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Effective FamilyPlanning Programs

The World BankWashington, D..C

o 1993 The Internatioral Bank for Reconstructionand Development / THE WORLD BANK1818 H Street, N.W.Washington, D.C. 20433

All rights reservedManufactured in the Uniited States of AmericaFirst printing February 1993

The findings, interpretations, and conclusions expressed in thisstudy are entirely those of the authors and should not beattributed in any manner to the World Bank, to its affiliatedorganizations, or to members of its Board of Executive Directorsor the countries they represent.

Libnuy of Congress Cataloging-in-Publication Data

Effective family planning programs.p. cm.

ncludes bibliographical references.ISBN 0-8213-2305-91. Birth control-Developing counties. L World Bank.

HQ766.5fl44E44 1993363.9'6'091724-dc2O 92-45644

CIP

Contents

Preface vii

Summary I

Part L Family Planning in the Developing World 5

1. The Unfinished Reproductive Revolution 7Demographk- Change 7Behavioral and Institutional Change 8Contraceptive Use and Family Planrnng 10

Why Fertility Regulation Spreads 10Cntraceptive Methods and Prevalence 11The Effectof Family Planning 11

Unfinished Tasks 13Shortcomings 13Future Needs 14

2. Program Successes and Obstacles 17East Asia 17Latin America 19South Asia 23Sub-Saharan Africa 25Conclusion 28

3. The Cost of Family Planning 31Public Expenditures 31

Donors 31Governments 33

User Expenditures 33Future Resource Needs 35

iii

iV CONTEN

Part I1. Elements of Effective Programs 37

4. Quality of Services 39Aces and Continued Use 39

Access to Services 39Access to Appropriate Methods 41Continuity of Use 42

Counseling and Interpersonal Relations 43Counseling and if ormed Choice 44Client Sensibilities 44Client Concems 46

Technical Competence 47Improving the Quality of Services 47

Commitment 48Reorientation 48Measurement and Rewards 48Cost of Quality 49

5. Strategic Management 51Approaches to Strategy 52

Congrence 52Stages of Development 54

Mobilizing Public Support 56Political Support 56Community Support 56

Designing the Organization 57Delivery Systems 57Interorganizational Links 58Organizational Structure 59

Managing Front-Line Staff 59Recruitment 60Training and Motivation 60Supervision 61

Ensuring Reliable Logistics 61Providing Control and Adaptability 62

Monitong and Feedback 63Evaluation 63Operations Research 63

CONTNIS U

6. The Private Sector in Family Planning 65Coverage and Potential 65Introducing Family Planning 68Reaching Specific Groups 70

Commercial Sales and Social Marketing 70Private Practitioners 71

Saving Public Funds 71Efficiency 71Private Financing 73

Encouraging the Private Sector 74Strategic Plamiing 74Reform of Laws and Regulations 74Family Planning Promotion 75Financial and Technical Assistance 75

7. Family Planning Promotion 76Effects of Promotional Activities 77

Interpersonal Conmunrication 77Mass Media 77

Desiging Effective Promotional Campaigns 78Costs and Financing of Promotion 79

8. Government and Donor Roles 81Program Directions 81Govement Policies 82Donor Assistance 83

Donor Counties and Agencies 84The Adequacy of Donor Financing 85Donor Coordination 86

Appendix A. The Proximate Determinants of Fertility 88

Appendix B. Chaactistdcs of Major ContracEptive Methods 90

References 96

Preface

This paper was prepared by Rodolfo A. Bulatao with the assistance ofAnn Levin, Eduard P. Bos, and Cynthia Green in the Population, Health,and Nutrition Division of the World Bank's Population and HumanResources Department. The work was under the general direction ofAnn 0. Hamilton and the immediate supervision of Anthony R.Measham. Maria C. Benedicto provided secretarial assistance.

Data, evidence, insights, and examples were provided by researdcersand practitioners inside and outside the Bank, partly in a number ofbackground papers listed among the references. Substantive commentson a draft of the paper were provided by family planning policymakersand program staff at a June 1991 consultation in Harare cosponsored bythe Bank's Economic Development Institute. Additional comments ofconsiderable value were provided by representatives of donor orgari-zations in a February 1992 meeting in London cosponsored by theRockefeller Foundation and organized with the assistance of the Inter-national Planned Parenthood Federation. Representatives of technicalassistance agences also commented on the paper at an April 1992meeting in Washington, D.C.

