World Development Report 1984

extended to the countryside, often by paramedical example-have long-established programs to
and semiskilled staff with backup support from reduce fertility. About half the countries in the
health centers. More attention is paid to increasing Middle East provide family planning to improve
the range of contraceptive methods, providing fol- child spacing and to promote health; only Turkey's
low-up services to clients, and working with com- program seeks to reduce fertility. In a few Middle
munity leaders to encourage local support. Com- Eastern countries, contraception is illegal. In othmercial
organizations are also encouraged to ers, cultural practices often confine women to their
provide family planning. Private associations are households, which makes it difficult for them to
delegated major responsibilities within the seek out family planning services. Programs that
national program for certain services or target include home visits by family planning workers
groups and continue to test new ways of providing are not well developed.
services. * Sub-Saharan Africa. Of forty-one governments
Public family planning programs are now at dif- for which data are available, only nine have demoferent
stages of development in different regions. graphic objectives. Most governments that sup-
* East Asia. Governments have a longstanding port family planning do so for health reasons, and
commitment to reduce population growth. They twelve countries still provide no official backing for
have been extremely successful in improving family planning. Where services exist, they are
access to family planning services and in widening provided through health care systems that have
the range of contraceptive methods available. only limited coverage, particularly in rural areas.
Large numbers of field workers have been Throughout Africa couples want large families,
recruited to provide family planning, and some- and infant mortality is high. There is some
times basic health care, in villages in China, Indo- demand for family planning but it is poorly met by
nesia, and Thailand. Contraceptive use has existing programs. As traditional ways of child
increased dramatically during the past decade. spacing (prolonged breastfeeding and sexual absti-
* South Asia. Official commitment to reduce fer- nence) erode, the demand for modern contraceptility
is strong, but results have been mixed. Con- tion increases. Private organizations have helped
traceptive use is highest in Sri Lanka and several to demonstrate that demand and to press for govstates
in southern India, and is lowest in Nepal ernment support.
and Pakistan. The demand for contraception is still
constrained by high infant mortality and by a pref- The management of family planning programs
erence for large families. At the same time, recent
surveys have revealed substantial unmet need for Perhaps more than any other social programs,
both limiting and spacing births. Most programs family planning programs can be effective only to
have yet to achieve the rural spread found in East the extent that they meet the needs of individuals,
Asia and have tended to emphasize sterilization. both for better information about the benefits of
Other methods have been largely supplied controlling fertility and for better services to facilithrough
subsidized commercial outlets. tate doing so. At the same time family planning
* Latin America and the Caribbean. At first, wide- programs, like all public programs, operate within
spread demand for family planning was met certain constraints: the availability of manpower
largely by private doctors, pharmacies, and non- and finance, the capacity for training and superviprofit
organizations, primarily in urban areas. sion, and the transport and communications infra-
Government support was weak, in part because of structure. Medical backup is necessary to deliver
opposition from some religious authorities. The some contraceptive methods. The challenge for
1970s saw a growing interest on the part of govern- family planning managers is to address individual
ments and a greater tolerance by religious authori- needs within the confines of these constraints, and
ties. Most governments now support family plan- in the longer term to ease such limitations.
ning services for health and humanitarian The personal nature of family planning services
purposes; Barbados, Colombia, the Dominican has several important implications for designing
Republic, El Salvador, Guatemala, Haiti, Jamaica, and managing programs. First, programs must be
Mexico, and Trinidad and Tobago do so to reduce able to accommodate local and individual needs
fertility as well. In rural areas, access to services is and a variety of users. Potential clients include
still inadequate in most countries. men and women; those who are married and un-
* Middle East and North Africa. Some countries married; those of different social, economic, culin
North Africa-Egypt, Morocco, and Tunisia, for tural, or religious backgrounds; and those who
137