|Reversing the Spiral - The Population, Agriculture, and Environment Nexus in Sub-Saharan Africa (WB, 1994, 320 p.)|
|7. Reducing population growth|
Key Issues and Challenges
Chapter 3 suggested several avenues for reducing population growth. Fertility rates can tee brought clown by emphasizing direct actions such as improving knowledge and availibility of family planning (FP) services. But to have maximum impact, these "supply-side" efforts need to be backed, if not preceded, by efforts to stimulate demandsuch as improving education, especially of females, reducing infant mortality, reducing environmental degradation, and, possibly, improving food security. Family planning education can be provided through FP services, along with the means to control fertility. By providing nutrition advice, FP services can also help in reducing infant mortality and improving nutritional standards. Rising density of population on cultivable land may also stimulate demand for fewer children. Acceptance and adoption of family planing will spread most rapidly in countries where demand for FP services is increasing fastest. This is likely to be in countries with the highest levels of female education, the lowest infant mortality, the highest population densities on cultivated land, the least environmental degradation, and, possibly, the greatest food security.
Governments are increasingly aware of the consequences of rapid population growth. In 1974, only Botswana, Ghana, Kenya, and Mauritius had adopted policies to reduce population growth By 1987, fourteen countries had adopted explicit national population policies (Cothrane, Sai and Nassim 1990:229), and a number of others have done so since then In 1989, twenty - six governments in Sub-Saharan Africa considered their population growth rates, and twenty-nine their TFRs, to be too high (Stephens and others 1991:xxxv). But few have provided adequate technical, financial, and managerial resources to promote and deliver FP services broadly Hence, progress has been slow.
Only a few countries on the continentnotably Botswana, Kenya, and Zimbabwehave been implementing population programs that have shown some measurable success (Tables A-2 and A-8). The Contraceptive Prevalence Rate (CPR) in Botswana more than doubled, from 16 percent to 33 percent, between 1984 and 1990, as FP services were placed within easy reach of the majority of the population. Botswana's TFR declined from 6.9 m 1965 to 4.7 in 1988. Kenya succeeded in raising the CPR from 5 percent in the mid-1970s to 17 percent in 1984 and to 27 percent in 1989, and the TFR declined from 8.0 in 1965 to 65 in 1989. In Zimbabwe, the CPR is now estimated at 43 percent, and the TFR dropped from 8.0 to 53 between 1965 and 1988; the creation of a network of FP clinics and of a community-based outreach program which widely distributed contraceptives was instrumental in providing access to FP services. An indication of changing attitudes concerning fertility and of growing demand for FP services is evident in the number of children desired by women in these three countries. In 1988 - 1989, women wanted only 4.7, 4.4, and 4.9 children, respectively, in Botswana, Kenya, and Zimbabwefar fewer than their counterparts in other SSA countries and also far fewer than women in the same three countries only ten years ago (Table A-8).
Government policies in these countries have played a major role in achieving fertility reduction through an expansion of FP services and education. However, in each of these countries the fundamental forces have also been working: relatively dense population on cultivated land, relatively high female school enrollments, good agricultural performance contributing to enhanced food security, and declining infant mortality. Yet even in these three relatively successful countries, the TFR must be brought down further.
To lower the population growth rate to 1.8 percent a year for SubSaharan Africa by 2030, the average TFR for Sub-Saharan Africa as a whole must drop steadily to 3.1 by that time (Table A-4). This is possible, as shown by evidence from countries outside Africa where per capita incomes are low and populations largely rural, and where infant mortality rates and life expectancy, when the effort was initiated, were comparable to those in Sub-Saharan Africa today. It requires determined effort and commitment from the political leadership to shape public attitudes and implement policies and programs to reduce population growth.
Significant reductions in fertility cannot be expected until the CPR reaches 25 to 30 percent. Slowing population growth to only 1.8 percent per year during the period 2020-2030 would require increasing the CPR substantially above even this level. This underscores the need for fostering greater awareness of the consequences of population growth as well as the need to stimulate demand for FP services. Increasing the availability of FP services raises the level of their use. There is evidence that, even at the present levels of demand for family planning, the CPR in Sub-Saharan Africa could be raised to 25 percent within the current decade by making services widely, regularly and reliably available. It requires a rapid expansion of access to FP services, and this, in turn, requires strengthening and expanding public health care systems and developing multiple channels (public sector, private commercial, NGO, community organizations) to deliver services as well as information, education, and communication (EC). The progress achieved in Botswana, Kenya, and Zimbabwe shows what is possible when venous other factors that bear upon demand for children are also moving in the right direction (Table A-8).
The ethical issues in family planning in Sub-Saharan Africa form a complex web of social, economic, cultural, and developmental concerns, and dialogue on ethical issues in family planning is crucial if the process of 'depoliticizing' family planning is to continue (Sai and Newman 1989). The promotion of family planning as a basic human right and as an important health measure has increased its acceptability, and family planning is now increasingly regarded a legitimate component of overall development efforts. But the "human right" to control one's own fertility, remains elusive without full and ready access to FP information, education, and services. This entails full and voluntary choice of method, right of access for young people, and financial affordability of fertility regulation services. Each of these has caused ethical controversy in some countries. The right of access to FP services is derived from the basic right to make decisions about reproductive behavior. This, too, has been controversial in some countries.