The paper was discussed by the Executive Directors of the Bank at aseminar on May 11, 1992.

vii

Summary

Part I of tliis book assesses the performance of family planning programsin developing countries, looling at their contributions and their costs.Part II then attempts to identify the attributes and approaches critical toeffective programs, drawing on research to provide not a primer onrunning programs but a broad overview of what makes programssucceed. Focusing on family planning programs and their operation, thepaper notes but does not elaborate on the contributions that other socialdevelopment interventions make to an ongoing reproductive revolu-tion, which is gradually transforming demographic prospects and indi-vidual lives.

The reproductive revolution is evident in the transitions to lowerferlity that are occurdng in all developing regions: over two decadesthe average number of children per woman has fallen by a third. Asfertlity falls, so do infant, child, and maternal mortality. Women spenddecaeasing proportions of their lifetimes giving birth and caring foryoung childrerL

Despite progress, fertlity is still high overall, and real reproductivechoice is often an illusion. The fertility rate in the developing world,excluding China, is 4.3 children per woman. This is two-thirds of the ratein the 1950s and 1960s but stDll twice the number in industrial countriesand high enough to double the population in 30 years. The developingcounties produce most of the 90 million people added to world popu-lation every year-the largest increases in human history. Maternalmortality in developing countries is ten times as high as in industialcountries. Not surprisingly, a quarter of married women express someunmet need for contraception.

To effectively meet such needs, programs should be organized toprovide quality services, with such features as a strong client focus,strategic management, effective promotion, and broad participation ofthe private sector. Government conmmitmnent to effective programsneeds to be reinforced. Donor resources, which have been essential inthe past, are not keeping pace with the need.

1

2 UWPECTVU FAMILY PLANNINC P'RORAMS

The following points are discussed in detail in chapters 1 through 8.

Family planning programs are succeeding and should be expanded. Familyplanning programs, public and private, have helped cut in half the timerequired for the transition from high fertility (six to eight children perwoman) to low fertility (about two children per woman). This transitiontakes as few as 20 years today, despite inidally higher levels of fertilitythan Europe had at the start of its transitions, and despite a variety ofcultural and political barriers. During the 1980s, programs helped avert250 milLion births in developing countries. Infant mortality rates, whichwere 74 per thousand by the end of the decade, would have been 10points higher in the absence of family plarning programs.

Programs have raised contraceptive use in counties of varied culturesand levels of socioeconomlic development. Even in adverse circum-stances-low incomes, limited education, and few opportunities forwomen-family planning programs have meant slower populationgrowth and improved family welfare. But progress in increasing contra-ceptive prevalence has been more rapid when socioeconomic condi-tions-female education, in particular-were also improving morerapidly.

Considerable unmet need for contraception exists. At least 10 percentand as many as 40 percent of married women of reproductive age in eachdeveloping country surveyed recently want to avoid a birth but are notcontracepting. Filling all unmet need would bring ferdtlity down, for themajority of countries outside Sub-Saharan Africa, to dlose to two chil-dren per woman.

In the absence of organized programs for providing contraceptionwidely-free or at low cost-users would have to spend, on average, 3-4percent of annual per capita income for contraception (which, whenavailable commercially, can cost more than $100 a year). Further fertilitydecline would be uncertain, delayed, and burdensome for individuals,and improvements in maternal and child health would be greatlyslowed.

Program quality must be an organizationl priority. Successful programshave been those that are responsive to client needs and provide goodaccess to methods that clients want In many countries, access to a widerange of methods is still poor, and clients are uninformed and inade-quately counseled, leading, frequently, to discontinuation. Clients alsosuffer through long waits and other indignities.

Better program quality requires good support for front-line staff-nurses and paramedics in clinics, feidworkers and distributors in

sUMMARY 3

communities, and pharmacists and other commercial distributors.Supervision of these staff is weak and seldom supportive; supervi-sory visits are infrequent and often focus on bureaucratic procedures.Logistical systems fail to provide contraceptives on time for staff todistribute.

Program quality can be improved, sometimes at little cost, if manage-ment gives it high priority and continual attention. Quality needs to bemeasured and monitored at least as intensively as are stocks and flowsof contraceptives.

Strmtegic management is critical. Each program should plan strategically,to take into account evolving contraceptive demand, shifting politicaland public support, and changing staff and factilites. Very weak pro-grams first need to ensure local support; weak programs need tostrengthen their management; intermediate programs must cope withsubstantial expansion and outreach; and strong programs need to max-imize their efficiency and recover costs.

Inproving the flow of information to managers and staff wouldstrengthen many programs. Management information systems needto focus on essential information, which must be processed, analyzed,distributed, and used in a timely manner. Operations research needsto be planned and designed so that it provides key inputs fordecisions.

