FIRST ANNUAL REPORT ON US INTERNATIONAL POPULATION POLICY

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP79M00467A002500120004-8
• Release Decision: RIFPUB
• Original Classification: C
• Document Page Count: 142
• Document Creation Date: December 14, 2016
• Document Release Date: June 16, 2003
• Sequence Number: 4
• Publication Date: July 30, 1976
• Content Type: MF

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DEPARTMENT OF STATE
NSC UNDER SECRETARIES COMMITTEE
CONFIDENTIAL
NSC-U/DM-130A
July 30, 1976
TO: The Deputy Secretary of Defense
The Assistant to the President for
National Security Affairs
The Director of Central Intelligence
The Chairman of the Joint Chiefs of Staff
The Deputy Secretary of the Treasury
The Under Secretary of Agriculture
The Under Secretary of Commerce
The Under Secretary of Health, Education
and Welfare
The Director, Office of Management and
Budget
The Chairman, Council of Economic Advisers
The Chairman, Council on Environmental
Quality
The Director, National Science Foundation
The Administrator, Agency for International
Development
The Acting Executive Director, Council for
International Economic Policy
SUBJECT: First Annual Report on US International
Population Policy
The Chairman has forwarded the attached Memorandum,
to the President. A copy is provided for your
information.
Attachment:
As stated
Rutherford M.. Poats
Acting Staff Director
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THE DEPUTY SECRETARY OF STATE
WASHINGTON
NSC UNDER SECRETARIES COMMITTEE
CONFIDENTIAL July 29, 1976
NSC-U/DM-130A
MEMORANDUM FOR THE PRESIDENT
Subject: First Annual Report on U.S.
International Population Policy
Responsive to NSDM-314, I submit herewith the first
annual report on International Population Policy,, which
has been prepared by the Interagency Task Force on
Population Policy. The report was approved by all Members
of the Under Secretaries Committee; Treasury submitted a
statement of clarification, which is attached to the
report.
This report develops further the general strategy
set forth in NSSM-200 study (approved by NSDM-314). It
underscores in particular the NSSM-200 recommendation
that the President and the Secretary of State, as well as
our Ambassadors and others, treat the subject of popula-
tion growth as a matter of paramount importance and
address it specifically in their regular contacts with
leaders of other governments, particularly less developed
countries (LDC`s).
In order to maximize U.S. popular and Congressional
understanding and support for our international popula-
tion programs, we recommend that at a suitable time
there be at least a brief public Presidential statement
of our international population policy and objectives.
In the last analysis, the problem must be
resolved by the countries threatened by excessive
population growth. Increasingly, these problems are
being met through specific measures such as better
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education and information programs, better outreach
of family planning services and supplies, the
development of more effective and acceptable means
of contraception, changes in laws and policies to
support family planning such as delayed marriage,
and,. most importantly, the improved status of women.
However, even in the aggregate, we believe that
these approaches are inadequate to cope with the
.total problem. The report (Section II) therefore
emphasizes three additional principal lines of attack
that have already proved successful in several
countries; and we should find ways to encourage
their replication elsewhere: (a) strong direction
from national and provincial leaders; (b) emphasis
on community participation to root family planning
in village life; and (c) integration of health,
family planning, and nutrition, including training
of competent multi-purpose paramedics to provide
fellow villagers with family planning as well as
other medical services. As for (c), Secretary
Kissinger has already advocated this approach at the
United Nations General Assembly Special Session last
September and more recently at the Nairobi United
Nations Conference on Trade and Development.
It should be emphasized that the funding levels
set forth in Section VI of the attached report are
illustrative only.
In the next few months as a matter of high
priority, the Task Force will be directing special
attention to how best to promote and strengthen
effective population strategies in the key 13
countries cited in NSSM-200/NSDM-31.4, including our
estimates of projected funding requirements. In
addition, the Task Force will examine expected
sources and adequacies of food, the relationship
between these patterns and population growth, and
implications for our population and other assistance
programs. Over the longer term, the Task Force
will be assisting AID's continuing efforts to develop
and improve methods by which performance criteria
for our programs in the key 13 and other countries
can be utilized in the most. effective and directed
way.
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Clearly, there is need for an expanded worldwide
effort to cope with the problem. As pointed out in
our assessment (Section I), excessive population
growth is causing serious environmental deterioration,
rising unemployment and underemployment, and a surge
of humanity into cities where jobs, housing, sanita-
tion, and other basic facilities are lacking. These
overcrowded cities are spawning crime, social unrest,
and potential extremism, all with serious strategic
implications. Our own national. security interests
are ultimately affected. As nations increasingly feel
the impact of excessive population growth, interest
grows, and requests for assistance mount in this field.
Any delays in implementing effective population
programs will only make the ultimate problem far more
serious and intractable. Under these circumstances,
we believe there is clear justification for increased
funding levels (generally as recommended in NSSM-200)
which, together with anticipated increased contributions
by recipient nations, other donors, and international
organizations and private voluntary groups, will
result in a more vigorous, effective attack on the
problem.
It is specifically recommended that you:
(a) Approve the general strategy reflected in
this paper, including a Presidential statement
(proposed text is attached) at a suitable time, and
(b) Approve in principle an expansion of AID's
population assistance program. The attached First
Annual Report (specifically in Section VI) sets forth
general program directions as well as illustrative
funding levels.
Charles W. Robinson
Chairman
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U.S. INTERNATIONAL POPULATION POLICY
FIRST ANNUAL REPORT
Prepared by the
INTERAGENCY TASK FORCE ON POPULATION POLICY
May 1976
INTRODUCTION
NSDM-314 of November 26, 1975, requires that the Chair-
man of the NSC Under Secretaries Committee submit annual
reports, the first to be prepared within six months of the
above date, on the implementation of U.S. international
population policies as set forth in the Executive Summary
of NSSM-200, modified by NSDM-314. The first required
annual report is herewith submitted by the Interagency
Task Force on Population Policy, established by the Under
Secretaries Committee for the purpose of coordinating and
implementing the above policy.
The first step taken by the Task Force in implement-
ing the new Presidentially approved policies was to ensure
that all responsible officials in Washington and the field
were informed of the essential content of NSSM-200 and
NSDM-314. It would be difficult to overstress the import-
ance of involvement of our leaders, Ambassadors, and Country
Teams in overseas population issues. In fact, this may be
the most important conclusion of NSSM-200. Our officials
must know about the facts of population growth and be fully
persuaded of the importance of this issue. They must then
find suitable occasion and discreet means to bring the
message most persuasively to the attention of LDC leaders
whose influence is decisive in shaping national policies
and programs. Without this total involvement of our
diplomacy, our efforts will fall far short of the mark.
To this end, and in order to increase U.S. popular
support for involvement in international population pro-
grams, we recommend that there be at some suitable time
at least a brief public Presidential statement of our
international population policy and objectives.
This report is divided into six main sections, as
follows:
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I. The world population crisis: Its dimensions
and responses by nations most affected.
II. Overall U.S. strategy and development of world
commitment to population stabilization.
III. Maximizing efforts and contributions of other
donors and organizations and improved coordina-
tion.
IV. Improved demographic information and database.
V. Biomedical and social sciences research on
broader factors affecting birth rates.
VI. Future direction for our AID programs, with .
projected funding levels for population assist-
ance.
Special attention is called to the interrelationship
between Sections I, II, and VI. Section I is a worldwide
review of the population crisis based on information recently.
received from 77 U.S. Embassies in response to a Task Force
circular instruction. This Section highlights fully as
much as NSSM-200 the serious consequences -- environmental,
economic, social, political, and even strategic -- of current
population growth in many areas of the world, and yet
Embassy responses also serve to underline the rising aware-
ness amongst the LDC's, especially in Asia, of the need for
effective counter-measures.
Section II underscores the need for our dealing with
this worldwide problem as an integral part of our total
diplomacy, specifically recommending how best we can direct
our influence and support: with regard to countries with
varying degrees of commitment toward coping with their
population problem.
Section VI, the major review of AID's population pro-
gram directed in NSDM-314, recommends how, within that broad
framework, our foreign assistance programs can be most effec-
tive, with particular emphasis on future directions and fund-
ing levels of population assistance.
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I. The World Population Crisis: Its Dimensions
and Responses by Nations Most Affected*
A. Embassy evaluations of the world population crisis
largely substantiate the conclusions of NSSM-200, but with
even greater emphasis on the significant impact of popula-
tion growth on environment and on generating unemployment.
Embassy evaluations are somewhat less concerned than NSSM-
200 with regard to the availability of food to meet popula-
tion growth in the immediate future. However, our Ambassadors
see this as a serious threat in the longer run, with the
LDC's increasingly dependent upon food imports, running
deeper and deeper into debt and unable to finance the con-
siderable capital cost involved in adequately expanding food
production.**
B. A majority of our Embassies in Africa, Asia, and
some in Latin America report large pockets of declining agri-
cultural productivity due to widespread slash-and-burn
farming, overgrazing, overcropping, often necessitated by
population pressures. The cutting of forests for firewood
and to clear ground for cultivation is particularly serious
where it undermines soil stability and reduces protection
against erosion. The examples of Nepal and Java are most
striking in this regard, as is the northward and southward
advancement of the Sahara.
C. Embassy responses also emphasize the serious im-
plications of rising unemployment/underemployment, with count-
less millions unable to eke out a living in rural areas,
jamming into already overcrowded cities where living conditions
*This section of the report is responsive to NSDM-3l4's re-
quest that we take a new hard look at the world population
problem. All conclusions in this section are based on a
lengthy analysis (summarized at Annex I) of responses
the Task Force has just received from 77 U.S. Embassies in
less developed countries. In other words, this section
objectively reviews the problem as seen through the eyes
of our Ambassadors and Country Teams.
**This conclusion is generally confirmed by a recent USDA
report which concludes that, unless there is some check on
population growth rates, "there ultimately is no solution
to the world food problem."
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for many are appalling. Such conditions can only spawn
social unrest with serious political and even potential
strategic implications. Embassy responses also underline
the fact that migration abroad is no longer the safety
valve is once was for relieving population pressures.
European countries, in particular, are now more restric-
tive with regard to accepting migrant workers.
D. We were particularly struck by the trouble shaping
up in our own Latin American backyard, basically due to some
of the highest population growth rates in the world. Em-
bassy Mexico points out that the number of "subsistence-
level Mexicans may pose a severe internal security threat;"
and that large numbers of illegal immigrants "could cause
overwhelming political, economic, and social problems in
the United States ..." and that it would be "an understate-
ment to note that our bilateral relations will experience
a great strain." A similar danger is brewing in Hispaniola.
Embassy Santo Domingo reports serious concern over potential
illegal immigration from Haiti and -- should domestic con-
ditions deteriorate -- of the possibility of a Cuban-
Haitian intervention in the Dominican Republic. Embassy
Port-au-Prince agrees that attempts to emigrate illegally
to the Dominican Republic "would lead to stern Dominican
counter-measures and the resumption of open hostilities."
E. Despite these ominous conclusions, Embassy responses
nevertheless point up the fact that more and more countries,
including most of the big population countries, have taken
counter-measures in the form of national policies and pro-
grams to control population growth, though the strength
of their commitment and the efficiency of their programs
vary widely. We conclude from Embassy responses that, of
the 1.8 billion people living in surveyed LDC's (1) 1.3
billion live in 26 countries. whose governments now have
explicit population control programs related to their
national economic development plans*; (2) 462 million live
in 36 countries whose governments accept family planning
as a means of improving maternal/child health but do not
have government programs to limit population growth; and
(3) 91 million live in 15 countries (mostly in Africa)
where there are no population programs, and some of the
governments are pro-natalist.
*With the inclusion of China and North Vietnam, 2.1 billion
people live in 28 LDC countries with explicit anti-natalist
policies.
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F. Some 15 of the LDC's, according to Embassy reports,
have already significantly reduced their birth rates. They
include: China, Thailand, Republic of Korea, Colombia,
Taiwan, Sri Lanka, Malaysia, Tunisia, Singapore, Jamaica,
Costa Rica, Panama, Trinidad and Tobago, Mauritius, and
Barbados. Additionally, Indonesia and the Philippines
and at least parts of India (e.g., Kerala) have hopeful
outlooks in fertility reduction.
G. On the other hand, our Embassies note persistent
obstacles to acceptance of birth control in the LDC's
including all the factors mentioned in NSSM-200 but also
underscoring the fact that program implementation is badly
handicapped in a number of countries through lack of
executive talent (e.g., Egypt, Kenya, Ghana, Haiti, Iran,
Malyasia, Nicaragua, Mali, Botswana, Nepal, Ecuador, .
Liberia) and shortages of professional manpower. Political
sensitivities -- re birth control issues -- also impede
vigorous implementation of governments' declared family
planning policy in some countries such as Turkey, Morocco
and Malaysia.
H. The overall conclusion to be drawn from Embassy
reports is that current LDC population growth poses serious
problems, but this is counter-balanced to some extent by
encouraging evidence of greater attention to population
policies on the part of most of the LDC's, significantly
including the three largest: China, India, and Indonesia.
II. Overall U.S. Strategy and Development of World
Commitment to Population Stabilization
A. U.S. strategy in dealing with the world population
problem proceeds from a recognition of the disastrous impli-
cations of current population growth rates (including threats
to our national security), and yet a counter-balancing recog-
nition that the problem can be significantly eased if the
nations of the world take prompt and effective counter-
measures. The main task is up to nations handicapped by
excessive population growth, which includes almost all the
developing world. But these nations need outside help, and
it must be our principal task to see that, in cooperation
with other donor nations and organizations, we render
effective assistance, when requested and desirable.
B. Whatever promotes stability, economic development,
better health, improved education, and so on, particularly
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as such measures broaden opportunities for women, will also
create a more favorable setting for reducing current ex-
cessive population growth. rates which in turn should induce
countries to become committed to population stabilization.
We therefore draw attention not only to the specific re-
commendations relating to AID programs in Section VI below
but also to the need for overall assistance to the develop-
ing world along lines of the proposals made by Secretary
Kissinger before the Seventh United Nations General Assembly
Special Session and his specific suggestions made more
recently before the UNCTAD Conference at Nairobi.
C. In the case of countries that have an announced
national policy on family planning and development (here-
after termed the "committed countries"), the U.S. should,
in addition to its current AID programs, discreetly promote
three approaches that are interrelated and have proved
highly effective:
1. Encourage national leaders to speak out clearly
and firmly in support of broad-based population
programs, while maintaining discipline down the line
to see that population policies are properly adminis-
tered and implemented, particularly at the village
level where most people live;
2. Encourage these countries to adopt innovative
approaches (which have already proved successful in
several countries), designed to root family planning
in the villages, relating family planning to the
economic interests of the community, and thus creating
peer pressures for limiting the size of families;
3. Train paramedics, midwives, volunteers, and others
to provide general health services, including family
planning in villages where these people are known and
trusted. This extended personalized family planning
advice, to be most effective, must reach women before
they become mothers (so first births can be postponed
if women so wish) and at least from the moment they
have their first child, when spacing of children should
be strongly recommended. Sterilization should be offered
when the desired family size has been reached.
D. We recommend that U.S. officials refrain from public
comment on forced-paced measures such as those currently
under active consideration in India. The Indian Government's
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demand for accelerated action is understandable, but there
are moral considerations as well as practical obstacles to
involuntary sterilization programs (inadequacy of medical,
legal, and administrative facilities), and they might have
an unfavorable impact on existing voluntary programs. This
is not to be confused with a variety of individual and com-
munity incentive schemes the Indian authorities have under
consideration to promote voluntary sterilization and other
forms of contraception.
E. In the case of LDC countries uncommitted to popula-
tion programs, our efforts must be fine-tuned to their par-
ticular sensitivities and attitudes. In the main, we should
avoid the language of "birth control" in favor of "family
planning" or "responsible parenthood," with the emphasis
being placed on child spacing in the interests of the health
of child and mother and the well-being of the family and
community. Introduction and extension of primary health
services are, in fact, the principal ways of successfully
introducing family planning into many of these countries.
We should also find ways, such as through informal personal
contacts and special graphic presentations, to show leaders
how current growth rates detract from their countries'
economic development prospects. This, together with econ-
omic and demographic training of promising LDC officials,
is particularly important in view of widespread unawareness
of the economic facts of life, including wishful thinking
that economic development will automatically resolve the
population problem. Other recommended steps in dealing
with the non-committed countries are to be found in
Annex II.
F. We should lend even stronger support to worldwide
efforts for the improved status of women and for their active
participation in community and national life. The advancing
status of women in parts of Asia and Latin America has evi-
dently been a major factor in promoting successful family
planning and in reducing birth rates.
G. In order to increase U.S. population support for
involvement in international population programs, it would
be helpful at some suitable time and occasion to have at
least a brief public Presidential statement of our inter-
national population policy and objectives, in the context
of our desire to improve conditions of life for mankind for
endless generations to come. In all our statements, we
should accent the positive, though warning that effective
solutions will require the concentrated, sustained efforts
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of nations and international organizations.as well as the
cooperative involvement of millions of dedicated people.
We should ensure that all countries have the benefit of
learning about approaches that have proved successful and
might have wider applicability.
H. We must nevertheless be selective and low-key in
our approaches, lest population programs otherwise be seen
as primarily serving U.S. interests rather than those of
other countries. That is why it is so important that the
LDC's take more of a lead on population issues at inter-
national conferences and at home. A great deal of our
work must involve personal contacts with men and women of
influence in the LDC's and in donor countries, as well as
with our Congress, the media, U.S. organizations, and
groups of concerned citizens. We must help ensure that
international organizations like IBRD, WHO, UNDP, UNICEF,
and UNFPA, as well as private voluntary organizations, play
an active, positive role in support of population programs,
although we do not believe that further Bucharest-type
meetings on population issues would serve any useful pur-
pose at this time. The focus should now be on effective
implementation of the Bucharest Plan of Action.
I. Over the next year, the Task Force will devote
special attention to the five major population countries
(Brazil, Nigeria, Egypt, Turkey, and Ethiopia) where there
is little or no action in the population field; as well as
to the other eight countries of the "big 13" listed in
NSSM-200 (India, Indonesia, Bangladesh, Pakistan, Philippines,
Thailand, Mexico, Colombia) which have active population
programs, but where in most cases performance can be
improved.
III. Maximizing Efforts and Contributions of Other
Donors and Organizations and Improved Coordination
A. At a time when there is growing LDC concern and
interest in combatting excessive population growth, it is
particularly important that as many financial resources as
possible are brought to bear on the problem, including
assistance from other donor states as well as international
organizations. While U.S. population assistance declined
in 1974 and 1975 due to reduced appropriations, the contri-
butions of other donor countries rose from $40 million in
1973 to $80 million in 1975 (about 1/3 of which was directed
through UNFPA and IPPF); and further increases are projected
for 1976. However, such key countries as the Federal Republic
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of Germany, Sweden, and Belgium may be leveling off their
population assistance. Our ability to play the leadership
role stipulated in NSDM-314 and our success in getting other
donor nations to do more will necessarily relate to increasing
our own population assistance funding.*
B. If the U.S. announces its intention to increase its
funding, we will be in a better position to carry out a major
effort to get other donors to increase their funding beginning
later this year. In addition to the traditional donors, we
should also encourage the newly rich, oil-producing states to
make contributions to the UNFPA, using the recent Libyan
($1 million) and Algerian ($500,000) contributions as a basis.
The most effective channels in this regard are likely to be
UNFPA or representatives of countries which have particularly
close ties with the oil-producing states.
C. There is also need for improved coordination efforts
amongst donors, particularly since many donors are now re-
examining their overall development assistance programs in the
context of population growth and are also giving greater atten-
tion to programs which provide improved basic integrated health/
family planning/nutrition services with maximum rural outreach.
With regard to coordination within countries, experience
indicates that it can best be achieved in the capital of the
recipient country through a group consisting of representatives
of that country and all donor countries and organizations
concerned. Although such formal groups are occasionally
unacceptable to the host country for political reasons, some
degree of coordination, however informal, is advisable in
order that priority needs are met with minimum overlap and delay.
D. For international coordination, we recommend a three-
tiered mechanism. First, general coordination of the population
activities of donor nations could take place in the OECD
Development Assistance Committee (DAC), with associated inter-
national organizations participating. Second, questions of
population program funding levels and the impact of general
development programs on fertility could be discussed at other
meetings such as the "Tidewater" Conferences which are attended
by heads of donor aid agencies. Third, senior officials
specifically concerned with population assistance could discuss
program design, recipient country problems, and other technical
questions at periodic meetings which focus on specific issues.
Efforts are already beginning in this direction.
* OMB Member questions this statement on the grounds that, as
the major and most experienced donor in the field, the United
States could presumably continue to play a leading role even
if total funding remained level.
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E. The United Nations Fund for Population Activities
(UNFPA) and the private International Planned Parenthood
Federation (IPPF) represent the two most important channels
for assistance provided through international organizations.
and private intermediaries. These intermediaries can operate,
though sometimes with limited efficiency, in countries where
AID's bilateral assistance programs are not now acceptable.
In over half of the key 1.3 NSSM-200 countries, the total U.S.
effort is limited to our indirect support for activities of
these intermediaries.
F. International and regional awareness of the problem
of population growth has essentially been achieved; the time
for national action is upon us. In response to country re-
quests, the UNFPA is shifting from regional to specific coun-
try programs for which 80% of its 1977 budget will be allocated,
either directly or through other UN agencies. However, UNFPA
has not concommittantly shifted its program content emphasis
from "consciousness raising" to the delivery of effective
family planning services/information and to efforts to
use development policies and programs more generally to
affect fertility. We recommend that we use our influence
through our UN delegation and in donor and recipient nation
capitals to seek such a shift. Moreover, we must continue to
press UNFPA to improve the efficiency of its operations.
G. In the past, the UN Specialized Agencies (SA's),
e.g., FAO, ILO, UNESCO, UNICEF, and WHO, have administered
most of UNFPA's operational programs using UNFPA funds.
The SA's have used only limited amounts of their own re-
sources for population programs and even then only for
general and academic purposes rather than country specific
and practical ones. As a. result, we support the current
trend in UNFPA to administer more of its own projects and
the related need for increased staff and monitoring capa-
bility. We recommend, however, that UNFPA maintain liaison
with the SA's to ensure that SA projects support fertility
reduction. In addition, we recommend that the U.S. dele-
gations to the various SA's be instructed to support coor-
dination with the UNFPA and to push for consideration of
secondary fertility reduction effects in SA projects.
