Global Health Policy
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April 21, 2008
A New Lens on a Familiar Question: Did Organized Family Planning Efforts Do More Harm Than Good?
Posted by Rachel Nugent at 03:32 PM
*This blog was co-authored by Barbara Seligman, consultant to CGD
In his recently released book, Fatal Misconceptions: The Struggle to Control World Population, Matthew Connelly, an associate professor of history at Columbia, tells a cautionary tale about the arrogance that marked the origins and early history of international 'population control' programs. Of the many topics on which we could post, we focus here on his conclusions about the role of organized family planning programs in helping to reduce fertility rates. Professor Connelly repeats the assertion that family planning efforts explain "less than five percent of fertility levels in developing countries" (p.338). The reader might unwittingly conclude that there is widespread agreement regarding the "five percent" attribution, which is certainly not the case. Here we take a closer look at the analysis where this attribution first appeared, and at a more recent study using "gold standard" data from a controlled experiment that suggests the benefits of organized family planning efforts are significant and go well beyond 'births averted.'
1994, the year of the landmark 4th International Conference on Population and Development held in Cairo, marked a shift away from a narrow view of curbing rapid population growth through organized family planning efforts to a more holistic reproductive health approach. That year economist Lant Pritchett, then with the World Bank and now at Harvard and a Senior non-resident Fellow at the Center, published results of a cross-national study in which he concluded that only five to 10 percent of differences in fertility levels across countries could be attributed to family planning programs or lack of access to contraceptives. Pritchett attributed the vast majority of the difference in fertility levels to demand factors, which he maintained were not affected by contraceptive supply. In repeating this assertion without further discussion Connelly may lead some readers to conclude that in spite of billions of dollars of cumulative investment (and the indignities and physical harm it sometimes caused), international family planning assistance didn't make a difference in slowing fertility and curbing population growth rates.
In his 1994 study Pritchett uses cross-national regression analyses to test the hypothesis that demand for smaller family size - not supply of contraceptives - explains variations in fertility levels across countries. He also reviews evidence from the most important family planning controlled experiment available, the Family Planning and Health Services Project (FPHSP) in Matlab, Bangladesh which was designed to effectively eliminate the costs of using contraception. These costs included the time and money spent traveling to a clinic or other source for contraceptive supplies or advice as well as the costs of social opprobrium of using contraception, which were significant in this conservative district where many women practiced purdah and family planning workers were sometimes stoned. FPHSP’s "doorstep delivery" program ensured the women of Matlab uninterrupted and reliable access to their contraceptive method of choice even during the worst weeks of the rainy season. Pritchett acknowledges that Matlab proves that family planning can have a role in determining fertility. But, he argues, 'fertility is not invariant with respect to the cost of contraception, just that it is sufficiently inelastic to make cost variations an unlikely source for explaining or causing major demographic changes.' Generally speaking, Pritchett contends contraceptive cost should be a minor consideration affecting a person's decision to have another child. To underscore the relative insignificance of contraceptive cost relative to the cost of raising a child, he asks his readers, presumed to be mostly from industrialized countries, 'How many additional automobiles would people buy if motor oil were free?' (p.25)
Since Pritchett published his article, fellow economists Shareen Joshi (University of Chicago) and T. Paul Schultz (Yale University) have completed an exhaustive evaluation of fertility and other health and social consequences associated with the Matlab program. The authors found fertility levels in the program area were 15 percent lower and that fertility was at least one child lower for women between the ages of 30 and 55 (in 1996) compared to the comparison area. Contraceptive use increased and fertility declined more in the program area than in the comparison area where government family planning efforts were underway and fertility declined from more than six to less than four children per woman. Joshi and Schultz' results indicate that reducing the cost of contraceptives, particularly for poorer women who, for a variety of reasons, may not be able to buy contraceptives or for whom the costs of contracepting are especially high, appears to make a significant difference for voluntary reduction of fertility. While Dr. Pritchett acknowledged that reducing the cost of contraception and contracepting in the situation of Matlab, Bangladesh did increase contraceptive use and reduce fertility, he contends that the very high costs of making contracepting 'cheaper than free' as was done under the program mean that it cannot be replicated at the national level. Since 1994 when Pritchett published his article, the FPHPS effort has been extended to the national level. The costs of the 'door-step' model did not prevent this kind of scaling up of the program as Pritchett predicted would be the case.
Joshi and Schultz also look at benefits from the FPHSP that go beyond 'births averted.' They find the program is associated with important non-fertility benefits - not considered by Dr. Pritchett - including improvements to women's health, their economic productivity outside their household and their household assets not present in the comparison area. Professor Connolly's book might have also considered the value of some of these non-fertility benefits associated with organized family planning efforts, especially in settings like Bangladesh where they served as catalysts for important social changes. The realization that fertility was something over which a woman might reliably exercise some control would seem to be a vital first step in encouraging investments in daughters for whom life might hold the possibility of non-reproductive roles. Other side benefits in Bangladesh of the organized family planning programs included that women counselors be hired (eventually more than 25,000 women would serve as Family Welfare Advisers) with civil service benefits otherwise enjoyed mostly by men, and that unrelated men and women worked together in a professional environment.
