Introduction

Discussion

[** It is clear that the availability of contraceptive services and information, important as that is, is not the only element required to address the population problems of the LDCs. Substantial evidence shows that many families in LDCs (especially the poor) consciously prefer to have numerous children for a variety of economic and social reasons. For example, small children can make economic contributions on family farms, children can be important sources of support for old parents where no alternative form of social security exists, and children may be a source of status for women who have few alternatives in male-dominated societies.**]

The desire for large families diminishes as income rises. Developed countries and the more developed areas in LDCs have lower fertility than less developed areas. Similarly, family planning programs produce more acceptors and have a greater impact on fertility in developed areas than they do in less developed areas. Thus, investments in development are important in lowering fertility rates. We know that the major socio-economic determinants of fertility are strongly interrelated. A change in any one of them is likely to produce a change in the others as well. Clearly development per se is a powerful determinant of fertility. However, since it is unlikely that most LDCs will develop sufficiently during the next 25-30 years, it is crucial to identify those sectors that most directly and powerfully affect fertility.

In this context, population should be viewed as a variable which interacts, to differing degrees, with a wide range of development programs, and the U.S. strategy should continue to stress the importance of taking population into account in "non-family planning" activities. This is particularly important with the increasing focus in the U.S. development program on food and nutrition, health and population, and education and human resources; assistance programs have less chance of success as long as the numbers to be fed, educated, and employed are increasing rapidly.

Thus, to assist in achieving LDC fertility reduction, not only should family planning be high up on the priority list for U.S. foreign assistance, but high priority in allocation of funds should be given to programs in other sectors that contribute in a cost-effective manner in reduction in population growth.

There is a growing, but still quite small, body of research to determine the socio-economic aspects of development that most directly and powerfully affect fertility. Although the limited analysis to date cannot be considered definitive, there is general agreement that the five following factors (in addition to increases in per capita income) tend to be strongly associated with fertility declines: education, especially the education of women; reductions in infant mortality; wage employment opportunities for women; social security and other substitutes for the economic value of children; and relative equality in income distribution and rural development. There are a number of other factors identified from research, historical analysis, and experimentation that also affect fertility, including delaying the average age of marriage, and direct payments (financial incentive) to family planning acceptors.

There are, however, a number of questions which must be addressed before one can move from identification of factors associated with fertility decline to large-scale programs that will induce fertility decline in a cost-effective manner. For example, in the case of female education, we need to consider such questions as: did the female education cause fertility to decline or did the development process in some situations cause parents both to see less economic need for large families and to indulge in the "luxury" of educating their daughters? If more female education does in fact cause fertility declines, will poor high-fertility parents see much advantage in sending their daughters to school? If so, how much does it cost to educate a girl to the point where her fertility will be reduced (which occurs at about the fourth-grade level)? What specific programs in female education are most cost-effective (e.g., primary school, nonformal literacy training, or vocational or pre-vocational training)? What, in rough quantitative terms, are the non-population benefits of an additional dollar spent on female education in a given situation in comparison to other non-population investment alternatives? What are the population benefits of a dollar spent on female education in comparison with other population-related investments, such as in contraceptive supplies or in maternal and child health care systems? And finally, what is the total population plus non-population benefit of investment in a given specific program in female education in comparison with the total population plus non-population benefits of alternate feasible investment opportunities?

As a recent research proposal from Harvard's Department of Population Studies puts this problem: "Recent studies have identified more specific factors underlying fertility declines, especially, the spread of educational attainment and the broadening of nontraditional roles for women. In situations of rapid population growth, however, these run counter to powerful market forces. Even when efforts are made to provide educational opportunities for most of the school age population, low levels of development and restricted employment opportunities for academically educated youth lead to high dropout rates and non-attendance..."