H. Assuming that (1) the trends toward UNFPA-administered
country-specific programs continue; (2) program content begins
to shift as indicated in paragraph F; and (3) UNFPA program
efficiency generally improves, we plan to increase our UNFPA
contribution in order to bridge the current UNFPA gap between
contributions ($76 million) and promising assistance requests
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($105 million). This increase would be additive to the
proposed expansion of the U.S. bilateral efforts espoused
in Section VI.
I. Unlike UNFPA, IPPF and other private population-
oriented intermediaries do not require explicit country
agreements to operate. As private organizations, they
require only acquiescence. As a result, they operate in
the eight NSSM-200 big population countries in which the
U.S. does not have bilateral population programs, most
importantly in those whose governmental commitment to
family planning is limited or non-existent, i.e., Brazil,
Ethiopia, Nigeria, and Turkey. Through local subsidiary
organizations, intermediaries like IPPF can act as local
family planning advocates using local community leaders,
a role no foreign government or international organiza-
tion can hope to play. Although contributions to private
voluntary population-oriented organizations mean less
direct control of programs, we recommend, for reasons
enumerated above, that AID continue to extend financial
support to these groups provided they can program funds
roughly according to the directions we outline in Section
VI below and provided they can demonstrate that funds will
be used with reasonable efficiency.
J. The World Bank Group is the principal international
financial institution providing population programs. However,
the Bank's policy prevents it from financing consumables
such as contraceptives and other family planning commodi-
ties. This restricts its ability to finance population
projects with its available funds. At present a high-
level outside consultant group is evaluating the Bank's
population programs. This evaluation and our review of
it should help provide a clearer picture of what improve-
ments there might be in the Bank's role and activities in
the population field.
K. In addition, given the important secondary effects
on fertility that general development efforts can have, we
recommend that the Bank analyze the population impact of all
its new projects, especially those in the newly constituted
project area of nutrition.
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L. As UNFPA has more demands for its assistance than
it can fund, and as the World Bank is willing to provide
more population assistance if promising requests exist, we
recommend that the Bank coordinate with UNFPA to determine
if some of these outstanding requests for population assist-
ance can be met.
IV. Improved Demographic Information and Data Base*
A. U.S. policy in this field should focus on (1) in-
creasing the flow of accurate and timely demographic informa-
tion and (2) improving the demographic data base in both
quantity and quality by:
1. Improving LDC capabilities to participate in both
shorter and longer-term detailed survey activities.
which will generate more immediate information about
the effectiveness of health, family planning, and
related development assistance programs; and
2. Improving the capabilities of LDC's to partici-
pate. in longer-term population census activities.
B. Given severely limited AID resources, primary
emphasis should be given to the first area because of the
urgent need to produce data in connection with on-going and
projected studies and to take advantage of the opportunity
to include the collection of data as an.integral part of
such programs. It is clear, however, that U.S. support for
the latter, particularly the 1980 census program, should.
continue through U.S. assistance to activities basic to
censuses such as training, computer software packages, and
technical advisory services.
C. In the months ahead, activities in this field will
be considered in light of available resources, other demands
on these resources, and opportunities to relate them to pro-
grams of other agencies active in this field, including the
United Nations and other international. agencies.
This draws on a special report by the Bureau of the Census.
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V. Biomedical and Social Sciences Research on
Broader Factors Affecting Birth Rates
A. The review of current research programs of the
various agencies suggests limited change in prospective
future actions in the various research areas. However,
there is need for better focus and coordination among the
two principal Federal agencies concerned: AID, which has
been the leader in international population research, parti-
cularly as applied to developing countries; and the Center
for Population Research in the National Institutes of
Health, which has the world's largest research effort in
population.
B. In coordination with NIH, AID should moderately
expand its biomedical research effort, especially focusing
on developing new and promising contraceptive methods
(particularly reversible sterilization and injectibles)
that will be appropriate to the needs of the LDC's, and
exploring the adverse side effects of current contracep-
tive methods on various population groups among whom
peculiar side reactions might be anticipated. NIH, in
coordination with AID, should also pursue its biomedical
research, which is oriented more to developed countries
like the U.S. but frequently with potential worldwide
application.
C. AID should expand its LDC-based research on com-
parative effectiveness of family planning systems with par-
ticular emphasis on low cost/village-based services using
health auxiliaries and laymen, and it should continue to
address the desirability and feasibility of integrating
health, nutrition, and family planning services in a
variety of ways in different circumstances.
D. AID should expand its social sciences research on
the links between fertility and various aspects of develop-
ment, particularly female education and employment, health
conditions (especially of children), incentives/disincentives
to encourage small families, income growth and distribution,
and laws and policies which are supportive of family plan-
ning. Additional research is also needed on the implica-
tions of population growth for development.
E. The Center for Population Research in the National
Institute of Child Health and various philanthropic agencies
of the United States should also continue their work on the
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development of contraceptive methods. Field-testing of new
contraceptive methods in the LDC's should be only on request
and with approval of the local government, and should have
as its prime objective a benefit for the particular people
upon whom it is being tested.
F. Finally, the Interagency Committee on Population
Research should develop a plan for the improvement of coor-
dination among the various U.S. public and private agencies
to ensure maximum productivity from public outlays. Similarly,
the U.S. should encourage closer coordination with the research
programs of other international donors to provide maximum
exchange of information and earlier exploitation of prospec-
tive breakthroughs.
VI. Future Direction for our AID Programs, with
Projected Funding Levels for Population Assistance
A. This Section of the report relates how, within the
broad framework of the preceding Sections, our foreign
assistance programs can best achieve the most voluntary
reduction in fertility with limited funds. We fully support
the conclusions of NSSM-200 that far greater efforts, in-
cluding more U.S. population assistance, will be required
to cope adequately with world population growth. The need
is compelling (see Section I); the interest and demand
are rising (see Section II). Moreover, more attention
must be given to the potential indirect impact on fertility
of development programs and policies in general.
B. This broad-gauge approach could reduce fertility
dramatically in the next decades, but the population prob-
lem cannot soon be erased. Because of the youthful age
structure of the populations of today's developing coun-
tries, population growth will persist for some time to
come, even if the two-child family should suddenly become
the norm.
C. In response to NSSM-200 and NSDM-314, AID had
undertaken a broad review of efforts (particularly U.S.-
assisted efforts) to reduce fertility. Based on this
analysis, AID has established program directions for
population-related assistance over the next several years.
D. Consistent with the findings of NSSM-200 and NSDM-
314, due priority is given to the 13 big population growth
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countries (Brazil, Colombia, Mexico, Nigeria, Ethiopia,
Egypt, Turkey, Bangladesh, India, Pakistan, Indonesia,
Philippines, and Thailand). AID has given major assist-
ance directly or indirectly to Colombia, India, Bangladesh,
Pakistan, Indonesia, Philippines, and Thailand. But India,
Brazil, and Mexico do not now desire U.S. bilateral assist-
ance; Colombia has asked AID to phase out; Turkey has taken
only limited steps; and Nigeria and Ethiopia have shown
little or no interest in their population problems. Each
of the 13 countries poses special problems; the courses
appropriate to each country are not the same.
E. In the past several months, useful high-level
meetings on population issues have been held with Asian
leaders. As a result, our Embassies report both the
Philippines and Pakistan are undertaking additional
measures to make contraceptives more widely available to
the villages. Other steps are under active consideration
to promote family planning measures in Brazil, Colombia,
and Egypt. In the countries not desiring bilateral U.S.
population assistance, particular attention is paid to
specific opportunities to assist through intermediaries
(e.g., IPPF or UNFPA) that can operate efficient pro-
grams along the directions outlined below.
F. Moreover, AID seeks additional opportunities to
assist in a limited number of other countries where pros-
pects for demographic impact are bright or where experience
applicable to major countries can be gained. Specific
country program strategies will be developed and reviewed
in the next year in the context of the overall program
directions described below.
G. Designing programs to reduce fertility must take
into consideration individual couples' choices about child-
bearing and family planning. Couples need not affirmatively
decide to have a child. But they must affirmatively decide
to practice family planning. Consciously or unconsciously,
they weigh the pros and cons of another child against the
pros and cons of available means of family planning. Their
attitudes toward family planning depend on the type, cost,
and accessibility of the services available to them and also
on the extent to which they accurately understand those ser-
vices. Their views on the desirability of a child are most
complex, and depend largely on the social, cultural, and
economic milieu.
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H. Providing better family planning services and
information is the most obvious way to tip parental deci-
sions in favor of family planning. Better services and
information can avert extra births that couples do not
affirmatively seek. They can also help reduce insurance
births as wider spacing of pregnancies helps to improve
the health of existing children. Less obviously, they
can indirectly influence the number of children parents
seek; for as services change family size, they help
modify future family-size norms.
I. Thus, most population programs have concentrated
on developing and extending better family planning services
and information. Over the past decade, AID has devoted
some $750 million to population assistance, primarily to
improve and extend services and information. While it is
difficult to quantify the demographic impact precisely,
available evidence indicates that AID assistance has been
quite significant, particularly in Asia. Since services
are as yet really accessible to only about 15% of most
LDC populations, expansion of AID population assistance
of this sort should bring about further birth-rate reduc-
tions. A principal focus of the program directions is on
determining more accurately what assistance measures work
best. While the Annex (and other studies available
to those interested) summarize available evidence, there
is as yet no litmus test to guide us in predicting the
most successful program mix in each country setting.
Similarly, there are as yet no universally applicable per-
formance criteria, but benchmarks are established for
assessing program performance that reflect individual
country conditions.
J. But family planning services and information alone
will not likely bring birth rates down to current LDC tar-
get levels, much less to stable population levels which would
require an average family of only slightly more than two
children. As emphasized at the World Population Conference
and elsewhere, many parents apparently want three or more
children even when safe, effective, acceptable, and afford-
able family planning services are readily available. Thus,
development policies and programs can be specifically
tailored to change the social, cultural, and economic
milieu to encourage smaller families, thereby effectively
complementing better family planning services and informa-
tion. The policy options vary widely, but improving the
status of women and increasing their basic opportunities
is apparently of fundamental importance in lowering fer-
tility. Finally, and most importantly, the types of
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measures specified in Section II above with regard to
leadership direction, community approaches, etc., should
help influence decisions for smaller family sizes.
K. Program Directions: Consistent with the broad
policy emphasis described above, this section sets forth
AID's program directions in two parts -- (1) Population
Assistance and (2) Other AID and P.L. 480 Assistance.
(1) AID Population Assistance
L. As in the past, AID population assistance funds
will be used primarily for family-planning service delivery;
education and publicity programs; training of family plan-
ning personnel; directly relevant research; provision of
population-related components in broader education, health,
nutrition, rural development, and other programs; and ex-
ploration of the links between development and fertility.
The new emphasis will be reflected in the program mix as
indicated below.
M. A major AID thrust in family-planning service
delivery, as in the broader health area, will be the develop-
ment of less expensive and more widely dispersed systems of
service delivery capable of reaching the large masses of the
poor, and particularly of the rural poor. The expensive and
usually urban clinics with which family planning programs
have typically started cannot reach the rural poor. Thus,
AID is vigorously encouraging development and extension of
basic, low-cost, village-based services. This will involve
both greater use of paramedical and volunteer staff and inte-
gration of health, nutrition, and family planning efforts at
the lowest sensible level.
N. AID's program directions are arrayed in six func-
tional categories of assistance and are as follows:
Category 1: Demographic Data
-- Place less emphasis on relatively less detailed
censuses (see Section IV above).
-- Moderately expand efforts to develop more detailed
demographic data to permit better program-impact
analysis.
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Category 2: Population Policy
Moderately expand research, particularly LDC-based,
on linkages between fertility and various aspects of
development, particularly including:
a)
female
education of various types and levels;
b)
female
employment;
c)
health
(especially of children) ;
d)
nutritional stratus of women and children;
e)
incentives/disincentives to encourage smaller
families;
f) income growth, distribution, and rural develop-
ment (especially as to food);
g) laws and policy statements supporting family
planning.
-- Moderately expand. measures to bring out the develop-
ment implications of population growth and the
potential for influencing fertility through develop-
ment programs.
-- Moderately expand pilot projects and experiments in
areas a)-f) above, providing technical assistance or
financial support.
Category 3: Research
a) Bio-medical Research*
-- Moderately expand projects to field-test internationally
promising new family planning methods.
-- Moderately expand research to develop or improve new
methods (especially once-monthly methods and reversible
sterilization) and international research on side
effects of available methods, especially pills, among
particular users.
-- Moderately expand research on the relationship bet-
ween nutritional status and fertility.
*Subject.to legislative restrictions, e.g., the Helms Amend-
ment which prohibits support for abortion-related assist-
ance other than research.
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b) Operations Research
-- Sharply expand LDC-based research on the compara-
tive effectiveness of alternative approaches to
family planning services and information, focusing
particularly on low-cost, village-based distribu-
tion using health auxiliaries, etc.
-- Sharply expand research on the extent to which such
village-distribution schemes require clinic backup.
-- Moderately expand research on prospects for LDC pro-
duction of contraceptives and other family planning
supplies.
Category 4: Family Planning Services
-- Encourage provision. of a variety of family planning
methods, particularly pills, condoms, and steriliza-
tion.*
-- Sharply increase efforts to help establish and expand
village-based distribution of family planning services
in rural areas particularly through low cost systems
relying on health auxiliaries and laymen, working
through local leadership, and promising short start-
up time.
-- Encourage integration of health, nutrition, and family
planning services wherever sensible, taking care to
encourage movement on either the health or family
planning front where simultaneous movement may be
very difficult.
-- Seize opportunities to "piggyback" family planning
services on existing delivery systems, particularly
clinics, where they are available (e.g., some Latin
countries).
-- Encourage allocation of health funds to establish
broad-based, low-cost delivery systems that could
add in family planning where that approach seems
most promising (e.g., some African countries).
*Subject to legislative restrictions, e.g., the Helms Amend-
ment which prohibits support for abortion-related assistance
other than research.
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-- Encourage provision of appropriate contraceptives
through private channels (e.g., midwives) or com-
mercial outlets.
-- Work with intermediaries, public-funded programs,
or both,depending on potential effectiveness.
Category 5: Information, Education, and Communication (IEC)
-- Undertake broad family-planning awareness campaigns
largely only where general awareness is very limited.
-- Where basic awareness exists, fine-tune existing IEC
efforts so they are:
a) country and culture specific;
b) informative on, each specific method of family
planning;
c) related to personal needs and aspirations;
d) focused considerably on the interface between
village family planning worker and village client;
e) reliant on relatively inexpensive media with broad
outreach that require little or no reading
(e.g., radio).
-- Sharply expand operational field testing to better
determine which combinations of the many modern and
traditional media are most effective and appropriate.
Category 6: Manpower and Institutional Development
-- Sharply expand efforts to assist LDC-based training
of health auxiliaries or laymen for village-based
distribution.
-- In-countries having enough basic family planning workers
at present, focus on filling specific institutional
and personnel needs.
-- Moderately expand efforts to strengthen planning and
management capacity at all program levels.
0. Funding Levels: To carry out this program, AID
estimates population funding levels of over $200 million
(including UNFPA) will be needed annually over the next
several years with a possibility for increased levels beyond
this, given the enduring quality of the population problem.
Obviously, the exact budget level in any given year will
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need to reflect LDC interest and absorptive capacity, the
effectiveness of on-going programs, other donor activities,
research breakthroughs, and competing demands on funds. In
Table 1 at the end of this Section, rough suggestions for
total future population funding indicate-the scope of the
population problem and the shape an expanding program might
take, consistent with the policies described above. These
estimates could -- and should -- change based on specific coun-
try program strategies that will be drawn up as a result of
this NSDM review.
(2) Other AID and P.L. 480 Programs Relating
to Fertility
P. In the FY 1978-79 Foreign Assistance Act legislation
recently forwarded to the Congress, the importance of non-
population programs as an influence on fertility is recog-
nized. AID will increasingly give this factor weight in
developing and implementing its programs, as the following
illustrations suggest:
1. Rural development.
-- Plan, administer, and evaluate coordinated packages
of policies and programs (including P.L. 480 Title II,
Food-for-Work) designed to foster production, pro-
mote employment, lessen urban migration, expand
opportunities particularly for women, promote more
equitable distribution of goods and services, and
encourage smaller families.
Reducing fertility is a primary objective since it
contributes directly to better health of mothers
and children.
-- Appropriate integration of health, nutrition, and
family planning measures is receiving higher priority.
-- The relationship with fertility is also very close;
for example, breastfeeding helps both to improve
child nutrition and to postpone pregnancy.
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-- Much greater attention should go to seeing that
programs of all sorts reach more girls and women,
who are usually a distinct minority among the
beneficiaries.
While imperfections of both statistical data and method-
ologies preclude precise estimates of the impact of these
approaches, more will be done to clarify the picture.in the
future. Thus, the Agency will be better able to assure that
all measures having a major influence on fertility -- or on
health, or on well-being however measured -- can be coordinated
more effectively to assure maximum impact. An independent
analysis of population-related assistance (Annex III) has
been prepared by AID to provide more detailed information.
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TABLE 1
-23-
U.S. Population Program Assistance
Estimate of Future Requirements
($ millions)
Functional Area
FY 1975
Actual
FY 1976
CP*
IQ
CP
FY 1977
CP*
FY 1978
Est.
FY 1979
Est.
1.
Demographic Data
11.9
11.6
5.6
11.3
16
20
2.
Population Policies
4.8
7.2
1.6
8.6
16
20
3.
Fertility Control
5.6
8.5
2.4
13.0
22
30
4.
Family Planning Services
.53.0
71.8
16.1
84.4
115
143
5.
Information Programs
13.0
17.1
4.2
16.2
20
27
6.
Manpower & Institutions
11.7
.17.2
6.5
20.6
26
30
100.0
133.4
36.5
154.1
215
.270
(of which UNFPA)
(20)
(21)
(4.6)
(25)
(42)
(46)
*CP (Congressional Presentation) indicates the population assistance program to Congress with AID's
request for appropriations. For FY 1976 there is a Conference Report appropriating at least $103
million for population assistance.
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The World Population Problem: Its Dimensions
and Responses by Nations Most Affected
(Summary of Embassy Evaluations)
1. Economic Implications of Population Growth
A. The majority of Embassies perceive serious economic
consequences of population trends in host countries. Inability
to feed the growing numbers is a major concern. Inadequate
domestic production, it is pointed out, necessitates food
subsidies and imports which, in turn, impose a priority claim
on the nation's limited budgetary resources and foreign
exchange.
In the absence of more stringent birth control
measures, Embassy Manila expects severe strains
on the Philippines' food supply. Presently,
large segments of the population are suffering
caloric and protein deficiencies. This situa-
tion can be expected to continue and worsen
until a significant decline in population
growth is achieved.
Burma's population is eating up the nation's
exportable rice surplus. This will soon elimi-
nate the country's most important source of
foreign exchange and put an additional strain
on Burma's already precarious balance of
payments.
In order to achieve domestic self-sufficiency
in food-grains and to raise average consumption
to minimum caloric requirements by 1985-86,
Bangladesh would have to increase its annual
rate of growth of food production from the
present 1.6 percent to 3.3 percent. This would
have to be accomplished almost entirely
.through improved productivity, including
multiple cropping. Despite the theoretical
possibility of achieving this goal, Embassy
Dacca considers it "most likely" that Bangladesh
will continue to require substantial food imports.
Before 1960, Morocco was capable of exporting
its surplus cereals. Since the late 1960's,
cereal production has not kept pace with
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population growth. Cereal imports absorb
much of the increasing foreign exchange
revenues generated by the sale of phosphates.
Morocco registers a 40 percent incidence of
degree malnutrition (i.e., between 20 to 40
percent underweight) among children 0-4 years
of age.
.B. The probability of rising unemployment and/or under-
employment is emphasized by a majority of reporting posts.
The bases for their conclusions are the inevitable acceleration
in the growth of the population in working ages, resource
constraints for job-producing investments, and in some countries,
policies favoring more profitable, technically advanced,
capital-intensive projects.
The Philippines have failed to provide adequate
productive employment for the past 30 years,
due to their rapid population growth. Currently,
"with 800,000 new entrants and 300,000 retirees,
the economy must produce 500,000 new jobs
annually, at a time when the agricultural
frontier of Mindinao is closing and when the
recently expanding service sector appears
bloated." It is "highly problematic" whether
the employment picture will improve significantly
in the future, as by 1980, there will be over
one million new entrants into working ages.
C. Embassy responses also touch upon the broader ramifi-
cations of the unemployment problem, including the question
of popular participation in the generation and distribution
of national income. Lack of productive job opportunities is
seen as helping to perpetuate politically destabilizing
economic inequities within LDC's.
-- Present prospects in Honduras are for income
distribution to become more inequitable.
Unemployment, already high, will increase,
exerting downward pressure on wage levels and
reducing the possibility for accumulation of
savings.
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"Although Mexico's economic growth has been
outstanding,, the position of the lowest income
group has probably not improved over the past
20 years, nor is it likely to do so in the next
-- Indonesia's development program appears to have
become more rather than less capital-intensive.
"If this is true and continues... [it] would
lead to a substantial worsening of the distribu-
tion of income in Indonesia and quite possibly
to an increase in the number of people unable
to meet their minimum economic and social needs."
-- Although Kerb had achieved a commendable growth
record, development planning was not addressing
the question of distribution of benefits of
growth.
In Pakistan, the potential for economic develop-
ment is high. However, "if the dependency ratio
remains high, if population pressure does create
increasing unemployment, Pakistan will find its
scarce resources being siphoned off into sub-
sidies and welfare programs..."
D. In addition to population imbalances in respect to
food and work, Embassies emphasize that the need for health
care, education, housing, and other vital services created both
by increasing numbers and the youthfulness of the age structure,
puts a severe strain on limited public and private investment
resources. Pakistan, for example, has steadily been losing
ground to population growth, despite the government's efforts
to increase the provision of such services. While between
1950 and 1975 the number of school-age children in primary
schools increased from 0.9 to 4.7 million, the absolute number
out of school increased from 4.5 to 5.3 million. An illustration
of the growth of awareness of the population's impact on the
need for public services is given by Embassy Lagos:
-- "The leadership has recently, and for the first
time perhaps, been brought face to face with the
reality of what a high growth rate can mean for
the provision of adequate facilities for a
rapidly growing population even when necessary
resources to do so are available. In launching
the Universal Primary Education (UPE) scheme
scheduled to begin in next September, the
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authorities have been confronted with a host
of problems in planning and providing the
necessary infrastructure and facilities for
the huge and growing primary school population.
