**USAID Policy Paper**

**Population Assistance**

**Bureau for Program and Policy Coordination**

**U.S. Agency for International Development**

**Washington, D.C. 20523**

**September 1982**

**TABLE OF CONTENTS**

Page

Executive Summary

I. Background 2

A. Population Growth in Developing Countries 2

B. Implications for Economic Development 2

C. Family Planning in the LDC Setting 3

D. Factors Influencing Fertility 3

\(1\) Health 3

\(2\) Education 3

\(3\) Income/Employment 4

\(4\) Urbanization 4

E. The Role of Modern Contraception 4

II\. The U.S. Population Assistance Program 4

A. USAID Policy Objectives 4

B. Population Program Assistance Activities 5

C. Specific Policies Governing U.S. Population

Assistance 6

\(1\) Abortion 6

\(2\) Voluntary Sterilization 7

\(3\) Natural Family Planning 7

\(4\) The Relationship between Population and

General Development 8

\(5\) Contraceptives 8

III\. Factors Affecting Policy Implementation 8

A. Host Country Policies 9

B. Private Sector 9

C. Institutional Development 10

D. Technology Transfer 10

IV\. Conclusion 11

V. Annex 11

Executive Summary

Assistance for voluntary population and family planning programs is an
essential part of a cost-­effective program of U.S. development
assis­tance. Continued high rates of population growth significantly
increase the cost and dif­ficulty of achieving basic development
objectives by imposing burdens on economies presently unable to provide
sufficient goods and services for the growing population. Family
planning assistance materially advances social and economic development;
enhances individual freedom to choose voluntarily the number and spacing
of children; and, provides critically im­portant health benefits for
mothers and young children.

Although only one of many challenges confront­ing less developed
countries (LDCs), rapid population growth compounds the already serious
and costly problems faced by LDC public and private sectors. Population
and family plan­ning\' policies and programs alone will not achieve
economic miracles; they must be undertaken in conjunction with other
economic and social measures to promote comprehensive develop­ment.

The need for voluntary family planning has never been greater. In the
next twenty years, the world\'s population is projected to grow by
almost 2 billion, and 90 percent of that growth is expected to occur in
developing countries. There are already hundreds of millions of couples
in the Third World, most of whom do not currently have access to modem
family planning methods, who want smaller, healthier families.
Twenty-­five years ago only a handful of developing countries explicitly
recognized the problems posed by rapid population growth; today over 60
LDCs, containing over three-fourths of the total developing world
population, have adopted policies which address population growth.

USAID\'s experience in countries such as Thailand, Colombia, South
Korea, and Indonesia demonstrates that a balanced program which provides
modern contraceptive services and in­formation, combined with strong
community and family support for family planning, is the most effective
way of helping couples achieve their fertility goals.

The underlying principles of U.S. assistance for family planning are
voluntarism and informed choice. The implementation of USAID assistance
for population activities is governed by legis­lative requirements as
well as USAID policies. Specific legislation prohibits the use of U.S.
government funds for abortion-related activities and requires all
sterilization programs supported by USAID to be shown to be truly
voluntary. U.S. development assistance is not conditioned on the host
government adopting a particular population policy; nevertheless USAID
actively seeks and responds to opportunities for policy discussions on
voluntary family planning. USAID intends to capitalize on the
flexibility and innovativeness of the private sector as an impor­tant
channel for the development and delivery of safe, effective
contraceptives. USAID also stresses the involvement of local
institutions, and sup­ports efforts to strengthen them.

The major focus of the U.S. program is volun­tary family planning service
delivery. The U.S. also supports dissemination of family planning
information and education, including natural family planning; training
for service providers; research on new contraceptive methods and
im­proved delivery systems; and demographic and social science research
and analysis designed both to improve voluntary family planning pro­grams
and to assist LDCs develop and improve their development policies and
programs. U S. population assistance supports the work of private
voluntary and profit-making organiza­tions and universities; multilateral
and interna­tional population agencies; and LDC govern­ments through
bilateral agreements.

**1. Background**

**A. Population Growth in Developing Countries**

The 1982 world population is 4.6 billion and is growing at an increment
of about 78 million an­nually. Ninety percent of this growth is occur­ring
in less developed countries. Indeed, between 1980 and 2000, the number
of women of child bearing age will grow by more than 60 percent or 480
million. The developing world\'s population of about 3.4 billion is
growing at 2.1 percent an­nually; at this rate, it will double in 33
years. By contrast, the population of the developed coun­tries will
double in 116 years at the present rate of increase.

