Cover: International Family Planning

International Family Planning

A Success Story So Far

Published 1998

by Rodolfo A. Bulatao

Research Brief

Family planning programs have been highly successful in providing women in developing countries with access to contraceptive services and helping them to achieve desired family size. These programs also yield other benefits, notably improvements in women's and children's health. Although host countries provide about 75 percent of family planning funds, financial and technical assistance from donor nations, especially the United States, has been crucial to the success of family planning programs and remains important for future efforts.

These conclusions emerged from a RAND report that synthesized research on family planning programs in developing countries. The report focused on three issues: fertility trends in developing countries and their implications, the value of family planning programs, and program costs and donor support.

Population Growth by Decade in Industrial and Developing Countries (millions)

SOURCE: United Nations (1996) and projections using the World Bank (1997a) model.

High Fertility and the Unmet Need for Contraception

Although global fertility has fallen from about 5.0 children per woman in 1950 to 2.9 in 1998, the world still adds 800 million people per decade, a figure projected to decline only gradually over the next 50 years. Most of this growth is occurring in developing nations (see figure). Fertility rates in many of these countries remain high. Sub-Saharan Africa in particular has experienced little decline in historically high fertility rates. More than two dozen countries have fertility rates over 6.0.

Even in countries where fertility has declined from previously high rates, the population will continue to grow for some time after fertility rates stabilize at "replacement level" (2.1 children per couple). 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 result of high fertility in the past), the population can increase even though the rate of childbearing per woman has stabilized. During the next few decades, momentum will account for about half of the world's population growth.

High fertility and rapid population growth can pose problems for developing nations. They can hinder opportunities for economic development, contribute to high levels of infant mortality, and strain public resources. In addition, high fertility runs counter to the preferences expressed by millions of women in developing countries who want smaller families. This gap between preferences and fertility springs from what demographers label "unmet need for contraception," the needs of women who want to avoid or postpone pregnancy but do not practice contraception. Survey research indicates that an estimated 10 to 40 percent of married women of reproductive age in developing countries have an unmet need for contraception.

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. Since the first national programs were established in the late 1950s, family planning has been associated with notable increases in the use of contraception in the developing world. Family planning programs have played a large role in decreased global fertility rates—by some estimates accounting for as much as 43 percent of the decline.

Lower fertility from increased use of contraception has also yielded other benefits for developing countries. At the macroeconomic level, reduced fertility has helped create favorable conditions for socioeconomic development in some countries, most notably the East Asian countries whose economies grew rapidly in the 1970s and 1980s. At the family level, family planning has improved the health of women and children. The clearest health benefit for women is reduced risk of death during childbirth, which is almost 20 times as likely in developing countries as it is in industrial countries. Having many successive pregnancies puts mothers at even greater risk. Fewer pregnancies, especially among the youngest and oldest women, and greater spacing between births also reduce the risk of infant and child mortality.

Family planning has also been successful in filling the unmet need for contraception by helping women overcome obstacles to the use of contraception, including lack of access. Reducing unmet need also helps prevent unintended pregnancies. Because these pregnancies are more likely to end in abortion, reducing them reduces the number of abortions.

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 during the past 30 years about how to design and operate successful programs, even in what appear to be unfavorable environments.

Program Costs and Donor Support

Worldwide, spending on family planning across all developing countries is approximately $10 billion each year. Governments in developing countries typically cover most of the costs. Funds from international donors cover about a quarter of public spending on family planning throughout the developing world. Sub-Saharan Africa, with its newer programs, receives the bulk of it—more than 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 as programs mature.

Historically, the United States has been the largest contributor to population programs and the most significant provider of technical assistance. However, congressional support for this role has eroded. Although U.S. law prohibits using U.S. aid to fund abortions, family planning has become linked with abortion in the minds of some lawmakers, despite evidence that family planning has the potential to reduce abortion. As a result, U.S. Agency for International Development funding for overseas programs has come under fire in Congress. U.S. population assistance was reduced by 20 percent from fiscal 1995 to fiscal 1996 and a further 10 percent in fiscal 1997. It is unclear whether other donor nations can make up the shortfall.

The Challenges Ahead

Despite their success, family planning programs still face challenges. These include addressing unmet need by reaching more women who want services; dealing with sexually transmitted diseases, including HIV/AIDS; and ensuring broader attention to women's reproductive health needs. One specific challenge will be serving the huge cohort of young women—the largest in history—that is just coming to childbearing age. Another necessity is further research to improve existing 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.

Dealing with these issues will require building on the past success of family planning programs and strengthening current efforts with continuing support from donor nations and the international community.

This report is part of the RAND research brief series. RAND research briefs present policy-oriented summaries of individual published, peer-reviewed documents or of a body of published work.

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