For the first time, officials in Nigeria are
dealing with the realities of a high growth
rate rather than the theory. It is felt that
the experience with UPE and other planned
programs designed to provide coverage to the
total population or large segments thereof,
will go a long way toward generating more concern
for population dynamics and their implications
than currently exists in Nigeria."
E. A number of Embassies view the rapid growth of major
cities in host countries as one of the most serious population
problems. Heavy rural-urban migration adds to pressures for
public services which in rural areas could be more easily
ignored. Embassy Manila also notes that urban migrants depress
wages in the industrial sector, "profliferate low [labor]
productivity," and make squatter settlements a "perennial
problem." Embassy Ankara reports that about 40 percent of
Istanbul-Ankara and 35 percent of the Izmir area "are made up
of squatter settlements of minimal housing standards." Sanitary
conditions and other vital services are inadequate and outbreaks
of cholera have been reported.
F. In a more comprehensive view of Ghana's development
problems, Embassy Accra observes:
"It would be a mistake to attribute the economic
and financial difficulties faced by Ghana solely
to population trends... Many other elements of
the politico-economic equation are more directly
responsible for the virtual absence of per capita
growth over the past sixteen years, the recurring
balance of payments crises and structural dis-
equilibrium, as well as the rising budget deficit.
Public sector consumption (i.e., current expen-
ditures) appear to. have absorbed the major part
of the increase in GDP in the period 1965-1975.
This trend appears to be significantly (though
not exclusively) related to demographic factors,
including the high dependency ratio...and rapid
[population] growth...
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"The high rate of increase in public consumption
has been a major reason for the disappearance of
public savings. The resource pinch restricts
the availability of funds for public investment,
with the result that the nation's infrastructure
has deteriorated over the past 15 years. While
economic difficulties and management decisions
and indecisions have played a major part in
determining these trends, demands deriving from
the high population growth rate have also clearly
had a key role."
G. Some eighteen Embassies perceive little impediment to
the growth of national economies in consequence of demographic
trends. Embassy N'Djamena argues, in fact, that the impact of
population growth on socio-economic development cannot be con-
sidered only in negative terms. It should be viewed also as a
factor "in the requirement for increased productivity and
markets." A few Embassies report special conditions which may
moderate the potentially negative impact of rapid population
growth (Iran, Nigeria, Zambia, and Costa Rica). The Government
of Zambia, for example, has been encouraging the urban unemployed
voluntarily to return to the farms. Since this approach has not
achieved the desired results, the Government--using Presidential
powers under the state of emergency proclaimed in January 1976--
may soon order compulsory transfers of "surplus urban population"
to the countryside. In Costa Rica, the extremely high popula-
tion increase of the 1950's and 1960's is now creating serious
socio-economic dislocations. Family planning efforts, however,
are already moderating the situation at particular points
in the social infrastructure (e.g., occupancy of maternity
wards, primary school enrollment).
2. Enviromental Implications of Population Growth
Most Embassies, particularly those in Latin America, take
note of the manifest deterioration of urban localities. Sanitary
facilities, to include potable water, sewer and waste disposal
systems, are frequently unable to cope with the massive inflow
of rural migrants. The most dramatic ecological problems
appear to arise in rural areas, however. A majority of Embassies
in Africa, Asia, and some in Latin America report large
pockets of declining agricultural productivity. This is
usually attributed to poor agricultural practices, including
widespre?d slash-and-burn farming, cultivation of steep
mountain slopes, overgrazing, overcropping, and the plowing up
of drought-prone grassland. Indiscriminate cutting of forests for
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firewood, or to clear land for cultivation, is particularly
serious where it undermines soil stability and reduces protec-
tion against water and wind erosion. Population pressure
severely compounds the problem and, in some countries, makes
harmful agricultural practices necessary (e.g., Mexico).
Nepal is considered an example of "ecological disaster in
the making," because of the pressure of population in the hills
and uncontrolled settlement in the lowlands. It is estimated,
for example, that food production on newly opened lands in the
lowlands is more than offset by losses in production caused by
erosion in the hills.
Java, in the judgment of the Embassy, may become a waste-
land. Soil erosion due to overpopulation is already creating
an ecological emergency. Overpopulation has led to deforesta-
tion (two-thirds of Java's forests have disappeared since 1940)
and misuse of hillside areas by land-hungry farmers.
With respect to the recent Sahelian disaster, Embassy
Dakar (Senegal) notes that "in the view of many observers," the
pressure of increasing numbers of men and animals on the fragile
Sahelian ecology removed vegetal cover and was instrumental in
bringing on the drought of 1969-1973. Embassy Nouakchott
(Mauritania), on the other hand, contends that,.although the
problem would have been less severe with fewer people to feed,
the drought was caused by a lack of rain, with no significant
contribution from overcropping, overgrazing, erosion, or over-
population. The Embassy, nevertheless, urges that the AID Task
Force include a prototype population program in its development
strategy for the Sahel region.
3. Political Implications of Population Growth
Review of Embassy responses to this question suggests a
distinction between internal and external threats to the stability
of governments in consequence of population growth. The former
derive from governments' inability to cope with the growing
populations' demands for food, work, and vital public services.
The latter derive from attempts to take advantage of the above
situation, from repatriation of migrant workers, from tensions
due to illegal border crossings in search of jobs, and finally,
from underpopulation which may invite external encroachment
and interference.
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30
Internal political disruptions in consequence of socio-
economic difficulties have arisen in, and still threaten,
Indonesia, Colombia, Ghana, and other LDC's. There are
countries like Turkey where high unemployment and huge squatter
settlements exist, but Embassies, believe that explicit policy
to control the high birth rate would itself be politically
destabilizing. Mexico's situation has international as well
as internal political ramifications. The Embassy calls
attention to high unemployment and poverty undiminished by
economic growth. Even under the most favorable projections
of population growth, the number of "subsistence-level
Mexicans may pose a severe internal security threat." More-
over, large numbers of illegal immigrants "could cause over-
whelming political, economic, and social problems in the
United States... Since the very movement of such large numbers
of people would be disruptive to both societies, it is an
understatement to note that our bilateral relations will
undergo great strain." The Embassy warns of the sensitivity
of the Government of Mexico to this subject and that "we must
be prepared for the possibility that Mexican birth control
programs cannot be implemented more rapidly than at present..."
The Embassy in Santo Domingo reports serious concern over
illegal immigration from overpopulated Haiti and--should
Dominican conditions deteriorate--of the possibility of a
Cuban-Haitian intervention in the Dominican Republic, which
would entail a threat to the Panama Canal. Embassy Port-au-
Prince agrees that attempts to emigrate illegally to the
Dominican Republic "would lead to stern consequences and the
resumption of hostilities." It also expects unrest in Haiti,
growth of radical movements, and reversion to more repressive
forms of rule.
In North Africa, the effect of a worsening of the popula-
tion situation in pro-Western Tunisia is described: "Sub-
version from Algeria and Libya is a threat-that will increase
dramatically if population growth leads to a reduced standard
of living and unrest." Similarly, Morocco's strategic
position in North Africa, its traditionally good relations with
the U.S., and its role of moderation in the Arab world make it
important, in the Embassy's view, that political and social
stability be maintained. The Embassy also sees pressing
population problems working against such stability.
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In countries where export of labor has been a safety
valve for local overpopulation, the return of this labor is a
matter of some concern. Large-scale repatriation of the 3 to
5 million Nepalese residing abroad, for example, would create
"intolerable economic and social burdens," with attendant
political repercussions. In Lesotho, the need to absorb its
labor force now residing in South Africa would create a
"disastrous" situation. A similar problem obtains in the
Middle East in consequence of migration to oil-rich countries.
Embassy Sana reports that "should Saudi Arabia expel the Yemeni
now working there, the pressure on savings, employment, and
social services (in Yemen) would quickly become crippling and
political disruption would follow on a domestic and visibly
international basis."
A special difficulty appears to exist in Burma. Partly
because of fears of illegal encroachment from China, India,
and Bangladesh, Burma maintains a high birth rate. This, in
turn (as mentioned above), threatens Burma's continued ability
to export rice.
Some twenty Embassies, including Ankara and New Delhi,
do not anticipate serious political or strategic consequences
because of population pressure, now or in the near future.
New Delhi's optimism is based on India's low population density.*
Embassy Ankara, perceiving at present no evidence of demogra-
phically induced disorder, conjectures that "several years
from now" concentration of the unemployed in Turkey's urban
areas may, under certain circumstances, increase political
problems.
Embassies in Argentina, Ivory Coast, Saudi Arabia, Libya,
Gabon, and Guinea express their own or host governments'
opinions that the small populations of the respective countries
weaken their political influence or strategic posture, as well
as impede development.
4. Family Planning Programs
By 1976, the majority of the LDC governments have accepted
the concept of the public provision of family planning services.
This group includes. People's Republic of China, Cuba, and North
Vietnam, not included in this review.
* Elsewhere in its response, the Embassy reports an "immense"
unemployment problem--"(so far) unexplosive in nature"--and a
steady growth in the number and proportion of landless laborers
in India.
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Of the 77 LDC's participating in the survey, 62 have
some kind of organized program. Of the 62, eight countries
only permit private organized activities in this field*
(Tables 1 and 2). Thus, 54 LDC's can be said to have dis-
cernible governmental sponsorship or involvement in family
planning programs. The nature, scope, and effectiveness of
these programs vary widely, however. This reflects, in no
small measure, the degree of governments' awareness of local
demographic trends and their perception of the significance
of high fertility levels for LDC priority concern: national
development. The Indonesian Government, for example, has
assigned very high priority to the family planning program in
terms of political, institutional, and budgetary support. The
Government of Brazil, on the other hand, having acknowledged
its responsibility to provide family planning services for the
poor, has done nothing to carry out this policy. Similarly,
in resource-rich Nigeria, the. Federal Government has announced
a population policy, but made no concerted effort either to
promote or to discourage responsible parenthood. "State
governments show a growing interest (as does the Federal
Government) in family planning integrated with MCH** services
but give no evidence of pursuing even this approach with much
vigor in the immediate future."
Ethiopia ranks lowest, perhaps, among the 13 priority
LDC's in terms of government's commitment to family planning
programs. The country's Provisional Military Government does
not see a need for a reduction in the population growth rate.
It stresses economic growth both as a solution to Ethiopia's
.underdevelopment and as the setting for fertility decline.
Since the two-year old government is currently preoccupied with
"efforts to define a political philosophy, to create a mass-
based political structure, and to retain or establish political
cohesion," the Embassy thinks it unlikely that the GOE will
reconsider its population views before 1980. Nevertheless,
the Government permits private efforts to add family planning
services, contraceptives, and training to both Government and
missionary-operated health clinics. The number of clinics
which include.a family planning component has grown from 29
in 1972 to 168 in 1976.
* Jordan, Syria, Senegal, and Madagascar, among the eight, have
shown evidence of increasingly favorable governmental attitudes
toward public provision of family planning services for non-
demographic considerations.
** MCH - maternal and child health.
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Among the 54 LDC's officially supporting family planning
programs,
26 LDC's, with a combined population of 1.3 billion,
have established explicit policies and programs to
reduce average fertility levels in the interest of
economic and social development (Table 2). While
this group represents about one-third of the countries
in the survey, it contains 70 percent of the population.
Singapore is reported to have reached replacement-
level fertility in 1975. Ten other LDC's in
this group, according to Embassy reports, have
measurably reduced their birth rates. They
include Thailand, Korea, Colombia, Taiwan, Sri
Lanka, Tunisia, Jamaica, Trindad & Tobago,
Mauritius, and Barbados. In addition, Embassy
Jakarta is hopeful about the outlook for fertility
reduction in Indonesia.*
28 other LDC's, including Brazil, Turkey, Nigeria, and
Ethiopia, support family planning as a means of im-
proving maternal and child health, of raising general
family welfare, and/or in recognition of the rights of
the couple to determine the number and spacing of
their children.
Three of the 28 LDC's, according to Embassy
reports, have significantly reduced their birth
rates (Malaysia, Costa Rica, Panama).
Among the remaining 13 priority LDC's, Mexico's program is too
recent to judge its effectiveness. Pending the completion of the
1976 census, Embassy Cairo does not have an accurate estimate of
Egypt's population growth. The country's relatively low growth
rate of 2.1 percent for 1973 may reflect a temporary decline in
the birth rate due to mobilization for the 1967 and 1973 wars.
Embassy New Delhi does not evaluate India's program in terms of
its effect on the birth rate. Policy innovations since 1974
suggest that the program's overall performance fell short of
expectations. More specifically, "lack of effective family plan-
ning programs particularly affects the rural problem." Embassy
Islamabad believes that "it is not yet possible to be very san-
guine about fertility decline in Pakistan." The program has not
been "dramatically effective," at least not prior to the inception
in early 1975 of the "contraceptive innundation" program, whose
* Results of the 1975 Philippine Census suggest some fertility
decline in the period 1970-75. Embassy has not analyzed the data
and cannot now assess their accuracy.
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Embassies. report declining birth rates in following host countries:
Birth Rates
(per 1,000 population)
Trinidad & Tobago
1950
37.5
1973
24.7
1960
39.9
1970
37.1
1974
31.2
Costa Rica
1960
47.5
1973
28.3
Mauritius
1965
41
1974
13*
Taiwan
1963
34.5
1975
23.4
Korea, Rep. of
1961
42.
1975
24
Tunisia
Over past
47
decade
36
Colombia
Late 1960's
44
Current
36-48**
Thailand
1972
3.1 percent growth rate
1974
2.56 percent growth rate
Sri Lanka
"declining growth rate"
Malaysia
"Population growth
rate declining"
Barbados
"An effective program"
"National acceptance of
:Family planning has been
excellent"
Singapore 1975
"Replacement-level fertility"
* UN's Monthly Bulletin of Statistics for April 1976 reports the birth rate
of 27.1 for Mauritius in 1974. It declined to 25.1 in 1975. The figure in
the Embassy's cable is believed to be a typographical error.
** Prelimi
`p roavec ror%jFe soe OS97C 1 ~9 t7 1()(q 0&8
c n
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aim is to assure "a virtual doorstep availability of contra-
ceptives."* In Bangladesh, execution of the program initiated
in 1973, "has not squared with the note of urgency surrounding
its adoption," although in 1976, the prospects for vigorous imple-
mentation appear to have improved. As in Pakistan, the "core"
of the current strategy is doorstep delivery of MCH and family
planning services.
In the Philippines, "overall program performance... is a
mixed picture. In the [short] span of five years, the country
has moved from a pro-natalist policy of the late 1960's to support
for family planning in the 1970's; from virtually none to over
2,400 family planning clinics at present; from involvement by a
token number of voluntary organizations to widespread participa-
tion by both government and private agencies. There have been
changes in taxation and labor laws to decrease incentives for
large families. Progress has been made, but in terms of impact
on... the nation's rate of growth a difficult road lies ahead."
Impediments. Apart from the persistence of formidable cul-
tural and economic impediments to population acceptance of birth
control in LDC's (notably, the low status of women in the family
and society and the backwardness of the countryside), the Embassies
cite a number of program weaknesses which could help explain the
lack of satisfactory progress.
-- The shortage of executive talent for family planning
programs appears to be a particularly serious con-
straint (e.g., Egypt, Kenya, Ghana, Haiti, Iran,
Malaysia, Nicaragua, Mali, Botswana, Nepal, Ecuador,
Liberia). The critical role of administrative perform-
ance is noted both when, by its effectiveness, family
planning programs have been successful, and when, by
its ineffectiveness, they have yielded poor results.
In Kenya, "the most obvious obstacle to family
planning progress is bureaucratic lethargy,
inefficiency, delay, and lack of planning and
administrative capability within the MOH...**
A shortage of professional manpower is also handicapping some
programs. The low priority of family planning in some countries
contributes to this situation.
* This is in addition to the widespread and growing clinical and
hospital system of delivering family planning services.
** MOH - Ministry of Health.
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-- In countries where family planning services are
channeled, by and large, through public health
facilities, geographic distribution of these
services is rather limited. Development of alter-
native rural delivery systems is high on the list
of priorities in many program strategies.
The most serious continuing deficiency of the
Philippines' program is that the GOP efforts
have been largely restricted to towns, and
the program has not developed an effective
rural outreach where 70 percent of the country's
population 'Lives.
In Ethiopia, under the strategy of offering
family planning as part of MCH health service,
only 15 percent of the rural population-can
be reached.
-- The political sensitivity of the birth control issue,
still evident in a number of LDC's, impedes vigorous
implementation of the governments' declared family
planning policies (e.g., Turkey, Morocco, Malaysia,
Nigeria). This requires a "low profile" in organized
family planning activities, for fear of jeopardizing
government's relations with the Church, opposition
parties, ethnic/religious minorities, and other
politically influential groups.
Importance of social setting. Organized family planning
programs have made valuable contributions toward fertility
reductions in the 14 LDC's listed above. Nevertheless, Embassies
in these countries also stress the importance of the social
setting for widespread acceptance of small family norms.
Embassy Kuala Lumpur, for example, attributes the declining
population growth rate in Malaysia in part to rising educational
attainment, women's increasing participation in the labor
force, and rising age at marriage. Korea's success is credited,
in large-measure, to social and cultural trends accompanying
rapid economic development and to cultural characteristics of
Korean society. Thus, while the GOK family planning program
has helped directly to reduce the birth rate, much of the
success is "obviously attributable to non-program factors."
Embassy Taipei offers a particularly thought-provoking obser-
vation about one of the most successful family planning
programs.
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"To what extent the birth rate in Taiwan can be reduced
further, even with more personnel, better program
direction, additional money, and new approaches, is still
unknown. It is clear, however, that standing still will
not solve the problem. Taiwan has gone through the first
stage of family planning programming in which motivation
of the ready-to-accept group was the main task. It has
now entered the second and more difficult stage, in
which the decline of fertility will depend primarily on
reduction of family size and spacing of births. This
is a new area in which Taiwan has little experience."
5. Foreign Aid to Population Programs
Embassy Nairobi does not agree that priority emphasis in
U.S. foreign aid should be given only to the 13 LDC's which
contribute most to world population growth. Kenya's economic
and ecological realities, in the Embassy's view, qualify it
for continuing and increased USG assistance, as the country's
future is "very much linked to its ability eventually to control
its population problems."
In countries where either birth control programs or USG
assistance to them are sensitive issues, the Embassies usually
prefer that USG aid be channeled through international--multi-
lateral or private--agencies. This recommendation applies to
three countries with explicit commitments to fertility reduction
programs, namely, India,* Iran, and Sri Lanka. Also, indirect
assistance is recommended to Taiwan, since its program may be
progressing to the politically charged "beyond family planning"
stage. USG support of surgical sterilization programs is
specifically not advised in Colombia, Ecuador, and the Dominican
Republic.
In a number of LDC's whose governments do not give high
priority to family planning, Embassies suggest that USG and
other donors support the development of the countries' usually
limited health facilities.** Health infrastructure, in this
* Embassy New Delhi recommends expanded collaboration between
the U.S. and India in research on human reproduction.
** In a number of African states, Special Population Assistance
and Self-Help funds were used to support maternal and child
health services, including a family planning component (Malawi,
Rwanda, Swaziland, Zambia, Togo, Central African Republic (CAR),
Mauritania). The Embassies consider this money well spent.
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context, is regarded as the likely "vehicle" for eventual
dissemination of family planning services (e.g., Brazil, CAR).
Embassy Nairobi is also of the opinion that "an involvement
in health care per se offers the USG the best chance ultimately
to help the Kenyans to deal with a serious population problem."
A somewhat broader strategy suggested by Embassy Ouagadougou
(Upper Volta) would probably find support among most Embassies
in Africa. It calls for (1) donor assistance in developing
effective rural health and nutritional programs, based essen-
tially on preventive medicine; (2) continued provision of
information on population, statistics, and problems caused by
increasing population density, with information in readiness
on acceptable population programs. Embassy Brasilia also
noted that U.S. can contribute to the "healthy evolution"
of internal debate on population issues "through judicious
and carefully monitored use of U.S. information and exchange
programs."
Embassy Togo recommends flexibility in imposing donor re-
quirements on foreign requests for assistance in the population
field. Tanzania appears to provide support forithis view. A
UNFPA offer of vehicles for Tanzania's massive rural health
project is tied to a requirement that the GOT ennunciate a
policy of reduced birth rates. The Government will not accept
assistance on these terms. Scandinavian donors in the country
are said to have observed that Tanzania's need to take effec-
tive actions to reduce population growth rates is far greater
"than any need to provide a stated population policy." Embassy
Dar es Salaam appears to agree.
Multinational agencies. Intergovernmental agencies active
in the population field did not receive unqualified praise.
In Jakarta's view, the effectiveness of both UNFPA and IBRD,
seems to be undermined by "centralized decision making, in-
sufficient field mission discretion, inadequate country staff-
ing, slow response capability, cumbersome/complicated imple-
mentation, insensitivity to feedback, and lack of interest
in adjusting programs in midstream." In addition, it is
stated that international organizations (notably in the UN
system) often lack technical competence and follow cautious
bureaucratic procedures, even in countries where governments
have a high commitment to fertility reduction. (Embassy
Rabat recommends renewed efforts to stimulate IBRD's active
support of the GOM's program.)
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Embassy Bogota expects some cautious rhetoric but not
much action from IBRD and WHO, if they become involved in the
local family planning program. The Embassy does not consider
UNFPA support in Colombia particularly vigorous, imaginative,
or efficient, in spite of some recent improvement. Bureau-
cratic problems are expected to inhibit UNFPA action, unless
drastic reforms are undertaken. UNFPA's lengthy time frame
for project study and decision and lack of demonstrated vigor
in working together with countries to stimulate, develop, and
implement effective family planning programs is not consistent,
in the Embassy's view, with their stated policies or the crit-
ical nature of the (population) problem.
UNFPA and other UN agencies using the country personnel
quota system, have produced "a very mixed bag" in respect to
the qualifications of their technical experts. In Bangladesh,
for example, senior members of the UNDP and some government
officials are expressing disenchantment with the general ex-
pertise available through the UN system. More attention, in
Dacca's view, should be paid in recruitment to professional
qualifications, if the USG is to shift to multilateral assistance
with confidence. Multilateral organizations, likewise, should
demonstrate their ability to move funds and implement projects
expeditiously when entering the population assistance field.
