Summary1

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 contraception
· The benefits of family planning programs
· 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 environments.

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 water.

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 community.