The common strategy for dealing with rapid population growth should encourage constructive actions to lower fertility since population growth over the years will seriously negate reasonable prospects for the sound social and economic development of the peoples involved.
While the time horizon in this NSSM is the year 2000 we must recognize that in most countries, especially the LDCs, population stability cannot be achieved until the next century. There are too many powerful socio-economic factors operating on family size decisions and too much momentum built into the dynamics of population growth to permit a quick and dramatic reversal of current trends. There is also even less cause for optimism on the rapidity of socio-economic progress that would generate rapid fertility reduction in the poor LDCs than on the feasibility of extending family planning services to those in their populations who may wish to take advantage of them. Thus, at this point we cannot know with certainty when world population can feasibly be stabilized, nor can we state with assurance the limits of the world's ecological "carrying capability". But we can be certain of the desirable direction of change and can state as a plausible objective the target of achieving replacement fertility rates by the year 2000.
Over the past few years, U.S. government-funded population programs have played a major role in arousing interest in family planning in many countries, and in launching and accelerating the growth of national family planning programs. In most countries, there has been an initial rapid growth in contraceptive "acceptors" up to perhaps 10% of fertile couples in a few LDCs. The acceleration of previous trends of fertility decline is attributable, at least in part, to family planning programs.
However, there is growing appreciation that the problem is more long term and complex than first appeared and that a short term burst of activity or moral fervor will not solve it. The danger in this realization is that the U.S. might abandon its commitment to assisting in the world's population problem, rather than facing up to it for the long-run difficult problem that it is.
From year to year we are learning more about what kind of fertility reduction is feasible in differing LDC situations. Given the laws of compound growth, even comparatively small reductions in fertility over the next decade will make a significant difference in total numbers by the year 2000, and a far more significant one by the year 2050.
The proposed strategy calls for a coordinated approach to respond to the important U.S. foreign policy interest in the influence of population growth on the world's political, economic and ecological systems. What is unusual about population is that this foreign policy interest must have a time horizon far beyond that of most other objectives. While there are strong short-run reasons for population programs, because of such factors as food supply, pressures on social service budgets, urban migration and social and political instability, the major impact of the benefits - or avoidance of catastrophe - that could be accomplished by a strengthened U.S. commitment in the population area will be felt less by those of us in the U.S. and other countries today than by our children and grandchildren.
In order to assist the development of major countries and to maximize progress toward population stability, primary emphasis would be placed on the largest and fastest growing developing countries where the imbalance between growing numbers and development potential most seriously risks instability, unrest, and international tensions. These countries are: India, Bangladesh, Pakistan, Nigeria, Mexico, Indonesia, Brazil, The Philippines, Thailand, Egypt, Turkey, Ethiopia, and Colombia. Out of a total 73.3 million worldwide average increase in population from 1970-75 these countries contributed 34.3 million or 47%. This group of priority countries includes some with virtually no government interest in family planning and others with active government family planning programs which require and would welcome enlarged technical and financial assistance. These countries should be given the highest priority within AID's population program in terms of resource allocations and/or leadership efforts to encourage action by other donors and organizations.
However, other countries would not be ignored. AID would provide population assistance and/or undertake leadership efforts with respect to other, lower priority countries to the extent that the availability of funds and staff permits, taking into account of such factors as : long run U.S. political interests; impact of rapid population growth on its development potential; the country's relative contribution to world population growth; its financial capacity to cope with the problem; potential impact on domestic unrest and international frictions (which can apply to small as well as large countries); its significance as a test or demonstration case; and opportunities for expenditures that appear particularly cost-effective (e.g. it has been suggested that there may be particularly cost-effective opportunities for supporting family planning to reduce the lag between mortality and fertility declines in countries where death rates are still declining rapidly); national commitment to an effective program.
For both the high priority countries and the lower priority ones to which funds and staff permit aid, the form and content of our assistance or leadership efforts would vary from country to country, depending on each nation's particular interests, needs, and receptivity to various forms of assistance. For example, if these countries are receptive to U.S. assistance through bilateral or central AID funding, we should provide such assistance at levels commensurate with the recipient's capability to finance needed actions with its own funds, the contributions of other donors and organizations, and the effectiveness with which funds can be used.
In countries where U.S. assistance is limited either by the nature of political or diplomatic relations with those countries or by lack of strong government desire. In population reduction programs, external technical and financial assistance (if desired by the countries) would have to come from other donors and/or from private and international organizations, many of which receive contributions from AID. The USG would, however, maintain an interest (e.g. through Embassies) in such countries' population problems and programs (if any) to reduce population growth rates. Moreover, particularly in the case of high priority countries, we should be alert to opportunities for expanding our assistance efforts and for demonstrating to their leaders the consequences of rapid population growth and the benefits of actions to reduce fertility.
In countries to which other forms of U.S. assistance are provided but not population assistance, AID will monitor progress toward achievement of development objectives, taking into account the extent to which these are hindered by rapid population growth, and will look for opportunities to encourage initiation of or improvement in population policies and programs.
In addition, the U.S. strategy should support in these LDC countries general activities (e.g. bio-medical research or fertility control methods) capable of achieving major breakthroughs in key problems which hinder reductions in population growth.
For example, in Mexico our strategy would focus on working primarily through private agencies and multilateral organizations to encourage more government attention to the need for control of population growth; in Bangladesh we might provide large-scale technical and financial assistance, depending on the soundness of specific program requests; in Indonesia we would respond to assistance requests but would seek to have Indonesia meet as much of program costs from its own resources (i.e. surplus oil earnings) as possible. In general we would not provide large-scale bilateral assistance in the more developed LDCs, such as Brazil or Mexico. Although these countries are in the top priority list our approach must take account of the fact that their problems relate often to government policies and decisions and not to larger scale need for concessional assistance.
Within the overall array of U.S. foreign assistance programs, preferential treatment in allocation of funds and manpower should be given to cost-effective programs to reduce population growth; including both family planning activities and supportive activities in other sectors.
While some have argued for use of explicit "leverage" to "force" better population programs on LDC governments, there are several practical constraints on our efforts to achieve program improvements. Attempts to use "leverage" for far less sensitive issues have generally caused political frictions and often backfired. Successful family planning requires strong local dedication and commitment that cannot over the long run be enforced from the outside. There is also the danger that some LDC leaders will see developed country pressures for family planning as a form of economic or racial imperialism; this could well create a serious backlash.
Short of "leverage", there are many opportunities, bilaterally and multilaterally, for U.S. representations to discuss and urge the need for stronger family planning programs. There is also some established precedent for taking account of family planning performance in appraisal of assistance requirements by AID and consultative groups. Since population growth is a major determinant of increases in food demand, allocation of scarce PL 480 resources should take account of what steps a country is taking in population control as well as food production. In these sensitive relationships, however, it is important in style as well as substance to avoid the appearance of coercion.