The Embassy in Nepal has been "appalled" at times by the ig-
norance of population matters among certain technicians em-
ployed by multilateral donors. In its view, a series of inter-
agency training programs on population might be useful for
employees of UN agencies, in particular. One of the most
important initiatives which Embassy Kathmandu recommends is
an increased worldwide effort to improve understanding of,
and commitment to, population issues within international
agencies.
Private organizations are judged, by and large, to be
very effective and receive Embassies' recommendation for con-
tinued support from the USG in fields in which they have a
strong capability. Embassy Kathmandu finds most bilateral
donor personnel reasonably knowledgeable on population issues.
Embassy Seoul is of the opinion that "private intermediary
groups such as IPPF and Population Council (New York) have
been more effective in providing support than members of the
UN. system." In El Salvador, Nicaragua, and elsewhere, they
have been particularly successful in initiating and carrying
out small innovative projects, some of which the government
has subsequently taken-over on a large scale (El Salvador).
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Coordination among donors is considered good in Thailand,
Nepal, and the Philippines. It is "fairly well established"
in Pakistan where an annual meeting of donors is convened by
the GOP in Islamabad. In addition, the major donors represented
in the country meet with the Government officials on a quarterly
basis. Islamabad believes that the regular meetings of the
IBRD-headed Pakistan Consortium have been helpful in keeping
the population issue "front and center" in development policy
in Pakistan. Embassy New Delhi reports, on the other hand,
that Indian Consortium meetings, while showing great interest
in family planning plans and progress, do not lend themselves
to critical in-depth review of technical or organizational
aspects of the program, other than for encouraging adequate
budget.
Some governments do not wish a formal consortium of inter-
national donors in the population field (e.g., Nigeria,
Tunisia). Prospects for one in the Philippines (which has
effective coordination at working levels) is deemed remote,
since the GOP insists on maximum domestic control of its
program. Similarly, in Bangladesh, in spite of many donor
requests, the GOB has not agreed to take an active donor
coordination role. Also, both IBRD and UNDP representatives
declined the job for fear of GOB's objection. In Kenya, where
donor coordination has been very poor, the IBRD similarly "has
virtually abdicated its role in this area."-
Too much coordination may be counterproductive, in Manila's
view, since it may increase tension between donors pushing for
accelerated program performance and the local executive agency.
In Bogota's view, excessive emphasis on coordination could
inhibit the pioneering, innovative approaches of the private
sector which have been essential for the population programs
in Colombia.
Problems in coordination may arise from differences in
basic approaches to the population problem. For example, in
Bangladesh, AID strategy is aimed toward rapid expansion of
delivery of contraceptive services. IBRD, on the other hand,
attempts to address all parameters of the population control
equation at once. Thus, while AID/Dacca views the coordination
with UNFPA as good, its coordination with IBRD is deemed
inadequate. Embassy Dacca recommends greater coordination
between AID and IBRD in Washington. It also suggests that, in
countries where AID is providing major population assistance,
AID should be represented on the IBRD population project
development team.
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Embassy Jakarta thinks that U.S. can best cooperate with
international organizations by encouraging them to re-examine
their programming capacities and traditional project approach.
Embassy Quito urges that the USG consider, and seek to have
others consider, how each development project impacts on the
desired family size of the affected households. Embassy San
Jose believes that the USG should promote seminars, conferences,
and dialogues between the various international organizations
actively involved in development assistance, to exchange
information and discuss policies and programs for lowering
mortality and fertility.
Finally, in recognition of "the seriousness of the world
population problem and [its] impact upon [U.S.] interests...,"
Embassy San Salvador recommends that all Foreign Service
Officers receive a proper briefing on the magnitude of the
population problem, its policy implications, and the USG
initiatives in this area, prior to an overseas assignment.
It also recommends the establishment of a position of Popula-
tion Attache (to serve in selected LDC's), to ensure that the
population dynamics receive "the attention afforded agriculture,
defense, economics, and commerce in the staffing of [U.S.]
Embassies." In a similar vein, the Ambassador in Tunis
believes that the U.S. cannot discharge its obligations through
material help alone. To assist a national family planning
program to achieve self-sufficiency will also require a
demonstration by the entire U.S. Mission of the seriousness
with which the U.S. views the population problem.
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Family Planning Programs in Less Developed Countries, by Government Policy and Region, 1976
(Population data in thousands)
Family Planning.Programs
Total LDC population, 1
975* 2,874.036
Centrally-planned economies
(China, North Korea, Vietnam,
Mongolia) 883,352
Developing market economies 1,990,684
Programs to
reduce
fertility**
Programs in
. the interest
of family-
welfare**
Private
programs
only
No
organized
programs
Countries in the survey
Number
77 26
.28
8
15
Population
1,828,028 1,274,972
395,294
66,994
90,768
Mort: Africa
Number
5 3
1
1
Population
79,841 60,794
16,792
2,255
Sub-Saharan Africa
Number
29 3
13
2
11
Population
231,962 24,023
153,862
12,438
41,639
Asia
Number
22 13
4
2
3
Population
1,223,344 1,092,552
73,971
9,947
46,874
Latin America
Number
21 7
10
4
Population
292,881 97,603
150,669
44,609
* United Nations' coverage of "Less Developed Countries" excludes Temperate South America,
included in the 2,874,036,000 figure. The population of Temperate South America is estimated
at 38,747,000.
** Government and private.
Source of population data: United Nations, World Population Prospects, 1970-2000, as
Assessed in 1973. .ESA/P/WP.53. March 10, 1975.
Medium variant.
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Family Planning Policies and Programs, 1976
I. POLICY OF FERTILITY REDUCTION IN THE INTEREST OF NATIONAL DEVELOPMENT
1. Declared policy
*India *Mexico *Egypt
*Indonesia *Colombia *Morocco
*Bangladesh *Dominican Rep. *Tunisia
*Pakistan *El Salvador
*Philippines *Jamaica *Kenya
*Thailand *Trinidad & *Ghana
*South Korea Tobago *Mauritius
*Iran *Barbados
Taiwan
*Sri Lanka
*Nepal
*Singapore
*Fiji
2. Policy in the making
(Papua New Guinea) (Haiti)
(Costa Rica)
II. POLICY OF FAMILY PLANNING FOR REASONS OF FAMILY HEALTH AND WELFARE
(explicit or de facto)
1. Family planning part of the health system; private programs in
operation
*Malaysia *Ecuador
Papua New Guinea *Honduras
*Nicaragua
*Costa Rica
*Panama
2. Planned integration of family planning services into the health
system; private programs in operation
*Turkey
*Afghanistan
*Brazil
*Venezuela
#Haiti
#Algeria
*Nigeria
*Ethiopia
#Zaire
*Tanzania
*Mali
*Sierra Leone
Togo
*Liberia
#*Botswana
#Swaziland
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III. NO CLEAR FERTILITY POLICY
1. Some government famillanning services available;_private fro rams
permitted
*Bolivia *Zambia
*Paraguay *Benin
*Lesotho
2. Private programs permitted
*Syria
*Jordan
*Peru *Madagascar
Senegal
3. No organized programs
Cameroon
Upper Volta
Rwanda
Mauritania
4. Evidence of increasingly favorable governmental attitude toward
family planning services for non-demographic reasons
.(Syria)
(Jordan)
(Madagascar)
(Cameroon)
(Rwanda)
(Senegal)
IV. PRO-NATALIST FERTILITY POLICY/ATTITUDE and/or GOVERNMENT HOSTILITY TO
FAMILY PLANNING
1. Private programs permitted
2. No organized programs
Burma
Saudi Arabia
*Argentina
*Uruguay
Guyana
Malawi
Ivory Coast
Guinea
Chad
Somalia
CAR
Gabon
* Member of the International Planned Parenthood Federation (IPPF)
# No private programs
()Primarily classified elsewhere
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Development of World Political and Popular
Commitment to Population Stabilization
The Task Force recognizes that our approach to world
population issues must be based on mutuality and respect
for the rights and responsibilities of other countries in
developing their own policies and programs. Every country
faces somewhat different problems whose solutions must
accommodate to the realities, pecularities, and circum-
stances of that particular country. There is, however, a
degree of growing global interdependence that makes un-
controlled population growth in any one country or area
of the world a matter of concern for all.
We also recognize that there is no single solution,
no simple solution, and no short-term solution to the
population problem. It is one that calls for the combined
talents of scientists, economists, doctors, educators,
government workers, and private voluntary organizations.
Above all, it calls for greater involvement of leaders and
diplomats than there has been over the past several decades.
What we and others in the world community do to pro-
mote the effective development of poorer nations of the world
will also have an important impact on the population prob-
lem. Therefore, it is not just our AID population program
that is involved but our total AID program as well as all
the other types of measures referred to in the Secretary
of State's message to UNGASS in September 1975 and to
UNCTAD in May 1976.
If we are to help persuade other countries as to the
importance of taking adequate, timely steps to cope with
excessive population, growth, we must be fully persuaded
ourselves. Our leaders, diplomats, and others in authority
must not only be persuaded, but they must also know the
facts about population growth, in order to be effective in
encouraging leaders of other countries to take the required
action. Instructions have accordingly been sent, most
recently by the Secretary of State, to our Ambassadors and
country teams in each country where population presents
problems, requiring that our Ambassadors and their staffs
be informed on population issues and that they find appro-
priate occasions to raise the matter in discussions with
host country leaders. We have already arranged for special
population briefings for our Ambassadors assigned to coun-
tries with population problems. We are also circulating
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population information materials to the field and are intro-
ducing more population education attention into Foreign
Service Institute training.
For purposes of organized presentation, the balance
of this paper is divided into three sections: (1) How
to increase effective action in countries already committed
to population programs (i.e., countries that have a stated
national policy on family planning and development); (2)
How to increase acceptability and action in countries not
now committed to population programs; and (3) How to
develop greater commitment to world action on population
both in the United States and abroad. It should be stressed
at the outset that there is a wide range of commitment
within each of the categories (1) and (2) above. Among
the committed countries, for example, some are far more
active than others, as brought out in the preceding section
of this report.
1. Countries Committed to Population Program.
The committed nations include almost all of the countries
of East Asia and South Asia plus a scattering of others. in
Central America (including Mexico), the Caribbean, North
Africa, and in the Pacific and Indian Oceans. Since this
group includes the PRC with over 800 million people, India
with over 600 million, as well as other large developing
countries like Indonesia, Bangladesh, Pakistan, Philippines,
and Thailand, it means that almost one-half of the world's
population live in developing countries whose leaders are
committed to population policies and programs. This
represents roughly two-thirds of the developing world.
Within the committed grouping, the U.S. has no influence
over PRC programs (which have no outside support), relatively
little influence in India and Mexico (where we have no direct
bilateral programs but where we can assist through UNFPA,
IPPF, etc.), but the U.S. does have considerable influence
in other committed countries, especially those where U.S.
AID programs, including family planning, are considerable.
AID's principal means to support population policies
in these countries has been, and is likely.to continue to
be, related to supplies and supply systems. AID is also
seeking to help improve demographic data, expand applied
biomedical and social sciences research, improve information/
education/communications programs in support of family
planning, and extend training and education activities
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related to population programs. The U.S. is also supporting
measures affecting family planning, such as broad economic
development, improved status of women, changes in laws
and statutes (such as raising the legal age for marriage
and incentives for smaller families), and better income
distribution. These measures lend themselves to treatment
(e.g., via USIS informational programs) pointing out the
lessened potential for economic development given the impact
of population increases on energy and food requirements,
the environment, health, and other social services.
However, many leaders recognize that all these measures,
significant as they are, will not help reduce population
growth rates sufficiently to avert major disasters.
Prerequisites for real success are likely to involve three
approaches that are interrelated and have proved highly
effective, as follows:
(1) strong direction from the top,
(2) developing community or "peer" pressures from
below, and
(3) providing adequate low-cost health-family planning
services that get to the people.
With regard to (1), population programs have been
particularly successful where leaders have made their
positions clear, unequivocal, and public, while maintaining
discipline down the line from national to village levels,
marshalling government workers (including police and military),
doctors, and motivators to see that population policies are
well administered and executed. Such direction is the
sine-qua-non of an effective program. In some cases, strong
direction has involved incentives such as payment to
acceptors for sterilization, or disincentives such as giving
low priorities in the allocation of housing and schooling
to those with larger families.
Of particular significance right now is India's con-
sideration of involuntary sterilization. Some argue that
these methods are morally reprehensible, but others maintain
that they are more humane than allowing current population
growth rates to visit disaster on millions of people, which
might be the case if hard-line measures are not adopted.
Some may argue that there are many practical obstacles to
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involuntary sterilization programs (inadequacy of medical,
legal, and administrative facilities), and others point out
that involuntary programs, like Gresham's Law, may drive
out current voluntary programs. On the other hand, pro-
ponents of involuntary sterilization argue that high dis-
incentives tend to prejudice the children of parents with
three or more children, whereas involuntary sterilization
penalizes the parents. Whatever our reservations may be
on this subject, it is important that U.S. officials avoid
public criticism. Population policies are a matter for
each country to decide for itself in terms of its own
circumstances and perceived needs.
As to (2) above, there are a number of innovative
approaches, like "wives"' or "mothers'" clubs in Korea and
Indonesia, which are designed to popularize family planning
at the village level and to create peer pressures within
communities for limiting the size of families. These
approaches should be encouraged and shared with other coun-
tries. In this connection, we welcome movements in many
countries to strengthen the local communities--usually the
village--and to create within that village a spirit of
social and economic cooperation. Among many other advan-
tages, family planning has a better chance of success when
it is rooted in community life and when people can see
within their own visible horizons how limiting family size
improve.s health and economic prospects for everyone in
that community.
The very permanence of the community is an important
consideration. National governments come and go. Individ-
uals come and go. But communities go on forever. Since
population programs must continue for many years to take
real effect, a community--wide approach will ensure longevity
of programs among new generations. A solid community or-
ganization also provides effective means for group involve-
ment, as well as for making family planning services locally
available and for monitoring and encouraging their use.
A third promising way of promoting effective population
programs is to combine family planning with health and
nutrition in a single integrated structure with maximum
outreach at minimum cost. Success of this approach, which
is being increasingly adopted by committed countries,
depends to a large extent: on the quality of paramedics
(health workers) and midwives (including auxiliary) and
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their ability to win the confidence of villagers. Once
this is achieved, paramedics and midwives can, among their
other duties, effectively extend personalized family plan-
ning advice. It should reach women when they have their
very first child at which time spacing of children should
be strongly recommended. Thereafter, personalized advice
can be extended on all available means of contraception,
including sterilization, the final contraception, when
desired completed family size has been reached, as well
as medical termination of pregnancy where it is legal and
desirable.
Two important reservations should be mentioned in
regard to the integrated approach: (1) In several coun-
tries where family planning now has greater outreach than
health services, family planning may initially suffer
through full integration with health services; (2) Low-
cost health services still require professional medical
backup. There should ideally be enough doctors and pro-
fessional nurses available in rural areas to handle cases
referred to them by the paramedics and midwives, and to
perform those aspects of contraception that require higher
medical skills. Moreover, any attempt to by-pass the
medical profession is likely to incur their opposition
to the low-cost integrated system.
2. Countries Not Committed to Population Programs
LDC countries uncommitted to population programs in-
clude most of Africa, Latin America, and the Middle East,
with a combined population of about three-quarters of a
billion people. Population policies of these nations
range from the pro-natalism of a few to the non-commitment
of most of the others, where, in varying degrees, family
planning is tolerated or even encouraged. Abortion is
generally abhorred, and sterilization disfavored.
The relative lack of concern these countries reflect
on population issues can be explained by a variety of factors
such as:
(1) no perceived need to limit population growth;
(2) or, if there is a perceived need, wishful thinking
that economic development will solve the problem;
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(3) belief that a large family is necessary for old-
age security or to meet needs for labor at certain
points of farming cycle;
(4) preoccupation with other, more immediate, issues;,
(5) religious influences; and
(6) ignorance as well as racialism, tribalism, and
traditionalism.
To the extent family planning is identified with the
Westerm world, particularly the United States, there are
even greater inhibitions in some countries toward family
planning. This factor may be particularly noticeable in
international conferences where Third World countries tend
to combine against the West, against capitalism, and in
favor of the "New International Economic Order." It thus
becomes particularly difficult to raise anything smacking
of "birth control" in such international conferences, where
Communist countries are only too prepared to line up with
the Third World against the West, even though some of the
Communist countries practice stringent birth control.
It follows that our efforts to promote family planning
amongst uncommitted countries must be fine-tuned to the
particular sensitivities in each of those countries. This
serves to underline the important role of our Ambassador
and his or her country team in each LDC country in terms of
advising Washington on how commitment can be best achieved
in terms of the particular circumstances of that country
and being alert to take timely initiatives on their own to
further these objectives.
A number of conclusions can be drawn with regard to
countries whose governments do not officially favor or
promote family planning:
(1) Terminology: use of such phrases as population
control or birth control is inadvisable, and in some cases
resented, especially in Africa where they may have genocidal
connotations. Family planning or "responsible parenthood"
are generally acceptable terms, with emphasis being placed
on child spacing in the interests of the health of child
and mother.
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(2) Development: anything that increases awareness,
especially amongst leaders, of how excessive population
growth detracts from national development will advance the
cause of population policies. It would be especially
helpful if the World Bank and UNDP, as well as donor coun-
tries having close relations with developing countries,
could find suitable occasions to convey specifics to LDC's
showing how population growth is a drag on development in
their countries. Our Ambassadors and Washington leaders
may also have suitable occasions to make these points
effectively. Computer projections of demographic and
economic information as well as Census Bureau presenta-
tions can be made available to the governments of developing
countries and to their media services in some cases.
(3) Education: closely related is the fact that
educating promising LDC officials, scientists, and tech-
nicians in demography, economics, and other subjects related
to population growth and development will be a sound long-
term investment. Reduction of illiteracy, especially of
women, is of special importance, as are national education
programs and curriculae relating to basic population and
health education.
(4) Primary health services: this subject has been
treated in a section above, but it has particular relevance
in countries unwilling to embrace family planning except in
the context of health and nutrition. Since this is rather
generally the case amongst the uncommitted countries, we
would do well to place considerable emphasis on this approach
in seeking to engage them in family planning. It is an
approach that places family planning in a most acceptable
context, and is particularly cost-effective where countries
have not yet launched family planning programs.
(5) Working through international organizations and
private groups: support of family planning in uncommitted
countries will normally have to be through international
organizations like UNFPA and WHO and private voluntary
organizations like the IPPF. International organizations
should be encouraged to work family planning content into
their assistance programs insofar as possible and particu-
larly in countries whose sensitivities make a direct
approach on population planning inadvisable. Private
voluntary organizations have played an invaluable role in
family planning, including their support for small groups
interested in family planning before governments in those
countries were involved.
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(6) Status of women: in many of the uncommitted
countries, male machismo, inhibitions about discussing sex
issues, and the subservient role of women combine as major
obstacles to family planning. There must be the creation
of opportunities for women beyond the rearing of children.
Accordingly, we should discreetly strive to lend every
possible support to movements in the LDC's for the improved
status of women, not just within the family but in community
and national life as well.
(7) Strategy for developing an effective population
program: this has been proposed by our Ambassador to
Ethiopia. He describes a possible multi-year program
involving cooperation with international organizations in
moving Ethiopia from its present non-committed position to
one of government commitment, with a. generalized description
of each phase in the re-orientation process. Such an
approach may be helpful in a number of uncommitted countries
in setting new directions for the future.
(8) Mutual reinforcement within regions: we should
see that positive statements on population issues by
respected leaders are picked up and played back among
neighboring countries. While direct programming may not be
possible due to the sensitivities of the population issue,
USIA could explore cooperative arrangements with private
or multilateral organizations of good standing in the
countries in question. Leaders of developing countries
committed to population programs should be encouraged to
share their thoughts and concerns on population growth and
their successes in dealing with it in discussions with the
non-committed. Wider publicity on the affects of success-
ful family planning programs must be given to encourage
others.
3. Developing Greater Commitment at Home and Abroad
Virtually all countries have population problems of
sorts, and the United States is no exception. Fortunately,
there has been a drop in the U.S. birth rate to parallel the
drop in the death rate so that our rate of increase was only
.81 percent for 1975 including immigration. But we do have
distribution problems, and our larger cities with declining
tax bases in particular are showing strains in providing
services. Some areas have serious pollution problems. Many
are faced with mounting crime rates.
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Rapidly growing populations in some countries have tended
to spur emigration to the U.S. This includes illegal immi-
gration which probably exceeded 800,000 in 1975 or almost
double the legal immigration that year. In 1976, the Senate
took legislation under consideration which would establish
penalties on U.S. employers who knowingly hire illegal
aliens. Similar, tighter legislation is already contained
in the Rodino Bill on Immigration approved by the House.
U.S. concern over population issues, nevertheless, relates
primarily to how excessive population growth rates around
the world create dangers of famine, environmental degrada-
tion, social unrest, political turmoil, and war that could
involve the entire planet. This must be everyone's concern,
and mankind must be committed to corrective measures before
it is too late.
Even though the Bucharest World Population Plan of Action
calls, among other things, upon countries to develop national
population policies and programs, the United States has no
national program of its own. This detracts somewhat from
our effectiveness in urging others to develop programs. On
the other hand, we can point to a de facto policy in the U.S.
supported by legislative action, federal funding, and recent
Supreme Court decisions. Also important are many effective
family planning activities in the United States and certain
steps being taken here which have wide relevance in other
countries, such as courses in population studies that were
recently introduced in the Baltimore Public School System or
the integrated health delivery system of our Frontier Nursing
Service which operated under conditions similar to those in
many developing countries. An excellent film has been done
on the Frontier Nursing Service which should be widely dis-
tributed abroad.*
In order to obtain the support of U.S. citizens for
our involvement in international population programs, it is
important, as stated in NSDM-314, that they recognize how
excessive world population growth can affect domestic prob-
lems including economic expansion as well as world instability.
*The Federal Interagency Committee on Education is now pre-
paring a series of recommendations for the Secretary of HEW
on how to build a system of population education both in the
schools and among the public, and how the Federal Government
can support such a system.
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While many people fail to grasp the vast dimensions of the
population problem and its impact on their lives, there is
a body of opinion that tends to see the problem as so vast
and complex that it is beyond man's capacity to solve. Our
position must, therefore, always be balanced between (1) the
many dangers in current population growth rates and (2) what
can be done about it. We must stress that the world stage
has at long last been set for more effective action by the
nations of the world; that many countries have drawn up, or
will soon draw up, population policies and programs; and
that family planning has enlisted the active support of
many leaders and dedicated people,.especially women, who
have a particular stake in successful family planning pro-
grams. As a result of these developments, as well as other
factors on the changing world scene, birth rates are gener-
ally tending to go down in many areas.
