Family planning programs: efforts and results, 1972-94.

In this article, time trends and differentials for family planning program effort are presented for most developing countries for 1972, 1982, 1989, and 1994. Overall program effort for the developing world increased sharply from 1972 to 1982, and again from 1982 to 1989, but only modestly thereafter. Some countries had already reached ceiling levels. A few with very low fertility rates deliberately weakened their programs, and other programs deteriorated for reasons that are unclear. On the other hand, within the small overall rise, numerous countries with weak programs improved their scores substantially. Regions with the lowest 1989 ratings improved the most, mainly on policy positions, and they improved least on availability of contraceptive methods. The relationship of program strength to socioeconomic setting has steadily weakened across the 22-year period studied. The stronger programs overall are stronger on essentially all 30 features of effort. Programs that have improved over the years have changed to resemble the profiles of the stronger programs.

PIP: The varied strengths of key elements of selected national family planning programs were assessed. 93 developing countries were rated according to the strength of their family planning efforts in 1972, 97 in 1982, 98 in 1989, and 94 in 1994. 77 countries were rated for all four dates. 30 program elements were scored, grouped into the following categories: policies and stage-setting activities, service and service-related activities, record-keeping and evaluation, and the availability of contraceptive methods. Time trends and program efforts are presented for those countries. Overall program effort for the developing world increased sharply from 1972 to 1982, and again from 1982 to 1989, but only modestly thereafter. Some country programs were already nearing their ceiling levels, a few with very low fertility rates deliberately weakened their programs, and other programs deteriorated for undetermined reasons. After 1989, the lowest rated regions improved the most, mainly with regard to their policies, and improved least with regard to the availability of contraceptive methods. The relationship of program strength to socioeconomic setting has steadily weakened over the 22-year period.

Direct and judgmental measures of family planning program inputs.

This report compares two different approaches to measuring the strength of family planning programs in Bangladesh and Kenya. The first approach, the judgmental approach, has been used in a number of studies during the past two decades; scores on the characteristics of family planning programs are derived from the responses knowledgeable persons give to a series of questions. The second approach is to obtain direct measures of each item being considered. In Bangladesh, the total score varied trivially between the direct and the judgmental approaches. In Kenya, the total direct score was substantially higher than the judgmental score. The primary advantage of the judgmental approach is that comparative scores can be obtained for a larger number of countries for the same time period at a much lower cost than would be required by the direct approach.

PIP: Two different approaches were compared to measure the strength of family planning programs in Bangladesh and Kenya. The judgmental approach has been used in a number of studies in the past two decades: scores on the characteristics of family planning programs are derived from the responses given by knowledgeable persons to a series of questions. The direct approach obtains measures of key program inputs based on direct evidence. The sources for the two measures were leaders' favorable statement, use of the civil bureaucracy, multiministry and agency involvement, import law and regulations, involvement of private sector agencies budgets, and social marketing. Of the 16 feasible variables, scores were obtained for 13 in Bangladesh and for all 16 in Kenya. In addition, scores were also developed for 11 other variables in Bangladesh and 6 others in Kenya. In Bangladesh, the total program effort score for 1993 for both the direct and the judgmental approaches was 72%; while in Kenya the scores differed substantially: 61% for the direct approach and 53% for the judgmental approach. In Bangladesh, the 1993 direct score was 73% of the maximum, above the judgmental score of 67%. In Kenya, the direct score for the feasible variables was 64%, above the judgmental score of 55%. There was a definite decline in effort in Bangladesh from 1989 to 1993 (75% to 67%) and a mild one in Kenya (59% to 55%). However, the full set showed little change in Bangladesh (74% to 72%) and essentially no change in Kenya (54% to 53%). The family planning program in Bangladesh was pushed vigorously in the late 1980s; however, the intensity lessened in the latter part of 1991 until 1993. The primary advantage of the judgmental approach is that scores can be obtained for a larger number of countries at much lower cost than by the direct approach.