Two main advances are required for providing safe and effective fertility control techniques in the developing countries:
1. Expansion and further development of efficient low-cost systems to assure the full availability of existing family planning services, materials and information to the 85% of LDC populations not now effectively reached. In developing countries willing to create special delivery systems for family planning services this may be the most effective method. In others the most efficient and acceptable method is to combine family planning with health or nutrition in multi-purpose delivery systems.
2. Improving the effectiveness of present means of fertility control, and developing new technologies which are simple, low cost, effective, safe, long-lasting and acceptable to potential users. This involves both basic developmental research and operations research to judge the utility of new or modified approaches under LDC conditions.
Both of these goals should be given very high priority with necessary additional funding consistent with current or adjusted divisions of labor among other donors and organizations involved in these areas of population assistance.
We know that certain kinds of development policies -- e.g., those which provide the poor with a major share in development benefits -- both promote fertility reductions and accomplish other major development objectives. There are other policies which appear to also promote fertility reduction but which may conflict with non-population objectives (e.g., consider the effect of bringing a large number of women into the labor force in countries and occupations where unemployment is already high and rising).
However, AID knows only approximately the relative priorities among the factors that affect fertility and is even further away from knowing what specific cost-effective steps governments can take to affect these factors.
Nevertheless, with what limited information we have, the urgency of moving forward toward lower fertility rates, even without complete knowledge of the socio-economic forces involved, suggests a three-pronged strategy:
1. High priority to large-scale implementation of programs affecting the determinants of fertility in those cases where there is probable cost-effectiveness, taking account of potential impact on population growth rates; other development benefits to be gained; ethical considerations; feasibility in light of LDC bureaucratic and political concerns and problems; and timeframe for accomplishing objectives.
2. High priority to experimentation and pilot projects in areas where there is evidence of a close relationship to fertility reduction but where there are serious questions about cost-effectiveness relating either to other development impact (e.g., the female employment example cited above) or to program design (e.g., what cost-effective steps can be taken to promote female employment or literacy).
3. High priority to comparative research and evaluation on the relative impact on desired family size of the socio-economic determinants of fertility in general and on what policy scope exists for affecting these determinants.
In all three cases emphasis should be given to moving action as much as possible to LDC institutions and individuals rather than to involving U.S. researchers on a large scale.
Activities in all three categories would receive very high priority in allocation of AID funds. The largest amounts required should be in the first category and would generally not come from population funds. However, since such activities (e.g., in rural development and basic education) coincide with other AID sectoral priorities, sound project requests from LDC's will be placed close to the top in AID's funding priorities (assuming that they do not conflict with other major development and other foreign policy objectives).
The following areas appear to contain significant promise in effecting fertility declines, and are discussed in subsequent sections.
Food is another of special concern in any population strategy. Adequate food stocks need to be created to provide for periods of severe shortages and LDC food production efforts must be reenforced to meet increased demand resulting from population and income growth. U.S. agricultural production goals should take account of the normal import requirements of LDC's (as well as developed countries) and of likely occasional crop failures in major parts of the LDC world. Without improved food security, there will be pressure leading to possible conflict and the desire for large families for "insurance" purposes, thus undermining other development and population control efforts.
Therefore, it is vital that leaders of major LDCs themselves take the lead in advancing family planning and population stabilization, not only within the U.N. and other international organizations but also through bilateral contacts with leaders of other LDCs. Reducing population growth in LDCs should not be advocated exclusively by the developed countries. The U.S. should encourage such a role as opportunities appear in its high level contact with LDC leaders.
The most recent forum for such an effort was the August 1974 U.N. World Population Conference. It was an ideal context to focus concerted world attention on the problem. The debate views and highlights of the World Population Plan of action are reviewed in Chapter VI.
The U.S. strengthened its credibility as an advocate of lower population growth rates by explaining that, while it did not have a single written action population policy, it did have legislation, Executive Branch policies and court decisions that amounted to a national policy and that our national fertility level was already below replacement and seemed likely to attain a stable population by 2000.
The U.S. also proposed to join with other developed countries in an international collaborative effort of research in human reproduction and fertility control covering bio-medical and socio-economic factors.
The U.S. further offered to collaborate with other interested donor countries and organizations (e.g., WHO, UNFPA, World Bank, UNICEF) to encourage further action by LDC governments and other institutions to provide low-cost, basic preventive health services, including maternal and child health and family planning services, reaching out into the remote rural areas.
The U.S. delegation also said the U.S. would request from the Congress increased U.S. bilateral assistance to population-family planning programs, and additional amounts for essential functional activities and our contribution to the UNFPA if countries showed an interest in such assistance.
Each of these commitments is important and should be pursued by the U.S. Government.
It is vital that the effort to develop and strengthen a commitment on the part of the LDC leaders not be seen by them as an industrialized country policy to keep their strength down or to reserve resources for use by the "rich" countries. Development of such a perception could create a serious backlash adverse to the cause of population stability. Thus the U.S. and other "rich" countries should take care that policies they advocate for the LDC's would be acceptable within their own countries. (This may require public debate and affirmation of our intended policies.) The "political" leadership role in developing countries should, of course, be taken whenever possible by their own leaders.
The U.S. can help to minimize charges of an imperialist motivation behind its support of population activities by repeatedly asserting that such support derives from a concern with:
(a) the right of the individual couple to determine freely and responsibly their number and spacing of children and to have information, education, and 1means to do so; and
(b) the fundamental social and economic development of poor countries in which rapid population growth is both a contributing cause and a consequence of widespread poverty.
Furthermore, the U.S. should also take steps to convey the message that the control of world population growth is in the mutual interest of the developed and developing countries alike.
Family planning programs should be supported by multilateral organizations wherever they can provide the most efficient and acceptable means. Where U.S. bilateral assistance is necessary or preferred, it should be provided in collaboration with host country institutions -- as is the case now. Credit should go to local leaders for the success of projects. The success and acceptability of family planning assistance will depend in large measure on the degree to which it contributes to the ability of the host government to serve and obtain the support of its people.
In many countries today, decision-makers are wary of instituting population programs, not because they are unconcerned about rapid population growth, but because they lack confidence that such programs will succeed. By actively working to demonstrate to such leaders that national population and family planning programs have achieved progress in a wide variety of poor countries, the U.S. could help persuade the leaders of many countries that the investment of funds in national family planning programs is likely to yield high returns even in the short and medium term. Several examples of success exist already, although regrettably they tend to come from LDCs that are untypically well off in terms of income growth and/or social services or are islands or city states.
We should also appeal to potential leaders among the younger generations in developing countries, focusing on the implications of continued rapid population growth for their countries in the next 10-20 years, when they may assume national leadership roles.
Beyond seeking to reach and influence national leaders, improved world-wide support for population-related efforts should be sought through increased emphasis on mass media and other population education and motivation programs by the U.N., USIA, and USAID. We should give higher priorities in our information programs world-wide for this area and consider expansion of collaborative arrangements with multilateral institutions in population education programs.