On the other hand, we should not err in the direction
of over-simplifying the problem or suggesting that it is
amenable to any short-term solutions. Obstacles are many.
The task is formidable. It will require the concentrated,
sustained efforts of all countries and international or-
ganizations, as well as the commitment of millions of
dedicated people, if mankind is to be spared disaster.
This is our message.
In projecting our position, we must convince people at
home as well as abroad. Promotional aspects of our job
cannot be overstated. A Presidential statement on popula-
tion policy reflecting the thrust of NSDM-314 would be most
helpful, particularly in enlisting support and understanding
of the American people.
At home, it involves gaining the attention and support
of the media, of Congress, of organizations, and of groups
of concerned citizens and including the subject of popula-
tion in official publications and speeches, especially
those of national leaders.
Abroad, it takes the form of private conversations with
leaders and others (involving our own leaders, diplomats,
.and other representatives), of getting international or-
ganizations like IBRD, UNDP, WHO, and UNICEF, as well as
other countries, to speak to the issues; of USIA ensuring
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that our message comes through effectively by radio/TV,
press, exhibits, books, panphlets, slides, and films as
well as through education programs, lectures, and work-
shops. We should press for the inclusion of population
and population-related issues, as appropriate, on the
agenda of the UN and other international gatherings re-
lated to foreign assistance, development objectives, and
resource utilization. Often this is best done in close
cooperation with developing countries which have their
own national population programs.
In all of these approaches, we must be selective,
bearing in mind the danger of population programs other-
wise being seen as serving primarily our interests rather
than those of other countries. That is why emphasis in
the preceding paragraph is on private conversation and
on getting international organizations and other coun-
tries to get out in front. This is particularly true
with regard to international conferences involving the
LDC's where population issues are relevant. In those
circumstances, we should encourage LDC representatives
to take the lead. Credit for accomplishment should be
theirs, not ours.
We have learned from experience that the United
States, though it must retain a leadership role, cannot
solve the problems of other nations. It is up to those
nations to take action, but we can help those countries'
problem-solvers.
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Analysis and Recommendations
A.I.D.
Washington, D.C.
April 1976
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Summary
Rapid population growth in developing countries continues
to exacerbate the already difficult task of improving the welfare
of millions living at or near subsistence. While birth rates in
developing-countries have begun to fall, death rates have also
declined, and resulting annual rates of natural increase of
around two percent threaten to double the population every thirty-
five years or so. The basic question of this analysis is how
to achieve the greatest additional voluntary reduction in fertility
at a given program cost in those LDC's wishing to slow population
growth., We recommend a "package" approach involving increased
levels of Title X assistance and sharply increased attention to
the potential impact on fertility of other development programs
or policies.
Fertility control remains a sensitive subject; three
caveats on this paper are in order. First, it must be seen in
light of AID's assistance objectives as delineated in our legis-
lation, which are in turn grounded in the mutual interests of
LDC's and the U.S. Most LDC's take their fundamental develop-
ment objective- to be improving individual levels of well-being
particularly among the rural pcor -- by encouraging broader
participation in development, helping increase supplies of key
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goods and services, supporting their equitable distribution,
and limiting the numbers who must share (through family planning).
This particular paper, however, addresses one aspect of AID's
programs -- their impact on fertility. The Agency considers
voluntary fertility reduction as only one means, albeit an
important one, for achieving improvements in individual well-
being. This view is compatible with the view of many LDC's as
expressed at the World Population Conference, the International
Women's Year Conference, and other public fora -- and with the
implicit priorities reflected in development policies and programs
of some LDC's whose public pronouncements on fertility have been
limited. The paper concludes that AID-assisted family planning
services and development programs can all affect fertility.
This does not suggest, however, that. AID programs with little
or no fertility effect should be downgraded, for such programs
may be justified on independent grounds.
Second, the paper does not seek to prescribe any particular
approach to reducing fertility for any particular country. AID
provides population assistance only when requested, firmly
believes that ultimate responsibility should rest with the LDC
concerned, and implements any assistance in a collaborative
style.
Third, the paper does not address whether the U.S. practices
what it preaches in terms of population policy. The U.S. lacks
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an official population policy, but does have many of the programs
(public or private) discussed here, and the average family size
implied by current U.S. fertility rates is slightly less than two
children.
Population growth rates reflect the sizes of individual
families. Couples need not affirmatively decide to have a
child, but they must affirmatively decide to practice family
planning to postpone pregnancy either temporarily or indefinitely.
Consciously or unconsciously they weigh the pros and cons, as
they see them,of another child against the pros and cons, as
they see them, of available means of family planning. Their
attitudes toward family planning depend on the type, cost, and
,accessibility of the family planning services available and on
the extent to which they accurately understand those services.
Their views on the desirability of a child are more complex,
and depend largely on the social, cultural, economic, political,
and medical milieu.
The number of children parents actually have includes:
(1) the minimum desired number of children that
parents would want even if the best possible
family planning services were available;
(2) any additional "insurance" births they may
want to insure survival of the desired minimum;
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(3) any extra births they don't really consciously
l/
seek.
Providing better family planning services and information
is perhaps the most obvious way to tip parental decisions in
favor of family planning. Better services and information can
avert extra births that couples do not affirmatively seek.
They can also help reduce insurance births as wider spacing
of pregnancies works to improve the health of existing children.
And they can indirectly influence the minimum number of children
parents seek; as services change family size now, they help
modify future social expectations on appropriate family size.
Thus most population assistance and domestically. financed
population programs have concentrated on developing and extending
better family planning services and information. Over the past
decade AID has devoted some $750 million to population assistance,
primarily to improve and extend services and information. While.
it is difficult to quantify their demographic impact precisely,
available evidence shows that providing good services has
helped siginficantly to reduce birth rates, particularly in Asia.
The exact role of AID is difficult to pinpoint, of course, But
where.AID has supplied a large part of the wherewithal needed to
develop and extend family planning services and information or
1/ No one pretends, of course, that sharp lines divide these
three categories of births. But they do reflect reality
and they also help to clarify analysis.
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supportive. measures, it can claim considerable credit for
subsequent drops in birth rates. (AID programs have also
worked to stimulate the gathering of more curate demographic
data, inform leaders and policy makers on the urgency of
population problems, and encourage the development'of needed
institutions and skills, etc.)
Since services are as yet available to only. about 15%
of most LDC populations, further extension of better services
should bring substantial further birth rates reduction.
But family planning services and information alone may
not suffice to bring birth rates down to current LDC target
levels, much less to stable-population levels. That would
require an average family of only slightly more than two
children. As emphasized at the World Population Conference
and elsewhere lately, for socio-economic reasons many parents
may feel they want three, four, or more children at a minimum
even when safe, effective, acceptable, and affordable family
planning services are made available. A small-scale farmer in
India may want several children, particularly sons, to provide
reliable labor at planting or harvest, to support him during
old age, and to dispose of his body according to his religious
rituals. The illiterate wife of a Latin campesino may be content
to kdep bearing and rearing children; it was what she was always
expected to do. And so on. AID believes development policies
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and programs can be tailored to change the socio-economic milieu
to encourage smaller families, thus effectively complementing
better family planning services and information. Indeed such
a package approach involving both development programs and
policies and improved family planning services and information
may be the most effective way to accelerate declines in birth
rates.
Development policies and programs that can encourage smaller
families include:
Policy statements favoring small families and opinion
leaders' support for family planning.
Laws and regulations raising the minimum age of
marriage and easing access to and lowering the
cost of family planning services.
Increased education for women.
Increased female employment in non-menial occupations
that compete with continual childbearing, bearing in
mind the need to assure that children., particularly
among the poor, can be cared for.
Increased economic incentives for smaller families,
whether for individuals or whole communities.
Rural development: promising higher incomes and more
egalitarian distribution.
Improved rural organization like multi-purpose cooperatives
and. other such village organizations that can be used
for a variety of related purposes like increasing
income earning opportunities, improving health, or
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The importance of improving the status of women and increasing
their opportunities deserves special mention.
PROGRAM RECOMMENDATIONS
Focusing on improving the well-being of the rural pagr
will help generally to lower fertility, while lowering fertility
may in turn help improve living conditions particularly in poor,
crowded, rural areas. Thus reducing fertility may itself call
for about the same "package" of development policies and programs
that seem most promising as means of generally improving welfare,
though some qualifications on that statement must be made.
The following are our basic recommendations for both
Title X population assistance and other AID and PL-480 assistance
as it may affect fertility.1/
A. Title X Program Directions
Since the primary purpose of Title X population assistance
is to encourage voluntary reduction in fertility, decisions on
allocation of these Title X funds should be based on the
cost effectiveness of alternative approaches to reducing
fertility, including (a) more and better family planning
services; (b) more and better family planning information;
(c) exploration of the links between. fertility and the
development process; (d) provision of population-related com-
ponents in broader education, health, nutrition, rural develop-
ment or other programs; and (e) other appropriate measures designed
primarily to limit fertility. At present we believe somewhat
higher Title X funding levels, perhaps around $200 million,
1/ As indicated below, we do propose using non-Title X
funds to affect fertility, inter alia, as appropriate
gimpprc adf #~taa~s2Gt08/(tad ~/,10585O0~~d~4-8
objectives.
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8
could be justified over the next several years depending on
LDC interest and absorbing capacity, though we need to improve
data and refine statistical methodology in order to make a
better case for precise levels. With that in mind, we suggest
the following program directions within the six functional
categories of Title X population assistance.
Category 1: Demographic: Data
Place less emphasis on financing broad-based
but relatively undetailed censuses in the
future.
Moderately expand efforts to.develop more
complete and detailed demographic data at
least on parts of populations to permit
more accurate estimates of the demographic
impact of various programs.
Category 2: Population Policy
--- Moderately expand LDC-based research on
the linkages between fertility and various as-
pects of development, particularly including:,
a) female education of various types and
levels;
b) female employment;
c) health (especially of children);
d) nutritional status of women and children;
e) incentives/disincentives to encourage
smaller families;
f) income growth, distribution, and rural
development (focusing specifically on
food);
g) laws and policy statements supporting
family planning;
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Moderately expand "population impact" analysis
and other measures to encourage broader under-
standing of the development implications of
population growth and the potential for bringing
development programs to bear on fertility.
--- Moderately expand pilot projects and experiments
in areas a) - f) above, providing technical
assistance or financial support.. (Title X
or other AID funding for expansion of pilot
programs in these areas would depend on such
things as estimated cost-effectiveness, the extent
to which lack of funding constrains program
expansion, and competing demands on fund/
Category 3: Research'
a) Bio-medical Research i/
--- Moderately expand projects to field-test
promising new family planning methods.
--- Moderately expand research to develop new
methods (particularly once-monthly methods
and better and more reversible methods of
male and female sterilization) and research
on side effects of available methods,
particularly pills.
--- Moderately expand research on the relationship
between nutritional status and fertility.
b) Operations Research
Sharply expand LDC-based research on the
comparative effectiveness of alternative
approaches to family planning services and
information, focusing particularly on basic,
low-cost, village-based distribution with
short start-up times.
Sharply expand LDC-based research on what
services, health auxiliaries, and laymen may
be able to provide.
Sharply expand research on whether or under
what conditions village-distribution schemes
using low-level health auxiliaries or lay
personnel can be established without much
clinic backup.
11 As noted elsewhere, of course, Title X funds would not be
used for programs whose primary objective is not reduding
fertility, except for the parts of such programs that might
directly affect fertility.
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--- Moderately expand research on prospects for
LDC production of contraceptives and other
family planning supplies.
Category 4: Family Planning Services
we expect the major focus of Title X population assistance
to continue to be on extending better family planning services;
within that focus, we shall give priority to providing more low-
cost services for the poor, particularly in rural areas where
the vast majority still lack any but traditional services. we
shall:
--- Encourage provision of a variety of family
planning methods, particularly pills,
condoms, and sterilization.
Sharply increase efforts to help establish
and expand village-based distribution of
family planning services in rural areas
particularly through low cost systems relying
on health auxiliaries and laymen and promising
short start-up time.
Encourage integration of health, nutritnn, and family
planning services wherever sensible). Making
care to encourage movement on either the
health or family planning front where
simultaneous movement may be very difficult.
Seize opportunities to "piggyback" family
planning services on existing delivery systems,
particularly clinics, where they are available
(e.g. some Latin countries).
--- Encourage allocation of health funds to the
establishment of low-cost delivery systems
reaching into rural areas that could add in
family planning where that approach seems
most promising (e.g. some African countries).
Encourage provision of appropriate contraceptives
through private channels (e.g. midwives) or
commercial outlets like pharmacies or small
shops.
--- Work with intermediaries, public-funded programs,
or both depending on potential effectiveness.
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In terms of country priorities, we take our primary
objective to be getting family planning services started in
developing countries. We will, of course, give careful
attention to encouraging those countries to assume total respon-
sibility for their own programs, including their major contra-
ceptive requirements.
Category 5: Information, Education, and Communication
--- Where broad-based family planning awareness
campaigns have not been undertaken, we would
encourage those; but since many countries
have undertaken such campaigns, we expect
relatively- less emphasis in this area.
--- Where basic awareness exists, fine-tune
existing IEC efforts so they are:
a) country and culture specific;
b) informative on each specific method of
family planning;
c) related to personal needs and aspirations;
d) focused considerably on the interface
between village family planning worker
and village client;
e) reliant on relatively inexpensive media
with broad out-reach that require little
reading (e.g. radio);
--- Sharply expand operational field testing and
collaboration with other agencies, such as
UNESCO and UNDP to better determine which
combinations of the many modern and traditional
media are more efficient, effective, and
suited to the special and evolving needs of
differing countries and family planning programs.
Category 6: Manpower and Institutional Development
Sharply expand efforts to help train health
auxiliaries or laymen for village-based
distribution.
In countries having enough basic family
planning workers at present, focus on filling
specific institutional and personnel needs.
--- Moderately expand efforts to strengthen
planning and management capacity at all
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 RReed~ ~~~~ 12/ CC
B. ~oeF$rRC~GWS2.AND 8PL 4810:RDPROGRAM7DIRECTIONS4-8
RELATING TO FERTILITY
Other AID programs -- in food and nutrition (and broader
rural development), in education, and in health -- can affect
fertility indirectly but significantly as discussed above.
Except for low-cost health systems designed to provide an
integrated package of health, nutrition, and population
services to larger proportions of LDC populations, the
primary objectives of AID's other programs do not include
fertility reduction, though that may be an important
secondary result. It is expected that. due weight will be
given to a;Wy secondary impact on fertility when the benefits
and costs of possible programs are considered, though final
funding decisions will of course depend on all benefits
and costs. It should be stated specifically, however, that
non-Title X population funds can be used to explore links
between fertility and development and assist in planning,
implementing, and evaluating programs designed to affect
fertility.
Specific suggestions follow. We emphasize, however, that
in each are additional LDC-based research is needed.
Food, Nutrition, and Rural Development
--- Give increased attention to projects that will help
elucidate and take advantage of the linkages between these
program areas and fertility, particularly focusing on the
very poor. (It is particularly important to have an over-view
of the problem in order to plan the best possible combination
of individual projects that will act in coordination to improve
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 --App Give Fincreased0/Je/ri idli tx5 Pi~l~MR%4 4 s12~nq
reduce unequal distribution of income and other goods and
services.
--- For rural development as a whole, give increased
attention to a "package" of policies designed both to foster
production and slow fertility growth as consistent with LDC
objectives and preferences and with managerial capacity.,
--- Give increased attention to projects which
encourage community-based organizations and local managerial
capability.
--- Give increased attention to potential fertility effects
of any proposed redistribution of the land.
--- Give increased attention to the use of community or
personal incentives (relevant for either AID or PL 480; major
additional attention should be devoted to this area).
--- Give increased attention to ways of fostering rural
development that discourage traditional forms of child and
female labor.
--- Give increased attention to ways to encourage
profitable employment for women in non-traditional, non-menial
occupations.
--- Give increased attention to the problems of planning
administering, and evaluating multi-purpose or "package"
programs that may affect fertility inter alia.
Particularly on Nutrition:
--- Encourage integration with health and family
planning services where appropriate.
--- Encourage programs with direct impact on lower
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14
Education
Give increased attention to raising the number of
female beneficiaries in all programs (especially where males
outnumber females significantly), bearing in mind other benefits
and costs of such pxogranj.
--- Give major attention to expanding basic education
for girls as well as boys.
--- Encourage incorporation of messages on the benefits
and methods of family planning into formal and non-formal
education programs of all types -- in schools, through rural
extension work, through clubs, etc.
Health
--- Encourage development: of integrated health, nutrition,
and family planning services where appropriate (either in one
organization system particularly at the village level or at
the planning level) for the majority. Also encourage integration
at the planning level, to assure efficient coordination of
all programs that may substantially affect health and fertility.
--- Give major attention to maternal and child health.
Country Priorities
Obviously the same type of program will not do for all
countries; thus, our general policy and program strategy must
be adjusted considerably for a given country, and an approach
developed that makes sense in that country. The overall shape
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15
of all AID programs actually operating will depend on what
countries we actually assist. Country allocation decisions
naturally reflect both U.S. economic and political interests
and prospects for meeting program objectives -- in this case,
1/
reducing world fertility. Here we propose to give only
rough guidelines as to the countries in which AID may concentrate
its population-related assistance. Special concern exists for
thirteen countries excluding China who contribute most to world
population growth: Bangladesh, Brazil, Colombia, Ethiopia,
Egypt, India, Indonesia, Mexico, Nigeria, Pakistan, Philippines,
Thailand and Turkey. But AID does not operate major bilateral
population programs in about half of those countries at present;
nor can we mount massive programs through intermediaries of
the scope, design, and vigor we would want. Thus the Agency is
also determined to pursue opportunities in a limited number
of other countries interested in reducing fertility where
prospects seem bright or where unusually good opportunities
exist for development prototypes of programs that may also
prove helpful in other countries. We are continuing our analysis
of program prospects, requirements, problems, etc. in order to
refine our list of country recipients, assuring adequate program
focus, and expect to make considerable further progress in this
area in the next several months.
1/ It bears emphasizing. that reducing fertility is only one of
AID's objectives under the mandate -- and that it is viewed
asAIpr rc:i!el i kM/ g C?&E 4r.7i# 5@% @Q4-$n welfare.
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U.S. POPULATION-RELATED ASSISTANCE
Analysis and Recommendations
Page
THE PURPOSE 1
CURRENT POPULATION GROWTH 1
THE PROBLEM 3
OUTLINE OF THE ANALYSIS 9
FAMILY PLANNING SERVICES 10
INFORMATION, EDUCATION, AND COMMUNICATION 21
DEVELOPMENT/POPULATION POLICIES AND PROGRAMS 23
CONCLUSION : DIRECTIONS AND POSSIBLE FUNDING LEVELS
FOR U.S. POPULATION-RELATED ASSISTANCE 41
SUMMARY: AN INTEGRATED APPROACH 55
For interested readers, annexes to this paper giving
supportive data and additional detail are available.
Annex 1: EVALUATION OF WORLD-WIDE EXPERIENCE:
Family Planning Services
A. Africa
Ghana
Tanzania
B. Asia
Bangladesh
Indonesia
Korea
Pakistan
Philippines
Latin America
Colombia
El Salvador
D. Near East
Tunisia
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 THE PU S .% ed For Release 2003/08/08 : CIA-RDP79M00467A002500120004-8
AID has been asked to evaluate experience with alter-
native approaches to reducing fertility in LDC's, to identify
promising approaches for the future, and to suggest directions
for U.S. population-related assistance in the next decade.
The Agency gives continual attention to program directions;
the analysis presented here builds on substantial earlier
efforts.
In reviewing this paper, it is crucial to bear in mind
the caveats presented above, particularly noting that this
paper focuses on only one aspect of AID's program -- its
impact on fertility. AID's overall purpose, like that of
many LDCs, is to improve the well-being of the poor;
limiting population growth is only one means, albeit an
important one, to that end. AID does not seek to impose
any course upon an LDC, and provides population assistance,
like other assistance, only when asked.
CURRENT POPULATION GROWTH
Rapid ?opulation growth in developing countries seriously
exacerbates the already difficult task of improving the
welfare of millions who already live at or near subsistlnce.
Such growth creates additional demands on already scarce
resources and impairs the already precarious health of
women and children who share present and future development
burdens. Wcrldwide, population growth generates increasing
environmental pressures that may be serious now or eventually.
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And it contributes to international political and economic
disruption. In developed countries population growth has
abated recently, averaging about 0.71 percent annually, with
birth rates at about 16.3 per thousand and death rates at
about 9.2 per thousand.!/ In developing countries, however ,
the picture is different. While birth rates have begun to
fall in many countries recently, the rates still average
about 32..7 per thousand; death rates, which have also declined
dramatically over the last two decades, still remain at
about 12.8 per thousand.!/ Resulting population growth
averages about two percent annually.!/,4/.This growth rate
implies a doubling of LDC population every thirty years or so,
at least until birth planning or increasing disease and
malnutrition intervene. Moreover, the task of containing
population growth through birth planning is complicated by
the "built-in momentum" of a growing population: with a
high proportion of young people who have yet to bear children,
growth would inevitably persist for many years even if the
two-child family should suddenly become the norm. Thus,
though an encouraging start has been made in reducing fertility,
much of the task remains ahead. Development programs over the next
decadeswill inevitably have to consider population growth; the
question is how much, and what the funding implications will be.
1/ North America, Europe, excl. USSR, Oceania, Japan.
/ Latin America, Africa, 'dear East, Asia incl. PRC but with Japan
among the developed countries.
3/ These rates assume our best estimates on the PRC. Without
the PRC, birth rates would.be about 39.1, death rates about
.15.2, and the resulting rate of natural increase about 2.39..
4/ WoridAppd prftlesatdROB(@AfttfelA21$4F17 W4f2yAQ Mg1,2q$@ $h rates.
average 11.8 per thousand, and the resulting rate of..natural
increase is 1.63 percent annually.
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THE PROBLEM
Population growth rates reflect the size of individual
families.