Fortunately, the situation is by no means as ambiguous for all of the likely factors affecting fertility. For example, laws that raise the minimum marriage age, where politically feasible and at least partially enforceable, can over time have a modest effect on fertility at negligible cost. [** Similarly, there have been some controversial, but remarkably successful, experiments in India in which financial incentives, along with other motivational devices, were used to get large numbers of men to accept vasectomies.**] In addition, there appear to be some major activities, such as programs aimed to improve the productive capacity of the rural poor, which can be well justified even without reference to population benefits, but which appear to have major population benefits as well.

The strategy suggested by the above considerations is that the volume and type of programs aimed at the "determinants of fertility" should be directly related to our estimate of the total benefits (including non-population benefits) of a dollar invested in a given proposed program and to our confidence in the reliability of that estimate. There is room for honest disagreement among researchers and policy-makers about the benefits, or feasibility, of a given program. Hopefully, over time, with more research, experimentation and evaluation, areas of disagreement and ambiguity will be clarified, and donors and recipients will have better information both on what policies and programs tend to work under what circumstances and how to go about analyzing a given country situation to find the best feasible steps that should be taken.

Recommendations:

1. AID should implement the strategy set out in the World Population Plan of Action, especially paragraphs 31 and 32 and Section I ("Introduction - a U.S. Global Population Strategy") above, which calls for high priority in funding to three categories of programs in areas affecting fertility (family- size) decisions:

a. Operational programs where there is proven cost-effectiveness, generally where there are also significant benefits for non-population objectives;

b. Experimental programs where research indicates close relationships to fertility reduction but cost-effectiveness has not yet been demonstrated in terms of specific steps to be taken (i.e., program design); and

c. Research and evaluation on the relative impact on desired family size of the socio-economic determinants of fertility, and on what policy scope exists for affecting these determinants.

2. Research, experimentation and evaluation of ongoing programs should focus on answering the questions (such as those raised above, relating to female education) that determine what steps can and should be taken in other sectors that will in a cost-effective manner speed up the rate of fertility decline. In addition to the five areas discussed in Section II. B 1-5 below, the research should also cover the full range of factors affecting fertility, such as laws and norms respecting age of marriage, and financial incentives. Work of this sort should be undertaken in individual key countries to determine the motivational factors required there to develop a preference for small family size. High priority must be given to testing feasibility and replicability on a wide scale.

3. AID should encourage other donors in LDC governments to carry out parallel strategies of research, experimentation, and (cost-effective well- evaluated) large-scale operations programs on factors affecting fertility. Work in this area should be coordinated, and results shared.

4. AID should help develop capacity in a few existing U.S. and LDC institutions to serve as major centers for research and policy development in the areas of fertility-affecting social or economic measures, direct incentives, household behavior research, and evaluation techniques for motivational approaches. The centers should provide technical assistance, serve as a forum for discussion, and generally provide the "critical mass" of effort and visibility which has been lacking in this area to date. Emphasis should be given to maximum involvement of LDC institutions and individuals.

The following sections discuss research experimental and operational programs to be undertaken in the five promising areas mentioned above.

1. Providing Minimal Levels of Education, Especially for Women

Discussion

There is fairly convincing evidence that female education especially of 4th grade and above correlates strongly with reduced desired family size, although it is unclear the extent to which the female education causes reductions in desired family size or whether it is a faster pace of development which leads both to increased demand for female education and to reduction in desired family size. There is also a relatively widely held theory though not statistically validated that improved levels of literacy contribute to reduction in desired family size both through greater knowledge of family planning information and increasing motivational factors related to reductions in family size. Unfortunately, AID's experience with mass literacy programs over the past 15 years has yielded the sobering conclusion that such programs generally failed (i.e. were not cost-effective) unless the population sees practical benefits to themselves from learning how to read e.g., a requirement for literacy to acquire easier access to information about new agricultural technologies or to jobs that require literacy.

