trinidad & TobagoIranZambiaRepublicSyriaOman
TunisiaJamaicaZimbabweCongoTanzaniaSaudi Arabia
Viet NamKenyaEthiopiaTogoSomalia
GuineaTurkeySudan
Guinea-BissauUgandaUnited Arab
HaitiUruguayEmirates
JordanYemen
LesothoZaïre
Source: W. Parker Mauldin and John Ross, The Population Council.
Source: W. Parker Mauldin and John Ross, The Population Council.

East and Southeast Asia. This region had some of the earliest family planning programs and showed rapid increases in contraceptive use. The chart shows dates when national family programs started in selected countries and subsequent trends in contraceptive use. Contraceptive prevalence increased steadily by around 3 percentage points annually in Indonesia, Korea, and Thailand. Prevalence increased much more slowly in the Philippines, by only 1.7 points annually on average (see chart).

Initial conditions in these East and Southeast Asian countries were not particularly favorable to fertility transition. Socioeconomic conditions when programs were established—income, infant mortality, female education, and urbanization—were roughly comparable to conditions in the average low-income economy today. The cultural barriers to reducing fertility included, for instance, Confucian traditions in Korea that stress the centrality of the family. The extended household was common, and the patrilineal family structure allowed parents to influence their children’s reproductive decisions. Political opposition to family planning also appeared, often based on religion.

But some desire for smaller families did exist, and increased over time. Near the start of fertility transition in Indonesia, Korea, and Thailand, women reported their ideal families to be around four children. Over the next two decades, this number fell by one child every 12 years in each country. As ideal family size declined, socioeconomic conditions—especially income and infant mortality—were improving rapidly.

Family planning programs in these countries succeeded by taking advantage of opportunities to mobilize political support, meeting the existing demand for contraception, and developing innovative ways to deliver services. Political stability and strong governments created conditions in which such social programs could be run effectively, although political upheaval sometimes provided some initial impetus. In Korea, the program started in the context of a massive reconstruction effort begun by a new administration a decade after the end of the Korean War. Widespread existing demand for contraception was demonstrated by pilot projects, such as the Jakarta pilot project in Indonesia, and by private voluntary organizations, such as the Planned Parenthood Federation of Korea—which was instrumental in laying the groundwork for the government program.

The contribution of programs to the rise in contraceptive use was substantial in all the countries. For instance, 40 percent of the fertility decline in Korea in 1963-73 was contributed by program-supplied contraceptives, as opposed to other proximate determinants (for example, abortion) or other sources of contraceptives.

Fertility transition is far from complete in the region, however. A number of countries, such as the Philippines and Viet Nam, remain mired in slow fertility transitions. Even in the more successful countries significant numbers of people still do not have adequate access to contraception. In Indonesia, the Outer Islands are well behind Java and Bali. Provincial total fertility rates range from 2.4 in Bali to as high as 5.3 in South East Sulawesi and Irian Jaya.

Sub-Saharan Africa. Family planning programs have made much less headway in sub-Saharan Africa. Even in this region, however, some countries show unmistakable signs that fertility transition is underway, and in other countries, small-scale successes in particular communities demonstrate the potential for family planning programs.

Programs in Botswana, Kenya, and Zimbabwe started in the late 1960s or early 1970s, but prevalence did not exceed 10 percent until the 1980s. When fertility transition started, contraceptive prevalence increased at widely divergent rates: 1.7 points a year in Kenya, 2.1 points a year in Botswana, and 3.1 percentage points a year in Zimbabwe.

Both socioeconomic and cultural influences have been used to explain the delay in the start of transition, but neither provide an adequate explanation. Socioeconomic conditions when programs started were slightly behind conditions in Korea and Thailand, but better than conditions in Indonesia. Relative to Asian countries, these countries experienced relatively slower income growth but comparable improvements in social indicators—infant mortality, female education, and urbanization.

A remarkable increase in contraceptive use1

Selected Asian and African countries

1 Percent of married women between the ages of 15–49 or spouse using family planning methods.

Source: The World Bank.

The cultural barriers to family planning in these countries, and elsewhere in sub-Saharan Africa, parallel in important ways those in Asia. For both regions, children are seen as assets to the older generation, providing assistance and security—strong motives for the extended family to encourage high fertility. As in Asia, these motives have not proven to be absolute barriers to fertility transition.

What was distinctive about Botswana, Kenya, and Zimbabwe was the nature of existing demand for contraception, which was largely to space births rather than to reduce the total number. Programs attempted to address this demand by emphasizing the benefits of child spacing and providing temporary methods, often birth control pills. However, delivery systems have been quite different. Botswana, with presumably stronger demand because of socioeconomic factors, as well as a public health system that covers the country fairly evenly, has relied on health posts and health centers to provide contraceptives. Zimbabwe has placed primary emphasis on community-based distribution to the rural population. Kenya has also emphasized outreach, but has relied to a much greater extent than Zimbabwe on private voluntary organizations to complement public services.

In contrast, Ghana, Rwanda, and Zaire have not started fertility transition. They differ from the other three countries not in initial socioeconomic conditions—they actually had slightly higher GNP per capita at the time their programs started—but in socioeconomic trends since then. They have had negative economic growth and relatively small improvements in social indicators. Nevertheless, family planning programs have had some effect in small areas.