Couples need not affirmatively decide to'have a child,
but they must affirmatively decide to practice family
planning, whether they just want to postpone pregnancy or
whether they want to end their childbearing./ Consciously or
unconsciously they weigh the pros and cons, as they see
them, of a child against the pros and cons, as they see
them, of available means of family planning. Their attitudes
toward family planning depend on the type (hopefully
reflecting both cultural acceptability and bio-medical concerns),
cost, and accessibility of the family planning services
available and on the extent to which they accurately understand
those services. Their views on the desirability of a child
are more ccmplex, and depend largely on their social, cultural,
political, economic, and medical milieu.
Thus, the number of children parents actually have includes:1/
(1) the minimum desired number of children that
parents would want even if the best possible
family planning services were available;
1/ Couples who wish to have a child for whatever reason (including
sub-fecundity) will plainly not be interested in family planning
to prevent pregnancy.
2/ No one pretends, of course, that sharp lines divide these
three categories of births. But they do reflect reality
and they also help to clarify analysis.
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4
(2) any more "insurance" births they may want to
insure survival of the desired minimum;
(3) any extra births they don't consciously seek,
but which result from miscalculations, laissez-
faire attitudes, casual assessments of long
run costs and benefits, etc,
Minimum desired gamily size depends on all the
economic, social, cultural., and personal influences on the
family. It does. not depend directly on the availability of
family planning services, though it is likely that the
successful use of services available now may well influence
future attitudes and expectations on appropriate and acceptable
family size. Attitudes on minimum desired family size.can
also be directly influenced by information and education
programs specifically designed to influence them. And
development policies in any number of seemingly unrelated
areas can change minimum desired family size by changing the
economic, social, cultural, and personal circumstances of
the family in such a way as to make smaller families a more
attractive option.
Insurance births can be reduced by improving child
health -- by providing better health services, better nutrition-
and even better family planning services (since wider spacing
of pregnancies greatly improves child health where mothers
and children are ill and poorly fed).
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5
Extra births, which may be numerous, can be greatly
reduced or even eliminated by providing acceptable, affordable,
and accessible family planning services and appropriate
information.
The basic question of this particular paper is how to
achieve the most voluntary reduction in family size and fertility
with limited resources, bearing in mind that both LDC and AID
objectives are of course much broader than this, as discussed
above. But many LDC's receiving U.S. aid have low target
birth rates; for argument's sake, we take their ultimate demographic
objective to be a stable population.l/
Providing better family planning services -- effective,
safe, affordable, and accessible -- seems the simplest way
to tip parental decisions in favor of family planning. In
the few countries that have such services on a wide scale,
birth rates are falling -- not to stable population levels
yet, but far below their recent high levels.Y The cost-
effectiveness of such services depends on whether they are
used efficiently, on how many children the users have, on
how many fertile-age couples are users, and so
1/ A stable population requires essentially a two-child family --
or a "net population rate" of one (meaning each woman has,
on average, one daughter).
2/ Examples of countries where birth rates have declined from
high levels: Taiwan (23 per thousands population), Costa
Rica (28), Korea (29); Colombia (32). Several other countries,
.including India and Thailand, now have birth rates in the
mid-30s. Sri Lanka. and the State-of Kerala in India also
have low birth rates.
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on.1/ So far, really good services -- i.e. safe, effective,
affordable, and accessible -- do seem to be used extensively and
by people who otherwise probably would have had several more
children.2/ Thus good services probably represent the cheapest
approach to reducing birth rates so fa. And a good many
more people in LDC's stand ready to use good services. It is
only sensible to provide them with such services, which need
not be costly, as a start./ That much is clear. Thus AID
has devoted most Title X assistance, totaling some $750
million over the past decade, largely to improving and
extending family planning services (including information),
and plans to continue to do so.
But family planning services. and information alone will
probably not suffice to reduce birth rates to near stable-
population levels.Ll/ Essentially, this would require an average
1/
2/
3/
4/
The demographic impact of services depends on the proportion
of fertile-age couples using them ("prevalence"), on the
number of children those users have ("parity"), on service
effectiveness, etc. Parity data are poor, but available
prevalance data suggests birth rates do fall as prevalence
rises, especially over 20%. Some people believe, at present
levels of acceptance and birth rates, a two percent increase
in prevalence leads to about a one-point decline in the birth
rate, through this relationship is very tentative. Prevalence
in most LDCs, is under 15%; such countries have few good
services on the whole.
This is particularly true when both conceptive and post-
conceptive services are made available, data seem to suggest.
The question of where acceptance rates-may peak is discussed
below.
Most family planning experts believe that population stability.
would require prevalence-on the order of 60-70%, based largely
on developed-country and Asian experience.
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family size of only slightly more than two children. Making
family planning as easy as possible can certainly eliminate
unwanted pregnancies and help reduce "insurance births" as
wider spacing of pregnancies improveschild health. And
through their influence on social expectations over
time, services may encourage people to want fewer children
as a minimum. But services alone may not much reduce the
.minimum number of children parents want. That maybe no
problem if most parents would be content with two children.
But if many parents want three, four, five, or more children
even when good services are available, then it will be essential
to combine services with development policies and programs that
also encourage smaller families.
No one really knows what the situation is in fact. In
the few places (including some poor, rural areas primarily
in Asia) where good services are really available, indications
are that around a third of the couples, mostly with 3-4 children,
may use them.!," This suggests that extending good services
further can indeed reduce family size sharply, and certainly
good services should be provided as rapidly as possible.
But historical evidence also suggests reductions in average
family size sufficient for population stability can be achieved
faster when family planning services and information are
combined with appropriate development policies and programs.
For as parents become more. determined to have smaller
1/ In other words, prevalence exceeds 30%. One major example
is in parts of Indonesia.
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8
families, they naturally become more willing to use the
services available, however imperfect those may still be.
In recent years, AID has devoted both Title X and other
LID resources to exploring the links between fertility and
development policies and programs so that all AID assistance
programs-- or those of other donors or LDCs -- can be designed
as appropriate with a view to their possible impact on fertility.
We expect to expand such efforts in the future.i"
Developing a strategy for population-related assistance
thus requires determining what sorts of family planning
services and.information appeal most (and what they cost),
what development policies and programs encourage smaller
families most (and what they cost), and how these may best be combined.
one major conclusion is that we are woefully short of
hard information on which to judge services, information, or
policies -- because services and information are not widely
enough available to permit measuring their ultimate impact
accurately, because measuring anything is difficult in many
LDC's, and because sorting out the tangled influences on
fertility -- services, information, and all the other changes
development brings -- is difficult even with sophisticated
statistical analytic techniques.?/ That sort of analysis
certainly cannot get far with the data now available. Major
attention needs to go into developing and refining the
1/ The trades-offs among different types of Title X expenditures
will be discussed briefly in the conclusions section.
2/ Multi-variate analysis of fertility determinants requires
data sufficient to permit reasonable separation of the impact
of a #pVyedfot8@Mee 2GO3 i8/l78ioG P fiM002i5124p@ thing else.
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necessary data and techniques. Only thus can we sort out
just which approaches are likely to reduce birth rates
fastest and at lowest cost and what the trade-offs and
complementarities among such approaches may be. Among other
things the Agency should build more such analysis into its
annual program review process.
Even at present, however, some reading of the comparative
effectiveness of various services, information and education
programs, and development policies and programs can be
made.
OUTLINE OF THE ANALYSIS
We examine experience in reducing fertility. through
policies and programs divided into three categories:
Development policies and programs; information, education,
and communication efforts; and family planning services. We
give particular but not exclusive attention to U.S.-assisted
efforts, both bilateral and intermediary programs. Given
what has worked in the past, what AID's role has been, and
what new approaches seem most promising, we suggest future
policy and program directions for U.S. population-related
assistance for countries requesting such assistance.
We base our analysis on assessments of development
policies, IEC, and family planning services in most LDCs of
major U.S. interest. These are available as Annex 1 to
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to interested readers. In addition, we have made special
studies of ten countries of major importance to the U.S.
or with particularly interesting family planning programs:
Bangaldesh, Indonesia, Korea, the Philippines, and Pakistan
in Asia; Ghana and Tanzania in Africa; Colombia and El Salvador
in Latin America; and Tunisia in the Near East. The country
studies are also available as Annex 2 to interested readers.
FAMILY PLANNING SERVICES
.Methods: offering variety
In terms-of methods, the most effective approach seems to
be to offer variety. Each method has its own adherents. No
program focusing on a single method has achieved dramatic success.
But several methods -- pills, condoms, sterilization, and
abortion -- seem particularly effective and appe=cling to
users.
Pills, which are effective and easy to use, appeal
particularly to the young, to those with few or no children,
to those with little access to clinics, and. to those who
want to space births. Many family planning programs began
before pills were widely available, and enjoyed sharp increases
in acceptor rates when pills were introduced.
Not all pills have the same chemical composition, and
some are less likely to produce side-effects like nausea.
Choosing one of the pills less likely to cause side effects
and maintaining a supply of the same pill can be crucial to
continued use.l/
1/ Thus AID is supporting research to explore side effects and
thus AF~~Povj& F i '' el ` 610ft6> 1+B '~tI k 918046 UD0120004-8
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The appeal of condoms is less well documented, but
given their low cost, ease of distribution, effectiveness,
and absence of side-effects, they deserve further attention.
Sterilization -- both vasectomy and tubal ligation --
has proved surprisingly appealing even among poor, ill-educated
people with no more than three children; it is an obviously
effective method, can be handled on an outpatient basis fairly
inexpensively, and deserves to be encouraged considerably.
IUD's have proved acceptable, but particularly in
better-off LDCs like Taiwan and Korea where medical follow-
up is good and where side-effects did not cause undue medical
problems or cultural backlash.-
Foam and diaphragms have their adherents but do not
appeal to many people and are relatively difficult to use
effectively. They should be considered, but probably not
encouraged.
Available data indicate that safe, legal abortion
finds ready acceptance in many countries, even where good
contraceptives are widely available. AID is barred by
the Helms Amendment from financing abortion.
In terms of AID's own assistance to family planning service
programs, perhaps pills, condoms, and sterilization stand
out as deserving priority over the next several years.
1/ In.some countries, the extra bleeding sometimes caused by
IUD's is regarded as unclean, and the woman is not allowed
to cook for her family.
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Acceptance rises when methods improve, and the methods
we have are imperfect. Ideally family planning should be so
easy and inexpensive that no couple would think of doing
without it unless they truly want a child. Thus, research
is particularly needed to explore possible side effects of
pills and other methods to achieve reversible sterilization,
and to develop longer-acting contraceptives, including
injectibles.
Modes of delivery: village distribution
In terms of delivery systems, village-level distributions"
(incorporating village-level leadership) deserves major focus
at the moment. The fastest growing and most vigorous programs
seem to be moving in the direction of non-clinical and non-commercial
distribution of services in villages. Early results are encouraging;
acceptor rates exceed 30% of fertile-age couples in some areas.Y
Most family planning programs have begun in clinics,
and most are still clinic-based. For countries able to
afford to put clinics within easy reach of all people,
extending the clinic system may be the best way to improve
family planning services. In some areas (particularly in
Latin America) where. clinics are already fairly plentiful,
1/ House-to-house or at least with services accessible
within the villages.
2/ Notably in rural Indonesia and Egyptian pilot programs.
In Indonesia, strong peer pressure is a key point of the
program.
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additional family planning services should certainly be
integrated into clinics or expanded to assure they are
available daily. In some areas we may have no choice but to
limit programs to clinics, though there may be a better way
than exclusively clinic-based (or clinic-bound) services.
Few developing countries can really afford the clinic
route; most now serve only 15-20% of their populations with
clinics. To reach the poor majority and keep total program
costs manageable, most countries must limit per-user costs
by paring services down to bare essentials. This means
trying to serve areas beyond easy reach of clinics with
paramedics or "health auxiliaries" -- midwives, "promotoras"
and othertow-level and possibly multi-purpose workers --
instead of physicians.
. Pilot level experience indicates that health auxiliaries
or even village people with a little training can be used
effectively to provide excellent family planning information
and services. They can distribute contraceptive pills
(though easing prescription requirements is a prerequisite),
and auxiliaries can insert IUDs (even in the U.S.!). Some
do sterilizations safely if well trained and supervised, though
AID so far has preferred physicans in'the-'performance of
sterilizations.l/
(See page l3a for footnote.)
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13a
if It bears emphasizing that consumer safety arguments
actually militate in favor of a judicious easing of
prescription requirements and restricitions on health
auxiliaries. Present evidence indicates strongly that
the hazards to poor, undernourished women of repeated
pregnancy and childbirth in the absence of a physician
are far greater than any hazards, which appear to be
minimal, from contraception in the absence of a physician
particularly when good paramedic supervision can be
provided. Maternal mortality rates in many poor LDCs
approach 500 per hundred thousand (as compared to about
20 in the U.S.). Mortality from complications of oral
contraceptives (mostly thromboembolic) in developed
countries is on the order of 3 per hundred thousand per
year (bearing in mind that three year's use averts one
birth on the average), increasing several-fold for women
over forty who of course also suffer higher maternal
mortality. But women in LDCs have fewer thromboembolic
complications from oral contraceptives because their different
diets, work habits, exercise levels, genetic background,
etc. leave them far less prone to blood clots. Of
course some people may be reluctant to assume the
risks of a "new" method however they compare to
the long-endured risks of pregnancy, just as people
are sometimOs hesitant to try new medicines or indeed
any innovation, however promising. And to the extent
pills substitute for traditional methods like abstention
or withdrawal, they entail an added risk; to the extent
they substitute for methods like illegal abortion,
they probably entail lower risks.
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While the ideal may be a doctor in every village, that
cannot be achieved easily even in developed countries.
Well-trained paramedics are an excellent solution and should
be used far more where otherwise many people (rich or poor)
will simply do without services.
Indeed, a village worker may be more effective in
dealing with her peers on a personal subject like family
planning than white-coated health technicians or doctors --
who are too often disdainful of their poor and illiterate
clients. Much more needs to be done to expand the use of
village laymen and health auxiliaries, particularly women.
Private traditional or modern providers of health or family
planning services -- midwives, pharmacists, herbalists --
can also be encouraged and equipped to provide a broader
range of modern family planning services. Often, indeed,
they already enjoy the confidence of clients, which facilitates
acceptance of new family planning services.
In teriis of program development, where services have
begun in clinics, one generally reasonable course of action
may be to gradually move pill and condom distribution to
the village level and reserve clinics for more complicated
services such as sterilization, IUD insertion, etc., or
initial introduction to pills. In Indonesia, for example, a
woman goes to the clinic for initial supplies and screening
(but is served by a paramedic, not a physician) and returns
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to village distribution points for re-supply. But for poorer
countries, a key question is whether village-based distribution
of just the simplest and most basic services can precede major
clinic-based distribution, or whether a substantial clinic
network must be in place to provide reasonable back-up. l/
In poorer countries, focusing on village-level distribution
before many clinics are in place may make sense, but pilot
projects and research should be undertaken before ambitious
national programs are.launched.
Reaching the poor while keeping costs low may also call
for combining delivery systems where possible, so that
related health, nutrition, and family planning services can
be delivered as a package. Such integration of services
permits taking advantage of joint products, program synergisms,
and scale economies -- getting more done for the same cost.
As with family planning services only, integrated basic
health, nutrition, family planning information and services
can be provided effectively by health auxiliaries or trained
laymen to help keep costs down. Integration at a higher
level of planning and implementation for all programs with
major impact on health and fertility may also be essential
to get the most out of a limited budget.
Consumers may also prefer integrated services. People
may more re&dily accept family planning services as part of
l/ This question is being explored in Tunisia among other
places.
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a broader health package because the combined services
protect their privacy, because they have learned to trust
health workers, because they find it cheaper and easier to
get health, nutrition, and family planning services on the same
trip (which may be long, expensive, and difficult), or
because they want to assure the health of their existing
children before foregoing additional births.
As with family planning, most rural health services
have been provided through clinics. Indeed, such family
planning services as are available are usually provided
through those clinics, so that integration at this level has
occurred. But often it has occurred imperfectly; clinic staff
tend to focus on family planning one. day, sick babies the
next, etc. necessitating multiple trips that seriously
discourage use of services.
AID is, of course, promoting integration of services
wherever that makes sense. The Agency urges more complete
integration at the planning level so that more programs can
be brought to bear on health, nutrition, and fertility in an
organized way, at a village level so that consumers have greater
access to non-clinical services; and at the clinic level so
that services of various sorts can be obtained daily.
In some siruations it may be possible or sensible for
political, economic, administrative, or other reasons to move ahead
on either the health, nutrition, or the family planning front
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first. That should be done; the second service can then be
grafted onto the first. There is no good reason to hold
back on one service until both can be implemented simulta-
aneously. Particulary in Africa, it may be essential to
provide both health, nutrition, and family planning services
in an integrated way.
Of course, no family planning services will be effective
without adequate administrative capacity -- procuring the
necessary commodities, distributing them to assure continued
re-supply, training and locating personnel, and so on.
Because LDCs are often critically short of administrators,
relying on local leadership (particularly for village-level
distribution) can pay off very well. And intermediaries
like IPPF can play a major role in reaching really large
numbers of people, sometimes by piggy-backing their family
planning services on publicly financed health services,
sometimes by providing free-standing family planning services.
But whether services are provided by government or private
agencies, some central direction is crucial. Among government
programs, it seems to matter less which ministry controls
the family planning services than that the controlling
ministry be. able to coordinate effectively with others whose
programs also affect services and their appeal. Giving
family planning responsibility to a minister rather than a
lower level bureaucrat naturally helps assure leadership.
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 It is worgtpt~r~l ~e 31198/ % : ~ '004~5~6' ~ ants
may be reluctant to give de jure backing to family planning,
de facto backing can go a long way if sustained and practical.
Such informal arrangements may affect provision of all
contraceptives, pill prescription requirements, etc.
At current program levels, most country analysts seem to
consider present bilateral funding and supplies adequate for
now, given current program scale and problems, but program planning
and administration inadequate. In terms of AID programs,
helping train additional family planning personnel, particularly
program planners and administrators, may therefore be crucial.
While funding may well become a more serious constraint as
programs expand, administration is the greater bottleneck now.
Interregional program funding is, however, inadequate in AID's
view at.present. And of course this does not suggest that
services are on an optimal scale at current program levels.
The ccmparative cost of alternative approaches to
family planning services is extremely difficult to estimate
from present sketchy data. Available sources disagree,
sometimes by more than 100%, on total family planning program
costs for a given year. AID and other donor inputs can
usually be pinpointed, but. LDC inputs are more difficult to
fix because health, family planning, and other expenditures
are often lumped together in government accounts.Y Nor
are data from small pilot projects or intermediary operations
much better.2/ Far more attention should go to cost data
1/ The two major sources used here are Population Council and
the AID/IGA worksheet; the latter are relied on here, and
generally give higher estimates.
2/ It is difficult to draw conclusions from either Danfa or
Nara MWV9dFvr p2 3M1D5; Ct nMJ 1804B 28Qg4-&lso
has relatively little detailed data.
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to assure better estimates of comparative cost-effective-
ness in the future.
At present our best guess is that annual expenditures
on family planning of at least $.10 per capita of total
population are necessary, though certainly not sufficient,
have a meaningful program. Good programs seem to run in the
$.10-.25 range by and large, though some of these are more
efficient than others or are in different program stages.l/
Only a few have expenditures exceeding $.50 per capita;
these include both mature and start-up programs?/ whose
effectiveness varies widely.
. Reported costs per new acceptor seem to run around $10-15
in most good programs.3/ 4/ Of course some new acceptors
drop out; continuation rates vary. Taking into account (a)
continuation rates and (b) the usual assumption that one
birth is averted for every three yearsoprotection against
pregnancy, the cost per birth averted will naturally be far
higher -- perhaps $50-100.5/ 6/
1/ These countries include Korea, Taiwan, Thailand, Indonesia,
India, Ghana, and Nepal -- a wide variety of programs. Of
course, these are only the official financial costs
reported; volunteer labor, etc. would have to be included
to give real resource costs.
2/ Costa Rica (impressive mature program); Tunisia
(disappointing mature program); and Pakistan (ambitious
new program).
3/ These are not true marginal costs; they include all
program costs for old and new acceptors and may not
count new acceptors accurately either. But probably
they exceed true marginal cost.
4/ The 5.10-.25 per capita expenditure implies a broad range of
$2.50-$15 per acceptor, depending on prevalence of 10-20%. But
see note 3/.
5/ Sterilization and abortion do not have continuation rate
problems, and each abortion prevents one birth.
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As a program matures, we expect the cost curves associated
with each major program approach to look "U-shaped". Per-
acceptor costs will be high in the beginning because of high
start-up or "fixed" costs; they will drop as the program
matures and reaches many acceptors; and they will rise again
as ready acceptors become scarcer.!/ Hence, combining many
approaches will help ward off diminishing returns to any one
approach.
We believe that normally lower costs can be achieved
through village distribution?/ and through piggybacking.
family planning services on available distribution systems
including public clinics, private clinics, private commercial
channels, and cooperative systems. We should try to avoid
spending population funds on bricks and mortar or on services
other than family planning, though such expenditures might
be perfectly justified for non-population programs. Where
family planning and other services are integrated,?however,
we would normally favor cost-sharing according to program shares,
as determined from some reasonable if necessarily approximate analysis
But per capita program costs are not the only consideration
in allocating AID population funds. One of.AID's principal
purposes has been to help get family planning started in
1/ There is a constantly changing flow of acceptors as time
goes on. Exactly how this affects cost patterns will
depend on differences in the characteristics of acceptors.
2/ The cost-data from the previous page is based largely on
clinic-based family planning services. But village-based
distribution may have resource costs far in excess of
official financial costs because so many volunteers may be
involved, etc.
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countr ff whereo su cn service/s 8areA- ery l imited0025This004-8
has required AID to bear a fairly high share of total program
costs to yet programs off the ground. Such a policy can be
cost-effective utlimately if it does inspire good LDC programs.
It is not easy to predict success, but we try. And we must
undertake some start-up risks to have any chance of eventual
broad success. Of course, we take pains to avoid investing in
programs that are obviously too capital-intensive -- too many
buildings, too much training compared to what is required, and
so on. We look to find programs promising real impact from
lean services. And we pay particular attention to shifting
financial responsibility to LDCs, including the responsibility
for funding contraceptive purchases or production. Given the
paucity of data on which to judge comparative cost-effectiveness
of alternative approaches to family planning services, the
Agency is undertaking major experiments to test and evaluate
alternatives under different conditions.