Prospects and programs for fertility reduction, 1990-2015.

What is the likelihood that each of the 37 developing countries with populations of 15 million or more in 1990 will reach replacement fertility by the year 2015? These countries have a combined population of 3.9 billion, 91 percent of the population of all developing countries. For this article, a composite index was used as the basis for predicting future levels of total fertility. The index was constructed from socioeconomic variables (life expectancy at birth, infant mortality rates, percent adult literacy, ratio of children enrolled in primary or secondary school, percent of the labor force in nonagricultural occupations, gross national product per capita, and percent of the population living in urban areas), total fertility rates for the years 1985-90, total fertility rate decline from 1960-65 to 1985-90, family planning program effort scores in 1989, and the level of contraceptive prevalence in 1990. Eight countries are classified as certain to reach replacement fertility by 2015, and an additional thirteen probably will also. Five countries are classified as possibly reaching replacement fertility, and eleven as unlikely to do so.

PIP: What is the likelihood of 37 countries with population of 15 million or greater reaching replacement fertility by 2015? The 37 countries had in 1990 a combined population of 3.9 billion, 91% of total developing country population. Bernard Berelson in 1978 assessed the likelihood of reaching a crude birth rate (CBR) of 20 births per year per 1000 population by the year 2000 for 4 groups of countries: 1) The Certain: Taiwan, South Korea, and Chile; 2) The Probable: China, Brazil, Mexico, Philippines, Thailand, Turkey, Colombia, Sri Lanka, Venezuela, and Malaysia; 3) The Possible: India, Indonesia, Egypt, and Peru; and 4) The Unlikely: Bangladesh, Pakistan, Nigeria, Iran, Zaire, Afghanistan, Sudan, Morocco, Algeria, Tanzania, Kenya, and Nepal. Those countries which by 1994 have already or almost reached replacement level include: Taiwan, South Korea, China, Thailand, Chile, and Sri Lanka. What accounts for the miscalculation is the slow growth between 1965-85 in gross national product, the smaller decline in total fertility rate [TFR], the smaller decrease in infant mortality and life expectancy, insufficient increases in literacy, and larger increase in males in nonagricultural labor. Contraceptive prevalence has increased and family planning efforts have improved. World TFRs declined by 33% between the 1960s and 1980s. Socioeconomic improvements are needed worldwide. Likelihood projections were based on socioeconomic setting, total fertility rate, total fertility rate decline, contraceptive prevalence, program effort score, and composite index. The certain group now includes China, both Koreas, Sri Lanka, Taiwan, and Thailand. The probable group includes India, Indonesia, Malaysia, Philippines, Vietnam, Argentina, Venezuela, Brazil, Peru, Egypt, Morocco, Turkey, and South Africa. The possible group includes Bangladesh, Myanmar, Algeria, Iran, and Kenya. The unlikely group is comprised of Afghanistan, Nepal, Pakistan, Iraq, Sudan, Ethiopia, Ghana, Nigeria, Tanzania, Uganda, and Zaire. When proximate determinants (marriage, contraceptive use, induced abortion, and breast feeding) are considered, the groups of countries change. TFR projections extrapolating from past trends compared to UN projections showed all the certain countries the same, 4 of the probable countries reaching a TFR of 2.3, and none of the possible or unlikely countries reaching replacement fertility.

Measuring the effort levels of family planning programmes (profile of 30 programme effort scores, 1982 and 1989).

