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What has Happened to Family Planning since Cairo
and What are the Prospects for the Future?
Presentation to the AMPPA Meeting on “Male Fertility Control – Where are we?”
Schloß Groß Ziethen, Germany
Steven W. Sinding
Senior Fellow, Guttmacher Institute, USA
I am very pleased to be among so many old friends and colleagues and honored to have
been invited to address you on the subject of the future of family planning. I recall
vividly the launch of AMPPA above the sparkling waters of Lake Como and want to
salute my dear friend and former Rockefeller Foundation colleague, Prof. Mahmoud
Fathalla, for having had the vision and the commitment to form this unique collaboration.
I must also pay tribute to Prof. Egon Diczfalusy for the leadership and support he has
given the effort and to our Ernst Schering Foundation colleagues who have so generously
supported and contributed to the effort, particularly Prof. Günter Stock and Dr. Ursula
Habenicht. Finally, I must recognize Drs. Henry Gabelnick and Mike Harper for the
support CONRAD has provided to AMPPA over these years. It has been nearly eight
years since I left the Rockefeller Foundation and began to lose touch with AMPPA, so I
am particularly eager to hear what has been accomplished over its lifetime, but especially
during these years when I have been absent from your meetings.
A bit of history
Well, where to begin on so broad a topic as what has happened since Cairo and future
prospects for family planning? Perhaps the best place to start is by defining terms. By
family planning, I mean both the individual act of avoiding a pregnancy and organized
efforts to make contraception and contraceptive services available to women and men
who otherwise might lack either the information or the means or the desire to use
contraception. In this first section of my presentation, it is the latter definition that I am
using – the family planning movement. Later, for reasons that will become clear I will
turn to the former – individual use of birth control.
It can be credibly argued that such programs, and the movement they became, represent
one of the most important and successful examples of development cooperation of the
last half century. Since roughly the mid-1960’s, organized family planning programs
around the world have contributed to an increase in contraceptive use from less than 10
percent of couples to nearly 60 percent today. Of that 60 percent, nearly 90 percent are
using modern methods of birth control such as the oral pill, the IUD, injectables,
implants, barrier methods, and sterilization. This represents a true reproductive revolution
as fertility rates in developing countries have declined from about six children per woman
in 1965 to less than three today. It means that the rate of population increase in these
countries has dropped from nearly three percent per year in the 1960’s to 1.5 percent
today. As I said: a true reproductive revolution.
The primary reason that governments, international organizations, NGOs and
philanthropic institutions gave such strong emphasis to family planning in the second half
of the 20th Century was because of their collective concern about the very high rates of
population growth prevalent at mid-century. It was thought at the time that, while family
planning programs themselves would not bring fertility down to the replacement level –
the level then prevailing in the industrialized countries – they represented the most
obvious and direct means to bring down birthrates. It was always understood that
commensurate improvements in living standards were also a critical component of efforts
to reduce high fertility. I must add here that while reducing high fertility was the primary
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motivation behind large-scale family planning programs and program assistance, there
was also a very strong value espoused especially by NGOs, to see family planning as a
means to empower women and to improve the well being of individuals and families
(and, particularly in Latin America, as a means to reduce very high rates of unsafe and
illegal abortion). Through most of its history, the family planning movement represented
a sometimes uncomfortable alliance between those who were primarily motivated by
demographic considerations – mainly governments – and those whose motivation was
more humanitarian, a group that included some governments, but was mainly comprised
of NGOs.
Unfortunately, in their zeal to reduce high birth rates, some governments violated a basic
tenet of family planning: namely, that it should be an entirely voluntary service for
people to avail themselves of according to their own needs and desires. Approaches
ranging from subtle pressure to outright coercion occurred in enough places, particularly
during the 1970’s and 1980’s, that family planning became a controversial matter in
international discourse. Advocates of women’s health and rights were especially outraged
by government intrusion into reproductive freedom and they channeled this anger into
well organized efforts to influence the outcome of the third in a series of global
population conferences, the International Conference on Population and Development –
or ICPD – at Cairo in 1994.
What did Cairo mean for family planning?
I believe that Cairo effectively signaled the end of the family planning movement and
replaced it with what we know today as the reproductive health and rights movement,
sometimes expanded to also include sexual health and rights – what we now often refer to
as SRHR. While family planning is included in all definitions of reproductive health and
rights, the SRHR concept is much broader, encompassing not only other reproductive
services, such as emergency obstetrical care and STD diagnosis and treatment, but also
the fundamental right to be free from coercion and to have access to the highest possible
level of reproductive health care. What effectively ended at Cairo was the strong linkage
between family planning services and efforts to reduce high birthrates.
I believe that without intending to do so, the architects of the Cairo consensus, as it is
often called, transformed family planning from what had been seen as a global imperative
to one among many desirable but non-essential public services. The crisis mentality that
had sustained such high levels of support and so high a priority for family planning in the
years before Cairo was no longer present at Cairo and it has almost entirely disappeared
in the years since Cairo.
