Discussion

Exclusive of China, only 10-15% of LDC populations are currently effectively reached by family planning activities. If efforts to reduce rapid population growth are to be successful it is essential that the neglected 85- 90% of LDC populations have access to convenient, reliable family planning services. Moreover, these people largely in rural but also in urban areas not only tend to have the highest fertility, they simultaneously suffer the poorest health, the worst nutritional levels, and the highest infant mortality rates.

Family planning services in LDCs are currently provided by the following means:

1. Government-run clinics or centers which offer family planning services alone;

2. Government-run clinics or centers which offer family planning as part of a broader based health service;

3. Government-run programs that emphasize door to door contact by family planning workers who deliver contraceptives to those desiring them and/or make referrals to clinics;

4. Clinics or centers run by private organizations (e.g., family planning associations);

5. Commercial channels which in many countries sell condoms, oral contraceptives, and sometimes spermicidal foam over the counter;

6. Private physicians.

Two of these means in particular hold promise for allowing significant expansion of services to the neglected poor:

1. Integrated Delivery Systems. This approach involves the provision of family planning in conjunction with health and/or nutrition services, primarily through government-run programs. There are simple logistical reasons which argue for providing these services on an integrated basis. Very few of the LDCs have the resources, both in financial and manpower terms, to enable them to deploy individual types of services to the neglected 85% of their populations. By combining a variety of services in one delivery mechanism they can attain maximum impact with the scarce resources available.

In addition, the provision of family planning in the context of broader health services can help make family planning more acceptable to LDC leaders and individuals who, for a variety of reasons (some ideological, some simply humanitarian) object to family planning. Family planning in the health context shows a concern for the well-being of the family as a whole and not just for a couple's reproductive function.

[** Finally, providing integrated family planning and health services on a broad basis would help the U.S. contend with the ideological charge that the U.S. is more interested in curbing the numbers of LDC people than it is in their future and well-being. While it can be argued, and argued effectively, that limitation of numbers may well be one of the most critical factors in enhancing development potential and improving the chances for well-being, we should recognize that those who argue along ideological lines have made a great deal of the fact that the U.S. contribution to development programs and health programs has steadily shrunk, whereas funding for population programs has steadily increased. While many explanations may be brought forward to explain these trends, the fact is that they have been an ideological liability to the U.S. in its crucial developing relationships with the LDCs. A.I.D. currently spends about $35 million annually in bilateral programs on the provision of family planning services through integrated delivery systems. Any action to expand such systems must aim at the deployment of truly low- cost services. Health-related services which involve costly physical structures, high skill requirements, and expensive supply methods will not produce the desired deployment in any reasonable time. The basic test of low- cost methods will be whether the LDC governments concerned can assume responsibility for the financial, administrative, manpower and other elements of these service extensions. Utilizing existing indigenous structures and personnel (including traditional medical practitioners who in some countries have shown a strong interest in family planning) and service methods that involve simply-trained personnel, can help keep costs within LDC resource capabilities.**]

2. Commercial Channels. In an increasing number of LDCs, contraceptives (such as condoms, foam and the Pill) are being made available without prescription requirements through commercial channels such as drugstores [For obvious reasons, the initiative to distribute prescription drugs through commercial channels should be taken by local government and not by the US Government]. The commercial approach offers a practical, low-cost means of providing family planning services, since it utilizes an existing distribution system and does not involve financing the further expansion of public clinical delivery facilities. Both A.I.D. and private organizations like the IPPF are currently testing commercial distribution schemes in various LDCs to obtain further information on the feasibility, costs, and degree of family planning acceptance achieved through this approach. A.I.D. is currently spending about $2 million annually in this area.

In order to stimulate LDC provision of adequate family planning services, whether alone or in conjunction with health services, A.I.D. has subsidized contraceptive purchases for a number of years. In FY 1973 requests from A.I.D. bilateral and grantee programs for contraceptive supplies in particular for oral contraceptives and condoms increased markedly, and have continued to accelerate in FY 1974. Additional rapid expansion in demand is expected over the next several years as the accumulated population/family planning efforts of the past decade gain momentum.

While it is useful to subsidize provision of contraceptives in the short term in order to expand and stimulate LDC family planning programs, in the long term it will not be possible to fully fund demands for commodities, as well as other necessary family planning actions, within A.I.D. and other donor budgets. These costs must ultimately be borne by LDC governments and/or individual consumers. Therefore, A.I.D. will increasingly focus on developing contraceptive production and procurement capacities by the LDCs themselves. A.I.D. must, however, be prepared to continue supplying large quantities of contraceptives over the next several years to avoid a detrimental hiatus in program supply lines while efforts are made to expand LDC production and procurement actions. A.I.D. should also encourage other donors and multilateral organizations to assume a greater share of the effort, in regard both to the short-term actions to subsidize contraceptive supplies and the longer-term actions to develop LDC capacities for commodity production and procurement.

Recommendations:

1. A.I.D. should aim its population assistance program to help achieve adequate coverage of couples having the highest fertility who do not now have access to family planning services.

2. The service delivery approaches which seem to hold greatest promise of reaching these people should be vigorously pursued. For example:

a. The U.S. should indicate its willingness to join with other donors and organizations to encourage further action by LDC governments and other institutions to provide low-cost family planning and health services to groups in their populations who are not now reached by such services. In accordance with Title X of the AID Legislation and current policy, A.I.D. should be prepared to provide substantial assistance in this area in response to sound requests.

b. The services provided must take account of the capacities of the LDC governments or institutions to absorb full responsibility, over reasonable time-frames, for financing and managing the level of services involved.

c. A.I.D. and other donor assistance efforts should utilize to the extent possible indigenous structures and personnel in delivering services, and should aim at the rapid development of local (community) action and sustaining capabilities.

d. A.I.D. should continue to support experimentation with commercial distribution of contraceptives and application of useful findings in order to further explore the feasibility and replicability of this approach. Efforts in this area by other donors and organizations should be encouraged. Approx. U.S. Cost: $5-10 million annually.