In the city of Kananga, Zaire, the Institut Medical Chretien du Kasai reoriented its two family planning clinics to make their services more accessible; provided apprenticeships for nurses from a dozen other clinics and helped improve their procedures; and marketed subsidized contraceptives through 30 pharmacies and shops. Visits to the Institut’s clinics increased 15-fold, and the prevalence of modern methods went from 4 to 8 percent in 18 months.

In Ghana, the midwives association provided its members with training in family planning, supervision, and assistance with supplies. After one to two years, the first 130 midwives trained reported an average of 100 new family planning clients each, 80 percent of them using contraceptives for the first time.

In the Ruhengeri region of Rwanda, Abakangurambaga (wakers of the people), who provide information on development topics to small groups of households, were used to provide family planning information and referrals to clinics. In the commune where they were most active, a survey showed the prevalence of modern methods rising to 29 from 5 percent in 16 months.

Each of these approaches suggests a different way family planning can be effectively delivered in a relatively unfavorable socioeconomic setting.

Program challenges

By the year 2000, the number of contraceptive users in developing countries will have to be 40 percent higher if fertility declines are to match projections. New programs will be needed where family planning has received little attention so far, and new approaches must be invented for mature programs to enable them to expand their clients. Social development will also have to proceed apace: women need more education to appreciate the benefits of smaller families, and they need firmer assurance that their children will survive. Both new and ongoing programs will have to emphasize some basic approaches that research and experience have shown can contribute to wider contraceptive use.

Improving quality of services. Programs need to focus on providing quality services that attract clients. A good program provides access to a range of appropriate contraceptive methods and facilitates their continued use; provides adequate counseling, respects client sensibilities, and responds to client concerns; and is run by technically competent providers according to proper medical standards.

These elements of quality are not always present. About half of almost 100 national programs rated in 1989 were judged to provide inadequate access to each of five contraceptive methods. When methods are available, counseling may be unsatisfactory: large numbers of birth control pill users in such countries as Brazil and Egypt have been shown to be using them incorrectly. Client sensibilities are often offended by long waiting times and rude and impatient staff.

Quality services, on the other hand, attract clients. Providing an additional contraceptive method, for instance, appears to add an additional layer of contraceptive users. Reducing waiting times allows a clinic to serve more users. A clinic in Ecuador reduced waiting times with additional staff and experienced a more than proportional increase in clients served. At the same time, quality services can be more efficient. The Matlab project in Bangladesh stressed quality, offering more reversible methods than the government program, recruiting workers with higher credibility who were more intensively supervised, giving clients better counseling about side effects, adding more intensive follow-up through home visits, and providing added maternal and child health services. Because it attracted more users, the cost per birth averted through contraception was two thirds that of a comparison area with less intensive services.

Ensuring accountability and strategic management. Programs must be managed strategically. A program manager must be responsive to its environment, taking advantage of cultural tendencies and social factors and negotiating its way through the political and other obstacles that arise. Programs typically develop in three ways: from seeking clients among those already disposed to contracept to focusing on the large disadvantaged majority among whom the small-family norm must be cultivated; from heavy reliance on donors and volunteers to reliance on a network of agencies and eventually on the public at large; from services provided passively in a few sites to active outreach and eventually to services carefully differentiated by market segment. Programs need to recognize the challenges posed by this evolution.

Management responsibilities are varied, from mobilizing public support for a program to managing staff. Most critical are ensuring reliable logistics and providing adequate field supervision. The logistical systems for handling contraceptives are often weak. Supply shortages contribute to contraceptive discontinuation and user dissatisfaction, damage morale among staff, and contribute to a poor program image. Supervision of the field staff who actually distribute the contraceptives and provide counseling is critical, because it strengthens their motivation and helps them apply their skills to program tasks.

Encouraging the private sector. Programs need greater involvement of the private sector. In family planning, this sector is quite varied, including nongovernmental organizations, private practitioners, and commercial outlets for contraceptives. The sector can provide additional resources and is sometimes more flexible and efficient than public services.

Private services may be useful in introducing family planning generally, or in introducing specific services. They may reach specific populations, not only through their own clinics but also through networks of private practitioners and commercial distributors for the marketing of subsidized contraceptives. Involving the private sector often requires reform of laws or regulations that limit them, such as import duties on contraceptive supplies and prescription requirements that unnecessarily restrict contraceptive availability.

Designing effective promotion campaigns. The creative promotion of programs—both government and private—is essential to their success. Like any new product, contraceptives have to be brought to the attention of potential users, made attractive, and shown to be safe. This effort is essentially educational, aimed at producing satisfied and effective users willing to encourage others.

Interpersonal channels and the mass media can be effective tools. Both must be used with all the skills and techniques of modern public relations and advertising, so that family planning messages are able to compete in the noisy marketplace.

Obtaining official assistance. Government and donor support must be constant. By the standards of large-scale social interventions, family planning programs are not expensive. In 1990, programs cost about $4 billion-$5 billion. Donor assistance in population was about 1.2 percent of official development assistance, barely 2 percent more (in constant dollars) than it was in 1985. If individuals themselves had to pay for family planning, the cost could have been beyond the means of many. Commercial prices for contraceptives are such that, for over 60 percent of sub-Saharan countries, a supply of contraceptive pills would cost more than 5 percent of average annual income.

Political commitment is also essential to allow programs to recruit essential staff, obtain the cooperation of other agencies, and free programs from webs of regulation that could otherwise severely hamper their opera-

For an in-depth study of the evidence, see “Effective Family Planning Programs” to be published as a “Best Practice” paper by the World Bank.

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