The world\'s rapid population growth is a recent phenomenon. Only
several decades ago, the population of developing countries was
relative­ly stable, the result of a balance between high fer­tility and
high mortality. Life was a high risk proposition. Often, only one in two
children sur­vived infancy and early childhood. Epidemics, debilitating
diseases exacerbated by chronic malnutrition, and extremely poor public
health conditions all made early death an -ever-present threat. Against
these risks, fertility had to be high in order to assure that families
survived. High fertility, far from being a problem, was a necessity.

More recently, developing countries have ex­perienced extraordinary
changes in their societies and economies, and the changes have been, for
the most part, destabilizing ones\--both demographically and socially.
Death rates have dropped dramatically as nutrition has improved and the
major causes of population-wide epi­demics have been brought under
control. Birth rates have also risen in some areas, as the tradi­tional
customs and taboos which tended to space and limit births have been
dropped by the younger generation whose values and prospects differ from
those of their parents. Populations began to expand rapidly as the
traditional short and rather risky life expectancy gave way to one where
the chance of staying alive had never been better.

**B. Implications for Economic Development**

Sustained economic development and the achievement of a decent life for
LDC citizens can only occur when population growth no longer outpaces
economic progress. The factors that can inhibit progress toward
self-sustaining economic

growth as well as frustrate individual and na­tional aspirations include
the following problems associated with high birth rates and rapid
population growth:

· high dependency ratios;

· excessive exploitation of existing resources;

· low levels of household savings and invest­ment which in turn can slow
the development of markets for domestically produced and imported
consumer goods;

· low labor productivity as the labor force ex­pands more rapidly than
the demand for new workers;

· inability to maintain, much less improve, basic services and human
capital investments (health, education, technical training) which not
only can diminish the future productivity of the country but can also
result in both social and political in­stability;

· inability to take advantage of new tech­nologies because the
infrastructure and the finan­cial and human capital necessary to make
effec­tive use of technological advances are lacking.

To speak of the impact of population growth in global terms alone,
however, is to fail to ap­preciate the real impact on individuals,
families and nations. The demographic transition (high to low rates of
population growth) is characterized by unevenness, both between and
within coun­tries. The process of modernization, hastened in some
countries by sound government policies, a vigorous private sector, and
effective develop­ment assistance, has brought with it dramatic changes
in many aspects of public and private life, among them a desire for
smaller families and declining birth rates. In other less developed
countries, or even in remote areas of countries which have enjoyed
substantial economic pro­gress, high fertility and lack of adequate
re­sources may place severe strains on individuals, families and
communities. In such circumstances population growth can inhibit
improvements in living conditions and economic progress; at the same
time, the options open to individuals to plan the number and.spacing of
their children may be circumscribed by lack of family planning
information, education or services or by social and economic conditions
which militate against understanding and effective use of modern fami­ly
planning methods. Finally, especially in poor areas, the health and
nutrition status of women and children is linked to their ability to
regulate their fertility safely and effectively. Maternal mortality
rises with the number of births and infant mortality with births too
closely spaced. Complications of pregnancy are more frequent among women
who are very young or at the end of their reproductive years. While
medical pro­blems are associated with frequent and numerous pregnancies
in all countries, in societies with wide-spread malnutrition and
inadequate health conditions these problems are exacerbated. In turn,
under such conditions, numerous and closely spaced births lead to even
greater malnutrition of mothers and infants.

**C. Family Planning in the LDC Setting**

Developing countries vary considerably, not on­ly in their socioeconomic
settings and the type of infrastructures through which basic services,
in­cluding organized family planning services, may be delivered, but also
in their official policies on population. However, the vast majority of
LDC governments support or accept family planning services, both as a
means of lowering population growth rates and stabilizing the absolute
size of the population, and as a means of improving maternal and child
health through birth-spacing. Presently, over three-fourths of the
people in the developing world live in countries with policies
supporting the provision of voluntary family planning services.

The concept of spacing or limiting births is not new, nor is it Western.
Traditionally, for in­stance in Africa, birth spacing has been ensured by
long periods of abstinence or separation following a birth, and extended
breastfeeding. Abortion and infanticide (or neglect of children leading
to death) have been and continue to be means by which family size is
limited in many places where modem family planning methods are
unavailable. Modem family planning services provide a safe, effective
and humane substitute for traditional methods which are no longer
practicable or are less effective, safe or humane.

Demand for and effective utilization of family planning service tend to
accompany progress in other development sectors. Among the factors that
have been most responsible for the dramatic and rather rapid changes in
attitudes about fami­ly size have been improvements in health, educa­tion,
and employment opportunities (especially for women), and the ubiquitous
phenomenon of urbanization. Additionally, modem family planning
services, where accompanied by information and education about the
concept and methods of birth spacing, contribute to increased demand for
services.