Now, however, AID has recently revised its education strategy, in line with the mandate of its legislation, to place emphasis on the spread of education to poor people, particularly in rural areas, and relatively less on higher levels of education. This approach is focused on use of formal and "non-formal" education (i.e., organized education outside the schoolroom setting) to assist in meeting the human resource requirements of the development process, including such things as rural literacy programs aimed at agriculture, family planning, or other development goals.

Recommendations

1. Integrated basic education (including applied literacy) and family planning programs should be developed whenever they appear to be effective, of high priority, and acceptable to the individual country. AID should continue its emphasis on basic education, for women as well as men.

2. A major effort should be made in LDCs seeking to reduce birth rates to assure at least an elementary school education for virtually all children, girls as well as boys, as soon as the country can afford it (which would be quite soon for all but the poorest countries). Simplified, practical education programs should be developed. These programs should, where feasible, include specific curricula to motivate the next generation toward a two-child family average to assure that level of fertility in two or three decades. AID should encourage and respond to requests for assistance in extending basic education and in introducing family planning into curricula. Expenditures for such emphasis on increased practical education should come from general AID funds, not population funds.

II. B. 2. Reducing Infant and Child Mortality

Discussion:

High infant and child mortality rates, evident in many developing countries, lead parents to be concerned about the number of their children who are likely to survive. Parents may over compensate for possible child losses by having additional children. Research to date clearly indicates not only that high fertility and high birth rates are closely correlated but that in most circumstances low net population growth rates can only be achieved when child mortality is low as well. Policies and programs which significantly reduce infant and child mortality below present levels will lead couples to have fewer children. However, we must recognize that there is a lag of at least several years before parents (and cultures and subcultures) become confident that their children are more likely to survive and to adjust their fertility behavior accordingly.

Considerable reduction in infant and child mortality is possible through improvement in nutrition, inoculations against diseases, and other public health measures if means can be devised for extending such services to neglected LDC populations on a low-cost basis. It often makes sense to combine such activities with family planning services in integrated delivery systems in order to maximize the use of scarce LDC financial and health manpower resources (See Section IV).

In addition, providing selected health care for both mothers and their children can enhance the acceptability of family planning by showing concern for the whole condition of the mother and her children and not just for the single factor of fertility.

The two major cost-effective problems in maternal-child health care are that clinical health care delivery systems have not in the past accounted for much of the reduction in infant mortality and that, as in the U.S., local medical communities tend to favor relatively expensive quality health care, even at the cost of leaving large numbers of people (in the LDC's generally over two-thirds of the people) virtually uncovered by modern health services.

Although we do not have all the answers on how to develop inexpensive, integrated delivery systems, we need to proceed with operational programs to respond to ODC requests if they are likely to be cost-effective based on experience to date, and to experiment on a large scale with innovative ways of tackling the outstanding problems. Evaluation mechanisms for measuring the impact of various courses of action are an essential part of this effort in order to provide feedback for current and future projects and to improve the state of the art in this field.

Currently, efforts to develop low-cost health and family planning services for neglected populations in the LDC's are impeded because of the lack of international commitment and resources to the health side. For example:

A. The World Bank could supply low interest credits to LDCs for the development of low-cost health-related services to neglected populations but has not yet made a policy decision to do so. The Bank has a population and health program and the program's leaders have been quite sympathetic with the above objective. The Bank's staff has prepared a policy paper on this subject for the Board but prospects for it are not good. Currently, the paper will be discussed by the Bank Board at its November 1974 meeting. Apparently there is some reticence within the Bank's Board and in parts of the staff about making a strong initiative in this area. In part, the Bank argues that there are not proven models of effective, low-cost health systems in which the Bank can invest. The Bank also argues that other sectors such as agriculture, should receive higher priority in the competition for scarce resources. In addition, arguments are made in some quarters of the Bank that the Bank ought to restrict itself to "hard loan projects" and not get into the "soft" area.

A current reading from the Bank's staff suggests that unless there is some change in the thinking of the Bank Board, the Bank's policy will be simply to keep trying to help in the population and health areas but not to take any large initiative in the low-cost delivery system area.