Another challenge will be in obtaining the further understanding and support of the U.S. public and Congress for the necessary added funds for such an effort, given the competing demands for resources. If an effective program is to be mounted by the U.S., we will need to contribute significant new amounts of funds. Thus there is need to reinforce the positive attitudes of those in Congress who presently support U.S. activity in the population field and to enlist their support in persuading others. Public debate is needed now.
Personal approaches by the President, the Secretary of State, other members of the Cabinet, and their principal deputies would be helpful in this effort. Congress and the public must be clearly informed that the Executive Branch is seriously worried about the problem and that it deserves their further attention. Congressional representatives at the World Population Conference can help.
The conclusion of this view is that mandatory programs may be needed and that we should be considering these possibilities now.
This school of thought believes the following types of questions need to be addressed:
Should the U.S. make an all out commitment to major limitation of world population with all the financial and international as well as domestic political costs that would entail?
Should the U.S. set even higher agricultural production goals which would enable it to provide additional major food resources to other countries? Should they be nationally or internationally controlled?
On what basis should such food resources then be provided? Would food be considered an instrument of national power? Will we be forced to make choices as to whom we can reasonably assist, and if so, should population efforts be a criterion for such assistance?
Is the U.S. prepared to accept food rationing to help people who can't/won't control their population growth?
Should the U.S. seek to change its own food consumption patterns toward more efficient uses of protein?
Are mandatory population control measures appropriate for the U.S. and/or for others?
Should the U.S. initiate a major research effort to address the growing problems of fresh water supply, ecological damage, and adverse climate?
While definitive answers to those questions are not possible in this study given its time limitations and its implications for domestic policy, nevertheless they are needed if one accepts the drastic and persistent character of the population growth problem. Should the choice be made that the recommendations and the options given below are not adequate to meet this problem, consideration should be given to a further study and additional action in this field as outlined above.
Below are specific program recommendations which are designed to implement this strategy. Some will require few new resources; many call for major efforts and significant new resources. We cannot simply buy population growth moderation for nearly 4 billion people "on the cheap".
In pursuing these objectives, AID's population resources were focussed on areas of need where action was feasible and likely to be effective. AID has provided assistance to population programs in some 70 LDCs, on a bilateral basis and/or indirectly through private organizations and other channels. AID currently provides bilateral assistance to 36 of these countries. State and AID played an important role in establishing the United Nations Fund for Population Activities (UNFPA) to spearhead multilateral effort in population as a complement to the bilateral actions of AID and other donor countries. Since the Fund's establishment, AID has been the largest single contributor. Moreover, with assistance from AID a number of private family planning organizations (e.g., Pathfinder Fund, International Planned Parenthood Foundation, Population Council) have significantly expanded their worldwide population programs. Such organizations are still the main supporters of family planning action in many developing countries.
AID actions have been a major catalyst in stimulating the flow of funds into LDC population programs - from almost nothing ten years ago, the amounts being spent from all sources in 1974 for programs in the developing countries of Africa, Latin America, and Asia (excluding China) will total between $400 and $500 million. About half of this will be contributed by the developed countries bilaterally or through multilateral agencies, and the balance will come from the budgets of the developing countries themselves. AID's contribution is about one-quarter of the total - AID obligated $112.4 million for population programs in FY 1974 and plans for FY 1975 program of $137.5 million.
While world resources for population activities will continue to grow, they are unlikely to expand as rapidly as needed. (One rough estimate is that five times the current amount, or about $2.5 billion in constant dollars, will be required annually by 1985 to provide the 2.5 billion people in the developing world, excluding China, with full-scale family planning programs). In view of these limited resources AID's efforts (in both fiscal and manpower terms) and through its leadership the efforts of others, must be focussed to the extent possible on high priority needs in countries where the population problem is the most acute. Accordingly, AID last year began a process of developing geographic and functional program priorities for use in allocating funds and staff, and in arranging and adjusting divisions of labor with other donors and organizations active in the worldwide population effort. Although this study has not yet been completed, a general outline of a U.S. population assistance strategy can be developed from the results of the priorities studied to date. The geographic and functional parameters of the strategy are discussed under 2. and 3. below. The implications for population resource allocations are presented under 4.
There are three major factors to consider in judging the seriousness of the problem:
The first is the country's contribution to the world's population problem, which is determined by the size of its population, its population growth rate, and its progress in the "demographic transition" from high birth and high death rates to low ones.
The second is the extent to which population growth impinges on the country's economic development and its financial capacity to cope with its population problem.
The third factor is the extent to which an imbalance between growing numbers of people and a country's capability to handle the problem could lead to serious instability, international tensions, or conflicts. Although many countries may experience adverse consequences from such imbalances, the troublemaking regional or international conditions might not be as serious in some places as they are in others.
Based on the first two criteria, AID has developed a preliminary rank ordering of nearly 100 developing countries which, after review and refinement, will be used as a guide in AID's own funding and manpower resource allocations and in encouraging action through AID leadership efforts on the part of other population assistance instrumentalities. Applying these three criteria to this rank ordering, there are 13 countries where we currently judge the problem and risks to be the most serious. They are: Bangladesh, India, Pakistan, Indonesia, Philippines, Thailand, Egypt, Turkey, Ethiopia, Nigeria, Brazil, Mexico, and Colombia. Out of a total 67 million worldwide increase in population in 1972 these countries contributed about 45%. These countries range from those with virtually no government interest in family planning to those with active government family planning programs which require and would welcome enlarged technical and financial assistance.
These countries should be given the highest priority within AID's population program in terms of resource allocations and/or leadership efforts to encourage action by other donors and organizations. The form and content of our assistance or leadership efforts would vary from country-to-country (as discussed in 3. below), depending on each country's needs, its receptivity to various forms of assistance, its capability to finance needed actions, the effectiveness with which funds can be used, and current or adjusted divisions of labor among the other donors and organizations providing population assistance to the country. AID's population actions would also need to be consistent with the overall U.S. development policy toward each country.
While the countries cited above would be given highest priority, other countries would not be ignored. AID would provide population assistance and/or undertake leadership efforts with respect to other countries to the extent that the availability of funds and staff permits, taking account of such factors as: a country's placement in AID's priority listing of LDCs; its potential impact on domestic unrest and international frictions (which can apply to small as well as large countries); its significance as a test or demonstration case; and opportunities for expenditures that appear particularly cost-effective (e.g. its has been suggested that there may be particularly cost-effective opportunities for supporting family planning to reduce the lag between mortality and fertility declines in countries where death rates are still declining rapidly).
