1Prepared by RAND staff.
This report synthesizes research on family planning programs in
developing countries. It focuses on what is known on three principal issues:
· The implications
for developing countries of high fertility rates and unmet need for
· The benefits of family
· Program costs and the
role of donor nations.
The report concludes that family planning programs are providing
women in developing countries with desired access to contraceptive services and
helping to reduce fertility rates. These programs are also associated with a
range of other benefits, most notably improvements in women's and children's
health. Host countries provide about 60 to 75 percent of funding for family
planning. However, funding and technical assistance from donor nations,
especially the United States, have been crucial to the past success of family
planning programs and are equally important for strengthening and expanding
program efforts to meet future challenges.
HIGH FERTILITY AND UNMET NEED
The world's population is still growing. Although fertility has
fallen worldwide from about five children per couple to about three since 1960,
annual population growth in the 1990s is still approximately 80 million people,
equivalent to adding a country the size of Germany to the world's population
each year. Most of this growth is occurring in developing nations, where
fertility rates remain high. Sub-Saharan Africa in particular has experienced
little change in its high fertility rates. Over two dozen countries have
fertility rates over 6.0, notwithstanding decreases in a few countries, such as
Kenya and Zimbabwe.
Even in countries where family size has approached "replacement
level" - two children per couple - the population may continue to grow. This
phenomenon, known as "population momentum," occurs because of the population's
age structure: When a large proportion of women are in their childbearing years,
the population can increase even though the rate of childbearing per woman is
falling. Over the next few decades, this momentum will account for a substantial
share of the world's population growth.
High fertility and rapid population growth can pose problems for
developing nations. They can deny opportunities for socioeconomic development;
contribute to high levels of infant mortality; and strain public resources for
health, education, and other vital services.
In addition, high fertility runs counter to the preferences
expressed by millions of couples in developing countries, who actually want to
have smaller families. Motivated by practical concerns about finances, health,
and their families' futures, millions around the world would prefer to have
fewer children than they are actually having.
This gap between preferences and fertility springs from what
demographers label the "unmet need for contraception." This concept refers to
the needs of women who want no more children but do not practice contraception.
Survey research indicates that unmet need affects an estimated 10 to 40 percent
of married women of reproductive age in developing countries. Levels of unmet
need are high in high-fertility countries, such as Malawi (36 percent), and can
also be sizable in more developed regions, such as Latin America, where they
range from 12 to 29 percent. For all developing countries, the total number of
women with unmet need is estimated at 150 million.
BENEFITS OF FAMILY PLANNING
Family planning programs help developing countries address these
issues. They help to moderate high fertility, fill the unmet need for
contraception, and reduce the number of unwanted pregnancies. At their most
elemental, family planning programs are organized efforts to provide
contraception - ranging from temporary methods, such as oral contraceptives and
condoms, to sterilization - and related reproductive health services. Since the
first national programs in developing countries were established in the late
1950s family planning has been associated with notable increases in the use of
contraception in the developing world. This has been true across an astonishing
range of cultural, political, and socioeconomic environments.
Family planning has been successful in filling unmet need by
helping women in developing countries overcome obstacles to the use of
contraception. The two barriers women most commonly cite are (1) lack of
knowledge about contraceptive methods and availability and (2) concern about
health effects. By increasing access to contraception and promoting wider
knowledge about proper use and low health risks, family planning programs have
helped address these barriers as well as others, such as the supply and cost of
contraceptives. Reducing unmet need can also help to reduce the number of
unplanned and unwanted pregnancies. Since they are more likely to end in
abortion, these pregnancies increase health risks for mothers when the abortions
are unsafe. Unplanned children may have other negative impacts: Families with
unwanted children tend to invest less in each child's education.
However, the success of family planning programs has not been
uniform. Their effectiveness has depended on several factors, including a
favorable political climate, a well-structured program offering a variety of
contraceptive methods, flexibility in adapting to local conditions, and stable
funding sources. Nonetheless, there are success stories on all continents.
Researchers and program personnel have learned a great deal - in part through
work supported by the U.S. government - about how to design and operate
successful programs, even in what appear to be unfavorable social and cultural
Increased use of contraception has been instrumental in reducing
fertility rates since the mid-1960s from about six children per couple in
developing countries to about three during this interval. Statistical analysis
indicates that family planning programs have been responsible for as much as 40
percent of this decline.
Lower fertility from increased use of contraception has in turn
been associated with a range of benefits for developing countries. At the
macroeconomic level, reduced fertility has helped create favorable conditions
for socioeconomic development in some countries. A prime example of this
connection has been the so-called "Asian Economic Miracle." From 1960 to 1990,
the five fastest-growing economies in the world were in East Asia: South Korea,
Singapore, Hong Kong, Taiwan, and Japan. Two other Southeast Asian nations,
Indonesia and Thailand, were not far behind. During this 30-year span, women in
East Asia reduced their childbearing from an average of six children or more to
two or fewer in the span of a single generation. This reduction in fertility
contributed to East Asia's remarkable socioeconomic development.
One way in which lower fertility can help promote socioeconomic
development is by reducing the proportion of dependent children in the
population. A lower ratio of children to adults can create what demographers
call a "demographic bonus": With fewer children, families can save more or
invest more money per child in, for example, education or health care.