The privatesectorhaswidepotentialanddesnruesstrongerencourargeent.Theprivate sector in family planning directly serves anywhere from 5 to75 percent of users in a country. The sector is diverse, and many morepeople could be effectively reached by nonprofit or for-profit privatechannels. However, nonprofit agencies often lack the capacity toprovide services for large and difficult-to-reach populations, andfor-profit agencies laclk incentives to provide affordable services forthe poor.

Government action or inaction is critical in determining the capacityof the private sector. Public and publidy subsidized programs need tobe designed so as not to impede growth in the private sector; restrictionson the provision of various contraceptives need to be lifted; and assis-tance needs to be provided to private agencies in developing the marketfor contraceptives and in technical and financial areas.

The most successful form of public-private collaboration to date issocial marketing. In this system, subsidized contraceptives movethrough commeral channels, provding wrider distribution and conve-nienceforconsumers and someprogramsavings. Various other arrange-

4 EPIICI1VE FAMILY PLANNING PROGRAMS

ments for private financing of contraception, such as employment-based services and coverage through health insurance, are also worthdeveloping.

More effective promotion offamily planning is nweded. Promotion is essentialto let people know why family planning is advantageous to them, wheresupplies and services are available, and how to use them effectively.Promotion is also acceptable to the public: most people approve ofcontraceptive advertising in the mass media. Evaluation, however, hasoften been inadequate, and much promotion may be ineffective. Well-designed campaigns have been shown to increase not only awarenessbut also contraceptive use.

Effective promotion must be integrated and coordinated with otherprogram activities. Modem marketing approaches, using materials thatare professionally designed, carefully pretested, and able to capture anaudience in the competitive media marketplace, are essential for thegreatest impact

Long-run government and donor support is needed. Effective governmentsupport for family planning involves strong public statements, selectionof and support for competent leaders, adequate budgetary allocations,reform of regulations that hamper programs, and a coherent humandevelopment strategy, especially for increasing female education. Publicand private expenditures on family planning in the developing worldnow total $4 billion-$5 billion a year, or about $1 to $1.25 per capita?Expenditures will have to increase about 5 percent annually in the 1990sto provide for the expected number of contraceptive users. Since userpayments now cover not more than a quarter of costs, even rapid risesin user charges would not obviate the need for growth in both donor andgovernment expendituxres.

More efficient use of donor resources requires an expansion of limiteddonor expertise regarding population. Uncertainty about the adequacyof future donor assistance also needs to be confronbed.

1. Dollar amounts are curnrnt US. dollars unless otherwise specified. A bilion is athousand million.

In addition to per capita olsts, this book also cites per user costs, referring, by canven-tion, to women users only.

Part I

Family Planningin the Developing World

Family planning programs have contributed to a reproductive revolu-tion in developing countries-a revolution in the intimate behavior andrelations of men and women that has far-reaching consequences. Chap-ter I discusses the revolution and its benefits, the contribution thatfamidly plaming has made, and thec distance the revolution stll has togo. Subsequent chapters consider how family planring programs cancontribute most effectively to the completion of the revolution. Chapter2 reviews recent experience in selected countries, and chapter 3 dealswith costs.

S

1. The UnfinishedReproductive Revolution

The central observable event in the reproductive revolution is a substan-tial, irreversible declne in human fertility, a process often referred to asthe fertility transition. This transition is linked, partly as consequenceand partly as cause, with awidevariety of demographic, behavioral, andinstitutional changes, which collectively make up the reproductiverevolution.

Demographic Change

The fertility transition reduces family size and slows population growth.It contributes to, while also being partly impelled by, lower mortality.

In the developing world, the fertlity transition is most advanced inLatin America and East Asia. For example, in Chile, total fertility (thenumber of children a woman would have if her childbearing followedcurrent patterns) began to decline around 1964 fromn a pretransitionlevelof 5.3 and has now reached 2.6. (Most unattributed demographic statis-tics in this book are World Bank estimates; see Bulatao and others 1990.)Transitions in East Asia were in general much faster: in the Republic ofKorea total fertility began to fall around 1960 and dropped from 6.1 to2.1 in 25 years, essentially within one generation. The transition isincreasingly becong a worldwide phenomenon. In each reg: -it of thedeveloping world except Sub-Saharan Africa, fertility has fallen by atleast one child per woman in the past 20 years.

As in earlier fertility transitions in Europe, the declines accompanyeconomic development and associated social changes that make parentsvalue children more for themselves and less as economic assets. How-ever, current fertlity declines are much faster than in the past, startfromhigher levels of fertility, are preceded by even more rapid declines inmortality, and affect much larger populations. In many European coun-txies, ferility transition began in the late nineteenth or early twentiethcentury, and fertility gradually declined to dose to replacement level

7