The Bank stance is regrettable because the Bank could play a very useful role in this area helping to fund low-cost physical structures and other elements of low-cost health systems, including rural health clinics where needed. It could also help in providing low-cost loans for training, and in seeking and testing new approaches to reaching those who do not now have access to health and family planning services. This would not be at all inconsistent with our and the Bank's frankly admitting that we do not have all the "answer" or cost- effective models for low-cost health delivery systems. Rather they, we and other donors could work together on experimentally oriented, operational programs to develop models for the wide variety of situations faced by LDCs.

Involvement of the Bank in this area would open up new possibilities for collaboration. Grant funds, whether from the U.S. or UNFPA, could be used to handle the parts of the action that require short lead times such as immediate provision of supplies, certain kinds of training and rapid deployment of technical assistance. Simultaneously, for parts of the action that require longer lead times, such as building clinics, World Bank loans could be employed. The Bank's lending processes could be synchronized to bring such building activity to a readiness condition at the time the training programs have moved along far enough to permit manning of the facilities. The emphasis should be on meeting low-cost rather than high-cost infrastructure requirements.

Obviously, in addition to building, we assume the Bank could fund other local-cost elements of expansion of health systems such as longer-term training programs.

AID is currently trying to work out improved consultation procedures with the Bank staff in the hope of achieving better collaborative efforts within the Bank's current commitment of resources in the population and health areas. With a greater commitment of Bank resources and improved consultation with AID and UNFPA, a much greater dent could be made on the overall problem.

B. The World Health Organization (WHO) and its counterpart for Latin America, the Pan American Health Organization (PAHO), currently provide technical assistance in the development and implementation of health projects which are in turn financed by international funding mechanisms such as UNDP and the International Financial Institutions. However, funds available for health actions through these organizations are limited at present. Higher priority by the international funding agencies to health actions could expand the opportunities for useful collaborations among donor institutions and countries to develop low-cost integrated health and family planning delivery systems for LDC populations that do not now have access to such services.

Recommendations:

The U.S. should encourage heightened international interest in and commitment of resources to developing delivery mechanisms for providing integrated health and family planning services to neglected populations at costs which host countries can support within a reasonable period of time. Efforts should include:

1. Encouraging the World Bank and other international funding mechanisms, through the U.S. representatives on the boards of these organizations, to take a broader initiative in the development of inexpensive service delivery mechanisms in countries wishing to expand such systems.

2. Indicating U.S. willingness (as the U.S. did at the World Population Conference) to join with other donors and organizations to encourage and support further action by LDC governments and other institutions in the low- cost delivery systems area.

A. As offered at Bucharest, the U.S. should join donor countries, WHO, UNFPA, UNICEF and the World Bank to create a consortium to offer assistance to the more needy developing countries to establish their own low-cost preventive and curative public health systems reaching into all areas of their countries and capable of national support within a reasonable period. Such systems would include family planning services as an ordinary part of their overall services.

B. The WHO should be asked to take the leadership in such an arrangement and is ready to do so. Apparently at least half of the potential donor countries and the EEC's technical assistance program are favorably inclined. So is the UNFPA and UNICEF. The U.S., through its representation on the World Bank Board, should encourage a broader World Bank initiative in this field, particularly to assist in the development of inexpensive, basic health service infrastructures in countries wishing to undertake the development of such systems.

3. Expanding Wage Employment Opportunities, Especially for Women

Discussion

Employment is the key to access to income, which opens the way to improved health, education, nutrition, and reduced family size. Reliable job opportunities enable parents to limit their family size and invest in the welfare of the children they have.