Furthermore, a smaller proportion of children means that a greater percentage of
the population is in the working ages. The impressive rise in East Asian savings
and investment rates since the late 1960s can be explained in part by the
equally impressive decline in youth dependency burdens.
However, some caution is required in drawing connections between
lower fertility and socioeconomic development. The "demographic bonus" is not
automatic but contingent on appropriate policy in other areas. Furthermore, the
savings from the "bonus" must be handled wisely or the effects may be negative.
For example, the substantial liquidity created by savings in the East Asian
countries may actually have contributed to the financial excesses that led to
the Asian currency crisis of 1997.
In addition to moderating fertility, family planning can yield
other benefits, including improved health for women and children and a greater
degree of freedom for women. The clearest health benefit for women is reduced
risk of maternal death. Death in childbirth is almost 20 times as likely for
each birth in developing countries as in developed countries. Having many
successive pregnancies puts mothers at even greater risk. For example, at the
total fertility rate in sub-Saharan Africa of 5.6 children, the average woman
has a 1 in 18 lifetime risk of dying in childbirth. Reducing fertility by half
would also reduce this risk by about half. Also, lower fertility, especially at
younger and older ages, and greater spacing between births reduces the risk of
infant and child mortality.
Reduced dependency burdens can also improve educational
performance. Countries can send more children to school and invest more per
child, thus improving the quality of the future labor force. South Korea, for
example, raised net secondary enrollment from 38 percent to 84 percent between
1970 and 1990, while more than tripling per-pupil expenditure. During this time,
fertility declined from 4.5 births per woman to less than two. At the same time,
families can invest more time and resources in educating each child.
Additional opportunities created by lower fertility include
reduced pressures on public funds and a grace period for dealing with
environmental pressures and for managing typically limited resources, such as
PROGRAM COSTS AND THE ROLE OF DONOR SUPPORT
Expenditures on family planning across all developing countries
are approximately US$10 billion annually. Most of this amount is paid by
national governments or individual households. Equivalent to around US$1-2 per
person per year, this is not large by many standards.
Governments typically cover the bulk of family planning
expenditures in developing countries. The proportion of costs they cover tends
to rise as programs develop: from under 30 percent to over 60 percent of funding
during the 1980s in Tunisia, for instance. In addition, funds from
industrial-country development assistance, international agencies, and private
sources fill critical gaps, and households also pick up some proportion of the
costs, by some estimates about as much as donors do.
Funds from international donors cover a fourth to a third of
public spending on family planning throughout the developing world. Per capita,
developing countries receive approximately 15 cents from international donors
for population and reproductive health programs. Sub-Saharan Africa, with its
newer programs, receives more - over 50 percent of the total spent in the world
in 1995. Asia, by contrast, with its more developed programs, receives about 10
percent. International donors play an especially prominent role in helping
programs get started and later helping them expand. Typically, donor involvement
decreases over time as programs mature and recipient nations become more
self-sufficient in funding and operating them.
Donor commitments have fluctuated in recent years. They
increased substantially, to US$1.37 billion, the year following the 1994
International Conference on Population and Development held in Cairo (as they
did after the previous world conference in 1984). However, these comparisons are
complicated by the expanded mandate from the Cairo conference to tackle
reproductive health. Excluding funding for reproductive health, donor
commitments actually fell from 1994 to 1995 by 7 percent in real terms. Even
counting reproductive health funding, larger increases will be needed to meet
the Cairo conference goal of donor support for a third of the cost of population
and reproductive health programs by 2000.
The primary donor countries are the United States, Japan, and
the other member nations of the Organisation for Economic CoOperation and
Development. Historically, the United States has been the largest contributor to
population programs around the world and the most significant provider of
technical assistance. However, there are signs that the United States has
started to relinquish its role as world leader. The U.S. share of contributions
diminished in the late 1980s and has not recovered to previous levels. In fact,
U.S. population assistance fell 20 percent from fiscal 1995 to fiscal 1996 and
fell a further 10 percent to fiscal 1997. The effect of these declines is
uncertain. It is unclear whether other donor nations are willing or able to make
up the shortfall.
THE CHALLENGES AHEAD
Despite their history of success, family planning programs still
have much to accomplish. Programs face challenges in improving service, dealing
with sexually transmitted diseases, including HIV/AIDS, and ensuring broader
attention to women's reproductive health needs, as urged by the Cairo
conference. One specific challenge will be serving the needs of the huge cohort
of young women just coming to childbearing age. The group aged 15 to 24 will
total 900 million by the turn of the century. Programs increasingly recognize
the need for new strategies to reach these young adults. Much of the need for
contraception among young adults is for delaying or spacing births. With the
realization that delaying births can help reduce population momentum, programs
need to revisit their goals and promotional approaches.
Another critical need is further research to improve
contraceptive methods and develop new ones. Advances in this area could promote
increased contraceptive use and reduce contraceptive failures, which in turn
could reduce abortions, which are sometimes a consequence of such failure.
Dealing with these issues will involve building on the past
success of family planning programs and strengthening current efforts with
continuing support from donor nations and the international