Some of the countries in the high priority group cited above (e.g. Bangladesh, Pakistan, Indonesia, Philippines, Thailand) and some lower priority countries have recognized that rapid population growth is a problem, are taking actions of their own to deal with it, and are receptive to assistance from the U.S. (through bilateral or central AID funding) and other donors, as well as to multilateral support for their efforts. In these cases AID should continue to provide such assistance based on each country's functional needs, the effectiveness with which funds can be used in these areas, and current or adjusted divisions of labor among other donors and organizations providing assistance to the country. Furthermore, our assistance strategies for these countries should consider their capabilities to finance needed population actions. Countries which have relatively large surpluses of export earning and foreign exchange reserves are unlikely to require large-scale external financial assistance and should be encouraged to finance their own commodity imports as well as local costs. In such cases our strategy should be to concentrate on needed technical assistance and on attempting to play a catalytic role in encouraging better programs and additional host country financing for dealing with the population problem.
In other high and lower priority countries U.S. assistance is limited either by the nature of political or diplomatic relations with those countries (e.g. India, Egypt), or by the lack of strong government interest in population reduction programs (e.g. Nigeria, Ethiopia, Mexico, Brazil). In such cases, external technical and financial assistance, if desired by the countries, would have to come from other donors and/or from private and international organizations (many of which receive contributions from AID). The USG would, however, maintain an interest (e.g. through Embassies) in such countries' population problems and programs (if any) to reduce population growth rates. Moreover, particularly in the case of high priority countries to which U.S. population assistance is now limited for one reason or another, we should be alert to opportunities for expanding our assistance efforts and for demonstrating to their leaders the consequences of rapid population growth and the benefits of actions to reduce fertility.
In countries to which other forms of U.S. assistance are provided but not population assistance, AID will monitor progress toward achievement of development objectives, taking into account the extent to which these are hindered by rapid population growth, and will look for opportunities to encourage initiation of or improvement in population policies and programs.
In addition, the U.S. strategy should support general activities capable of achieving major breakthroughs in key problems which hinder attainment of fertility control objectives. For example, the development of more effective, simpler contraceptive methods through bio-medical research will benefit all countries which face the problem of rapid population growth; improvements in methods for measuring demographic changes will assist a number of LDCs in determining current population growth rates and evaluating the impact over time of population/family planning activities.
Some major actions in the area of creating conditions for fertility decline, as described in Section IIB, can be funded from AID resources available for the sectors in question (e.g., education, agriculture). Other actions come under the purview of population ("Title X") funds. In this latter category, increases in projected budget requests to the Congress on the order of $35-50 million annually through FY 1980 -- above the $137.5 million requested by FY 1975 -- appear appropriate at this time. Such increases must be accompanied by expanding contributions to the worldwide population effort from other donors and organizations and from the LDCs themselves, if significant progress is to be made. The USG should take advantage of appropriate opportunities to stimulate such contributions from others.
Title X Funding for Population
+----------------------------------------------------+
| Year Amount ($ million) |
+----------------------------------------------------+
| FY 1972 - Actual Obligations 123.3 |
| FY 1973 - Actual Obligations 125.6 |
| FY 1974 - Actual Obligations 112.4 |
| FY 1975 - Request to Congress 137.5 |
| FY 1976 - Projection 170 |
| FY 1977 - Projection 210 |
| FY 1978 - Projection 250 |
| FY 1979 - Projection 300 |
| FY 1980 - Projection 350 |
+----------------------------------------------------+
These Title X funding projections for FY 1976-80 are general
magnitudes based on preliminary estimates of expansion or
initiation of population programs in developing countries and
growing requirements for outside assistance as discussed in
greater detail in other sections of this paper. These estimates
contemplated very substantial increases in self-help and
assistance from other donor countries.Our objective should be to assure that developing countries make family planning information, educational and means available to all their peoples by 1980. Our efforts should include:
Increased A.I.D. bilateral and centrally-funded programs, consistent with the geographic priorities cited above.
Expanded contributions to multilateral and private organizations that can work effectively in the population area.
Further research on the relative impact of various socio-economic factors on desired family size, and experimental efforts to test the feasibility of larger-scale efforts to affect some of these factors.
Additional bio-medical research to improve the existing means of fertility control and to develop new ones which are safe, effective, inexpensive, and attractive to both men and women.
Innovative approaches to providing family planning services, such as the utilization of commercial channels for distribution of contraceptives, and the development of low-cost systems for delivering effective health and family planning services to the 85% of LDC populations not now reached by such services.
Expanded efforts to increase the awareness of LDC leaders and publics regarding the consequences of rapid population growth and to stimulate further LDC commitment to actions to reduce fertility.
We believe expansions in the range of 35-50 million annually over the next five years are realistic, in light of potential LDC needs and prospects for increased contributions from other population assistance instrumentalities, as well as constraints on the speed with which AID (and other donors) population funds can be expanded and effectively utilized. These include negative or ambivalent host government attitudes toward population reduction programs; the need for complementary financial and manpower inputs by recipient governments, which must come at the expense of other programs they consider to be high priority; and the need to assure that new projects involve sensible, effective actions that are likely to reduce fertility. We must avoid inadequately planned or implemented programs that lead to extremely high costs per acceptor. In effect, we are closer to "absorptive capacity" in terms of year-to-year increases in population programs than we are, for example, in annual expansions in food, fertilizer or generalized resource transfers.
It would be premature to make detailed funding recommendations by countries and functional categories in light of our inability to predict what changes -- such as in host country attitudes to U.S. population assistance and in fertility control technologies -- may occur which would significantly alter funding needs in particular geographic or functional areas. For example, AID is currently precluded from providing bilateral assistance to India and Egypt, two significant countries in the highest priority group, due to the nature of U.S. political and diplomatic relations with these countries. However, if these relationships were to change and bilateral aid could be provided, we would want to consider providing appropriate population assistance to these countries. In other cases, changing U.S.-LDC relationships might preclude further aid to some countries. Factors such as these could both change the mix and affect overall magnitudes of funds needed for population assistance. Therefore, proposed program mixes and funding levels by geographic and functional categories should continue to be examined on an annual basis during the regular USG program and budget review processes which lead to the presentation of funding requests to the Congress.
Recognizing that changing opportunities for action could substantially affect AID's resource requirements for population assistance, we anticipate that, if funds are provided by the Congress at the levels projected, we would be able to cover necessary actions related to the highest priority countries and also those related to lower priority countries, moving reasonably far down the list. At this point, however, AID believes it would not be desirable to make priority judgments on which activities would not be funded if Congress did not provide the levels projected. If cuts were made in these levels we would have to make judgments based on such factors as the priority rankings of countries, then-existing LDC needs, and divisions of labor with other actors in the population assistance area.
If AID's population assistance program is to expand at the general magnitudes cited above, additional direct hire staff will likely be needed. While the expansion in program action would be primarily through grants and contracts with LDC or U.S. institutions, or through contributions to international organizations, increases in direct hire staff would be necessary to review project proposals, monitor their implementation through such instrumentalities, and evaluate their progress against pre-established goals. Specific direct hire manpower requirements should continue to be considered during the annual program and budget reviews, along with details of program mix and funding levels by country and functional category, in order to correlate staffing needs with projected program actions for a particular year.
