World Development Report 1984
World Development Report 1984
World Development Report 1984
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traditional birth attendants) provided maternal reducing infant mortality and of providing more<br />
and child health care, as well as family planning schooling for children can be rapid-but these cost<br />
services in 1974-79. In those areas, fertility de- more in most settings to produce the same effect<br />
clined by 15 percent; elsewhere on the island, it fell on fertility. With respect to the single goal of<br />
by 9 percent. reducing fertility, one study concluded that family<br />
* A comprehensive rural health program was planning programs were at least seven times as<br />
undertaken in an area in Maharashtra, India, from cost effective in reducing fertility as were nutrition<br />
1971 to 1978. In a nonprogram area, fewer than 10 programs or education schemes for rural women.<br />
a percent of eligible couples used contraceptives in In Bangladesh, Korea, and the Philippines family<br />
1976, and the crude birth rate was thirty-seven per planning programs are estimated to be five times<br />
thousand. In the program area, contraceptive use as cost effective as health programs that reduce<br />
rose from 3 to 51 percent, and the crude birth rate fertility through reducing mortality. But where<br />
in 1976 was twenty-three per thousand. mortality is high and demand for family planning<br />
Unfortunately, experiments such as these are is limited, as in Kenya, reducing infant mortality is<br />
difficult to replicate. They often cost more than a a more cost-effective way to lower fertility.<br />
government could spend on a nationwide effort; Emphasis on the cost effectiveness of family<br />
more important, they may work because of the planning should not obscure the third point noted<br />
intense involvement of research and other staff. above: that family planning and social develop-<br />
Indeed, not all field projects work well; effects of ment complement each other. Analysis of fertility<br />
projects were small in a condom-marketing change across countries done for this <strong>Report</strong><br />
scheme in Kenya, and nonexistent in one in Rio de shows that between 1972 and 1982 family planning<br />
Janeiro, Brazil (the only project conducted exclu- programs have had minimal effect where female<br />
sively in an urban area, where contraceptives were education is low, in part because it is difficult to<br />
easily available). But the results still suggest that operate such programs without some educated<br />
good services reduce fertility significantly, by clos- women to staff them, and in part because of lack of<br />
ing the gap between actual and desired family size. demand for contraception. Equally, female education<br />
has had minimal effect where family planning<br />
COST EFFECTIVENESS OF FAMILY PLANNING PRO- services have been unavailable. However, the<br />
GRAMS. By increasing the supply of services, fam- effect of the two together has been powerful. The<br />
ily planning programs reduce the cost of using decline in fertility in Kerala, India, provides a good<br />
contraception to potential users. By contrast, illustration. Education levels have been higher in<br />
increased education, lower mortality, and other Kerala than in most other Indian states for many<br />
social changes increase the demand for contracep- years, and infant and child mortality rates have<br />
tion. For the single goal of reducing fertility, been lower. Around 1980 the literate proportion of<br />
spending on family planning services turns out to Kerala's population was twice that of India's as a<br />
be more cost effective (that is, it leads to the same whole, and the infant mortality rate less than half<br />
fertility reduction at lower cost) than does spend- the national rate. The fertility rate fell from 4.1 to<br />
ing on education, health (which reduces fertility by 2.7 between 1972 and 1978 in Kerala (compared<br />
reducing infant mortality), and other programs. Of with a fall from 5.8 to 4.9 for India as a whole), in<br />
course, this comparison does not take into account part because investment per capita in family plan-<br />
(1) that education and health programs have other ning in Kerala has been high, at times almost as<br />
.objectives in their own right, independent of great as in Hong Kong. But this investment would<br />
'effects in fertility; (2) that family planning has have had much less impact in less favorable condiother<br />
benefits-including reducing mortality; and tions of education and health.<br />
-(3) that these different approaches are not really<br />
alternatives but complement and reinforce each Incentives and disincentives<br />
other. At low levels of education and high levels of<br />
mortality, the underlying demand for family plan- To complement family planning services and social<br />
ning will be low. The same amount spent on a programs that help to reduce fertility, governprogram<br />
in a high-education, low-mortality setting ments may want to consider financial and other<br />
will induce a greater increase in contraceptive use. incentives and disincentives as additional ways of<br />
One reason family planning is cost effective is encouraging parents to have fewer children.<br />
that it has an immediate impact-at least where Incentives may be defined as payments given to an<br />
there is underlying demand. Similarly, the effect of individual, couple, or group to delay or limit child-<br />
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