So, did organized family planning programs do more harm than good? Professor Connelly implies that they did, and advises the public health crusaders of today not lose sight of the important lessons from the family planning past. His wise words and lessons from the past have special significance we believe for the public health 'battlefields' of the 21st century, especially HIV/AIDS. However, we urge Professor Connolly to pay more attention to the evidence regarding some of the good that family planning programs brought to the lives of poor women. In using history to avoid the mistakes of the past in the future, one must recognize the good as well as the bad.
Professor Connelly will appear at the Woodrow Wilson International Center on Tuesday, April 22 from 3:00-5:00, along with Mr. Bob Engleman, Vice President for Programs at the Worldwatch Institute.
Works Consulted
Mary Arends-Kuenning, 2002, "Reconsidering the Doorstep-delivery System in the Bangladesh Family Planning Program," Studies in Family Planning, vol. 33, no.1. March.
Joshi, Shareen and T.Paul Schultz, 2007. Family Planning as an Investment in Development: Evaluation of a Program’s Consequences in Matlab, Bangladesh. Yale University Economic Growth Center, Discussion Paper No.951. February.
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Comments
Of all the responses I have received regarding my book, this is one of the most thoughtful and challenging. The issue is complicated, to say the least, not least because of the way the arguments can affect decisions about whether and how to fund family planning programs now and in the future. I may be wrong, but I wonder whether donors’ concern about controlling fertility rates is one reason why this particular question has received so much attention – prompting Peter Donaldson’s letter to the New York Times, for instance. It is otherwise hard to understand. After all, the book documented many, many other problems with programs premised on changing fertility rates, as opposed to providing decent reproductive healthcare. A crisis mentality, donor driven agendas, short-term targets, and a lack of accountability led well-meaning people to do long-term damage. Even if some readers disagree with the particular point about the impact of family planning on fertility rates, I hope this history might help those dealing with contemporary challenges, such as HIV/AIDS, to avoid repeating the errors of the past. I am therefore deeply grateful to the authors for seizing the opportunity for a dialogue which can clarify the stakes in all of this, which go far beyond the historical reputation of certain individuals and institutions.
I wrote the book with the hope that, by acknowledging this difficult history, the family planning community could turn the page and focus on the many benefits of reproductive healthcare regardless of its effect on fertility rates. But in appearing to be dismissive of the demographic impact, some get the impression that I think family planning programs were a waste of time and money. This is very nearly the opposite of the truth. I wanted to show the opportunities missed, and the damage done, when programs were premised on meeting population targets, including how it made it more difficult to sustain support for reproductive healthcare over the long run. But even flawed programs helped many, many people who might otherwise have been left to their own devices. There were many unintended consequences, and not all of them were bad – such as allowing many thousands of women to enter the workforce for the first time, as Rachel and Barbara point out. And regardless of the intentions of donors, many family planning workers were attentive to the needs of clients and did not treat them as “acceptors.”
Alas, even now, many people support making contraception and abortion available mainly because of the impact they think it will have on population growth. I would like to see Lant Pritchett revisit the issue, and see whether he would come to a different assessment now. I've also had interesting discussions about it with Paul Demeny, who has also said (and written) that the impact has too often been overstated. But I wonder whether we can expect a definitive answer. Different researchers can make plausible arguments for taking different approaches, and there will always be the perception of bias as long as donor concerns loom in the background.
But the reason why I criticize some of the claims for the demographic impact of family planning is not just that I was persuaded that the impact was relatively small, at least compared to factors like increasing women’s access to education and paid employment. If we go on using population growth as a spur to fund family planning programs, where will we be when more and more governments begin to worry about population decline? This will not just be a challenge for rich countries. Sixty-five countries already have fertility rates too low to replace their population. By 2050, the number is projected to grow to 148. Where fertility rates declined more rapidly, population “aging” will also happen more quickly. To the extent that family planning is tethered to arguments for reducing fertility rates, it is vulnerable to those who would oppose access to contraception and abortion in order to raise fertility rates. In Poland, for instance, low fertility is already being cited as a reason to keep abortion illegal.
That is why I am so insistent in the conclusion to my book that we need to provide family planning not to shape population trends, one way or another, but simply because the ability to control one’s fertility is a basic human right. Of course, in making this kind of argument there is always the risk of appearing self-righteous, so I really would like to hear what Rachel and Barbara think. Do they think the possibility of population decline may pose a long-term challenge to the family planning field as it is presently funded and organized? And if so, how should we respond?
Posted by: Matt Connelly at April 25, 2008 05:21 PM