2. Within this overall strategy, the U.S. should give highest priority, in terms of resource allocation (along with donors) to efforts to encourage assistance from others to those countries cited above where the population problem is most serious, and provide assistance to other countries as funds and staff permit.
3. AID's further development of population program priorities, both geographic and functional, should be consistent with the general strategy discussed above, with the other recommendations of this paper and with the World Population Plan of Action. The strategies should be coordinated with the population activities of other donors countries and agencies using the WPPA as leverage to obtain suitable action.
4. AID's budget requests over the next five years should include a major expansion of bilateral population and family planning programs (as appropriate for each country or region), of functional activities as necessary, and of contributions through multilateral channels, consistent with the general funding magnitudes discussed above. The proposed budgets should emphasize the country and functional priorities outlined in the recommendations of this study and as detailed in AID's geographic and functional strategy papers.
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, non-formal 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 non-traditional 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.
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.
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.
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.
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.
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.
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.
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.
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.
Agriculture and rural development is already, along with population, the U.S. 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.
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.
USDA projections indicate that the quantity of grain imports needed by the LDCs in the 1980s will grow significantly, both in overall and per capita terms. In addition, these countries will face year-to-year fluctuations in production due to the influence of weather and other factors.
This is not to say that the LDCs need face starvation in the next two decades, for the same projections indicate an even greater increase in production of grains in the developed nations. It should be pointed out, however, that these projections assume that such major problems as the vast increase in the need for fresh water, the ecological effects of the vast increase in the application of fertilizer, pesticides, and irrigation, and the apparent adverse trend in the global climate, are solved. At present, there are no solutions to these problems in sight.
The major challenge will be to increase food production in the LDCs themselves and to liberalize the system in which grain is transferred commercially from producer to consumer countries. We also see food aid as an important way of meeting part of the chronic shortfall and emergency needs caused by year-to-year variation at least through the end of this decade. Many outside experts predict just such difficulties even if major efforts are undertaken to expand world agricultural output, especially in the LDCs themselves but also in the U.S. and in other major feed grain producers. In the longer run, LDCs must both decrease population growth and increase agricultural production significantly. At some point the "excess capacity" of the food exporting countries will run out. Some countries have already moved from a net food exporter to a net importer of food.
There are major interagency studies now progressing in the food area and this report cannot go deeply into this field. It can only point to serious problems as they relate to population and suggest minimum requirements and goals in the food area. In particular, we believe that population growth may have very serious negative consequences on food production in the LDCs including over-expectations of the capacity of the land to produce, downgrading the ecological economics of marginal areas, and overharvesting the seas. All of these conditions may affect the viability of the world's economy and thereby its prospects for peace and security.
(1) High priority for U.S. bilateral and multilateral LDC Agricultural Assistance; including efforts by the LDCs to improve food production and distribution with necessary institutional adjustments and economic policies to stimulate efficient production. This must include a significant increase in financial and technical aid to promote more efficient production and distribution in the LDCs.
(2) Development of national food stocks16 (including those needed for emergency relief) within an internationally agreed framework sufficient to provide an adequate level of world food security;
(3) Expansion of production of the input elements of food production (i.e., fertilizer, availability of water and high yield seed stocks) and increased incentives for expanded agricultural productivity. In this context a reduction in the real cost of energy (especially fuel) either through expansion in availability through new sources or decline in the relative price of oil or both would be of great importance;
(4) Significant expansion of U.S. and other producer country food crops within the context of a liberalized and efficient world trade system that will assure food availability to the LDCs in case of severe shortage. New international trade arrangements for agricultural products, open enough to permit maximum production by efficient producers and flexible enough to dampen wide price fluctuations in years when weather conditions result in either significant shortfalls or surpluses. We believe this objective can be achieved by trade liberalization and an internationally coordinated food reserve program without resorting to price-oriented agreements, which have undesirable effects on both production and distribution;
(5) The maintenance of an adequate food aid program with a clearer focus on its use as a means to make up real food deficits, pending the development of their own food resources, in countries unable to feed themselves rather than as primarily an economic development or foreign policy instrument; and
(6) A strengthened research effort, including long term, to develop new seed and farming technologies, primarily to increase yields but also to permit more extensive cultivation techniques, particularly in LDCs.
UNFPA's role was clarified by an ECOSOC resolution in 1973: (a) to build up the knowledge and capacity to respond to the needs in the population and family planning fields; (b) to promote awareness in both developed and developing countries of the social, economic, and environmental implications of population problems; (c) to extend assistance to developing countries; and (d) to promote population programs and to coordinate projects supported by the UNFPA.
Most of the projects financed by UNFPA are implemented with the assistance of organizations of the Untied Nations system, including the regional Economic Commission, United Nations Children's Fund (UNICEF), International Labour Organization (ILO), Food and Agriculture Organization (FAO), United Nations Educational Scientific and Cultural Organization (UNESCO), the World Health Organization (WHO). Collaborative arrangements have been made with the International Development Association (IDA), an affiliate of the World Bank, and with the World Food Programme.
Increasingly the UNFPA is moving toward comprehensive country programs negotiated directly with governments. This permits the governments to select the implementing (executing) agency which may be a member of the UN system or a non-government organization or company. With the development of the country program approach it is planned to level off UNFPA funding to the specialized agencies.
UNFPA has received $122 million in voluntary contributions from 65 governments, of which $42 million was raised in 1973. The Work Plan of UNFPA for 1974-77 sets a $280 million goal for fund-raising, as follows:
a) increasing, subject to congressional appropriation action, the absolute contribution to the UNFPA in light of 1) mounting demands for UNFPA Assistance, 2) improving UNFPA capacity to administer projects, 3) the extent to which UNFPA funding aims at U.S. objectives and will substitute for U.S. funding, 4) the prospect that without increased U.S. contributions the UNFPA will be unable to raise sufficient funds for its budget in 1975 and beyond;
b) initiating or participating in an effort to increase the resources from other donors made available to international agencies that can work effectively in the population area as both to increase overall population efforts and, in the UNFPA, to further reduce the U.S. percentage share of total contributions; and
c) supporting the coordinating role which UNFPA plays among donor and recipient countries, and among UN and other organizations in the population field, including the World Bank.
There are two main elements in this task: (a) improving the effectiveness of the existing means of fertility control and developing new ones; and (b) developing low-cost systems for the delivery of family planning technologies, information and related services to the 85% of LDC populations not now reached.
Legislation and policies affecting what the U.S. Government does relative to abortion in the above areas is discussed at the end of this section.
