Functional Assistance
Programs to Create Conditions for Fertility Decline
Introduction
Discussion
[** It is clear that the availability of contraceptive services
and information, important as that is, is not the only element
required to address the population problems of the LDCs. Substantial
evidence shows that many families in LDCs (especially the poor)
consciously prefer to have numerous children for a variety of
economic and social reasons. For example, small children can make
economic contributions on family farms, children can be important
sources of support for old parents where no alternative form of
social security exists, and children may be a source of status for
women who have few alternatives in male-dominated societies.**]
The desire for large families diminishes as income rises.
Developed countries and the more developed areas in LDCs have lower
fertility than less developed areas. Similarly, family planning
programs produce more acceptors and have a greater impact on
fertility in developed areas than they do in less developed areas.
Thus, investments in development are important in lowering fertility
rates. We know that the major socio-economic determinants of
fertility are strongly interrelated. A change in any one of them is
likely to produce a change in the others as well. Clearly
development per se is a powerful determinant of fertility. However,
since it is unlikely that most LDCs will develop sufficiently during
the next 25-30 years, it is crucial to identify those sectors that
most directly and powerfully affect fertility.
In this context, population should be viewed as a variable which
interacts, to differing degrees, with a wide range of development
programs, and the U.S. strategy should continue to stress the
importance of taking population into account in "non-family
planning" activities. This is particularly important with the
increasing focus in the U.S. development program on food and
nutrition, health and population, and education and human resources;
assistance programs have less chance of success as long as the
numbers to be fed, educated, and employed are increasing
rapidly.
Thus, to assist in achieving LDC fertility reduction, not only
should family planning be high up on the priority list for U.S.
foreign assistance, but high priority in allocation of funds should
be given to programs in other sectors that contribute in a
cost-effective manner in reduction in population growth.
There is a growing, but still quite small, body of research to
determine the socio-economic aspects of development that most
directly and powerfully affect fertility. Although the limited
analysis to date cannot be considered definitive, there is general
agreement that the five following factors (in addition to increases
in per capita income) tend to be strongly associated with fertility
declines: education, especially the education of women; reductions
in infant mortality; wage employment opportunities for women; social
security and other substitutes for the economic value of children;
and relative equality in income distribution and rural development.
There are a number of other factors identified from research,
historical analysis, and experimentation that also affect fertility,
including delaying the average age of marriage, and direct payments
(financial incentive) to family planning acceptors.
There are, however, a number of questions which must be addressed
before one can move from identification of factors associated with
fertility decline to large-scale programs that will induce fertility
decline in a cost-effective manner. For example, in the case of
female education, we need to consider such questions as: did the
female education cause fertility to decline or did the development
process in some situations cause parents both to see less economic
need for large families and to indulge in the "luxury" of educating
their daughters? If more female education does in fact cause
fertility declines, will poor high-fertility parents see much
advantage in sending their daughters to school? If so, how much does
it cost to educate a girl to the point where her fertility will be
reduced (which occurs at about the fourth-grade level)? What
specific programs in female education are most cost-effective (e.g.,
primary school, nonformal literacy training, or vocational or
pre-vocational training)? What, in rough quantitative terms, are the
non-population benefits of an additional dollar spent on female
education in a given situation in comparison to other non-population
investment alternatives? What are the population benefits of a
dollar spent on female education in comparison with other
population-related investments, such as in contraceptive supplies or
in maternal and child health care systems? And finally, what is the
total population plus non-population benefit of investment in a
given specific program in female education in comparison with the
total population plus non-population benefits of alternate feasible
investment opportunities?
As a recent research proposal from Harvard's Department of
Population Studies puts this problem: "Recent studies have
identified more specific factors underlying fertility declines,
especially, the spread of educational attainment and the broadening
of nontraditional roles for women. In situations of rapid population
growth, however, these run counter to powerful market forces. Even
when efforts are made to provide educational opportunities for most
of the school age population, low levels of development and
restricted employment opportunities for academically educated youth
lead to high dropout rates and non-attendance..."