**D. Factors Influencing Fertility**

Demographers agree that four direct biological factors determine
fertility patterns: breastfeeding and lactation patterns, age at which
sexual ac­tivity is initiated, contraceptive utilization and induced
abortion. These determinants control the initiation of sexual activity,
conception following intercourse, or births resulting from conception. A
wide range of social, economic and cultural factors in turn influence
fertility through one of these four \"direct\" determinants. Perhaps the
most significant of these socio­economic or \"indirect\" determinants are
health, female education, employment/income and ur­banization. The
interaction between the direct and indirect determinants of fertility is
complex; however, on-going research and the evidence from field programs
are beginning to offer some rather specific programmatic suggestions.

\(1\) **Health**

One of the reasons for high fertility levels in LDCs is high infant and
child mortality. Tradi­tionally, as discussed above, couples in LDCs
wanted and needed large families. Where 20-30 percent of infants died
before their first birthday, parents chose to have a certain number of
\"in­surance births\" to assure that a critical number of children would
survive to adulthood. As general health conditions improve and infant
mortality declines, the need for insurance births is greatly reduced and
interest in family planning in­creases.[^1] The relationship works the
other way as Well; family planning helps to lengthen the time between
births, which in turn promotes the health and survival of both mother
and infant.

\(2\) **Education**

Education of females appears to have a profound effect on fertility,
especially when girls are able to complete the primary grades. Where
initial improvements in female enrollment result in less than primary
school completion, fertility tends to rise with rising educational
attainment. Although the pattern varies greatly from country to country
and region to region, and exceptions can be cited, it appears generally
to be the case that where additional schooling takes girls beyond
primary school, fertility tends to fall as education rises. As women
become better educated, enter the wage economy, and have some measure of
control over their earnings, their role in the family and the community
changes. Education broadens women\'s horizons and predisposes them to
accept new ways and ideas. Preference for smaller families, use of
family planning, and later marriage all appear to be more acceptable to
women who have been educated beyond the primary level, and all are
correlated with lower fertility.

On the other hand, the prospects for education and training of women and
girls can often be thwarted by their own fertility. Delay of
childbearing either through postponement of marriage or the birth of the
first child can allow girls the chance to complete higher education or
training. And, with a smaller family size there is less need for girls
to stay out of school to care for younger siblings.

\(3\) **Income/Employment**

Employment of women, especially outside the home, increases the
opportunity costs of raising children, makes a smaller family a more
attrac­tive option, and heightens interest in the use of family planning
to achieve the desired family size. The role of income *per se* in
bringing birth rates down is less well understood. As aggregate income
rises initially so does fertility, but with further increases in income
the trend reverses, and fertility begins to drop. The threshold at which
the trend reverses varies from country to country, and unfortunately has
not been well defined.

\(4\) **Urbanization**

Urbanization brings with it more education, higher net costs of
children, lower infant mortali­ty, greater access to modern sector
employment for women, and easier access to contraceptives. The result is
a consistently lower incidence of births among urban women, who have
roughly 25 percent fewer children on average than do women in rural
areas. Probably the most signifi­cant difference between urban and rural
women is their use of contraceptives. Contraceptive use is a function
both of the desire to space births or limit family size and the
availability of and ac­cess to appropriate modern methods of family
planning. In urban settings those factors affect­ing demand for, as well
as supply of, modem contraceptives are likely to encourage voluntary
family planning.

**E. The Role of Modern Contraception**

Of the four \"direct\" determinants mentioned above, contraceptive use
has the greatest poten­tial impact on fertility; indeed, in the absence
of modern family planning services, some socio­economic changes (e.g.,
improved child health and changing patterns of breastfeeding) may
ac­tually lead to higher birth rates. In short, modem contraceptives
provide the means by which in­dividual couples can achieve their desired
family size most effectively, safely, and humanely.

Existing demand for modem family planning ser­vices is not currently
being met by programs in the developing world. World Fertility Survey
data from 29 countries indicate that 48 percent of married women 49
years of age want no more children. A study of 18 of those countries
sug­gests that the average birth rate of 32.3 per 1000 would drop to 23.5
births per 1000 population if all unwanted births were prevented. To
sum­marize, existing demand for family planning ser­vices is great and is
likely to become greater as development brings about improvements in
socioeconomic conditions throughout the developing world.