None of the currently available methods of fertility control is completely effective and free of adverse reactions and objectionable characteristics. The ideal of a contraceptive, perfect in all these respects, may never be realized. A great deal of effort and money will be necessary to improve fertility control methods. The research to achieve this aim can be divided into two categories:
1. Short-term approaches: These include applied and developmental work which is required to perfect further and evaluate the safety and role of methods demonstrated to be effective in family planning programs in the developing countries.
Other work is directed toward new methods based on well established knowledge about the physiology of reproduction. Although short term pay-offs are possible, successful development of some methods may take 5 years and up to $15 million for a single method.
2. Long-term approaches: The limited state of fundamental knowledge of many reproductive processes requires that a strong research effort of a more basic nature be maintained to elucidate these processes and provide leads for contraceptive development research. For example, new knowledge of male reproductive processes is needed before research to develop a male "pill" can come to fruition. Costs and duration of the required research are high and difficult to quantify.
With expenditures of about $30 million annually, a broad program of basic and applied bio-medical research on human reproduction and contraceptive development is carried out by the Center for Population Research of the National Institute of Child Health and Human Development. The Agency for International Development annually funds about $5 million of principally applied research on new means of fertility control suitable for use in developing countries.
Smaller sums are spent by other agencies of the U.S. Government. Coordination of the federal research effort is facilitated by the activities of the Interagency Committee on Population Research. This committee prepares an annual listing and analyses of all government supported population research programs. The listing is published in the Inventory of Federal Population Research.
A variety of studies have been undertaken by non-governmental experts including the U.S. Commission on Population Growth and the American Future. Most of these studies indicate that the United States effort in population research is insufficient. Opinions differ on how much more can be spent wisely and effectively but an additional $25-50 million annually for bio-medical research constitutes a conservative estimate.
1. Short-term approaches: These approaches include improvement and field testing of existing technology and development of new technology. It is expected that some of these approaches would be ready for use within five years. Specific short term approaches worthy of increased effort are as follows:
a. Oral contraceptives have become popular and widely used; yet the optimal steroid hormone combinations and doses for LDC populations need further definition. Field studies in several settings are required.
Approx. Increased Cost: $3 million annually.
b. Intra-uterine devices of differing size, shape, and bioactivity should be developed and tested to determine the optimum levels of effectiveness, safety, and acceptability.
Approx. Increased Cost: $3 million annually.
c. Improved methods for ovulation prediction will be important to those couples who wish to practice rhythm with more assurance of effectiveness than they now have.
Approx. Increased Cost: $3 million annually.
d. Sterilization of men and women has received wide-spread acceptance in several areas when a simple, quick, and safe procedure is readily available. Female sterilization has been improved by technical advances with laparoscopes, culdoscopes, and greatly simplifies abdominal surgical techniques. Further improvements by the use of tubal clips, trans-cervical approaches, and simpler techniques can be developed. For men several current techniques hold promise but require more refinement and evaluation.
Approx. Increased Cost $6 million annually.
e. Injectable contraceptives for women which are effective for three months or more and are administered by para-professionals undoubtedly will be a significant improvement. Currently available methods of this type are limited by their side effects and potential hazards. There are reasons to believe that these problems can be overcome with additional research.
Approx. Increased Cost: $5 million annually.
f. Leuteolytic and anti-progesterone approaches to fertility control including use of prostaglandins are theoretically attractive but considerable work remains to be done.
Approx. Increased Cost: $7 million annually.
g. Non-Clinical Methods. Additional research on non-clinical methods including foams, creams, and condoms is needed. These methods can be used without medical supervision.
Approx. Increased Cost; $5 million annually.
h. Field studies. Clinical trials of new methods in use settings are essential to test their worth in developing countries and to select the best of several possible methods in a given setting.
Approx. Increased Cost: $8 million annually.
2. Long-term approaches: Increased research toward better understanding of human reproductive physiology will lead to better methods of fertility control for use in five to fifteen years. A great deal has yet to be learned about basic aspects of male and female fertility and how regulation can be effected. For example, an effective and safe male contraceptive is needed, in particular an injection which will be effective for specified periods of time. Fundamental research must be done but there are reasons to believe that the development of an injectable male contraceptive is feasible. Another method which should be developed is an injection which will assure a woman of regular periods. The drug would be given by para-professionals once a month or as needed to regularize the menstrual cycle. Recent scientific advances indicate that this method can be developed.
Approx. Increased Cost: $20 million annually.
Family planning services in LDCs are currently provided by the following means:
1. Government-run clinics or centers which offer family planning services alone;
2. Government-run clinics or centers which offer family planning as part of a broader based health service;
3. Government-run programs that emphasize door to door contact by family planning workers who deliver contraceptives to those desiring them and/or make referrals to clinics;
4. Clinics or centers run by private organizations (e.g., family planning associations);
5. Commercial channels which in many countries sell condoms, oral contraceptives, and sometimes spermicidal foam over the counter;
6. Private physicians.
Two of these means in particular hold promise for allowing significant expansion of services to the neglected poor:
1. Integrated Delivery Systems. This approach involves the provision of family planning in conjunction with health and/or nutrition services, primarily through government-run programs. There are simple logistical reasons which argue for providing these services on an integrated basis. Very few of the LDCs have the resources, both in financial and manpower terms, to enable them to deploy individual types of services to the neglected 85% of their populations. By combining a variety of services in one delivery mechanism they can attain maximum impact with the scarce resources available.
In addition, the provision of family planning in the context of broader health services can help make family planning more acceptable to LDC leaders and individuals who, for a variety of reasons (some ideological, some simply humanitarian) object to family planning. Family planning in the health context shows a concern for the well-being of the family as a whole and not just for a couple's reproductive function.
Finally, providing integrated family planning and health services on a broad basis would help the U.S. contend with the ideological charge that the U.S. is more interested in curbing the numbers of LDC people than it is in their future and well-being. While it can be argued, and argued effectively, that limitation of numbers may well be one of the most critical factors in enhancing development potential and improving the chances for well-being, we should recognize that those who argue along ideological lines have made a great deal of the fact that the U.S. contribution to development programs and health programs has steadily shrunk, whereas funding for population programs has steadily increased. While many explanations may be brought forward to explain these trends, the fact is that they have been an ideological liability to the U.S. in its crucial developing relationships with the LDCs. A.I.D. currently spends about $35 million annually in bilateral programs on the provision of family planning services through integrated delivery systems. Any action to expand such systems must aim at the deployment of truly low-cost services. Health-related services which involve costly physical structures, high skill requirements, and expensive supply methods will not produce the desired deployment in any reasonable time. The basic test of low-cost methods will be whether the LDC governments concerned can assume responsibility for the financial, administrative, manpower and other elements of these service extensions. Utilizing existing indigenous structures and personnel (including traditional medical practitioners who in some countries have shown a strong interest in family planning) and service methods that involve simply-trained personnel, can help keep costs within LDC resource capabilities.