The chief results to emerge in this preliminary analysis are as follows: Stronger programmes are stronger on every score. Their overall superiority in the total score is not due to exceptional stress on any one feature, but rather to a substantial advantage score by score, across all 4 dimensions of effort. A further difference is that stronger programmes have more consistent values across the various scores, quite apart from their levels, whereas weaker programmes are erratic, displaying much greater variability around their own mean score than do the stronger programmes. The profiles themselves (apart from levels) have not changed from 1982 to 1989. Stronger programmes in 1989 show the same score patterns as did the smaller number of stronger programmes in 1982. This also holds true for weaker programmes: the profile of the weaker programmes in 1982 was duplicated in 1989, even though countries left that category and moved into the stronger group. The 19 countries that shifted to the higher category conformed to the profile of weaker countries in 1982 (though at a slightly higher level); but conformed to the profile of stronger countries in 1989 (though at a slightly lower level). Thus it is likely that maturing programmes tend to follow a special pattern of improvement: They improve differentially across the 30 scores. The prevalence of contraceptive use is closely associated with programme effort, but some programme features count more than others. The availability scores for contraceptive methods count most, and service and service-related efforts come next.(ABSTRACT TRUNCATED AT 250 WORDS)

Effort and achievement in national family planning programmes.

New data show that national family planning programmes have made impressive progress in the last 25 years. Fertility rates have been reduced dramatically, but during the current decade even greater achievements will be called for.

PIP: Over the last quarter century, large-scale family planning programs have spread to most of the developing world. 30 indices measured the efforts made in these programs. Questionnaires were sent to experts in 100 developing countries to answer questions on the programs as the basis for a score of 0 to 4 on each of the 30 indices. The total number of points awarded, expressed as a percentage of 120, was termed the Program Effort (PE) score. The results of three investigations made in 1972, 1982 and 1989 pointed to a substantial increase in program effort over the years. The mean PE score rose from 20 to 44 from 1972 to 1989 when each country was weighted equally. In 1972, half of the countries had a PE score of less than 10, but by 1989 half of them scored over 44. Policy improvements have been largest in Sub-Saharan Africa, and service-related activities along with record-keeping and evaluation also improved. Except in East Asia, a 13-16% rise in contraceptive availability occurred everywhere, across a low range in Sub-Saharan Africa and the Middle East, and across a higher one in South Asia and Latin America. East Asia continued with the highest score in all four dimensions of effort. Overall, Sub-Saharan Africa's score escalated from 15 to 36; the North Africa/Middle East score rose from 40 to 54. 13 countries had strong programs, principally in Asia and Latin America, 30 had moderately strong programs, chiefly in Central and South America, 36 had weak programs, largely in North Africa/Middle East and Sub-Saharan Africa, and 18 had very weak or non-existent programs, almost all in North Africa/Middle East and Sub-Saharan Africa. The proportion of couples using contraception has risen from about 14% in the mid-1960s to over 50% currently. The total fertility rate for the developing world as a whole has declined in the last 30 years from 6.1 to 3.9.

Family planning programs: efforts and results, 1982-89.

According to a set of 30 indices that assess the strength of large-scale family planning programs in developing countries, a strong upward shift in effort scores occurred between 1982 and 1989. During that period, many countries established or augmented their family planning programs, and effort scores improved in all developing regions and in all four dimensions of effort--policies and stage-setting activities, service and service-related activities, record keeping and evaluation, and availability of contraceptive methods. By region, the sharpest improvement was not in East Asia, where levels were already high, but in sub-Saharan Africa, where the movement was clearly upward, from a low base. Earlier associations between program effort and fertility declines are reaffirmed, additive to the contribution of socioeconomic improvements. In order to compute scores ranging from zero to 30 for each of the 30 indices, a detailed questionnaire was sent to 4-6 respondents in each of 103 developing countries having more than one million population. Respondents included program staff, donor agency personnel, local observers, and knowledgeable foreigners. The scores indicate that developing countries are continuing to move toward more favorable policy positions and stronger implementation of action programs, with consequent fertility effects. For the fertility decline to match the medium population projections of the United Nations, however, a substantial enlargement in the number of contraceptive users is necessary, not only to compensate for the enlarging base of couples, but also to increase the proportion who use contraceptives.