Family planning is also a major element of the rights of women. Many women prefer to have fewer children, but are discouraged from using family planning by sociocultural factors, including their husbands' wishes. This highlights the importance of reaching men, either at the workplace or through other means such as the agricultural extension services. It also suggests that women's groups would be an effective channel for delivering family planning services because they foster solidarity among women and may help them make fertility decisions on their own.
It is important to distinguish between population policies and family planning programs. Population policy includes family planning, but also includes a range of measures to influence decisions at the family and community levels as well as education and health programs effecting family size. It also comprises changing laws to encourage small families and providing effective incentives and disincentives (for example, cost sharing for health and education) A comprehensive population policy must also include policies to cope with the consequences of population growth. This means general deveIopment policies that encourage optimal use of resources in agriculture, urban development, and soon.
In about a dozen countries, fertility regulation programs are part of national population policies. In other countries with FP services, the rationale is not so much to reduce fertility but to improve maternal and child health (MCH). The health rationale for family planning, especially for preventing high-risk pregnancies, is proven and especially pertinent in SubSaharan Africa, where infant and maternal mortality and morbidity rates are high One key element of primary health care is MCH care, and this includes family planning. By providing the means to postpone childbearing until after adolescence, space births at two-to-three-year intervals, and prevent pregnancies after the age of 35, family planning can greatly improve maternal and child health.
Where the rationale for FP programs is demographic, it is often a matter of controversy whether government has the right to influence the reproductive behavior of the people. Clearly, unless population policies command broad popular support, the prospects for reducing population growth are dim And where poor governance causes people to question the legitimacy of governments, governmental population policies and FP programs tend to be viewed with particular skepticism. It is critical that anti-natalist policies be seen to apply to entire populations and be evenly implemented Policies can Justifiably become discredited when they appear designed to alter the balance of ethnic groups.
Needed is a deliberate fostering of pluralism in efforts to extend access to FP information and services by encouraging and supporting local government, community, and private initiatives. The successful involvement of nongovernmental groups in family planning m Sub-Saharan Africa strongly suggests the viability of such an approach Fostering pluralism entails a broad agenda of activities to facilitate local and private initiatives and learn from them. It involves difficult choices about how and where to expend governments' limited technical and administrative resources. Governments must take the lead in promoting the dissemination of FP information and in developing a social consensus on its legitimacy Especially in rural areas, where the government is the major provider of modern health care and specifically of MCH services, the public sector may have to be the principal provider of FP services for some tune to come Many factors still bear on the ethics of family planning in Sub-Saharan Africa, and these point to the need for a sensitive approach (Sai and Newman 1989).
Promoting Demand for Fewer Children
Even greatly improved supply of FP services will not succeed in bringing about the required declines in fertility, unless demand for fewer children rises considerably. Most past efforts in the FP field have been deficient in recognizing this. A recent evaluation of past World Bank operations in the population sector, fur instance, found that FP services have been offered in many countries when there was little evidence of significant demand for them (World Bank 1991e). The evidence of attitudinal and behavioral changes regarding fertility in many parts of the continent suggests, however, that it is possible to create such demand Between 20 and 40 percent of women in the countries of Sub-Saharan Africa wish to space their children at least two years apart (Table A-6). Rising pressure of rural populations on cultivated land is stimulating demand for smaller family size Migration and urbanization are loosening extended family ties and raising the private costs of children. Education of women is increasing, there is a clear trend toward later marriage,¹ and there are indications of considerable unmet demand for modern contraception (Table A-6). These changes in attitudes can be encouraged, promoted, and accelerated by a variety of means, including effective information, education, and communication (IEC) programs, so as to lead to increased demand for FP services.
Improving the legal, economic, and social status of women is critical overcoming the constraints imposed on them by their traditional roles that perpetuate high fertlIity. This entails, among other things, recognizing and emphasizing that women's status also derives from their economic contributions to family, community, and society It requires, therefore, expanding the range of opportunities available to them and supporting developments that provide women with greater control over their own lives and the output and income generated by their work. At the same time, efforts must be made to relieve both the environmental degradation and the work burden on women, both of which fuel demand for additional family labor.
To promote demand for FP services, actions such as the following are essential:
· Political leaders and communities need to be sensitized to the environmental and economic consequences of rapid population growth Demand for family planning and contraception, as well as for later female marriage, must be increased through widespread EC programs To ensure that people regard such programs as legitimate, governments must demonstrate continually their legitimacy and credibility, through good governance. Governments lacking credibility and popular acceptance are very likely to confront popular distrust of population programs
· Effective measures are needed to expand education, especially for females, and to improve women's income-earning opportunities This will tend to raise women's marriage age and reduce both their desired and actual number of children. To the extent that improved income-earning opportunities for women lead to increased control by women over such income, this will have strong positive effects on child health and welfare, on infant and child mortality, and, hence, on women's fertility preferences
· Health services need to be expanded and unproved to deal with major epidemic diseases and reduce infant and child mortality. This will greatly improve the probability of having descendant-c in one's old age and thereby weaken one of the major traditional motivations for desiring large families. It will also reduce the economic incentive for having larger families, since fewer, but surviving, children can ensure adequate availability of family labor.