INFORMATION, EDUCATION, AND COMMUNICATION
Educating and informing potential acceptors on the
benefits and requirements of family planning seems essential;
various IEC efforts have apparently helped encourage the use
of family planning services.l/But considerable debate exists
over which approaches work best. Data on IEC are extremely
sketchy; we do not yet have a precise sense for the proper
role of IEC or for IEC funding requirements particularly vis-
a-vis services. More attention must be directed to assessing
comparative cost-effectiveness of different IEC approaches,
1/ whether these are most appropriately funded locally or from
foreign exchange provided by aid do tion.
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and more approaches should be pre-tested.lr
Past IEC efforts span a broad range -- interpersonal
contact, meetings, TV, radio, posters, pamphlets, puppet
shows, traditional theater, etc. Many have been mass media
campaigns designed to spread a general awareness of family
planning among present and future generations. The limited
evidence now available suggests IEC efforts work best when
they are country-specific, when they advertise specific
family planning services, when they "make a case" for family
planning in personal health, economic, or other terms,?
when they involve short, self-contained messages, when they
reach many people at once, when they use a variety of approaches,
and when they use low-cost media requiring little or no
reading. For AID, use of radio and "comic book" materials
in preference to higher cost TV and films may be indicated,
though radio, TV's, and films can all have major outreach into
village life. Any opportunities to "piggyback" a family
planning message in existing publications, programs, etc.
should naturally be seized. The simultaneous use of
multiple channels and media may be crucial to encouraging
acceptance particularly as time goes on. Of course, peer pressure
can be the most persuasive form of communication, and should
be considered.
l/ Determining cost-effectivness of alternative IEC approaches
is extremely difficult, of course, because of the problems
of relating subsequent changes in behaviour to IEC as opposed
to other intervening influences like new services.
2/ Arguments in terms of national benefits seem less persuasive
generally, though there are cases where.they seem to have
effec~
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23
If the key to extending family planning services in
rural areas is simple and inexpensive information and a few
goods supplied through health auxiliaries or laymen, then
the role of the IEC message becomes critical. The key to
success in such programs will be the ability of the
health/family planning worker or volunteer to lead his or
her neighbors to do something differently. Much AID attention
could usefully be directed to this interface between worker
and villager. How can the worker best motivate on family
planning? Similar problems exist at clinics, of course,
where much family planning advice is provided by doctors or
auxiliaries. many of whom expect to be obeyed, not to motivate.
DEVELOPMENT/POPULATION POLICIES AND PROGRAMS
It is a common observation that family size
falls as modernization proceeds; in the more advanced countries,
family size began to fall even before good family planning
services were widely available. As parents become more
determined to have smaller families, they will be more
willing to use available family planning services despite
their imperfections. And when education, health, or other
non-family planning budgets can also be brought to bear on
fertility, the family planning budget will be that much more
effective. Thus it is important to ask what about the
development process most influences parents to seek smaller
families, and how smaller families may be encouraged.
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Answering this question requires unraveling a paradox:
for a nation as a whole, when population grows significantly
faster than supplies of other productive resources, the eventual
result must be low labor productivity, hence low living standards,
unless technical change continually intervenes to save
the day; yet in populous countries many poor parents
(particularly in rural areas) still insist it is in their
interests to have three or more children. Why? The answers
are complex, but some useful insights are emerging.l/
Odd as it may seem, even for the extremely poor -- the
landless rural laborer or very small-scale farmer -- the pittance
each additional child earns probably exceeds the additional cost
of supporting that child, for parents provide little more than
minimal extra food.?/ Crucial to this analysis is the parents'
belief, probably well-founded, that their children cannot break
out of their current poverty to anything qualitatively different -?
that substantial education, land acquisition, better health,
and other means to a really better life are simply not
realistic possibilities. The additional cost of another
1/ Certainly more research should be done.
2/ Dowries, bride-price, and a few other costs may
also concern poor rural parents.
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child is kept low in good part because of this ceiling on
parental expectations.l/ For such parents, the only road L~o
whatever modest improvements they can achieve lies in increasing
family income through the contribution of several children.
Moreover, since such parents must usually rely on their
children for old-age support (there being no institutional
form of social security), they need an ample supply of
children, particularly sons. With high child mortality, they
may well "over-insure" to prevent disaster. These high
family-size preferences get codified into social customs;
most women get their satisfaction and status from having
large families. Aspects of this description may be debatable
in different countries, but the gist of it emerges again and
again from analysis of poor rural areas.
All this suggests parents may opt for far fewer
children -- say just two -- only when they have a quantum
improvement in living standards that encourages them to
prefer fewer children of higher quality (in terms of health,
education, earning power, etc.) to many hungry, illiterate
ones who can earn but little. The key is to make-the fewer-
1/ If population growth persists, labor producivity may
decline until it equals the marginal cost of another
child--at subsistence wages or the equivalent. But
the basic purpose of development is to raise the
marginal product of labor, especially among the poor.
This may or may not be consistent with maximizing
GNP growth. It is possible that allocating invest-
ment capital to both human capital and, say, physical capital it
agriculture would raise individual living standards
of the poor faster than allocating it all to agriculture,
if the latter allocation would lead to faster GNP growth
but had less impact on fertility.
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but-better option be real--and seem real--to poorer parents.
There is ample reason to believe that massive rural
'development with major production increases directly benefiting the
poor, accompanied by education, health, nutrition, and family planning
services and supported by active community organizations,
encourages declines in fertility, especially as women are encouraged
to move beyond their traditional roles. A few LDC's, especially
those enjoying sustained and substantial GNP growth, can
afford this route and show encouraging progress. But what
about the others? They must be far more selective, finding
the pressure points of the development process that most
encourage lower fertility and focusing on those. Of course,
the better-off LDCs working to lower fertility will also
find the job that much less costly i` they too focus on
these pressure points.l/
What are these pressure points? They seem to fall in
five major areas. One is public leadership, laws anti
administrative regulations, which can encourage smaller
families at very little cost. High-level statements favoring
small families and opinion-leaders' visible support for
family planning can help. Other apparently effective measures
include raising the minimum legal age of marriage, relaxing
restrictions on abortion,Y easing prescription requirements
1/ This does not suggest that LDC'sfocus exclusively on
programs that encourage lower fertility, of course.
2/ There is no doubt that liberalization of abortion has
helped reduce birthrates even in countries with good
contraceptive services. The Helms Amendment restricts
AID's activities on abortion.
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on contraceptive pills, and permitting paramedics to provide
a broad range of family planning services. Other possibilities
include restricting child labor, passing right-to-work laws
for women, providing opportunities for working mothers to breastfeed,
and restricting subdivision of agricultural land, though these all
entail obvious problems.
Another key pressure point seems to be the status of women.
Female education, even if pursued for only four to six
years, seems to encourage significantly lower fertility. The
more extended the education, the fewer children the woman is
likely to prefer. But exactly how or why female education
encourages lower fertility is not entirely clear, and should
be explored further. Preferences for smaller families seem
to result from work activities outside the home, from middle-
class family aspirations shared with an educated husband, and
-- apparently particularly important for women with only a
few years' education -- from an introduction, however fleeting,
to the notion that women need not live today, even in poor
countries, quite as they always have.Y Where education affects
fertility primarily by equipping women to work outside the home,
the availability of jobs as well as education becomes important;
but aside from employment opportunities, education alone seems
to encourage lower fertility in many areas. Where budget
limitations prevent attaining even a few years' education, this
approach to reducing fertility may be limited.
l/some changes may be pro-natalist, of course. We need to sort
out better the sorts of changes that most encourage lower
fertility.
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28
Female employment, particularly in jobs '-ncompatible
with continual child-bearing, is also strongly tied to fertility
declines. We do not know what the fertility impact would be if
poor women were given access to more-than-menial jobs, but sketchy
evidence suggests that they might indeed opt for fewer but healthier.
and better educated children as their expectations and opportunities
for themselves and their children rise. In countries suffering
substantial and chronic male unemployment and underemployment,
of course, it may be argued that more good job opportunities
for women mast be put off for another day. It is particularly
important, therefore, that care be taken with employment
opportunities for women., that jobs do not simply continue the
exploitation of women which is all too common particularly among
the poor and that children are cared for, especially among the
poor.
Also promising are any measures like women's associations
for health, handicrafts, etc. that help replace the fatalism
of the traditional woman with a sense that one can improve
one's own life at least to a degree.
A third pressure point involves changing the economic
cost and benefits of children to encourage smaller families
through the deliberate use of rewards (incentives) to parents
who limit fertility or penalties (disincentives.) on parents
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who do not.l/- In considering incentives it should be remembered
that social and economic conditions inevitably influence
parental views on family size - or on health, savings,
employment, etc. Incentives are but one way of deliberately
adjusting economic conditions to encourage smaller families;
the alternative to deliberate action is, of course, laissez-
faire with all that implies for haphazard influences on
individuals. Incentives do,. of course, leave parents who
truly want many children able to choose large families.
It bears emphasizing that when population pressure on resources
is extreme enough so that labor productivity is very low, then
averting a birth can save resources; an incentive can be
designed to give part of this saving to those who made it
possible--the couple practicing family planning.
when demographic pressure exacerbates resource scarcities so that
some rationing of some goods outside the market is virtually
inevitable, then one reasonable basis (or practical basis) for
that rationing is to favor those who help ease demographic
pressure. When parents rely on children for old-age support in
the absence of social security, providing extra resources as an
incentive or reward for family planning can compensate for
what additional children might have provided to their
l/ Incentives at least preserve freedom of choice, and can
be designed to fill real economic needs of parents at
little or no social cost.
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parents, and so fill a real economic need of parents at little
or no real cost to society. (In the shorter run, of course,
there may be budgetary problems in managing incentives.)
A fourth pressure point is child health, as discussed
above. As more children survive, completed family size will
supposedly fall.! To the extent this argument is valid, it
militates in favor of integrating health and family planning
services or at least seeing that both are provided in a
coordinated way.
The fifth and perhaps most important over-arching pressure
point is broad rural development. Cross-country studies suggest
countries with more egalitarian income distribution have lower
fertility, but no one is quite sure why. Studies of poor countries over
time (as income distribution changes) are lacking. In these countries,
appears that income growth alone need not lead to lower fertility
at any time soon, at least if the increases are modest and bring
income to no more than low-to-moderate levels; it all depends on
how the income growth comes about. As we said at the start of
this section, massive rural development involving sustained
increases in agricultural production (particularly food),
infrastructure, health services, and education, supported by
active community-based organizations, can encourage lower fertility
if it involves and benefits the majority who are poor and if
1/ The evidence on this point is sketchy. Considerable
additional research is needed to determine whether
parents are over-insuring,-what it would take to get
them to stop, etc.
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it encourages new options for women.-L/ But because of budget
limitations, relatively few LDCs can afford such widespread
and massive rural development; most must take a more selective
approach to reducing fertility and stimulating development,
focusing on those aspects of rural development that promise
both increased output and smaller families in order to
raise individual living standards as much as possible given
available budgets./ Generally the aspects of rural development
that most encourage lower fertility are the same as in
development as a whole--the aspects we have just discussed
in points one through four../ Thus the wheel comes full
circle.
Given its Congressional mandate, which of the fertility-
reducing policies and programs should AID encourage particularly
through its programs?
AID's Congressional mandate includes among its several
objectives the voluntary reduction of fertility through both
provision of services and policies to strengthen motivation
for family planning; reducing fertility can be crucial to
efforts to improve per capita living standards, which is the
ultimate objective of our mandate and indeed of most LDCs. Thus
the question is whether working to lower fertility through
changes in development policies and programs will seriously compromise
(See page 31a for footnotes.)
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Footnotes for page 31.
1/
2/
3/
Many people believe the poor must reach a new
threshold of well-being (especially in terms of food)
before they will seek families of about two children.
Assuming reducing fertility is an objective of the LDC
concerned.
One must ask whether this suggests investing in health,
education, family planning "instead of" agriculture.
Of course the decision must be the LDC's. But the evidence
suggests it may be preferable to combine investments
in agriculture with modest investments in these other
fields to get both growth and lower fertility, hence
fastest improvement in per capita living standards.
If all productive resources were owned by all people
in equal shares and if each factor earned its efficient
economic return, the maximum improvement in per capita
living standards would occur when output growth was
maximized--in whatever factor intensities that resource
endowments and technology indicated were optimal. But
particularly if poor people have only limited claim on pro-
ductive resources other than their own labor, raising
their living standards requires raising their labor
productivity--technically, the marginal product of
labor. This in turn depends not only on how fast output
grows, but also on how slowly population (hence labor
force) grows and how labor quality changes. All things
being equal, the more output, the higher the MPL (Marginal
Product of Labor); the fewer the people, the higher the
MPL. With most LDC economies grounded in agriculture,
agricultural output is certainly the cornerstone of poverty-
focused development. Investing to augment capital supplies
and improve technology in agriculture may maximize
the growth of agricultural output, thus raising the
marginal product of labor. But it may not in and of
itself help dampen fertility. A more composite
investment package focusing on human as well as physical
capital may help more to stimulate output and dampen
fertility. More precisely, investing a little less in
agricultural capital and technology and a little
more in family planning, other health services, basic
education especially for women, etc., may provide almost
as much stimulus to agriculture, hence output growth,
while also encouraging smaller families-'-thus possibly
working more effectively to improve individual living
standards.
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32
other mandate objectives or violate mandate restrictions in
the attempt to improve per capita living standards for the
poor, particularly in rural. areas.
Basically, the policy changes needed to lower fertility
are the same ones needed to reach other mandate objectives.
While some qualification is necessary, generally the more
AID assistance serves to improve the well-being of the poor
(especially women) and involve them in development processes--
whether through rural development, improved food production
and more equitable distribution, widespread and practical
education, broad and effective health programs,!/ programs that
combat malnutrition, measures that help foster reasonable trust in
political and economic institutions, or programs that generally
encourage and equip people better to take charge of their own lives--
then the more AID's assistance also serves to contain fertility.
Thus the basic recommendation here is for more coordinated
programming, not only to reduce fertility where that is desired
but also to take other steps toward the ultimate goal of
improving the life of the poor. The principal focus of AID
efforts will be on rural areas, both because most poor
1/ Including child-spacing.
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people are in rural areas and because improving conditions
in rural areas will make it that much easier to combat urban
problems (most of which are exacerbated by migration from
rural areas of people who find too little there to persuade
them to stay).
In most AID developing program categories, like education,
agriculture, etc., of course, not all programs can serve
equally well both their own primary purposes and the secondary
purpose of reducing fertility. So far AID has stressed
maximum fulfillment of primary purposes. But without jeopardizing
the primary purpose of a given program, we may be able to
gain a secondary but significant impact on fertility through
reasonable and feasible changes in program design and
implementation.!/ It should be borne in mind, however, that
careful assessment of all the benefits and costs of alternative
programs should govern AID funding decisions. While fertility
benefits may be important, they must be considered alongside
other benefits and within the context of resource availabilities,
management capacity, etc. Specific suggestions follow; more
need to be developed.
1/ As such dual-purpose programs expand, a serious trade-off
may develop between the best primary-purpose programs and
the dual purpose ones, but that bridge can be crossed
when and if we come to it. For now, suffice to emphasize
that lowering fertility and meeting the mandate's other
objectives through development policies will in many cases
involve complementary, not competitive efforts. Recent
experience involving agricultural extension workers and
volunteers in teaching family planning may be one example.
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1. Food and Nutrition; Rural Development
a. Programs to promote growth in and more egalitarian
distribution of income and public benefits, goods, and services.
AID's mandate recommends increasesin and more egalitarian
distribution of income, goods, and services for non-population
reasons. 1/AID programs should therefore provide ample
opportunity for research identifying links between distribution
and fertility, and for programs better exploiting those
links as they become clearer.
b. Food production and distribution.
AID or PL 480 programs designed to stimulate food
production and assure its more equitable distribution can
affect fertility in several ways--as an addition to income,
as means of lowering food prices to make available income
go further, as an improvement to health through better diets,
and as food production depends on female or child labor.
AID is taking major steps to enhance the development
impact of PL 480 both Title I and Title II, particularly
in the areas of food production and population planning
consistent with LDC preferences. AID or PL 480 programs
designed to stimulate food. production and assure its more
equitable distribution can, affect fertility positively or
(See page 34a for footnote.)
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34a
negatively in several ways--as an addition to income and
employment (and a curb to urban migration), as a means of
lowering food prices to make available income go further, as
an improvement to health through better diets, and as a means
to lessen the involvement in food production of traditional
child labor. Provision of PL 480 Title II may be used
through Food-For-Work or other programs to support establishment
1/ This is a broad-based concept including such matters as
agricultural credit, provision of inputs, rural electrification,
etc. which may in fact have a strong impact on fertility.
In the Philippines in one area where rural electrification
has been carried out, birth rates are sharply down in
comparison with a similar area without electrification.
Increased access to desirable consumer goods (irons, stoves)
and increased employment opportunities especially for women
(who now do housework at night) seem to be part of the
story, resulting no doubt not just from electrification
but a1sc from other development policies increasing the
demand for labor, etc.
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of such things as schools, health outposts providing health,
nutrition, family planning services, etc. AID plans to give
major attention to the linkages between PL 480 and aspects
of the development process including population planning.
c. Employment
AID programs focusing on employment creation should
consider both men and women, particularly among the poor, not
only in order to fulfill the purposes of the mandate as
expressed in the Percy Amendment but also for fertility
reduction purposes. Attention should go to the need for
child-care that inhibits employment in non-traditional
occupations for many mothers especially poor ones. Food
processing and marketing of agricultural products may offer
special opportunities for women.
d. Education within rural development programs
AID's rural development programs should consider increasing
emphasis on women as well as in education provided through
agricultural extension or other program components. Moreover,
opportunities should be seized to integrate population and
family planning messages in agricultural or other rural
programs in ways meaningful to the poor who are supposed to
benefit.l/
e. Nutrition within rural development programs
As noted above, AID programs in health, nutrition, and
family planning can be mutually reinforcing. Agricultural
1/ Studies have demonstrated a coorelation between reduction of
fertility and some level of primary,
leveAplg'8v lCma 1e Z3 8~,:a~l~- Dfm9 b 1 500 ~0 ~$e required
oun rtes and will be
examined further.
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and broader rural development programs reaching the poor .-an
play a major role in improving nutrition, hence health,
by increasing the food supplies that will provide both home:
consumption and income needed to improve diets and by incorporating
information on health and nutrition (e.g. better lactation and
weaning practices) or feeding programs into other rural
development programs.
f. Community Organizations
The encouragement and improvement of administration and
organization at the village level have a number of primary
and secondary effects on fertility. Village cooperatives
can provide an organization for increasing agricultural
productivity and marketing capabilities. (They can also
become an interest group for land re Form, if that is a
needed structural change for agricultural development.)
Local government organization can foster individual participation
in community decisions and increase awareness of individual
responsibility to the community. It can serve as a vital
link between villagers and higher levels of government. And
it can become a mechanism for mobilizing support for community
infrastructure projects and for improving social services.
Specifically related to family planning, local government
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can act as focal point for entry of an integrated health, nutrition,
and family planning program or a single-purpose family planning
program into a community. Through education interest groups it can
improve local education opporturrities for the whole community and
women in particular. Through'Wives'" and "mothers" clubs and other
women's organizations local government can develop a peer-pressure
group for creating demand for family planning services, and a dis-
tribution system for supplying family planning services, and a feedbac
mechanism for determining family planning success or failure at the
family level, as well as a useful local adjunct to the national
census system. Moreover community organizations can assist
in the training of administrative and managerial talent and
can directly tie economic and social development (and family
planning in particular) to the village, the level of government
closest to and most involved and interested in the individual.
g. Incentives
Some LDCs may be interested in organizing individual
incentive programs with AID technical and financial assistance,
drawing on past experience with education bonds, savings
accounts, and the like. (Certainly savings institutions
including cooperatives should generally be encouraged.)
Community incentives--rewarding a community's efforts at
family planning with additional health, education, or other
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 38
services--(A"r6 8qo q2 i ?91/081 8i1d ?10bb k00.2@0M8d04-8
LDCs, especially in Asia, have expressed interest in or
tried such initiatives. (See point b.) Other changes --- increased
demand for labor, increased access to consumer Goes provided through
improved roads, rural electrification, etc. -- can provide more
several but powerful incentives for smaller families.
h. Women's status
Many of the measures discussed in a.-f. have the effect
of increasing opportunities for women, encouraging a sense
of being able to control and change one's own life at least
to a degree, and thus seem likely to encourage lower fertility.
Any other aspects of rural development with similar impact
on women are likely also to encourage lower fertility, and
thus merit AID consideration for both fertility and status-
of-women purposes. More women's associations dealing jointly
with family planning (see above), education, maternal/child
health, handicrafts for market, etc., may be particularly
effective.
2. Health and Population Programs
As Part 1 of this paper emphasizes, health, nutrition,
and family planning programs can be mutually reinforcing;
integration of basic, low cost health, nutrition, and family
planning services is specifically recommended in AID's legislation.
Thus AID is encouraging development of low-cost integrated health,
nutrition, and family planning services for the majority where
integration makes sense. The design of such delivery systems
is an essential principle of the health program. Thus AID
is supporting all sensible t
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organizational integration at clinic and household
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39
levels and integrated planning. Perhaps the greatest gains
in health and family planning can be made jointly through
greater integration at the household level, to emphasize
especially to women the interrelationships between health, nutrition,
and family planning and to encourage them to put more of
their own efforts into health and fertility management, thus
making public funds go further.
Integrated planning of all programs affecting health
should also be encouraged, of course, to assure maximum
impact on health, hence fertility, of those programs acting jointly.
This will assure appropriate weighing of the likely health
and fertility impact of single-purpose programs like malaria
eradication or free-standing family planning services or
commercial sales of contraceptives as well as the organizationally
integrated services.
3. Education
AID.seeks to avoid discrimination against both women
and men. But, in many LDCs far more boys receive rudimentary
education than girls (the ratio is 4 or 5 to 1 in many
areas), to say nothing of higher education. The knowledge
that educating girls even a few years may help lower fertility
can encourage further action to integrate women into the
development process as suggested both in AID's legislation
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and in the plan of action deriving from the International Women's
Year Conference. In short, lowering fertility and into='_,ratng
women more fully into educational processes go hand-in-hand,
though, of course, other benefits of education must be given
their weight. As to content of education programs, it
stands to reason that information on family planning and
family health, alternative roles and income-earning
opportunities for women, and the possibilities for managing
one's own life generally help to encourage smaller families.