3. In conjunction with other donors and organizations, A.I.D. should actively encourage the development of LDC capabilities for production and procurement of needed family planning contraceptives.

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Special Footnote: While the agencies participating in this study have no specific recommendations to propose on abortion the following issues are believed important and should be considered in the context of a global population strategy.

Abortion

1. Worldwide Abortion Practices

Certain facts about abortion need to be appreciated:

• [** No country has reduced its population growth without resorting to abortion. **]
• Thirty million pregnancies are estimated to be terminated annually by abortion throughout the world. The figure is a guess. More precise data indicate about 7 percent of the world's population live in countries where abortion is prohibited without exception and 12 percent in countries where abortion is permitted only to save the life of the pregnant woman. About 15 percent live under statutes authorizing abortion on broader medical grounds, that is, to avert a threat to the woman's health, rather than to her life, and sometimes on eugenic and/or juridical grounds (rape, etc.) as well. Countries where social factors may be taken into consideration to justify termination of pregnancy account for 22 percent of the world's population and those allowing for elective abortion for at least some categories of women, for 36 percent. No information is available for the remaining 8 percent; it would appear, however, that most of these people live in areas with restrictive abortion laws.
• The abortion statutes of many countries are not strictly enforced and some abortions on medical grounds are probably tolerated in most places. It is well known that in some countries with very restrictive laws, abortions can be obtained from physicians openly and without interference from the authorities. Conversely, legal authorization of elective abortion does not guarantee that abortion on request is actually available to all women who may want their pregnancies terminated. Lack of medical personnel and facilities or conservative attitudes among physicians and hospital administrators may effectively curtail access to abortion, especially for economically or socially deprived women.

2. U.S. Legislation and Policies Relative to Abortion

Although the Supreme Court of the United States invalidated the abortion laws of most states in January 1973, the subject still remains politically sensitive. U.S. Government actions relative to abortion are restricted as indicated by the following Federal legislation and the resultant policy decisions of the concerned departments and agencies.

A. A.I.D. Program

The predominant part of A.I.D.'s population assistance program has concentrated on contraceptive or foresight methods. A.I.D. recognized, however, that under developing country conditions foresight methods not only are frequently unavailable but often fail because of ignorance, lack of preparation, misuse and non-use. Because of these latter conditions, increasing numbers of women in the developing world have been resorting to abortion, usually under unsafe and often lethal conditions. Indeed, abortion, legal and illegal, now has become the most widespread fertility control method in use in the world today. Since, in the developing world, the increasingly widespread practice of abortion is conducted often under unsafe conditions, A.I.D. sought through research to reduce the health risks and other complexities which arise from the illegal and unsafe forms of abortion. One result has been the development of the Menstrual Regulation Kit, a simple, inexpensive, safe and effective means of fertility control which is easy to use under LDC conditions.

Section 114 of the Foreign Assistance Act of 1961 (P.L. 93-189), as amended in 1974, adds for the first time restrictions on the use of A.I.D. funds relative to abortion. The provision states that "None of the funds made available to carry out this part (Part I of the Act) shall be used to pay for the performance of abortions as a method of family planning or to motivate or coerce any person to practice abortions."

In order to comply with Section 114, A.I.D. has determined that foreign assistance funds will not be used to:

(i) procure or distribute equipment provided for the purpose of inducing abortions as a method of family planning.

(ii) directly support abortion activities in LDCs. However, A.I.D. may provide population program support to LDCs and institutions as long as A.I.D. funds are wholly attributable to the permissible aspects of such programs.

(iii) information, education, training, or communication programs that promote abortion as a method of family planning. However, A.I.D. will continue to finance training of LDC doctors in the latest techniques used in obstetrics-gynecology practice, and will not disqualify such training programs if they include pregnancy termination within the overall curriculum. Such training is provided only at the election of the participants.

(iv) pay women in the LDCs to have abortions as a method of family planning or to pay persons to perform abortions or to solicit persons to undergo abortions.

A.I.D. funds may continue to be used for research relative to abortion since the Congress specifically chose not to include research among the prohibited activities.

A major effect of the amendment and policy determination is that A.I.D. will not be involved in further development or promotion of the Menstrual Regulation Kit. However, other donors or organizations may become interested in promoting with their own funds dissemination of this promising fertility control method.

B. DHEW Programs

Section 1008 of the Family Planning Services and Population Research Act of 1970 (P.L. 91-572) states that "None of the funds appropriated under this title shall be used in programs where abortion is a method of family planning." DHEW has adhered strictly to the intent of Congress and does not support abortion research. Studies of the causes and consequences of abortion are permitted, however. The Public Health Service Act Extension of 1973 (P.L. 9345) contains the Church Amendment which establishes the right of health providers (both individuals and institutions) to refuse to perform an abortion if it conflicts with moral or religious principles.

C. Proposed Legislation on Abortion Research

There are numerous proposed Congressional amendments and bills which are more restrictive on abortion research than any of the pieces of legislation cited above.

It would be unwise to restrict abortion research for the following reasons:

1. The persistent and ubiquitous nature of abortion.

2. Widespread lack of safe abortion technique.

3. Restriction of research on abortifacient drugs and devices would:

a. Possibly eliminate further development of the IUD.

b. Prevent development of drugs which might have other beneficial uses. An example is methotrexate (R) which is now used to cure a hitherto fatal tumor of the uteruschoriocarcinoma. This drug was first used as an abortifacient.