Why has interest in and support for family planning declined since Cairo, and what is the
evidence that this has occurred? First the evidence:
Since 1995 – the year following the Cairo conference – the percentage of total population
assistance by donors that is represented by family planning has declined from 55 percent
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to 20 percent, according to Speidel.* In constant dollars, this is approximately a 35
percent decline. At the same time, the percentage allocated to STD prevention and
treatment, including HIV/AIDS, has risen from 10 percent to 50 percent. The family
planning budgets of many countries have either stagnated or declined. Almost none have
increased, even as health budgets have expanded enormously during this period – mostly
in response to the AIDS pandemic but also as a consequence of the much higher priority
accorded to health these days in many countries’ development plans. Unhappily, family
planning and SRH do not rank high in the priorities of many of these countries.
Now, why has this occurred? I can identify five primary reasons:
First, as mentioned above, because of the remarkable success of programs over the past
40-50 years, the population problem is no longer seen as being as pressing as it was when
the movement began. Indeed, with many developing countries at or near replacement
fertility and many industrialized countries well below replacement, it is not surprising
that rapid population growth is no longer as high as it once was on the global agenda.
Second, HIV/AIDS has replaced population growth as today’s health-related crisis. Many
countries are understandably shifting funds once devoted to family planning activities to
AIDS treatment and prevention.
Third, developing countries themselves are devoting less attention and are showing less
concern about population and family planning that they once did and have identified
more pressing priorities for their scarce budgetary resources.
Fourth, the Cairo goal of universal access to reproductive health services is missing from
the Millennium Development Goals (MDGs). Inasmuch as the MDGs have become the
consensus agenda for international development, both amongst developing countries and
international donors, to be missing from the list of eight MDGs is effectively to be left off
the development agenda.
Finally, the very strong opposition to the Cairo agenda adopted by the Vatican during and
after the ICPD and by the US administration in 2001 has weakened the consensus in
favor of SRHR. Many developing countries fear to antagonize either Rome or
Washington. For example, while they may not agree with the Bush Administration, they
are reluctant to jeopardize other aspects of the relationship that are important to them.
Taken together, this is a formidable array of obstacles to the full implementation of the
ambitious Cairo agenda and an important cause for concern regarding the future of family
planning. Nonetheless, I am not as pessimistic as this list of concerns might suggest.
* Since the mid-1990s, the Netherlands International Demographic Institute (NIDI) has gathered data on
“population spending” on behalf of the UN Population Fund (UNFPA). The categories of population
spending used by NIDI correspond to the definitions in the ICPD Program of Action: family planning; STD
(including HIV) services; basic reproductive health services; and research, data collection and population
and development policy analysis. Different governments and agencies use differing definitions of these
categories, so the percentages allocated to each dimension of “population spending” are inexact and
somewhat arbitrary.
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Looking ahead
One reason to be optimistic has its roots in this matter of definitions of terms. Many who
think of family planning as the movement that is now at or near its end – especially those
of a demographic turn of mind – bemoan the loss of momentum and the shift in emphasis
from family planning to the broader construct: reproductive health. On the other hand, if
one defines family planning in terms of individuals’ use of birth control, the picture
changes dramatically. This is because, although the large-scale national and international
programs may be languishing or being transformed, the use of contraception by
individuals continues to increase quite steadily. What is changing is where individuals
and couples get their contraceptives. It is very clear from the Demographic and Health
Surveys that as incomes rise and publicly provided family planning services are scaled
back, individuals shift over to commercial or quasi-commercial sources: shops and
pharmacies.
In other words, once people decide to limit or space their childbearing and have become
accustomed to using contraceptives, they usually find ways to secure the supplies they
need. In Asia and Latin America, as incomes have steadily risen over the past 30 years,
individuals have moved away from public and NGO sources of family planning supplies
to commercial sources or social marketing outlets. These are now “contracepting
societies,” if I may use such a term.† To be sure, deficiencies in existing female methods
and the absence of a male alternative to vasectomy and the condom remain important
constraints on effective contraceptive use for many individuals. There are still more than
300 million women who express an unmet need for contraception – women who want to
limit or space births and who know about contraception but are not using it. Some of the
reasons for non-use revolve around supply constraints, but fears about side-effects and
other method-related concerns surely continue to constrain use. A renewed effort to
develop new and improved methods, both male and female and particularly approaches
that exploit new scientific knowledge, are much needed and, I believe, would yield
significant commercial rewards.