Fortunately, the situation is by no means as ambiguous for all of
the likely factors affecting fertility. For example, laws that raise
the minimum marriage age, where politically feasible and at least
partially enforceable, can over time have a modest effect on
fertility at negligible cost. [** Similarly, there have been some
controversial, but remarkably successful, experiments in India in
which financial incentives, along with other motivational devices,
were used to get large numbers of men to accept vasectomies.**] In
addition, there appear to be some major activities, such as programs
aimed to improve the productive capacity of the rural poor, which
can be well justified even without reference to population benefits,
but which appear to have major population benefits as well.
The strategy suggested by the above considerations is that the
volume and type of programs aimed at the "determinants of fertility"
should be directly related to our estimate of the total benefits
(including non-population benefits) of a dollar invested in a given
proposed program and to our confidence in the reliability of that
estimate. There is room for honest disagreement among researchers
and policy-makers about the benefits, or feasibility, of a given
program. Hopefully, over time, with more research, experimentation
and evaluation, areas of disagreement and ambiguity will be
clarified, and donors and recipients will have better information
both on what policies and programs tend to work under what
circumstances and how to go about analyzing a given country
situation to find the best feasible steps that should be taken.
Recommendations:
1. AID should implement the strategy set out in the World
Population Plan of Action, especially paragraphs 31 and 32 and
Section I ("Introduction - a U.S. Global Population Strategy")
above, which calls for high priority in funding to three categories
of programs in areas affecting fertility (family- size)
decisions:
a. Operational programs where there is proven cost-effectiveness,
generally where there are also significant benefits for
non-population objectives;
b. Experimental programs where research indicates close
relationships to fertility reduction but cost-effectiveness has not
yet been demonstrated in terms of specific steps to be taken (i.e.,
program design); and
c. Research and evaluation on the relative impact on desired
family size of the socio-economic determinants of fertility, and on
what policy scope exists for affecting these determinants.
2. Research, experimentation and evaluation of ongoing programs
should focus on answering the questions (such as those raised above,
relating to female education) that determine what steps can and
should be taken in other sectors that will in a cost-effective
manner speed up the rate of fertility decline. In addition to the
five areas discussed in Section II. B 1-5 below, the research should
also cover the full range of factors affecting fertility, such as
laws and norms respecting age of marriage, and financial incentives.
Work of this sort should be undertaken in individual key countries
to determine the motivational factors required there to develop a
preference for small family size. High priority must be given to
testing feasibility and replicability on a wide scale.
3. AID should encourage other donors in LDC governments to carry
out parallel strategies of research, experimentation, and
(cost-effective well- evaluated) large-scale operations programs on
factors affecting fertility. Work in this area should be
coordinated, and results shared.
4. AID should help develop capacity in a few existing U.S. and
LDC institutions to serve as major centers for research and policy
development in the areas of fertility-affecting social or economic
measures, direct incentives, household behavior research, and
evaluation techniques for motivational approaches. The centers
should provide technical assistance, serve as a forum for
discussion, and generally provide the "critical mass" of effort and
visibility which has been lacking in this area to date. Emphasis
should be given to maximum involvement of LDC institutions and
individuals.
The following sections discuss research experimental and
operational programs to be undertaken in the five promising areas
mentioned above.
1. Providing Minimal Levels of Education, Especially for
Women
Discussion
There is fairly convincing evidence that female education
especially of 4th grade and above correlates strongly with reduced
desired family size, although it is unclear the extent to which the
female education causes reductions in desired family size or whether
it is a faster pace of development which leads both to increased
demand for female education and to reduction in desired family size.
There is also a relatively widely held theory though not
statistically validated that improved levels of literacy contribute
to reduction in desired family size both through greater knowledge
of family planning information and increasing motivational factors
related to reductions in family size. Unfortunately, AID's
experience with mass literacy programs over the past 15 years has
yielded the sobering conclusion that such programs generally failed
(i.e. were not cost-effective) unless the population sees practical
benefits to themselves from learning how to read e.g., a requirement
for literacy to acquire easier access to information about new
agricultural technologies or to jobs that require literacy.
