The Effect of Family Planning Programs

National programs were established beginning in the 1950s and multiplied most rapidly from the mid-1960s to the late 1970s when on average five new programs were established each year. In a number of instances, national programs expanded the work done by earlier, pioneering private programs, such as those supported by the International Planned Parenthood Federation. National programs naturally required government sanction and often also enjoyed substantial support and technical assistance in many phases of their operation from international donors.

Growth in contraceptive use after programs were established is illustrated in Figure 12, showing a range of experience and some notable spurts in contraceptive use that led to declines in fertility. These examples could be multiplied: Increases in contraceptive prevalence (the proportion of married women of reproductive age using contraception) and consequent fertility declines have occurred in every region of the developing world, from Peru to Mongolia, and from Iran to South Africa. But as Figure 12 illustrates, simply starting a program does not guarantee immediate increased contraceptive use. Contraceptive use did rise quickly in South Korea, where prevalence grew close to 3 percentage points a year - sufficient to reach low, replacement fertility within 25 years, essentially in a generation. But, in contrast, growth in contraceptive prevalence began late and proceeded haltingly in Ghana, where the increase was only 0.7 points a year. Even in such cases as South Korea, the credit that programs can fairly claim for fertility reduction has been a topic of some debate. Perhaps, some have argued, economic growth in Korea was so fast that fertility would have declined even in the absence of a program. Indeed, analysis suggests that programs cannot claim all the credit for fertility decline, but they can clearly claim some credit.

Figure 12 - Starting Date for Family Planning Program and Contraceptive Prevalence, Selected Countries

SOURCE: Based on World Bank (1993a).
^aDates indicate year of program start.

Field experiments usually indicate that well-done family planning programs are welcomed and make a difference. Researchers have looked at various elements of programs - the use of home visits, field-worker incentives, consistent supervision of field workers, pill prescription practices, postpartum education, etc. - to confirm a small but significant program effect on contraceptive acceptance or continuation (Bauman, 1994). Focusing on specific features of small-area programs, experiments can clearly demonstrate the contribution of program activities and exclude other explanations for changes in contraceptive use and fertility, in the process illustrating useful options for programs. However, such experiments do not address whether programs can have broader, nationwide effects.

This effect must be assessed against that of socioeconomic development. Improved standards of living should make contraceptives more affordable, as well as convincing many couples to opt for smaller families. Do programs then merely substitute for private provision of contraceptives - are they a natural but superfluous government response to consumer demand and consequent public pressure? Or do programs, through their promotional activities and the services they provide (much more promptly than market mechanisms would), play a leading role in reducing fertility?

Answering such questions and determining the historical contribution of large national programs is difficult. Comparisons are necessary across countries with different types of programs or with no programs. Analysts have generally relied on a reputational measure of "program effort," produced by rating 90 or so national programs with regard to the access they provide to contraceptive methods, their management effectiveness, their efforts at informing and educating people, and a number of other such dimensions, 30 in all. Analysis of program effort scores confirms that programs have been more active in more advanced developing countries. Socioeconomic development allows programs to operate more efficiently and, in leading to lower fertility preferences, to be more effective at providing contraceptive services. But relatively high levels of development, although helpful, do not appear to be essential. Bangladesh, one of the world's 20 poorest countries, has a program rated among the 10 best in the developing world and has seen a substantial decline in fertility over the last decade.

Multivariate statistical analysis suggests, in fact, that family planning programs do contribute independently to reduced fertility, even when the effects of socioeconomic development are accounted for. Cross-sectional regressions indicate that effective programs have a smaller effect than such factors as rising levels of female education but still reduce fertility - net of such other factors - by perhaps one-and-a-half births per woman. Skeptics put the reduction at only one birth instead but do not deny it exists (Pritchett, 1994a, 1994b). The reduction is in the region of 40 percent of the fertility decline in developing countries from the 1960s to the end of the 1980s (Bongaarts, forthcoming).

Cross-national statistical analysis, like experimental work, therefore indicates that family planning programs contribute to contraceptive use and lower fertility. But both types of studies agree that the contribution is contingent. Programs are not uniformly successful; their effects are influenced by the social context (level of development, cultural factors, political support) and depend on program performance (on the quality of program effort, the design of interventions, the adequacy of supervision of service providers, etc.). A brief overview of these factors affecting program effectiveness helps clarify when and why programs work.