Government Involvement

There are several arguments for government support of family planning - the utility of family planning programs for reducing fertility, the opportunities that lower fertility and dependency rates, and the resulting increased saving rates and reduced growth of expenditures on social programs. Paradoxically, however, these arguments are less compelling for poorer countries, which would benefit less because the amounts they could save are smaller relative to the cost of programs. In addition, any gains from family planning are strictly contingent, dependent first on the programs being well-run, and then on any opportunities opened up by lower fertility - for expanding enrollment, for instance - being used productively. This requires effective governance, which tends to be more difficult in more constrained environments.

In a different sense, however, government involvement in family planning is more critical in poorer countries. Commercial services are less likely to be available and more likely to be beyond the reach of individuals. Furthermore, family planning improves maternal and child health. By reducing exposure to pregnancy, family planning reduces maternal deaths at a cost below that of such programs as prenatal care and training of traditional birth attendants, particularly for poorer countries where maternal mortality rates are high (Maine, 1991). The cost per child death averted by a model family planning program is also quite low, being estimated at US$4-5 per added year of life in Mali, a poorer country, and at US$25 per added year in Mexico or Thailand. This is as cheap or cheaper than a model immunization program, which costs three times as much (US$12-17) per added year of life in lower-income countries and slightly more (US$25-30) in middle-income countries.⁴ Family planning services are therefore recommended as part of a primary health care package ensured for the entire population, most strongly although not only for poorer countries (World Bank, 1993b).

⁴These measures of added years of life are adjusted for disability and are therefore known as disability-adjusted life-years (DALYs). The comparison is with the EPI Plus cluster of interventions - the Expanded Programme of Immunization plus hepatitis B and yellow fever vaccines and vitamin A and iodine supplements, where these micronutrients are deficient (World Bank, 1993b, p. 74, 84-85). For some commentary on these estimates, see Haaga et al. (1996).

Whether to save money, to save lives, to guarantee reproductive rights and the reproductive health of women, or to temper environmental and social problems, governments in both the poorer and the more advanced developing countries, wherever fertility remains high, have strong reasons for financial support of family planning. Such support need not mean government provision of services. Many successful programs have been government run, but many government-run programs have also languished for years. Where appropriate private agencies exist or can be nurtured into existence, they could in principle take on some of this burden, with some public support, and enhance the performance of programs. But government does have an essential role in ensuring appropriate public education and an adequate flow of information about family planning, as well as in guaranteeing proper standards of care. Addressing both of these tasks adequately - which the private sector is generally not equipped to do - could help mitigate unfamiliarity with contraception and concern about its health effects, the two major reasons for the unmet need for contraception.

The majority of developing country governments do in fact take some responsibility for family planning, although their efforts have often been more notable at raising awareness levels than at ensuring quality services. Except in sub-Saharan Africa and scattered countries elsewhere, governments typically cover the bulk of publicly financed family planning expenditures in developing countries (Ross et al., 1993). The proportion of costs they cover tends to rise as programs develop: from under 30 percent to more than 60 percent of funding over the 1980s in Tunisia, for instance (Figure 16). But donor funds from industrial-country development assistance, international agencies, and private sources do fill critical gaps in funding.

Figure 16 - Government and Donor Spending on Family Planning, Selected Countries and Years

SOURCE: Donaldson and Tsui (1990, p. 27) and Ross et al. (1993, pp. 123-131).