PIP: A cross-national study of the strength of national family planning programs and the relationship of program strength to fertility change was conducted in 88 countries in both 1982 and 1989. Study data were obtained through detailed questionnaires sent to 4-6 respondents in each of 103 developing countries with over 1 million population. Respondents included program staff, donor agency personnel, local observers, and knowledgeable foreigners who ranked 30 indices along a 0-30 point scale. Many countries having established or augmented their family planning programs over this period, effort scores improved in all developing regions regarding policies and stage-setting activities, service and service-related activities, record keeping and evaluation, and availability of contraceptive methods. Greatest improvement was observed in sub-Saharan Africa where upward movement took place from a low base. Study results reaffirm an earlier association between program effort and fertility declines. They show developing countries to still be moving toward better policy positions and stronger implementation of action programs with corresponding fertility effects. Substantially more contraceptive users are, however, needed in order to meet medium UN population projections. Increases must be sufficient to both compensate for the enlarging base of couples while increasing the overall proportion of users. The indices included in the program effort scale are summarily discussed in the appendix.

The promotion of family planning by financial payments: the case of Bangladesh.

The government of Bangladesh and the World Bank commissioned a Compensation Payments Study, carried out in 1987, to assess the merits and demerits of payments for sterilizations to clients, medical personnel, and intermediaries who motivate and refer clients. The study conclusively shows that the decision of Bangladeshi men and women to undergo sterilization is a considered and voluntary act, taken in knowledge of the nature and implications of the procedure, and in knowledge of alternative methods of regulating fertility. There is a high degree of client satisfaction among those who have been sterilized, although among clients who had fewer than three children, 25 percent expressed regret that they had been sterilized. Money may be a contributing factor to the decision to become sterilized in a large majority of cases, but a dominant motive for only a very small minority. Payments to referrers have fostered a large number of unofficial, self-employed agents--particularly men who recruit vasectomy cases. These agents provide information about the procedures for being sterilized, particularly to the poor. They also concentrate on sterilizations to the exclusion of other methods, and are prone to minimize the disadvantages and exaggerate the attractions of sterilization.

The demographic impact of family planning programs.

In response to concerns about the adverse consequences of rapid population growth, family planning programs have been implemented in many developing countries. The aim of the present study is to assess the impact of this programmatic approach on long-range population growth. The result of a new and hypothetical population projection indicates that in the absence of family planning programs the population of the developing world could be expected to reach 14.6 billion in the year 2100 instead of the 10 billion that is currently projected by the World Bank. Despite the apparent success of existing interventions, fertility control is far from complete, as many women continue to bear unwanted births. To assess the impact of this unintended childbearing a second hypothetical projection is made. With perfect implementation of reproductive preferences, the population size of the developing world in 2100 would be reduced by an estimated 2.2 billion below the current projection. Further strengthening of family planning programs and improvements in birth control technology are therefore likely to provide important demographic benefits.

The effectiveness of family-planning programmes.

By the mid-1960s, countries that accounted for 66% of the population of developing countries had adopted policies designed to reduce their rates of population growth; by 1986, the corresponding figure had reached 78%. In the developing regions as a whole, fertility has fallen by more than 30% since 1950. Contraceptive use has risen sharply, and there has been more than 10-fold increase in the number of couples in developing countries who use contraceptives. There is a very strong association between use of contraception and fertility in developing countries. Social and economic modernization is also taking place, although quite unevenly in the developing regions, so that the relationship of modernization is fertility is not very easy to demonstrate. In general, the experience of the developing countries suggest that a strong family- planning program effort can, and does, lead to a more rapid fertility decline than would be likely based only on socioeconomic variables. The effectiveness of family-planning programs can be enhanced by increasing the range of choice of contraceptive methods offered. However, it is difficult to disentangle the various factors that contribute to the effectiveness of family-planning programs. The public sector is the main supplier of family-planning services in most developing countries, and there is no clear trend towards the reliance on the private sector.

Prevalence of contraceptive use: trends and issues.