2. Commercial Channels. In an increasing number of LDCs, contraceptives (such as condoms, foam and the Pill) are being made available without prescription requirements through commercial channels such as drugstores.17 The commercial approach offers a practical, low-cost means of providing family planning services, since it utilizes an existing distribution system and does not involve financing the further expansion of public clinical delivery facilities. Both A.I.D. and private organizations like the IPPF are currently testing commercial distribution schemes in various LDCs to obtain further information on the feasibility, costs, and degree of family planning acceptance achieved through this approach. A.I.D. is currently spending about $2 million annually in this area.
In order to stimulate LDC provision of adequate family planning services, whether alone or in conjunction with health services, A.I.D. has subsidized contraceptive purchases for a number of years. In FY 1973 requests from A.I.D. bilateral and grantee programs for contraceptive supplies -- in particular for oral contraceptives and condoms -- increased markedly, and have continued to accelerate in FY 1974. Additional rapid expansion in demand is expected over the next several years as the accumulated population/family planning efforts of the past decade gain momentum.
While it is useful to subsidize provision of contraceptives in the short term in order to expand and stimulate LDC family planning programs, in the long term it will not be possible to fully fund demands for commodities, as well as other necessary family planning actions, within A.I.D. and other donor budgets. These costs must ultimately be borne by LDC governments and/or individual consumers. Therefore, A.I.D. will increasingly focus on developing contraceptive production and procurement capacities by the LDCs themselves. A.I.D. must, however, be prepared to continue supplying large quantities of contraceptives over the next several years to avoid a detrimental hiatus in program supply lines while efforts are made to expand LDC production and procurement actions. A.I.D. should also encourage other donors and multilateral organizations to assume a greater share of the effort, in regard both to the short-term actions to subsidize contraceptive supplies and the longer-term actions to develop LDC capacities for commodity production and procurement.
Recommendations: 1. A.I.D. should aim its population assistance program to help achieve adequate coverage of couples having the highest fertility who do not now have access to family planning services.
2. The service delivery approaches which seem to hold greatest promise of reaching these people should be vigorously pursued. For example:
a. The U.S. should indicate its willingness to join with other donors and organizations to encourage further action by LDC governments and other institutions to provide low-cost family planning and health services to groups in their populations who are not now reached by such services. In accordance with Title X of the AID Legislation and current policy, A.I.D. should be prepared to provide substantial assistance in this area in response to sound requests.
b. The services provided must take account of the capacities of the LDC governments or institutions to absorb full responsibility, over reasonable timeframes, for financing and managing the level of services involved.
c. A.I.D. and other donor assistance efforts should utilize to the extent possible indigenous structures and personnel in delivering services, and should aim at the rapid development of local (community) action and sustaining capabilities.
d. A.I.D. should continue to support experimentation with commercial distribution of contraceptives and application of useful findings in order to further explore the feasibility and replicability of this approach. Efforts in this area by other donors and organizations should be encouraged. Approx. U.S. Cost: $5-10 million annually.
3. In conjunction with other donors and organizations, A.I.D. should actively encourage the development of LDC capabilities for production and procurement of needed family planning contraceptives.
Special Footnote: While the agencies participating in this study have no specific recommendations to propose on abortion the following issues are believed important and should be considered in the context of a global population strategy.
No country has reduced its population growth without resorting to abortion.
Thirty million pregnancies are estimated to be terminated annually by abortion throughout the world. The figure is a guess. More precise data indicate about 7 percent of the world's population live in countries where abortion is prohibited without exception and 12 percent in countries where abortion is permitted only to save the life of the pregnant woman. About 15 percent live under statutes authorizing abortion on broader medical grounds, that is, to avert a threat to the woman's health, rather than to her life, and sometimes on eugenic and/or juridical grounds (rape, etc.) as well. Countries where social factors may be taken into consideration to justify termination of pregnancy account for 22 percent of the world's population and those allowing for elective abortion for at least some categories of women, for 36 percent. No information is available for the remaining 8 percent; it would appear, however, that most of these people live in areas with restrictive abortion laws.
The abortion statutes of many countries are not strictly enforced
and some abortions on medical grounds are probably tolerated in
most places. It is well known that in some countries with very
restrictive laws, abortions can be obtained from physicians
openly and without interference from the authorities.
Conversely, legal authorization of elective abortion does not
guarantee that abortion on request is actually available to all
women who may want their pregnancies terminated. Lack of medical
personnel and facilities or conservative attitudes among
physicians and hospital administrators may effectively curtail
access to abortion, especially for economically or socially
deprived women.
2. U.S. Legislation and Policies Relative to Abortion
Although the Supreme Court of the United States invalidated the
abortion laws of most states in January 1973, the subject still
remains politically sensitive. U.S. Government actions relative
to abortion are restricted as indicated by the following Federal
legislation and the resultant policy decisions of the concerned
departments and agencies.
Section 114 of the Foreign Assistance Act of 1961 (P.L. 93-189), as amended in 1974, adds for the first time restrictions on the use of A.I.D. funds relative to abortion. The provision states that "None of the funds made available to carry out this part (Part I of the Act) shall be used to pay for the performance of abortions as a method of family planning or to motivate or coerce any person to practice abortions."
In order to comply with Section 114, A.I.D. has determined that foreign assistance funds will not be used to:
(i) procure or distribute equipment provided for the purpose of inducing abortions as a method of family planning.
(ii) directly support abortion activities in LDCs. However, A.I.D. may provide population program support to LDCs and institutions as long as A.I.D. funds are wholly attributable to the permissible aspects of such programs.
(iii) information, education, training, or communication programs that promote abortion as a method of family planning. However, A.I.D. will continue to finance training of LDC doctors in the latest techniques used in obstetrics-gynecology practice, and will not disqualify such training programs if they include pregnancy termination within the overall curriculum. Such training is provided only at the election of the participants.
(iiii) pay women in the LDCs to have abortions as a method of family planning or to pay persons to perform abortions or to solicit persons to undergo abortions.
A.I.D. funds may continue to be used for research relative to abortion since the Congress specifically chose not to include research among the prohibited activities.
A major effect of the amendment and policy determination is that
A.I.D. will not be involved in further development or promotion
of the Menstrual Regulation Kit. However, other donors or
organizations may become interested in promoting with their own
funds dissemination of this promising fertility control method.
The Public Health Service Act Extension of 1973 (P.L. 93-45)
contains the Church Amendment which establishes the right of
health providers (both individuals and institutions) to refuse to
perform an abortion if it conflicts with moral or religious
principles.
It would be unwise to restrict abortion research for the following reasons:
1. The persistent and ubiquitous nature of abortion.
2. Widespread lack of safe abortion technique.
3. Restriction of research on abortifacient drugs and devices would:
a. Possibly eliminate further development of the IUD.
b. Prevent development of drugs which might have other beneficial uses. An example is methotrexate (R) which is now used to cure a hitherto fatal tumor of the uterus -- choriocarcinoma. This drug was first used as an abortifacient.
