World Development Report 1984

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may be delaying a first pregnancy, spacing effects are assured, resupply is convenient, and between children, or preventing additional preg- the opportunity to switch methods is available. nancies. Staff must be discreet, sensitive to the Medical backup and referral is critical, as is the individual needs of clients, and familiar with local capacity to follow up on clients. Managers need customs and beliefs. This requirement has been information not only on new acceptors but also on addressed in several ways: by selecting staff from continuing users, dropouts, and nonparticipants local communities, by training staff in the environ- (see Box 7.4). Indonesia is one country with an ment in which they will work, and by making spe- effective monitoring system, including acceptor cial efforts to hire female workers. Special services records, quarterly follow-up surveys of acceptors, have also been targeted for specific client groups: and periodic sample surveys of households in adolescents, women who have just given birth, which information on fertility and contraceptive and mothers with young children. use is collected. Second, programs must encourage clients not Third, because information about the benefits of only to accept a method of contraception but also family planning and of small families may not be to use it effectively and continuously. In societies widespread, programs must create an awareness in which people marry young, couples who are of services and their benefits, as well as spread spacing and limiting births may have to use contra- information about the proper use of methods. ception for twenty years. Prolonged, effective use Information and education activities are necessary is easier if information and support regarding side both within and outside the system for delivering 138 Box 7.4 Management information systems for improved service delivery The rTangenmenr. tIr pri iding tamili health and tamil plnning s-erx ic* %tre repcris ton irrded i', prc.gram nianager; planning s.et lce- in man% *:untrie- are ;pending as muchas il! percent mt their ere replsced t a ,sinlm nmrothk report plagued b. Iack ;t reliable intormaijon tirre on 3in ti;es not direcil% rtlated tn b, *a-:h riieldschrker a sciln,ic report b, on- ihich to base m3r3gement dei,ions delering rhtir ser ices keeping rec- each uptriscor an a ;inglc r.eport tr:m Requiremenis tor data collection are .-rds and 3rtend.n,; mretings %,ere the each primarN health enter F3mil, plan imposed on .o,rburdened ;t3tl and m *;t common e%traieous actiities ;A ning statf %serc n.ld imrr'edi3te1 hci. ;upErni;ed b% medical or other technical total ot tn *si reilsters t ere mair.. the%i %ere mea;uring IP Wc predetvr- personnel untrained to mAke u-e cit the tamiied bLs i.te itpes * t elds%orkers r.mine target- T- encourvt- :c.nmpet- .niormatinrr \Iud tIre .- spent collect- relating tc. a range c1 sublects tamil ion teedtack repc.rtz irom lh d. tric to. r.g intormation that is ne'. er used planning maternal and child health ihe pnmars health cernters Also ranked A mn3ragemenrr ntcirm3aion ;sstem immunuiati.n mnalara conirohl :nd %. iuh crnters on rhe ta,-i- .-1 tn indJia3t,r; ,iNll-t an' ;n ztem %%hich l rganizet the c..nsider3ble uuorlap ot the da3t the% ;uch as the rumb,r .I immunia3tion- ,:.'I1,ciicn ind interprrtation )t daia reccrded An 3s'ist.,nt nurse-midi. it and IItIh number it srcr,h3Iiatons 3S a psr- n dted b% managers Lo ma3e decisions ai-rn, mainrtaind ti ent- iio reiords centage ot annual r3rget- The rural h,alth .uprrtis.r re% ie%uing 3 and prepartd tssei e rep-rts a month In thre d,ztrictr in ih *tai31 ... t .2nrrhra ulker; Iteurd 1c1 ds-e-- perttrmance The untu.rrnmuitn 'a.il nni u.ed bh super- Pr-d;7h i htr thi; ., 7ti at s- -rir.- and the health mini;ter resie ming intor- i ;irs 3nd manager4 nor did ti curkers diced the timt spent .- n re .-eptng mation on hiring and depl% ment ot statl recei%e ans s%stematic teedhack on the.r and reporting ha,; btrn reduid consid- are both usingan \11- For a family plan pert,amance compared nith oihers erabls An assistant nure-mtdi tie t.r ning propgar. an Nllc could include There %sa3 little incenti%e t.. maintain Exarrple rso's spends inlk abL.ut halt an untorm3tli-n r.n r3rgtt group size and g.-sod records and to. rep-Jrt regOtlarl and h.,ur a da s ith the nes ;s% stem com- haratl3r3;1ristics ness and continuing on iime p3red us th tsc. hours beo-tre Pe ar a.:eptor rates ind c:haracteri;tics. numr Follc, ing a re% ie- . thei sem cu-mplcts and are subhmtted on timre i bers and ispes ot tollcns up jsist birth reccurdkeeping and reporimti is ere ;ther diztrcts reporting is abh.t thre rStes stattmng patterns. and aailahilNts stre3rilined The number ct registers rronths behind schedultI and managers -. rupplie FheTe data all,%s managers kept bs ieldsorker. .sas reduced Irom ite retsp:cdin: beCitcr I.- 1.:c31 neWd tc mak decisucins based on up to-dare to-rtL-u t; sis 3 reg,.ter ot elh,ible .:c!U* ct ps toe.pand the si tem t;-r states.id~ 3nd reiiable imtcrnaiion that is colleted ples and children, a maternal and child ine are no%% being taken in indhra aS a matter o.t outIne health register 3 r-port on blood srmears Pradesh and the g.o%,rnmtErt ot India Is :'tudiez in ii criarcs in India Karna. r i malaria a birth and death register. a recommending that all 'taies adopt thE r3,3 and Lrrtar l'r3desh in the mid 1lt!s stock and issue register and a diari ot neis KIP1 sho, ed that tieldcs orkers pros iding dailk acti%.ties The tarious separat,