Now, however, AID has recently revised its education strategy, in
line with the mandate of its legislation, to place emphasis on the
spread of education to poor people, particularly in rural areas, and
relatively less on higher levels of education. This approach is
focused on use of formal and "non-formal" education (i.e., organized
education outside the schoolroom setting) to assist in meeting the
human resource requirements of the development process, including
such things as rural literacy programs aimed at agriculture, family
planning, or other development goals.
Recommendations
1. Integrated basic education (including applied literacy) and
family planning programs should be developed whenever they appear to
be effective, of high priority, and acceptable to the individual
country. AID should continue its emphasis on basic education, for
women as well as men.
2. A major effort should be made in LDCs seeking to reduce birth
rates to assure at least an elementary school education for
virtually all children, girls as well as boys, as soon as the
country can afford it (which would be quite soon for all but the
poorest countries). Simplified, practical education programs should
be developed. These programs should, where feasible, include
specific curricula to motivate the next generation toward a
two-child family average to assure that level of fertility in two or
three decades. AID should encourage and respond to requests for
assistance in extending basic education and in introducing family
planning into curricula. Expenditures for such emphasis on increased
practical education should come from general AID funds, not
population funds.
II. B. 2. Reducing Infant and Child
Mortality
Discussion:
High infant and child mortality rates, evident in many developing
countries, lead parents to be concerned about the number of their
children who are likely to survive. Parents may over compensate for
possible child losses by having additional children. Research to
date clearly indicates not only that high fertility and high birth
rates are closely correlated but that in most circumstances low net
population growth rates can only be achieved when child mortality is
low as well. Policies and programs which significantly reduce infant
and child mortality below present levels will lead couples to have
fewer children. However, we must recognize that there is a lag of at
least several years before parents (and cultures and subcultures)
become confident that their children are more likely to survive and
to adjust their fertility behavior accordingly.
Considerable reduction in infant and child mortality is possible
through improvement in nutrition, inoculations against diseases, and
other public health measures if means can be devised for extending
such services to neglected LDC populations on a low-cost basis. It
often makes sense to combine such activities with family planning
services in integrated delivery systems in order to maximize the use
of scarce LDC financial and health manpower resources (See Section
IV).
In addition, providing selected health care for both mothers and
their children can enhance the acceptability of family planning by
showing concern for the whole condition of the mother and her
children and not just for the single factor of fertility.
The two major cost-effective problems in maternal-child health
care are that clinical health care delivery systems have not in the
past accounted for much of the reduction in infant mortality and
that, as in the U.S., local medical communities tend to favor
relatively expensive quality health care, even at the cost of
leaving large numbers of people (in the LDC's generally over
two-thirds of the people) virtually uncovered by modern health
services.
Although we do not have all the answers on how to develop
inexpensive, integrated delivery systems, we need to proceed with
operational programs to respond to ODC requests if they are likely
to be cost-effective based on experience to date, and to experiment
on a large scale with innovative ways of tackling the outstanding
problems. Evaluation mechanisms for measuring the impact of various
courses of action are an essential part of this effort in order to
provide feedback for current and future projects and to improve the
state of the art in this field.
Currently, efforts to develop low-cost health and family planning
services for neglected populations in the LDC's are impeded because
of the lack of international commitment and resources to the health
side. For example:
A. The World Bank could supply low interest credits to LDCs for
the development of low-cost health-related services to neglected
populations but has not yet made a policy decision to do so. The
Bank has a population and health program and the program's leaders
have been quite sympathetic with the above objective. The Bank's
staff has prepared a policy paper on this subject for the Board but
prospects for it are not good. Currently, the paper will be
discussed by the Bank Board at its November 1974 meeting. Apparently
there is some reticence within the Bank's Board and in parts of the
staff about making a strong initiative in this area. In part, the
Bank argues that there are not proven models of effective, low-cost
health systems in which the Bank can invest. The Bank also argues
that other sectors such as agriculture, should receive higher
priority in the competition for scarce resources. In addition,
arguments are made in some quarters of the Bank that the Bank ought
to restrict itself to "hard loan projects" and not get into the
"soft" area.