While I am reasonably optimistic about the future of private family planning, the
situation in Africa and in some lagging economies elsewhere is not encouraging. In most
of sub-Saharan Africa, contraception has been largely unavailable in most countries
except in the major cities and contraceptive use has been quite low. In a word, except in
† Many sophisticated observers of family planning and SRH programs around the world worry that the loss
of momentum of the movement is causing “plateaus” in contraceptive availability and, consequently, use in
some countries. Examples that are sometimes given are Kenya, Bangladesh and Egypt. I am inclined to
take these concerns very seriously, especially in the near term, and I do believe that a reinvigorated effort to
ensure that strong family planning services are included within a comprehensive health system is much
needed. But I have tried to take a somewhat longer view here, which includes the proposition that once the
demographic transition is well established, as it is in so many countries today, it will continue. The pace at
which it proceeds will depend on a country’s overall living standards and, where living standards are low,
on the availability of free or subsidized services.
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such countries as Botswana, South Africa, Kenya, and Zimbabwe, family planning
programs have never really gotten off the ground. There is little “culture of contraceptive
use” – few “contracepting societies.” It is also important to point out that even in
countries where contraceptive use has advanced rapidly and economic growth has
occurred, growing income inequality within many countries has meant that there remain
many individuals whose incomes do not permit them to shift to commercial sources of
supply. For these people, free or subsidized contraception remains a real need and I worry
that they are precisely the ones being left behind in a world that has largely forgotten
about family planning as a public good and in which there is increasing income
inequality. This is particularly true of Latin America and may become a feature of Indian
development as time goes on.
So, to try to come to a conclusion regarding this aspect, I am reasonably optimistic about
future prospects for contraceptive use and the practice of family planning in every part of
the world except Africa. I really do believe that the “idea of family planning” is now so
firmly established in most countries and regions that there is no going back. The
demographic transition is so far advanced in so many places that the prospect of global
replacement fertility is no longer a distant dream. I think it will happen in our children’s
lifetime – or least our grandchildren’s. And I think whether it is in our children’s lifetime
or our grandchildren’s depends largely on whether the very troubling trend toward greater
income inequality can be reversed. Put differently, replacement fertility will come faster
the better we do in implementing the Millennium Development Goals, and especially the
goal of reducing, and eventually eliminating, poverty.
But the challenge remains very great in Africa. Desired family size remains quite high,
especially in Central and West Africa – the Francophone states. Family planning services
have never been widely available and efforts to expand access have been halting at best.
Poor governance and widespread poverty are endemic in the region, and the AIDS
pandemic has shifted health priorities everywhere away from the rest of reproductive
health. On the other hand, Africa is very rapidly urbanizing – a trend that everywhere has
been associated with declining fertility. Unmet need for contraception is far higher in
Africa than in any other region, showing that good programs are wanted and needed.
Furthermore, carefully conducted experimental research at the Navrongo Health Research
Centre in northern Ghana has shown just as definitively as similar research did in Matlab
thana of Bangladesh a decade earlier that even under conditions of extreme poverty and
low standards of living, well structured reproductive health services do respond to real
demand and can produce significant drops in fertility. As my former colleague Cheikh
Mbacké said, “If family planning can succeed in Navrongo, it can succeed anywhere.”
And succeed it did!
One can only hope that the intense donor focus on the region will eventually begin to lift
Africa out of poverty and into a new era of growth and development. I believe that the
AIDS pandemic notwithstanding, one important element of an African renaissance must
be effective family planning. I do hope that political leaders at both the national and
international levels will recognize this imperative and make sure that family planning is
an important component in future development efforts in Africa.
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One final point while I am on the subject of HIV and AIDS. People today often point to
the parallels between the global preoccupation with rapid population growth in the 1960s
and the preoccupation today with HIV/AIDS, and it is true that both spawned public
health movements that were primarily vertical in approach and extremely well funded.§
To my mind the biggest difference between the two fields is the absence of effective
technologies to prevent the further spread of the pandemic. Family planning had a new
generation of sophisticated technologies – the Pill and the IUD – with which to mount a
campaign to lower birthrates. These and subsequent technological refinements and
discoveries were produced as the result of effective collaboration between the scientific
community, the pharmaceutical industry, and the public sector. There is not yet a
comparable technology to combat HIV infection.
Work on an effective microbicide shows some promise but early enthusiasm about the
prospects of quickly finding an effective compound have faded somewhat. And an
effective vaccine seems even further down the road. To be sure, further advances in
contraceptive technology are needed but I do not think that technology represents nearly
the constraint in family planning that it does in AIDS prevention, although the absence of
male contraceptive methods, other than the condom and sterilization, is still a serious
constraint. One therefore hopes that the AMPPA research will contribute to the
development of an effective male method, or array of methods, to complement the many
gains that have been made in female contraception over the past 50 years.
§ This presentation does not directly address the gulf that has developed between HIV/AIDS and SRH
programs. It is tragic that the two fields have grown so far apart, especially in the last decade. I believe that
truly effective efforts to prevent the further spread of HIV will require that the full resources of the
erstwhile family planning movement be mobilized to assist in the task and that lessons learned by that
movement be applied to HIV prevention efforts, particularly in the areas of behavior change
communication, voluntary counseling and testing, and the prevention of mother-to-child transmission of the
virus.
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