services. Program staff recruit potential clients and of family planning services, and medical staff may offer information on proper use of methods. The give priority to curative rather than preventive mass media can be used to inform people of the services. Multipurpose workers who are overbenefits of small families and how to obtain contra- loaded with responsibilities will do none of their ceptive methods. Instruction on human reproduc- tasks well. If an integrated delivery system tion, family planning, responsible parenthood, employs single-purpose workers, friction may and problems of rapid population growth as part arise over differences in training, seniority, salaof school curricula can inform young people before ries, and promotion. For example, in addition to they marry; such instruction can also be offered their salaries, family planning workers have somethrough nonformal education, such as adult liter- times received incentive payments based on the acy programs. These efforts complement other number of acceptors they recruit, whereas health economic and social policies, discussed in Chapter workers receive only salaries. In Kenya family 6, to create demand for smaller families. health field educators (with family planning Because of the need for medical services for pro- responsibilities) were paid more than the enrolled vision or follow-up of many contraceptive meth- community nurses to whom they were to report. ods, most family planning programs are linked to These personnel issues can seriously affect worker the public health system. The nature of these links morale and performance. varies among countries and has often changed. In Although family planning programs need some some programs, family planning workers provide link with health systems, family planning services services through clinics administered by the minis- need not be confined to them. When services are try of health, but are responsible to some other provided through a maternal and child health probody. In Pakistan primary responsibility for family gram, important client groups may be overlooked: planning lies with the Population Welfare Division men, adolescents, unmarried women, and nonof the Ministry of Planning and <strong>Development</strong>, pregnant women. Ministries of health may be using the division's own specialized facilities and poorly equipped to organize social marketing workers. Elsewhere family planning is directly schemes (for subsidized commercial distribution of administered by the ministry of health, through a contraceptives, discussed below), to develop mass special department of family planning (as in media programs, or to coordinate public, private, Egypt) or as part of preventive or maternal and nongovernmental, and commercial activities. child health services (as in Botswana, Kenya, and Some of these responsibilities are often delegated, Malawi). Staff may specialize in family planning for example, to information or education minis- (that is, as "single-purpose" workers), as in Kenya, tries. Many programs have boards within or out- Pakistan, and Indonesia; or they may be responsi- side a ministry to coordinate the wide range of ble for general health or maternal and child health family planning activities. In Mexico the semiservices in addition to family planning (that is, as autonomous Coordinacion General del Programa "multipurpose" workers), as in Bangladesh, Bot- Nacional de Planificacion Familiar monitors and swana, and India. coordinates all family planning activities; it is There have been obvious advantages in integrat- located within the Ministry of Health but has direct ing health and family planning in the delivery of access to the president and works closely with the * services. The health benefits for mothers and chil- National Population Council (CONAPO), a sepadren of spacing and limiting births clearly establish rate body responsible for population policy. In family planning as a valuable component of mater- Indonesia the National Family Planning Coordinal and child health services. For both services the nating Board (BKKBN) is an autonomous body main target group-married women of childbear- that collects data, produces information and edu- - ing age-is the same. Joint delivery can reduce unit cation programs, coordinates activities, and has its costs, and in countries where family planning is own fieldworkers who promote family planning, controversial, integrated services make the pro- refer clients, and set up community distribution gram more acceptable. points. In some countries these family planning But integrated services also present difficulties. boards are also responsible for overall population Health ministries are often understaffed and policy-a role discussed more fully in Chapter 8. underfunded; they cannot always mobilize the In conclusion, there is no simple formula for the political and administrative wherewithal to imple- best organization of family planning programs. ment an effective family planning program. Heavy Programs that differ widely in structure can be demands for health care may eclipse the provision equally successful. Workers in India deliver both 139
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Public Disclosure Authorized Public
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Oxford University Press NEW YORK OX
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labor markets. And they have a vest