A current reading from the Bank's staff suggests that unless
there is some change in the thinking of the Bank Board, the Bank's
policy will be simply to keep trying to help in the population and
health areas but not to take any large initiative in the low-cost
delivery system area.
The Bank stance is regrettable because the Bank could play a very
useful role in this area helping to fund low-cost physical
structures and other elements of low-cost health systems, including
rural health clinics where needed. It could also help in providing
low-cost loans for training, and in seeking and testing new
approaches to reaching those who do not now have access to health
and family planning services. This would not be at all inconsistent
with our and the Bank's frankly admitting that we do not have all
the "answer" or cost- effective models for low-cost health delivery
systems. Rather they, we and other donors could work together on
experimentally oriented, operational programs to develop models for
the wide variety of situations faced by LDCs.
Involvement of the Bank in this area would open up new
possibilities for collaboration. Grant funds, whether from the U.S.
or UNFPA, could be used to handle the parts of the action that
require short lead times such as immediate provision of supplies,
certain kinds of training and rapid deployment of technical
assistance. Simultaneously, for parts of the action that require
longer lead times, such as building clinics, World Bank loans could
be employed. The Bank's lending processes could be synchronized to
bring such building activity to a readiness condition at the time
the training programs have moved along far enough to permit manning
of the facilities. The emphasis should be on meeting low-cost rather
than high-cost infrastructure requirements.
Obviously, in addition to building, we assume the Bank could fund
other local-cost elements of expansion of health systems such as
longer-term training programs.
AID is currently trying to work out improved consultation
procedures with the Bank staff in the hope of achieving better
collaborative efforts within the Bank's current commitment of
resources in the population and health areas. With a greater
commitment of Bank resources and improved consultation with AID and
UNFPA, a much greater dent could be made on the overall problem.
B. The World Health Organization (WHO) and its counterpart for
Latin America, the Pan American Health Organization (PAHO),
currently provide technical assistance in the development and
implementation of health projects which are in turn financed by
international funding mechanisms such as UNDP and the International
Financial Institutions. However, funds available for health actions
through these organizations are limited at present. Higher priority
by the international funding agencies to health actions could expand
the opportunities for useful collaborations among donor institutions
and countries to develop low-cost integrated health and family
planning delivery systems for LDC populations that do not now have
access to such services.
Recommendations:
The U.S. should encourage heightened international interest in
and commitment of resources to developing delivery mechanisms for
providing integrated health and family planning services to
neglected populations at costs which host countries can support
within a reasonable period of time. Efforts should include:
1. Encouraging the World Bank and other international funding
mechanisms, through the U.S. representatives on the boards of these
organizations, to take a broader initiative in the development of
inexpensive service delivery mechanisms in countries wishing to
expand such systems.
2. Indicating U.S. willingness (as the U.S. did at the World
Population Conference) to join with other donors and organizations
to encourage and support further action by LDC governments and other
institutions in the low- cost delivery systems area.
A. As offered at Bucharest, the U.S. should join donor countries,
WHO, UNFPA, UNICEF and the World Bank to create a consortium to
offer assistance to the more needy developing countries to establish
their own low-cost preventive and curative public health systems
reaching into all areas of their countries and capable of national
support within a reasonable period. Such systems would include
family planning services as an ordinary part of their overall
services.
B. The WHO should be asked to take the leadership in such an
arrangement and is ready to do so. Apparently at least half of the
potential donor countries and the EEC's technical assistance program
are favorably inclined. So is the UNFPA and UNICEF. The U.S.,
through its representation on the World Bank Board, should encourage
a broader World Bank initiative in this field, particularly to
assist in the development of inexpensive, basic health service
infrastructures in countries wishing to undertake the development of
such systems.
3. Expanding Wage Employment Opportunities, Especially
for Women
Discussion
Employment is the key to access to income, which opens the way to
improved health, education, nutrition, and reduced family size.
Reliable job opportunities enable parents to limit their family size
and invest in the welfare of the children they have.