The status and utilization of women in LDC societies is particularly important in reducing family size. For women, employment outside the home offers an alternative to early marriage and childbearing, and an incentive to have fewer children after marriage. The woman who must stay home to take care of her children must forego the income she could earn outside the home. Research indicates that female wage employment outside the home is related to fertility reduction. Programs to increase the women's labor force participation must, however, take account of the overall demand for labor; this would be a particular problem in occupations where there is already widespread unemployment among males. But other occupations where women have a comparative advantage can be encouraged.

Improving the legal and social status of women gives women a greater voice in decision-making about their lives, including family size, and can provide alternative opportunities to childbearing, thereby reducing the benefits of having children.

The U.S. Delegation to the Bucharest Conference emphasized the importance of improving the general status of women and of developing employment opportunities for women outside the home and off the farm. It was joined by all countries in adopting a strong statement on this vital issue. See Chapter VI for a fuller discussion of the conference.

Recommendations:

1. AID should communicate with and seek opportunities to assist national economic development programs to increase the role of women in the development process.

2. AID should review its education/training programs (such as U.S. participant training, in-country and third-country training) to see that such activities provide equal access to women.

3. AID should enlarge pre-vocational and vocational training to involve women more directly in learning skills which can enhance their income and status in the community (e.g. paramedical skills related to provision of family planning services).

4. AID should encourage the development and placement of LDC women as decision-makers in development programs, particularly those programs designed to increase the role of women as producers of goods and services, and otherwise to improve women's welfare (e.g. national credit and finance programs, and national health and family planning programs).

5. AID should encourage, where possible, women's active participation in the labor movement in order to promote equal pay for equal work, equal benefits, and equal employment opportunities.

6. AID should continue to review its programs and projects for their impact on LDC women, and adjust them as necessary to foster greater participation of women - particularly those in the lowest classes - in the development process.

4. Developing Alternatives to the Social Security Role Provided By Children to Aging Parents

Discussion

In most LDCs the almost total absence of government or other institutional forms of social security for old people forces dependence on children for old age survival. The need for such support appears to be one of the important motivations for having numerous children. Several proposals have been made, and a few pilot experiments are being conducted, to test the impact of financial incentives designed to provide old age support (or, more tangentially, to increase the earning power of fewer children by financing education costs parents would otherwise bear). Proposals have been made for son-insurance (provided to the parents if they have no more than three children), and for deferred payments of retirement benefits (again tied to specified limits on family size), where the payment of the incentive is delayed. The intent is not only to tie the incentive to actual fertility, but to impose the financial cost on the government or private sector entity only after the benefits of the avoided births have accrued to the economy and the financing entity. Schemes of varying administrative complexity have been developed to take account of management problems in LDCs. The economic and equity core of these long-term incentive proposals is simple: the government offers to return to the contracting couple a portion of the economic dividend they generate by avoiding births, as a direct trade-off for the personal financial benefits they forego by having fewer children.

Further research and experimentation in this area needs to take into account the impact of growing urbanization in LDCs on traditional rural values and outlooks such as the desire for children as old-age insurance.

Recommendation:

AID should take a positive stance with respect to exploration of social security type incentives as described above. AID should encourage governments to consider such measures, and should provide financial and technical assistance where appropriate. The recommendation made earlier to establish an "intermediary" institutional capacity which could provide LDC governments with substantial assistance in this area, among several areas on the "demand" side of the problem, would add considerably to AID's ability to carry out this recommendation.

5. Pursuing Development Strategies that Skew Income Growth Toward the Poor, Especially Rural Development Focusing on Rural Poverty

Income distribution and rural development: The higher a family's income, the fewer children it will probably have, except at the very top of the income scale. Similarly, the more evenly distributed the income in a society, the lower the overall fertility rate seems to be since better income distribution means that the poor, who have the highest fertility, have higher income. Thus a development strategy which emphasizes the rural poor, who are the largest and poorest group in most LDCs would be providing income increases to those with the highest fertility levels. No LDC is likely to achieve population stability unless the rural poor participate in income increases and fertility declines.

