World Development Report 1984

able several types of condoms, pills, and spermi- East Asia: incentives for small families
cides. And the program has recently put more
emphasis on IUDs by offering financial incentives The countries of East Asia have experienced
to staff and compensation for travel and lost wages marked declines in fertility in the last decade (see
to acceptors. There are plans to train more Figure 8.7). Total fertility (less than 3) and rates of
fieldworkers in IUD insertions and menstrual reg- natural increase (about 1.5 percent a year, 2.2 perulation,
but not all fieldworkers are in place, and cent excluding China) are the lowest of any develnot
all of those who are have received adequate oping region. For the most part, recent declines in
training. Injectable contraceptives have proved fertility have occurred in countries where fertility
popular in pilot projects, but are available on was already lower than would be expected, given
only a limited basis under the supervision of a the region's income. The most dramatic reductions
physician. have been in China: total fertility dropped from 7.5
* Follozv-up. As South Asian programs try to to 2.3 over the past two decades, despite a per
meet the demand for a wider range of reversible capita income of only $310 in 1982. Indonesia, the
methods, following up acceptors will become even Philippines, and Thailand have also experienced
more critical. The emphasis on sterilization has remarkably rapid falls in fertility with only modest -
meant that staff have had little continuing contact increases in income.
with clients. Lack of follow-up services greatly Population policy is more developed in East Asia
reduced the acceptability of the IUD throughout than in any other region. In most countries, politi-
South Asia in the 1960s; it has only recently cal commitment to reduce rapid population
regained public approval. At present, family plan- growth is high. Family planning programs are well
ning staff are judged (and are rewarded) according established, with outreach to rural areas and a reato
the number of acceptors they recruit, not by the sonable mix of contraceptive methods. Many govnumber
of users they assist. Programs will have to ernments, irrespective of level of income, have
adopt new performance criteria and incentive been highly successful in improving socioarrangements
to stress regular contact with clients. economic conditions favorable to fertility decline.
Certain administrative and operational difficul- Ninety percent or more of all girls of primaryties
also need to be resolved. Family planning serv- school age are enrolled in China, Hong Kong,
ices have undergone major reorganization in some Indonesia, Korea, Malaysia, the Philippines,
countries. In Bangladesh, for example, health and Singapore, and Viet Nam. Overall, secondaryfamily
planning services were initially separate, school enrollments are also high in a few counthen
integrated, then divided, and are now reinte- tries-53 percent in Malaysia, 63 percent in the
grated. The program in Pakistan has also recently Philippines, and 85 percent in Korea. Life expectundergone
a major reorganization. Whenever ancy in China, Hong Kong, and Singapore has
there are such upheavals, staff morale and perfor- risen to seventy years or more and in most other
mance suffer. Other problems are manifest in all countries exceeds sixty. In almost all countries,
programs. In some cases salaries are so low that infant mortality has been reduced by half or more
staff have to take on other work to support their over the past twenty years. Nevertheless, further
families. Inadequate training, incomplete staffing substantial reductions could be made in Indonesia
patterns, and lack of supervision have also low- (where the rate exceeds 100 per thousand live -
ered morale and performance. Where it exists, births), China (with a rate of 67), and Thailand, the
supervision takes the form of enforcing account- Philippines, and Viet Nam (about 50).
ability and targets rather than supportive training Despite dramatic declines in fertility, population
and advice. in the region will double in about forty-five years.
Program managers have tried to overcome prob- Burma, Indonesia, Malaysia, the Philippines, Thai-lems
of morale and supervision in two ways: by land, and Viet Nam all have annual rates of popupaying
workers according to their performance in lation growth of at least 2 percent a year. At its
recruiting acceptors, but this system carries the current growth rate of 2.4 percent a year, the popurisk
that follow-up services will be neglected; and lation of the Philippines will increase by half (25
by setting high program targets. But neither incen- million people) by 2000. Even in China, with an
tives nor targets can substitute for better training annual increase of 1.2 percent, population will
and supervision-the two requirements that are continue to grow rapidly for a long time because of
critical to improving the performance of family the momentum of past growth. According to the
planning programs in South Asia. standard projection, China's population will
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