The status and utilization of women in LDC societies is
particularly important in reducing family size. For women,
employment outside the home offers an alternative to early marriage
and childbearing, and an incentive to have fewer children after
marriage. The woman who must stay home to take care of her children
must forego the income she could earn outside the home. Research
indicates that female wage employment outside the home is related to
fertility reduction. Programs to increase the women's labor force
participation must, however, take account of the overall demand for
labor; this would be a particular problem in occupations where there
is already widespread unemployment among males. But other
occupations where women have a comparative advantage can be
encouraged.
Improving the legal and social status of women gives women a
greater voice in decision-making about their lives, including family
size, and can provide alternative opportunities to childbearing,
thereby reducing the benefits of having children.
The U.S. Delegation to the Bucharest Conference emphasized the
importance of improving the general status of women and of
developing employment opportunities for women outside the home and
off the farm. It was joined by all countries in adopting a strong
statement on this vital issue. See Chapter VI for a fuller
discussion of the conference.
Recommendations:
1. AID should communicate with and seek opportunities to assist
national economic development programs to increase the role of women
in the development process.
2. AID should review its education/training programs (such as
U.S. participant training, in-country and third-country training) to
see that such activities provide equal access to women.
3. AID should enlarge pre-vocational and vocational training to
involve women more directly in learning skills which can enhance
their income and status in the community (e.g. paramedical skills
related to provision of family planning services).
4. AID should encourage the development and placement of LDC
women as decision-makers in development programs, particularly those
programs designed to increase the role of women as producers of
goods and services, and otherwise to improve women's welfare (e.g.
national credit and finance programs, and national health and family
planning programs).
5. AID should encourage, where possible, women's active
participation in the labor movement in order to promote equal pay
for equal work, equal benefits, and equal employment
opportunities.
6. AID should continue to review its programs and projects for
their impact on LDC women, and adjust them as necessary to foster
greater participation of women - particularly those in the lowest
classes - in the development process.
4. Developing Alternatives to the Social Security Role Provided
By Children to Aging Parents
Discussion
In most LDCs the almost total absence of government or other
institutional forms of social security for old people forces
dependence on children for old age survival. The need for such
support appears to be one of the important motivations for having
numerous children. Several proposals have been made, and a few pilot
experiments are being conducted, to test the impact of financial
incentives designed to provide old age support (or, more
tangentially, to increase the earning power of fewer children by
financing education costs parents would otherwise bear). Proposals
have been made for son-insurance (provided to the parents if they
have no more than three children), and for deferred payments of
retirement benefits (again tied to specified limits on family size),
where the payment of the incentive is delayed. The intent is not
only to tie the incentive to actual fertility, but to impose the
financial cost on the government or private sector entity only after
the benefits of the avoided births have accrued to the economy and
the financing entity. Schemes of varying administrative complexity
have been developed to take account of management problems in LDCs.
The economic and equity core of these long-term incentive proposals
is simple: the government offers to return to the contracting couple
a portion of the economic dividend they generate by avoiding births,
as a direct trade-off for the personal financial benefits they
forego by having fewer children.
Further research and experimentation in this area needs to take
into account the impact of growing urbanization in LDCs on
traditional rural values and outlooks such as the desire for
children as old-age insurance.
Recommendation:
AID should take a positive stance with respect to exploration of
social security type incentives as described above. AID should
encourage governments to consider such measures, and should provide
financial and technical assistance where appropriate. The
recommendation made earlier to establish an "intermediary"
institutional capacity which could provide LDC governments with
substantial assistance in this area, among several areas on the
"demand" side of the problem, would add considerably to AID's
ability to carry out this recommendation.
5. Pursuing Development Strategies that Skew Income
Growth Toward the Poor, Especially Rural Development Focusing on
Rural Poverty
Income distribution and rural development: The higher a family's
income, the fewer children it will probably have, except at the very
top of the income scale. Similarly, the more evenly distributed the
income in a society, the lower the overall fertility rate seems to
be since better income distribution means that the poor, who have
the highest fertility, have higher income. Thus a development
strategy which emphasizes the rural poor, who are the largest and
poorest group in most LDCs would be providing income increases to
those with the highest fertility levels. No LDC is likely to achieve
population stability unless the rural poor participate in income
increases and fertility declines.