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8 The policy agenda 155 Population
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Boxes 1.1 The arithmetic of populat
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Glossary Demographic terms informat
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I I
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countries regain their momentum of
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4 Box 1.1 The arithmetic of populat
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example. Between 1955 and 1980 inco
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ment-all the more so if human skill
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etween 1 and 2 percent-moderate com
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FIGURE 2.1 directions-with a lag in
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14 Distribution of product among se
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TABLE 2.2 Rates of growth in the re
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export restraints and orderly marke
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Box 2.2 Comparisons between the 193
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TABLE 2.6 indebtedness is denominat
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TABLE 2.7 Change in export prices a
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Burundi, Guinea, Mali, Malawi, and
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TABLE 2.9 Exports from developing c
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of rapid and painful adjustment for
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In many countries internal adjustme
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3 Prospects for sustained growth Wi
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TABLE 3.2 Growth of GDP per capita,
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TABLE 3.4 Current account balance a
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over time. The main focus of indust
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TABLE 3.6 Growth of trade in develo
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Box 3.3 Delinking from the world ec
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nal surplus. The resulting rise in
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Because the public sector in low-in
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developing-country creditworthiness
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themselves and, by caring for young
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fertility in a changing world is a
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nize contraceptive services. As wil
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Economic transformation: Europe, Ja
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scious control of family size, prob
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Box 4.3 The European fertility tran
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FIGURE 4.2 Birth and death rates an
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Box 4.4 Alternative measures of fer
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largest city in 1950, will not even
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FIGURE 4.4 Fertility in relation to
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government goal is a nationwide rat
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North America's population in 2000
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IBox 4.6 Three views of population
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TABLE 4.6 Population size and densi
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Box 5.1 Consequences of population
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implied by a simple division of tot
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and on farms. But the evidence on e
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get in GDP. Alternatively, all or p
Page 102 and 103: youths, who are presumably able to
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Page 106 and 107: acre increased from 15.4 million to
Page 108 and 109: food they need. Although the amount
Page 110 and 111: is so scarce, they can do so only o
Page 112 and 113: from rural to urban areas mainly re
Page 114 and 115: other developing countries suggests
Page 116 and 117: emigration by providing information
Page 118 and 119: Box 5.7 Coping with rapid fertility
Page 120 and 121: 6 Slowing population growth Experie
Page 122 and 123: feTtility; nor is it easy to judge
Page 124 and 125: the education of mothers increases
Page 126 and 127: etter education and health services
Page 128 and 129: TABLE 6.1 Total fertility rates and
Page 130 and 131: effectiveness of existing laws, ins
Page 132 and 133: in the 1950s and 1960s, fertility w
Page 134 and 135: FIGURE 6.6 Fertility dedine within
Page 136 and 137: Box 6.3 Mleasuring the value of chi
Page 138 and 139: few births; to encourage spacing, T
Page 140 and 141: Box 6.4 A deferred incentive scheme
Page 142 and 143: Box"7.1 Family planning for health
Page 144 and 145: FIGURE 71 88 in Romania (1979). Res
Page 146 and 147: 132 Box 7.2 Birth planning technolo
Page 148 and 149: TABLE 7.2 Percentage of married wom
Page 150 and 151: TABLE 7.3 Discontinuation of contra
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Page 158 and 159: Box 7.6 The impact of service quali
