Development of Low-cost
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
Family planning services in LDCs are currently provided
by the following means:
1. Government-run clinics or centers which offer family planning
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
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
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
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
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
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
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
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
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
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
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
2. U.S. Legislation and Policies Relative to
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
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
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
1. The persistent and ubiquitous nature of abortion.
2. Widespread lack of safe abortion technique.
3. Restriction of research on abortifacient drugs and devices
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.