Agriculture and rural development is already, along with
population, the US. Government's highest priority in provision of
assistance to LDCs. For FY 1975, about 60% of the $1.13 billion AID
requested in the five functional areas of the foreign assistance
legislation is in agriculture and rural development. The $255
million increase in the FY 1975 level authorized in the two year FY
1974 authorization bill is virtually all for agriculture and rural
development.
AID's primary goal in agriculture and rural development is
concentration in food output and increases in the rural quality of
life; the major strategy element is concentration on increasing the
output of small farmers, through assistance in provision of improved
technologies, agricultural inputs, institutional supports, etc.
This strategy addresses three U.S. interests: First, it increases
agricultural output in the LDCs, and speeds up the average pace of
their development, which, as has been noted, leads to increased
acceptance of family planning. Second, the emphasis on small farmers
and other elements of the rural poor spreads the benefits of
development as broadly as is feasible among lower income groups. As
noted above spreading the benefits of development to the poor, who
tend to have the highest fertility rates, is an important step in
getting them to reduce their family size. In addition, the
concentration on small farmer production (vs., for example, highly
mechanized, large-scale agriculture) can increase on and off farm
rural job opportunities and decrease the flow to the cities. While
fertility levels in rural areas are higher than in the cities,
continued rapid migration into the cities at levels greater than the
cities' job markets or services can sustain adds an important
destabilizing element to development efforts and goals of many
countries. Indeed, urban areas in some LDCs are already the scene of
urban unrest and high crime rates.
Recommendation:
AID should continue its efforts to focus not just on agriculture
and rural development but specifically on small farmers and on
labor-intensive means of stimulating agricultural output and on
other aspects of improving the quality of life of the rural poor, so
that agriculture and rural development assistance, in addition to
its importance for increased food production and other purposes, can
have maximum impact on reducing population growth.
[**6. Concentration on Education and Indoctrination of The Rising
Generation of Children Regarding the Desirability of Smaller Family
Size**]
Discussion
Present efforts at reducing birth rates in LDCs, including AID
and UNFPA assistance, are directed largely at adults now in their
reproductive years. Only nominal attention is given to population
education or sex education in schools and in most countries none is
given in the very early grades which are the only attainment of
2/3-3/4 of the children. It should be obvious, however, that efforts
at birth control directed toward adults will with even maximum
success result in acceptance of contraception for the reduction of
births only to the level of the desired family size which knowledge,
attitude and practice studies in many countries indicate is an
average of four or more children.
[** The great necessity is to convince the masses of the
population that it is to their individual and national interest to
have, on the average, only three and then only two children. There
is little likelihood that this result can be accomplished very
widely against the background of the cultural heritage of today's
adults, even the young adults, among the masses in most LDCs.
Without diminishing in any way the effort to reach these adults, the
obvious increased focus of attention should be to change the
attitudes of the next generation, those who are now in elementary
school or younger. If this could be done, it would indeed be
possible to attain a level of fertility approaching replacement in
20 years and actually reaching it in 30.**]
Because a large percentage of children from high-fertility, low
income groups do not attend school, it will be necessary to develop
means to reach them for this and other educational purposes through
informal educational programs. As the discussion earlier of the
determinants of family size (fertility) pointed out, it is also
important to make significant progress in other areas, such as
better health care and improvements in income distribution, before
desired family size can be expected to fall sharply. If it makes
economic sense for poor parents to have large families twenty years
from now, there is no evidence as to whether population education or
indoctrination will have sufficient impact alone to dissuade
them.
Recommendation
1. That U.S. agencies stress the importance of education of the
next generation of parents, starting in elementary schools, toward a
two-child family ideal.
2. That AID stimulate specific efforts to develop means of
educating children of elementary school age to the ideal of the
two-child family and that UNESCO be asked to take the lead through
formal and informal education.
General Recommendation for UN Agencies:
As to each of the above six categories State and AID should make
specific efforts to have the relevant UN agency, WHO, ILO, FAO,
UNESCO, UNICEF, and the UNFPA take its proper role of leadership in
the UN family with increased program effort, citing the world
Population Plan of Action. |