World Development Report 1984

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