· Expanding access to effective primary health care is also essential to address the problems of sexually transmitted diseases (STDs). STDs are major causes of infertility, which in some regions discourages any interest in fertility control. High incidences of STDs are also an important factor contributing to the rapid spread of AIDS.
· Incentives for smaller families and disincentives for large families (such as limitations on tax deductions for children) may help in the longer term. Community leaders, teachers, agricultural extension agents, and the mass media should be used to convince people of the economic, environmental, and health benefits of having fewer children.
· Land tenure reform as well as improved access of women to land, to agricultural extension, and to credit are likely to reduce the pressure on women to have many children Greater food security may also lead to reductions in fertility rates.
Box 7-1 Increasing; the Private Costs of Having Children
Some observers argue for deliberate policy actions designed to impose more of the social costs of children directly on their parents. In some countries and under certain conditions, this would create pressure for reducing family size. Where, for example, education is a highly valued commodity, shifting the cost of schooling increasingly to the parents is Likely to have a dampening effect on fertility, rates. This appears to have been an important factor contributing to the decline in the TFR in Kenya.
Such a policy thrust conflicts, of course, with the important development policy objective to meet basic needs. Moreover, such a policy potentially faces important pitfalls.There is a high likelihood that parents would, out of economic necessity, decide to ration access to education among their children, favoring boys at the expense of girls (even more so than is already the case). This would have profound longer-term implicationsnot least for fertility rates.
Moreover, in many SSA settings, the cost of children is not necessarily borne by those responsible for their having been born Not only do fathers often have very limited responsibilities for child maintenance (or evade their responsibilities altogether through divorce or migration), but child fostering is a widespread custom in many societies.
Improving Access to Family Planning Services
Improving the supply and accessibility of FP services to respond to the demand created by measures such as those outlined above requires the combined efforts of governments, NGOs, and aid donors. The target must be to raise the CPR in each country sufficiently to achieve a 50 percent reduction in the TFR by 2030 (Tables AA and A-5) For SubSaharan Africa as a whole, this implies increasing the average CPR from less than 11 at present to over 45 by the year 2020 and to over 50 by 2025 (Table A-5).
The family planning effort of nearly every country in Sub-Saharan Africa ranks near the bottom of developing countries, with the notable exceptions of Botswana, Kenya, Mauritius, Zimbabwe, and, arguably, Ghana (Table A-7). Fertility can be reduced and population growth slowed if governments, schools, employers, and NGOs take measures to increase the demand for smaller families, while supplying the services needed for families to limit family size. The FP services provided must be of high quality and responsive to clients' needs, and there must be adequate provision for monitoring and evaluation.
In most SSA countries, FP services are integrated with and delivered through the public health system, usually as part of MCH care. But in many countries the public health system is unable to deliver widespread and effective FP services. Expanding the access to family planning requires strengthening and expanding public health care systems as well as developing alternative and supplementary channels to deliver FP services and IEC. Where AIDS is prevalent, this will be all the more critical, since health and sex education and the provision of condoms are the key instruments for combatting its spread.
The promotion of modern family planning can build on long-standing traditions of spacing births through prolonged breastfeeding and postpartum sexual abstinence. The significant potential health gains from family planning appeal to policymakers and to the people affected. And new methods of delivering FP services have been shown to be workable and to make a difference in parts of Sub-Saharan Africa. A focus on birth spacing, rather than on family size limitation, would appear to be most appropriate where demand for fewer children is not strong. This is most common in countries where population pressure on cultivated land is comparatively weak and where traditional incentives for wanting large families remain strong.
Supply and accessibility of FP services could be improved
substantially by measures such as the following:
· Governments should establish and strengthen public institutions charged with population and FP programs. This will involve staff training, management improvements, and strengthened program content.
· The role of NGOs in family planning should be expanded. NGOs have demonstrated their effectivenesss in dealing with family planning issues effectively all over the world.
· Private FP organizations, nongovernmental health care networks (churches, employers' schemes), private health care practitioners (including traditional health care providers), other nongovernmental development groups (women's groups and community associations), and nonhealth outreach networks (agricultural extension and community development workers) can all be effectively used as channels for FP services. So can commercial outlets such as pharmacies, traders, and rural stores, particularly for marketing contraceptives with AIDS an increasingly severe problem in many countries, a massive effort to expand the range of providers of condoms will be critical.
· Community incentive schemes should be developed and funded to induce communities to take action to reduce population growth through community-managed family planning programs. These programs can be managed, with government funding, by schools, employers, and community groups.
Periodic demographic and health and contraceptive prevalence surveys are needed to establish baseline data and provide essential information on fertility, family planning, and maternal and child health to policymakers and planners. Such data would reveal unmet demand for family planning and would indicate where service expansion or improvement is warranted and most needed.