This article discusses the sources of data for estimates of contraceptive use, including their reliability and validity. Data from sample surveys and from censuses are presented by countries from the 1960s to the present time. Tables on proportions of users by method of contraception for various time periods are included. The relationship between contraceptive use and level of fertility is also shown. Contraceptive use has increased rapidly in much of Asia and Latin America, but much less so in Arab countries and sub-Saharan Africa. Worldwide, about 400 million of the 800-850 million married couples of reproductive age practice contraception; of these, about 340 million use a modern method. Sterilization is the most widely practiced method of contraception in the world, with tubal ligations far outnumbering vasectomies.

Contraceptive prevalence: the influence of organized family planning programs.

Estimates of contraceptive prevalence for the period 1977-1983 are presented for 73 less developed countries. Socioeconomic conditions are associated with much of the variance in prevalence, but organized family planning programs strengthened this association significantly. The average percent of couples in the reproductive ages practicing fertility regulation is 26, with the range from 4 to 55 percent between the low and high socioeconomic groups of countries, and from 7 to 59 percent between groups of countries with very weak (if any) to strong family planning program effort.

Population trends and prospects.

For the next 20 years there is likely to be a slowing of population growth rates for all areas of the world except Africa. The present population of developed countries is expected to increase by about 12 percent by the year 2000; that of all developing countries is expected to increase by about 50 percent. The momentum of population growth is strong; a few analysts suggest that growth may cease at 8 billion, but a figure of more than 10 billion seems much more likely.

[Answering the four questions asked by Ruth B. Dixon in Outline of Political Conclusions of Multiple Regressions]. / Contestamos las quatros preguntas de Dixon.

PIP: In response to criticism from Ruth B. Dixon, published on Estudios de Poblacion 3 (7-12), 1978, about their study on the effects of family planning programs on fertility decrease in developing areas, and on its implications on population policies, the authors restate their views, as previously published in an article which appeared in Studies in Family Planning, May 1978. Such views are that: 1) family planning programs efforts are probably not as paramount as the improvement of socioeconomic conditions in causing fertility decrease; 2) it cannot be stated which type of program is the most conducive to fertility decrease; 3) good health and education are the 2 most important factors in improving socioeconomic status; and, 4) the status of women is greatly important in reducing fertility rate.^ieng

Patterns of fertility decline in developing countries, 1950-75.

Since 1965 there have been substantial declines in the crude birth rates of many countries in the developing world, particularly the largest countries. This auspicious trend is shown clearly in an analysis of population figures for the last 25 years, despite the fact that there are deficiencies in the data. In 1950 the average crude birth rate for developing countries was 42 per thousand per year. Over the next 15 years, declines in the crude birth rate were limited to a relatively few, and for the most part small, countries. After 1965, however, for the 13 developing countries with a population numbering 35 million and over, there have been declines in the crude birth rate averaging 13 percent, with declines of over 12 percent in 9 of them. The effects of a number of sociodemographic factors on crude birth rates are examined, and the analysis shows that increases in the age at marriage and decreases in marital fertility were the principal factors affecting declines since 1965.

Fertility trends: 1950-75.

During the past 25 years, the world's population increased by 60 percent to 4 billion people. The period witnessed a momentous decline in mortality, which will probably continue in the developed countries. Fertility has fallen dramatically in the developed countries to quite low levels. In the developing countries, where the bulk of the world's population is concentrated, fertility is still high, although it has begun to decline in some countries. Reductions in fertility have been dramatic in Asia and the Pacific; substantial in Central and South America; and hardly noticeable in Africa. Increasingly, population policies will be considered as an integral part of social and economic development; and family planning will receive increasing attention as a human right, as an element of improved maternal and child health, and also as a means of moderating high rates of population growth.

Assessment of national family planning programs in developing countries.

Today, 34 developing countries have policies and programs to lower fertility, and an additional 32 countries provide family planning services for health and humanitarian reasons. Specific causal relationships and linkages between social and economic development, family planning programs, and fertility levels and changes remain mostly unclear at this point. Based on percent acceptors, percent users, and changes in fertility rates (the most commonly used measures to evaluate family planning program accomplishments), however, the performance of programs on the whole has been moderately encouraging.