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Page 162 and 163: measuring social acceptability, or
Page 164 and 165: Box 7.7 Military versus social expe
Page 166 and 167: costs per user. Public cost per use
Page 168 and 169: sanguine, however, as soon as one t
Page 170 and 171: TABLE 8.1 Population policy indicat
Page 172 and 173: Box 8.2 China's census: counting a
Page 174 and 175: FAMILY PLANNING. In many countries-
Page 176 and 177: improving the availability of famil
Page 178 and 179: Box 8.4 Africa: how much land, how
Page 180 and 181: Box 8.5 Infertility: a challenge to
Page 182 and 183: FIGURE 8.2 upper Egypt want no more
Page 184 and 185: growth. Fertility has declined in t
Page 186 and 187: Box 8.7 Changing policies and attit
Page 188 and 189: FIGURE 8.6 childbearing age have un
Page 190 and 191: able several types of condoms, pill
Page 192 and 193: housing schemes to parents with onl
Page 194 and 195: and training, data collection and a
Page 196 and 197: 9 Ten years of experience Much that
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Page 200 and 201: Population data supplement The six
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Table 4. Factors influencing fertil
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190 Births and total fertility =Ice
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Table 1. Population projections Rat
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Table 2. Population composition Low
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Table 3. Contraceptive use and unme
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Table 5. Status of women Number enr
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Table 6. Family planning policy _ _
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Bibliographical note This Report ha
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Background papers Note: Source refe
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-1984. "The Malthusian Case: Preind
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I I
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Table 10. Structure of merchandise
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Key In each table, economies are li
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same order is used in all tables. T
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Population I~~~~ - * S: ~ -- ' X -
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Table 1. Basic indicators GNP per c
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Table 2. Growthi of production Aver
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Table 3. Structure of production GD
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Table 4. Growth of consumption-and
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Tadble 5. Structure of demand Distr
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Table 6. Agriculture and food Value
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Table 7. Industr Distribution of ma
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Table 8. Commercial energy Energy c
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Table 9. Growthi of merchandise tra
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Table 12. Origin and destination of
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Table 13. Origin and destination of
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Table 14. Balance of payments and r
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Table 15. Flow of public and public
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Table 16. External public debt and
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Table 17. Terms of public borrowing
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Table 18. Official development assi
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Table 19. Population growth and pro
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Table 20. Demographic and fertility
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Table 21. Labor force Percentage of
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Table 22. Urbanization Urban popula
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Table 23. Indicators related to lif
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Table 24. Health-related indicators
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Table 25. Education Number Number e
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Table 26. Central goverrnment expen
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Table 27. Central government curren
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Table 28. In-come distribution Perc
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Technical notes This edition of the
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difficulties in assigning subsisten
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series in national currencies are a
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Public loans are external obligatio
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estimates, the total fertility rate
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expenditure and current revenue sho
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Bibliography of data sources Nation
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World Development Report 1984

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