AID can encourage modifying educational content to include
more on such subjects.
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CONCLUSIONS: DIRECTIONS AND POSSIBLE FUNDING LEVELS FOR
U.S. POPULATION-RELATED ASSISTANCE
The analysis presented so far suggests program directions
and, though far more tentatively, possible funding levels
for U.S. population assistance including (a) Title X population
assistance and (b) other AID assistance and PL 480 that may
indirectly but significantly affect fertility. Since the
primary purpose of Title X assistance is to encourage
voluntary reduction in fertility, funding decisions should
be based on a careful assessment of the cost-effectiveness
of alternative, appropriate approaches to reducing fertility.
On the basis of current information, AID intends to use
Title X population assistance largely to improve and extend
better family planning services, to fund population-based
components of integrated programs (e.g. family planning
messages in education programs or family planning services
in integrated health, nutrition, and family planning services)
or to fund other measures with the primary purpose of
encouraging small families.
Generally, other monies will be used to fund programs in
education, health, nutrition, rural development, etc., whose primary
objectives do not include fertility reduction but which may
have a major secondary effect on fertility. It is expected
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that due weight will be given to any secondary impact on
fertility when the benefits and costs of alteL.native programs
in these other areas are considered, though final funding
decisions will of course depend on all the benefits and costs.
(Program planners in such areas should also consider research
on links with fertility.)
To explain how the new program directions suggested here
and the funding levels outlined here relate to present Title X
population assistance, we outline briefly the organizational
structure of that assistance.
Current AID Title X Population Assistance
AID's population program, since its beginning in 1965,
has become the world's. foremost source of such assistance and
a major source of ideas on fertility control. In the past
ten years, AID has provided about $750 million in population
assistance with annual amounts increasing to the current
level of $110 million. At present this assistance is
organized into six functional categories:
Category 1: Demographic data (to help assess
demographic trends)
Category 2: Population Policy (to identify the
national self-interests
that justify population
growth limitation policies
and to identify development
policies/programs that
encourage fertility decline.)
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Category 3: Research (to help develop better methods
of family planning and more
efficient delivery systems)*
Category 4: Family Planning Services (to help extend
safe, effective,
and affordable family
planning services
.especially to the poor)
Category 5: Information, Education, and Communication
(to help extend family planning
information especially to the poor)
Category 6: Manpower and Institutional Development
(to help develop adequate manpower and
institutional capacity in family
planning)
To countries wishing to reduce fertility AID extends
assistance through bilateral programs, through programs funded
by donor consortia, through official multilateral institutions
like the U.N., and through intermediaries like IPPF and
Pathfinder; assistance is implemented in a collaborative
style with the LDC's concerned.
As a next step we outline potential program directions
within the six functional categories. We assume somewhat
higher annual program levels, perhaps around $200 million for
the next few coming years, and indicate a) relative declines
in funding levels; b) stable or continuing levels; c) moderate
increases (0-50%) and sharp increases (over 50%) all in
real terms.
*Subject to any legislative restrictions (e.g. Helms amendment).
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Program Directions
Category 1: Demographic Data
-- Since many countries now have some sort
of at least superficial national censuses,
we expect to have stable or declining
funding for national censuses in the near future
except where needed to establish censuses or
where techniques for developing more detailed
data (see below) may be applicable nation-wide.
-- Moderately expand efforts at developing more
complete and detailed demographic data nationally
or at least for some representative samples
among the poor to permit more accurate
estimates of the demographic impact of
various family planning services, information
activities, and development programs.
Category 2: Population Policy
-- Moderately expand LDC-based research on
the policy variables that reflect linkages
between fertility and various aspects of
development, including:
a) female education of various types
and levels;
b) female employment;
c) health (especially of children);
d) nutritional status of women and children;
e) incentives/disincentives to encourage
smaller families;
f) income growth, distribution, and rural
development (focusing specifically on
food) ;
g) laws and policy statement supporting
family planning.
Moderately expand "population impact" analysis
and other measures to encourage broader
understanding of the development implications
of population growth and the potential
for bringing development programs to bear
on fertility;
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y expand pilot experiments in a)-f).
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Category 3: Research
a) Bio-medical Research*
-- Moderately expand projects to field-test promising
new family planning methods;
-- Moderately expand research to develop new methods
(particularly once-monthly methods and better
and more reversible methods of male and female
sterilization) and research on side effects of
available methods, particularly pills.
-- Moderately expand research on the relationship
between nutritional status and fertility.
b) Operations Research
-- Sharply expand LDC-based research on the
comparative effectiveness of alternative
approaches to family planning services and
information, focusing particularly on basic,
low-cost village-based distribution with
short start-up times.
-- Sharply expand LDC-based research on what
services health auxiliaries and laymen may
be able to provide.
-- Sharply expand research on whether or under what
conditions village-distribution schemes using
low-level health auxiliaries or lay personnel
can be established without much clinic backup.
-- Moderately expand research on prospects for LDC
production of contraceptives and other family
planning supplies.
Category 4: Family Planning Services
We expect the major focus of Title X population assistance
to continue to be on extending better family planning
services; within that focus, we shall give priority to
providing more low-cost services for the poor, particularly
in rural areas where the vast majority still lack any
but traditional services. We shall;
-- Encourage provision of a variety of family planning
methods, particularly pills, condoms, and sterilization;
-- Sharply increase efforts to help establish and expand
village-based distribution of family planning services
in rural areas particularly through low cost systems
q relying on health auxiliaries and laymen and promising
* Sub+~ct e o any TegisYaiv~re~sgf~S~i`67U,500~9Q-8dmendment) .
 46
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Encourage integration of health, nutrition, and family planning
services wherever sensible, taking care to encourage
movement on either the health or family planning
front where simultaneous movement may be very diifficult;
Seize opportunities to "piggyback" family planning
services on existing delivery systems, particularly
clinics, where they are available (e.g. some Latin
countries);
Encourage allocation of health funds to the establishment
of low-cost delivery systems reaching into rural areas
that could add in family planning where that approach
seems most promising (e.g. some African countries).
Encourage provision of appropriate contraceptives
through commercial outlets like pharmacies or small
shops or through private channels (e.g. midwives);
Work with intermediaries, public-funded programs, or
both depending on potential effectiveness.
In terms of country priorities, we take our primary objective
to be getting family planning services started in developing
countries; we will, of course, give careful attention to
encouraging those countries to assume total responsibility
for their own programs, particularly for their major
contraceptive requirements.
Category 5: Information, Education, and Communication
-- Where broad-based family-planning awareness campaigns
have not been undertaken, we would encourage those;
but since many countries have undertaken such
campaigns, we expect relatively less emphasis in
this area.
Where basic awareness exists, fine-tune existing
IEC efforts so they are:
a) country and culture specific;
b) informative on each specific methods of
family planning;
c) related to personal needs and aspirations;
d) focused considerably on the interface between
village family planning worker and village client;
reliant on relatively inexpensive media with broad
out-reach that require little reading (e.g.
radio).
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Sharply expand operational field testing and
collaboration with the research of other agencies
such as UNESCO and UNDP to better determine
which combinations of the many modern and traditional
media and methods are more efficient, effective
and suited to the special and evolving needs of
differing countries and family planning programs.
Category 6: Manpower and Institutional Development
-- Sharply expand efforts to help train health
auxiliaries or laymen for village-based dis-
tribution.
Continue efforts to provide advanced training
for leadership teams and supply technical assistance
to in-country training institutions to man
combined health delivery systems and focus on
filling specific needs, e.g. for personnel equipped
to provide surgical contraception.
Moderately expand efforts to strengthen planning
and management capacity at all program levels.
Continue efforts to assist in-country institutional
development to meet longer term support needs for
training, research, information storage and
retrieval, and the like.
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48
Title X Funding Levels
With data presently available, it is possible to make
a case only for very rough funding levels. We do believe,
however, that Title X population assistance could easily be
justified at considerably higher levels, perhaps $200 million
annually in program funds for several years, to finance pro-.
grams along the lines just outlined.l/
Ideally one would set a certain target reduction in
birth rates and from that deduce funding requirements for
various types of family planning services and information
and development policies. We cannot do that with any accuracy,
however (of course, we face similar problems in other pro-
gram areas). Both data and methodology are inadequate at the
moment to sort out all the tangled influences on birth rates
with any precision, though as emphasized above, more efforts
should go to improving both data and methodology. Current
AID projects along these lines will help considerably.
Using available estimates of population, numbers of
fertile age couples, costs of family planning services, and
the relationship between prevalence of family planning and
birth rates, one can make rough estimates of the annual costs
of just the services needed to increase prevalence enough to
reduce birth rates another 10 points -- apparently in the
l/ Excluding UNFPA.
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$300-400 million range. But such estimates are so rough as to
be of very limited value.
All this says nothing specific on appropriate levels
for AID funding of services, let alone other areas of our
population assistance. In the past, to get family planning
well underway in many LDCs, we have found an AID expenditure
for services of around $1.00 per capita total over a decade
is often enough; of course this does not bring down birth
rates to stable-population levels, but only to more moderate
levels where services are well enough established to be taken
over and expanded by the LDC concerned.l/ But this suggests
that U.S. expenditure in the neighborhood of $2.5-3.0 billion2/
over 1965-85 could go a long way toward at least getting
family planning services well established though probably not
on a scale sufficient to achieve anything close to population
stability. Of course additional funds would be needed to
support balanced efforts in areas other than provision of
services -- demographic data, information, research, manpower,
population policies, etc., our recommendation of $200 million
annually is based on such a total approach. The Agency,
the Executive Branch, and the Congress might focus on just
what the Agency's objectives in terms of fertility reduction
1/ These were people who already wanted services, the
extent of unmet demand is subject to serious debate,
of course.
2/ In 1975 dollars, roughly.
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should be. Funding for population must ultimately reflect
other concerns, however -- such as LDCs' interest in such
assistance, absorptive capacity and the ability to use
funds efficiently, the role of other donors, the role of
LDCs in funding, and competing demands on U. S. funds.
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OTHER AID PROGRAMS AND PL 480: DIRECTIONS AND FUNDING LEVELS
Other AID programs -- in food and nutrition (and broader
rural development), in education, and in health -- can affect
fertility indirectly but significantly as discussed above.
It bears reiterating that basically the same types of programs
in these areas will help to reduce fertility, increase
aggregate supplies of key goods and services, insure
their more equitable distribution, and otherwise foster
wider participation in development -- in pursuit of the
mandate's basic objective of improving individual well-being
among the poor. Many of the measures helping most to reduce
fertility also help particularly to improve the status of
women.
It is particularly important to improve our broad
understanding of the links between fertility and rural
development, education, health/nutrition/family planning
programs, etc. to permit planning, implementing, and evaluating
the best possible combination of programs and projects that will
act in coordination to improve welfare, ease population pressure, etc
Specific program directions are discussed below. We
emphasize, however, that in each area, additional LDC-based
research needs to be undertaken, financed not only by Title X
but also by the programs concerned.
Food, Nutrition, and Rural Development
-- Give increased attention to projects that will help
elucidate and take advantage of the linkages between these
program areas and fertility, particularly focusing on the
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-- Give emphasis to especially those programs that help
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52
reduce unequal distribution of income and other goods and
-- For rural development as a whole give emphasis to
a "package" of policies and supporting programs and projects
designed both to foster production and slow fertility growth
as consistent with LDC objectives and preferences and within
the limitations of management capacity, which has often proved
a particularly serious problem in "package" programs.
-- Give increased attention to projects which encourage
community-based organizations and local managerial capability.
-- Take account of potential fertility effects of any
proposed redistribution of the land.
-- Test the use of community or personal incentives
(relevant for either AID or PL 480; major additional study
should be devoted to this area).
-- Design ways to encourage profitable employment for
women in non-traditional, non-menial occupations.
-- Give increased attention to planning, administering,
and evaluating programs outlined in this section.
Particularly on Nutrition:
-- Encourage integration with health and family planning
services where appropriate.
-- Encourage programs having direct impact on reduced
fertility, such as promotion of breastfeedin
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Education
-- Give major attention to increasing the number of
female beneficiaries in all programs (especially where
males outnumber females significantly).
-- Give major attention to expanding, opportunities
for basic education for girls.
-- Encourage incorporation of messages on the benefits
and methods of family planning into formal and non-formal
education programs of all types -- in schools, through rural
extension work, through clubs, etc.
Health
-- Encourage development of low cost integrated health,
nutrition and family planning services for the majority where
integration makes sense (either in one organizational system
to assure efficient coordination of all programs -- organizationally
integrated or free-standing -- that may substantially affect
health and fertility).
-- Give major attention to maternal and child health
with attention to child-spacing and lactation as critical
health measures.
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Funding Levels
In the area of development policies and programs affecting
fertility it is even more difficult to discuss funding levels,
except to say that increased attention should go to programs
which, while serving their primary purposes, are likely to
have a secondary impact on fertility. It should be pointed
out specifically that non--Title X population funds may and
indeed should be used in addition to population funds to
explore links between fertility and other aspects of develop-
ment, to help plan multi-faceted programs affecting fertility,
and to help implement and evaluate such programs.
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SUMMARY: AN INTEGRATED APPROACH
Basically this analysis suggests the fastest way to
improve individual levels of well-being among the poor may
be a package or integrated approachl/ -- combining the most
effective, safe, affordable and accessible family planning
services and information with development policies and programs
tailored to affect fertility as well as to fulfill their
primary purposes. This will enable us to influence fertility --
always in keeping with the LDC's own objectives and preferences
through our Title X assistance and through other budgets
that may impact on fertility too. This course seems most
likely to achieve the rapid and massive reductions in birth
rates needed to reach birth rate targets of the LDCs and
eventual population stability. This strategy is in full
harmony with key recommendations of the World Population
Plan of Action adopted unanimously in Bucharest in 1974.
Specifically, it responds to paragraphs 31 and 32 of the
Plan:
It must always be kept in mind that "packaging" is
instrumental and that, therefore, (a) no one package
is optimum for universal application, and (b) the
acceptance of any package in a particular setting
requires the participation, in designing and developing
the package, of those who lead and influence the
potential acceptors.
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"31. it is recommended that countries wishing to
affect fertility levels give priority to implementing
development programs and educational and health
strategies which, while contributing to economic
growth and. higher standards of living, have a de-
cisive impact upon demographic trends, including
fertility. International co-operation is called
for to give priority to assisting such national
efforts in order that these programmes and strategies
be carried into effect.
32. While recognizing the diversity of social,
cultural, political and economic conditions among
countries and regions, it is nevertheless agreed
that the following development goals generally
have an effect on the socio-economic content of
reproductive decisions that tends to moderate
fertility levels:
(a) The reduction of infant and child
mortality, particularly by means of improved
nutrition, sanitation, maternal and child health
care, and maternal education:
(b) The full integration of women into the de-
velopment process., particularly by means of their
greater participation in educational, social,
economic and political opportunities and especially
by means of the removal of obstacles to their
employment in the non-agricultural sector wherever
possible. In this context, national laws and policies,
as well as relevant international recommendations,
should be reviewed in order to eliminate discrimination
in, and remove obstacles to, the education, training
employment and career advancement opportunities for
women;
(c) The promotion of social justice, social
mobility, and social development particularly by
means of a wide participation of the population
in development and a more equitable distribution
of income, land, social services and amenities;
(d) The promotion of wide educational opportuni-
ties for the young of both sexes, and the extension
of public forms of pre-school education for the % rising generation;
!e) The elimination of child labour and child
ab?_;se and the establishment of social security and
old age benefits;
(f) The establishment of an appropriate lower
limit {i.e. minimum age} for age at marriage."1/
17RPI rR s@-4@3/ /~a iq6- e7gR4i~a 00 ~5201t2Q 004-8
legal marriage, thus postponing.
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Country Priorities
We have assessed experience with fertility-reducing
programs and policies in a variety of countries where AID
has had significant programs, and have drawn conclusions on
program directions accordingly. Obviously the same type of
program will not do for all countries; thus, our general
policy and program strategy must be adjusted considerably
for a given country, and an approach developed that makes
sense in that country. The overall shape of all AID programs
actually operating will depend on what countries we actually
assist. Country allocation decisions naturally reflect both
U.S. economic or political interests and prospects for
meeting program objectives -- in this case, reducing world
~ertility.l/ Here we propose to give only rough guidelines
as to the countries in which AID may concentrate its
population-related assistance. Special concern exists for
thirteen countries, excluding China, which contribute most
to current world population growth: Bangladesh, Brazil,
Colombia, Ethiopia, Egypt, India, Indonesia, Mexico, Nigeria,
Pakistan, Philippines, Thailand and Turkey. But AID does
not operate major bilateral population programs in about
half of those countries at present; nor can we mount massive
l/ It bears emphasizing that reducing fertility is only
one of AID's objectives under the mandate -- and that it
is viewed as a means of facilitating per capita
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programs through intermediaries of the scope, design, and
vigor we would want. Thus the Agency is also determined to
pursue opportunities in a limited number of other countries
interested in reducing fertility where prospects seem bright
or where unusually good opportunities exist for developing
prototypes of programs that may also prove helpful in less
accessible or otherwise neglected countries. We are continuing
our analysis of program prospects, requirements, problems, etc.
in order to refine our list of country recipients, assuring
adequate program focus, and expect to make considerable further
progress in this area in the next several months.
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 COM
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TREASURY STATEMENT OF CLARIFICATION TO THE PRESIDENT
The Department of Treasury supports the general population
strategy put forward in the First Annual Report on U.S. Inter-
national Population Policy. In particular, we favor increasing
U.S. funding for population assistance provided that there are
adequate program controls to assure efficient allocation of the
additional resources.
Treasury believes that the report in its present form does
not deal adequately with a number of significant issues which
bear directly on the question of controls. These issues were
defined in NSDM 314, wherein you directed that the Under Secre-
taries Committee evaluate:
(1) The effectiveness of population control programs in
countries at all levels of development;
(2) The program efforts of AID and other national and
international groups; and
(3) Provide detailed analysis of the funding levels
recommended in the NSSM 200 study, including the
development of performance criteria.
Treasury's concern is that, in the years ahead, we could
easily lose sight of the necessity to establish stronger program
controls in a rush to increase the volume of U.S. population
assistance. Unless there is inter-agency agreement on appro-
priate controls in advance of any major programs expansion,
Treasury seriously doubts that the U.S. will derive maximum bene-
fit from any additional resources in terms of achieving meaning-
ful reductions in population growth rates abroad.
Therefore, Treasury is unable to give its unreserved endorse-
ment to the attached report until such time as we become convinced
that the Task Force intends to deal comprehensively with all the
issues you singled out for special attention in NSDM 314.
Treasury also believes that the Under Secretaries Committee must
assume a more important role in establishing overall population
funding levels. The appropriate levels would be based on an
analysis of the key-country program requests annually submitted
by the country missions. This, we believe, is the role you
envisaged that the Under Secretaries Committee should play when
you asked that it "examine specific recommendations for funding
in the population assistance and family planning field for the
period after FY 1976" (NSDM 314).
T?.? NSDII 314
_ y
l.~ 1. ~. ~R AL L:CT1_~:?S IF?CATICN
n-, ,T?, 11G2
T,1 7 L: D r,~GRft 'D AT TWO
..?%p>',S AND DECLASSIFIED
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1U!u'' J 'J.?v~Ctn
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PROPOSED PRESIDENTIAL STATEMENT
Today, August 19, marks the second anniversary
of the opening of the United Nations World Population
Conference at Bucharest, Romania.
This Conference, attended by high-level representa-
tives of 138 countries of the world, adopted a World
Population Plan of Action which proclaimed the principle
that "all couples and individuals have the basic right
to decide freely and responsibly the number and spacing
of their children and to have the information, education
and means to do so; the responsibility of couples and
individuals in the exercise of this right takes into
account the needs of their living and future children
and their responsibilities towards the community."
Further, the Plan of Action recommends that "all coun-
tries encourage appropriate education concerning res-
ponsible parenthood and make available to persons who
so desire advice and means of achieving it."
The Bucharest Conference represented a major advance
in achieving worldwide support for family planning, in
specifying measures to give equal status to women, and
in recognizing that population policies and programs are
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- 2 -
integral parts of economic and social development.
Over the past two years, there has been some
encouraging progress in the implementation of the Plan
of Action. Today, most people of the world live in
countries whose governments have adopted population
policies and programs of their own creation, responsive
to their own national needs. A number of developing
countries which initiated such programs 5 to 10 years
ago, have already been successful in reducing their
birth rates, thus demonstrating that population growth
can be moderated as proposed by the Plan of Action.
Even in countries whose governments have not taken a
stand on this issue, there are growing numbers of people
and organizations that recognize the importance of child
spacing in terms of the health. of mother and child.
For its part, the United States will continue to
join other donors in providing all feasible assistance
to developing countries which request and make good use
of aid in reducing rapid population growth. We will
continue to give full support to international organiza-
tions like the United Nations Fund for Population
Activities and to private voluntary organizations, in
marshalling resources and talent for coping with
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3 -
population issues in countries requesting assistance.
U.S. policy will comply with those suggestions in
the World Population Plan of Action which urge that
population program assistance granted to developing
countries with high population growth rates be inte-
grated into the overall development process so as to
assure that the on-going development programs will also
have a moderating influence on population growth.
Acting on its offer at Bucharest, the TJnited States
.pledged support at the Seventh Special Session of the
UN General Assembly last September for a major expansion
of the efforts already under way, including those of the
World Health Organization, to help developing countries
establish low-cost integrated delivery of basic health
services at the community level; These services will com-
bine medical treatment, family planning, and nutritional
information, using locally trained paramedical personnel.
All these and related measures are set forth in U.S.
policy on international population which I approved last
November and which is being carried out with the assist-
ance and advice of a nevay establishes Interagency Task
Force on Ponulation Policy that includes representatives
of all U.S. Government Agencies concerned.
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Clearly, there is a need for an expanded worldwide
effort to cope with the problem. Excessive population
growth is responsible in many parts of the world for
rising dependence on imported food, for growing unemploy-
ment and underemployment, for serious environmental
deterioration, and for a surge of humanity into already
overcrowded cities lacking in housing, sanitation, and
other basic facilities. All this creates serious social
and political problems, as well as dashing the hopes of
countless millions of people for economic development
and progress.
Population policies are not an end in themselves but
they are directly related to mankind's aspirations: to
improve conditions of life for ourselves, our children,
and for countless generations to come, as well as to
promote security and lasting peace among nations.
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