Agriculture and rural development is already, along with population, the US. Government's highest priority in provision of assistance to LDCs. For FY 1975, about 60% of the $1.13 billion AID requested in the five functional areas of the foreign assistance legislation is in agriculture and rural development. The $255 million increase in the FY 1975 level authorized in the two year FY 1974 authorization bill is virtually all for agriculture and rural development.

AID's primary goal in agriculture and rural development is concentration in food output and increases in the rural quality of life; the major strategy element is concentration on increasing the output of small farmers, through assistance in provision of improved technologies, agricultural inputs, institutional supports, etc.

This strategy addresses three U.S. interests: First, it increases agricultural output in the LDCs, and speeds up the average pace of their development, which, as has been noted, leads to increased acceptance of family planning. Second, the emphasis on small farmers and other elements of the rural poor spreads the benefits of development as broadly as is feasible among lower income groups. As noted above spreading the benefits of development to the poor, who tend to have the highest fertility rates, is an important step in getting them to reduce their family size. In addition, the concentration on small farmer production (vs., for example, highly mechanized, large-scale agriculture) can increase on and off farm rural job opportunities and decrease the flow to the cities. While fertility levels in rural areas are higher than in the cities, continued rapid migration into the cities at levels greater than the cities' job markets or services can sustain adds an important destabilizing element to development efforts and goals of many countries. Indeed, urban areas in some LDCs are already the scene of urban unrest and high crime rates.

Recommendation:

AID should continue its efforts to focus not just on agriculture and rural development but specifically on small farmers and on labor-intensive means of stimulating agricultural output and on other aspects of improving the quality of life of the rural poor, so that agriculture and rural development assistance, in addition to its importance for increased food production and other purposes, can have maximum impact on reducing population growth.

[**6. Concentration on Education and Indoctrination of The Rising Generation of Children Regarding the Desirability of Smaller Family Size**]

Discussion

Present efforts at reducing birth rates in LDCs, including AID and UNFPA assistance, are directed largely at adults now in their reproductive years. Only nominal attention is given to population education or sex education in schools and in most countries none is given in the very early grades which are the only attainment of 2/3-3/4 of the children. It should be obvious, however, that efforts at birth control directed toward adults will with even maximum success result in acceptance of contraception for the reduction of births only to the level of the desired family size which knowledge, attitude and practice studies in many countries indicate is an average of four or more children.

[** The great necessity is to convince the masses of the population that it is to their individual and national interest to have, on the average, only three and then only two children. There is little likelihood that this result can be accomplished very widely against the background of the cultural heritage of today's adults, even the young adults, among the masses in most LDCs. Without diminishing in any way the effort to reach these adults, the obvious increased focus of attention should be to change the attitudes of the next generation, those who are now in elementary school or younger. If this could be done, it would indeed be possible to attain a level of fertility approaching replacement in 20 years and actually reaching it in 30.**]

Because a large percentage of children from high-fertility, low income groups do not attend school, it will be necessary to develop means to reach them for this and other educational purposes through informal educational programs. As the discussion earlier of the determinants of family size (fertility) pointed out, it is also important to make significant progress in other areas, such as better health care and improvements in income distribution, before desired family size can be expected to fall sharply. If it makes economic sense for poor parents to have large families twenty years from now, there is no evidence as to whether population education or indoctrination will have sufficient impact alone to dissuade them.

Recommendation

1. That U.S. agencies stress the importance of education of the next generation of parents, starting in elementary schools, toward a two-child family ideal.

2. That AID stimulate specific efforts to develop means of educating children of elementary school age to the ideal of the two-child family and that UNESCO be asked to take the lead through formal and informal education.

General Recommendation for UN Agencies:

As to each of the above six categories State and AID should make specific efforts to have the relevant UN agency, WHO, ILO, FAO, UNESCO, UNICEF, and the UNFPA take its proper role of leadership in the UN family with increased program effort, citing the world Population Plan of Action.