**II. The U.S. Population Assistance Pro­gram**

**A. USAID Policy Objectives**

Family planning programs are an essential ele­ment of the U.S.
development assistance strategy, and this Administration has reaffirmed
a 20-year U.S. commitment to voluntary family planning efforts. The
objective of the USAID ­population assistance program is twofold: (1) to
enhance the freedom of individuals in LDCs to choose voluntarily the
number and spacing of their children; and (2) to encourage population
growth consistent with the growth of economic resources and
productivity.[^2] The two parts of this objective are reciprocal. The
ability to deter­mine freely the number and spacing of one\'s children
allows the individual greater potential to take advantage of
opportunities for improving skills, seeking employment and increasing
in­come. Experience has shown that when couples can freely determine the
number and spacing of their children, they tend to have smaller families
and population growth rates tend to decline. Fur­ther, when aggregate
national wealth and population are in balance, individual families tend
to have better prospects for education, employment and health. Such
increased op­portunities and improvements in the standard of living tend
to raise individual and family aspira­tions, and couples tend to prefer
to have fewer children whom they can educate and care for well, rather
than many to whom they cannot of­fer these advantages.

The basic premises of U.S. population assistance are the following:

· individuals and couples should be able to decide freely the size of
their families; 0 voluntary family planning programs are needed and
wanted by the citizens of the Third World;

· it is in line with U.S. strategic as well as humanitarian interests to
help LDC governments achieve economic development, and to support their
citizens\' efforts to attain a better life for themselves and their
children;

· sustained economic development and the achievement of a decent life
for all LDC citizens can only occur when population growth no longer
outpaces economic progress;

· the impact of development resources is max­imized through coordination
of policies and pro­grams that broaden access to education and
employment, especially for women, with the provision of modern family
planning services; and

· the U.S. has unique strengths in this area of in­ternational
development assistance.

USAID support for family planning service pro­grams is based on two
fundamental principles: voluntarism and informed choice. USAID does not
support programs in which there is any ele­ment of coercion of
individuals to practice family planning or to accept any particular
method of contraception. In fact, A .1. D. supported pro­grams must
include a description of the effec­tiveness and risks of all major
methods of family planning and an agreement either to provide other
family planning methods if requested or to refer couples to programs
offering other methods as appropriate. USAID supports the provision of
family planning methods within the medical and cultural context of each
particular country.

**B. Population Program Assistance Activities**

The Agency for International Development has traditionally played a
strong role in supporting population programs, consistently leading
bilateral and multilateral donors in program in­itiatives and in funding.
USAID\'s cumulative population assistance since the mid-1960\'s ex­ceeds
\$2 billion, and constitutes about half of all population assistance
provided to the developing world. On an annual basis, it is estimated
that donor assistance and host country government (excluding China)
expenditures for population programs total something over one billion
dollars. For the past several years, USAIDs population account has
represented about 20 percent of these aggregate budgets.

USAIDs allocation of population funds reflects Agency priorities in the
population sector. Voluntary family planning service delivery and
related supplies form the heart of the program and consistently absorb
the greatest proportion of population assistance. Support for service
delivery systems includes: commodities, training for physicians,
paramedicals and fieldworkers and technical assistance in the design and
im­provement of services. Innovative field oriented research to improve
existing delivery systems and to develop new \"outreach\" programs for
delivering family planning and health services that are less expensive
and more appealing are also important USAID supported activities.

USAID has led the way among donors in developing and disseminating the
most widely used high quality contraceptive methods in the world today;
the U.S. will continue to support the development of promising new
contraceptive methods and improvement of existing methods, as well as
research on the safety and effectiveness of contraceptives under actual
conditions in developing countries.

Accompanying the provision of services is dissemination of information
and education on family planning and population, both for in­dividual
users and also for government policy makers. Where requested by
governments, the U.S. provides technical assistance to help analyze
government policies which may affect the availability of, and the demand
for, family planning services, as well as to analyze the impact of rapid
population growth on other development sectors, such as food, health and
energy.

The U.S. population assistance program does not operate in isolation
from our other development efforts, but takes into account the linkages
be­tween population, health, nutrition, education, employment and
agricultural productivity. USAID has led the way in developing and
apply­ing new ways to measure program impact and the degree to which
fertility and the use of family planning services is influenced by
women\'s education and employment opportunities, child health and other
social and economic conditions. Based on our knowledge of the
relationship be­tween population and other development fac­tors, we seek
to make our total development strategy for each country one in which the
objec­tives and activities in all areas, including popula­tion are
mutually reinforcing.