Nevertheless, progress in the technology for mass media communications has led to the suggestion that the priority need might lie in the utilization of this technology, particularly with large and illiterate rural populations. While there are on-going efforts they have not yet reached their full potential. Nor have the principal U.S. agencies concerned yet integrated or given sufficient priority to family planning information and population programs generally.
Yet A.I.D.'s work suggests that radio, posters, printed material, and various types of personal contacts by health/family planning workers tend to be more cost-effective than television except in those areas (generally urban) where a TV system is already in place which reaches more than just the middle and upper classes. There is great scope for use of mass media, particularly in the initial stages of making people aware of the benefits of family planning and of services available; in this way mass media can effectively complement necessary interpersonal communications.
In almost every country of the world there are channels of communication (media) available, such, as print media, radio, posters, and personal contacts, which already reach the vast majority of the population. For example, studies in India - with only 30% literacy, show that most of the population is aware of the government's family planning program. If response is low it is not because of lack of media to transmit information.
A.I.D. believes that the best bet in media strategy is to encourage intensive use of media already available, or available at relatively low cost. For example, radio is a medium which in some countries already reaches a sizeable percentage of the rural population; a recent A.I.D. financed study by Stanford indicates that radio is as effective as television, costs one-fifth as much, and offers more opportunities for programming for local needs and for local feedback.
NASA's sixth Applications Technology Satellite was launched into geosynchronous orbit over the Galapagos Islands on May 30, 1974. It will be utilized for a year in that position to deliver health and educational services to millions of Americans in remote regions of the Rocky Mountain States, Alaska and Appalachia. During this period it will be made available for a short time to Brazil in order to demonstrate how such a broadcast satellite may be used to provide signals to 500 schools in their existing educational television network 1400 miles northeast of Rio de Janeiro in Rio Grande do Norte.
In mid-1975, ATS-6 will be moved to a point over the Indian Ocean to begin beaming educational television to India. India is now developing its broadcast program materials. Signals picked up from one of two Indian ground transmitters will be rebroadcast to individual stations in 2500 villages and to ground relay installations serving networks comprising 3000 more. This operation over India will last one year, after which time India hopes to have its own broadcast satellite in preparation.
Eventually it will be possible to broadcast directly to individual TV sets in remote rural areas. Such a "direct broadcast satellite," which is still under development, could one day go directly into individual TV receivers. At present, broadcast satellite signals go to ground receiving stations and are relayed to individual television sets on a local or regional basis. The latter can be used in towns, villages and schools.
The hope is that these new technologies will provide a substantial input in family planning programs, where the primary constraint lies in informational services. The fact, however, is that information and education does not appear to be the primary constraint in the development of effective family planning programs. AID itself has learned from costly intensive inputs that a supply oriented approach to family planning is not and cannot be fully effective until the demand side - incentives and motivations - are both understood and accounted for.
Leaving this vast problem aside, AID has much relevant experience in the numerous problems encountered in the use of modern communications media for mass rural education. First, there is widespread LDC sensitivity to satellite broadcast, expressed most vigorously in the Outer Space Committee of the UN. Many countries don't want broadcasts of neighboring countries over their own territory and fear unwanted propaganda and subversion by hostile broadcasters. NASA experience suggests that the U.S. #notemust tread very softly when discussing assistance in program content. International restrictions may be placed on the types of proposed broadcasts and it remains technically difficult to restrict broadcast area coverage to national boundaries. To the extent programs are developed jointly and are appreciated and wanted by receiving countries, some relaxation in their position might occur.
Agreement is nearly universal among practitioners of educational technology that the technology is years ahead of software or content development. Thus cost per person reached tend to be very high. In addition, given the current technology, audiences are limited to those who are willing to walk to the village TV set and listen to public service messages and studies show declining audiences over time with large audiences primarily for popular entertainment. In addition, keeping village receivers in repair is a difficult problem. The high cost of program development remains a serious constraint, particularly since there is so little experience in validifying program content for wide general audiences.
With these factors it is clear that one needs to proceed slowly in utilization of this technology for the LDCs in the population field.
2. Limited donor and recipient family planning funds available for education/motivation must be allocated on a cost-effectiveness basis. Satellite TV may have opportunities for cost-effectiveness primarily where the decision has already been taken -- on other than family planning grounds -- to undertake very large-scale rural TV systems. Where applicable in such countries satellite technology should be used when cost-effective. Research should give special attention to costs and efficiency relative to alternative media.
3. Where the need for education is established and an effective format has been developed, we recommend more effective exploitation of existing and conventional media: radio, printed material, posters, etc., as discussed under part I above.
In the United States, we do not yet have a domestic population policy despite widespread recognition that we should -- supported by the recommendations of the remarkable Report of the Commission on Population Growth and the American Future.
Although world population growth is widely recognized within the Government as a current danger of the highest magnitude calling for urgent measures, it does not rank high on the agendas of conversations with leaders of other nations.
Nevertheless, the United States Government and private organizations give more attention to the subject than any donor countries except, perhaps, Sweden, Norway and Denmark. France makes no meaningful contribution either financially or verbally. The USSR no longer opposes efforts of U.S. agencies but gives no support.
In the LDCs, although 31 countries, including China, have national population growth control programs and 16 more include family planning in their national health services -- at least in some degree -- the commitment by the leadership in some of these countries is neither high nor wide. These programs will have only modest success until there is much stronger and wider acceptance of their real importance by leadership groups. Such acceptance and support will be essential to assure that the population information, education and service programs have vital moral backing, administrative capacity, technical skills and government financing.
b. The Executive Branch should give special attention to briefing the Congress on population matters to stimulate support and leadership which the Congress has exercised in the past. A program for this purpose should be developed by S/PM with H and AID.
The U.S. should continue to play a leading role in ECOSOC and General Assembly discussions and review of the WPPA.
b. The State Department should also encourage organization of a UNFPA policy staff to consult with leaders in population programs of developing countries and other experts in population matters to evaluate programs and consider actions needed to improve them.
c. A senior officer, preferably with ambassadorial experience, should be assigned in each regional bureau dealing with LDCs or in State's Population Office to give full-time attention to the development of commitment by LDC leaders to population growth reduction.
d. A senior officer should be assigned to the Bureau of International Organization Affairs to follow and press action by the Specialized Agencies of the U.N. in population matters in developing countries.
e. Part of the present temporary staffing of S/PM for the purposes of the World Population Year and the World Population Conference should be continued on a permanent basis to take advantage of momentum gained by the Year and Conference.
Alternate View on 3.c.
c. The Department should expand its efforts to help Ambassadorial and other high-ranking U.S.G. personnel understand the consequences of rapid population growth and the remedial measures possible.
d. The Department would also give increased attention to developing a commitment to population growth reduction on the part of LDC leaders.
e. Adequate manpower should be provided in S/PM and other parts of the Department as appropriate to implement these expanded efforts.