Successful family planning programs tend to occur in countries where
there is a strong commit­ment by the host government, an infrastructure
with the capacity to deliver services throughout the country, and social
and cultural acceptance of the concept of family planning. The largest
share of U.S. population assistance is directed to countries where these
three conditions exist. In countries, notably but not exclusively in
Africa where awareness of the impact of rapid popula­tion growth on
sustained economic development and of the need and demand for modem
family planning services is more recent, USAID works closely with host
governments and private organizations to help them analyze and
strengthen their policies and programs. Where infrastructures are weak
or inadequate, USAID supports activities to strengthen local service
delivery institutions and also works with the private sector.

In recent years, USAID has increased the propor­tion of population funds
allocated to bilateral family planning programs, reflecting not only the
Agency\'s commitment to integrate family planning programs into overall
country develop­ment assistance programs, but also the growing interest
of LDC governments to collaborate with the U.S. in developing strong
national family planning programs.

Among USAID\'s major strengths in assisting LDC population program
efforts are its strong field presence and its early and sustained
leadership in developing innovative approaches to low-cost service
delivery that are responsive to particular country requirements. USAID
has also been a leader because of its strong analytical orienta­tion,
whether in the testing of outreach systems for delivery of family
planning services, in analysis and interpretation of survey findings to
measure program impacts, in biomedical re­search or in developing overall
family planning strategies. The very size of the U.S. supported family
planning effort is also one of its strengths; the U.S. provides about
half of the Development Assistance Committee (DAC) assistance for
population and is the principal donor to the United Nations Fund for
Population Activities (UNFPA) and the private intermediaries. This
preeminence gives the U.S. a unique voice in en­couraging high quality
voluntary family planning services for interested couples throughout the
world. USAID\'s population program in the 19 is rooted in this highly
successful past.

**C. Specific Policies Governing U.S.**

**Population Assistance**

Beyond the fundamental principles of volun­tarism and informed choice
upon which U.S. population assistance is based, specific legislative
requirements and USAID policies govern assis­tance under this account.

\(1\) **Abortion**

In accordance with authorizing legislation adopted in 1974, USAID must
not provide sup­port for abortion services or a number of other
abortion-related activates, such as the provision of abortion equipment,
or the motivation of per­sons to practice abortion. In January, 1981,
USAID discontinued funding of research on methods of abortion as a means
of family plan­ning. Funding of all such research was terminated in 1981,
although USAID continues to other descriptive epidemiological data to
assess the incidence, extent or adverse consequences of abortion.

All USAID funded population contracts and grant agreements with private
and voluntary organizations (PVOs) and with host govern­ments incorporate
language to prohibit use of USAID funds for abortion-related activities;
PVO subgrant agreements also incorporate such pro­hibitions.

Such prohibitions include:

· Procurement or distribution of equipment in­tended to be used for the
purpose of inducing abortion as a method of-family planning.

· Procurement or distribution of Menstrual Regulation (MR) kits.

· Special fees or incentives to women to coerce .or motivate them to
have abortions.

· Payments to persons to perform abortions or MR procedures or to
solicit persons to undergo abortions or MR procedures as a means of
family planning.

· Information, education, lobbying, training or communication programs
that seek to promote abortion as a method of family planning.

· Funding of biomedical research which relates to methods of abortion as
a method of family planning.

· Training of individuals for the performance of abortion as a means of
family planning.

\(2\) **Voluntary Sterilization**

Section 104(f) of the Foreign Assistance Act enacted in 1978 prohibits
the use of U.S. funds *for involuntary* sterilization. It states:

None of the funds made available to carry out this pan May be used to
pay for the performance of in­voluntary sterilizations as a method of
family plan­ning or to coerce or provide any financial incentive to any
person to undergo sterilization.

USAID Policy[^3] governing the use of Agency funds for sterilization
provides that USAID funds can only be used to support voluntary
steriliza­tion activities if the following six conditions are met:

1\) *Fully Informed Consent.* An explanation must be made to the client
in his or her own language of the nature of the procedure, its risks and
benefits, and its irreversibility. The client\'s witnessed signature or
mark is re­quired on the consent document, which must be retained for
three years.

2\) *Availability of Other Methods.* Other family planning methods must
be readily available to insure that the client has a free choice of
approved methods.

3\) *Incentive Payments.* No USAID funds can be used to induce clients
to accept voluntary sterilization, also the cost of the procedure must
be such that it does not favor voluntary sterilization over other
methods.

4\) *Quality of Services.* The medical personnel must lie well trained
and the surgical equipment should be the best available that is suitable
to the field situations in which it will be used.

5\) *Integration with Health.* To the fullest possi­ble extent, voluntary
sterilization programs shall be conducted as an integral part of the
total health care services of the recipient country and shall be
performed with respect to the overall health and well-being of the
prospective acceptors.

6\) *Country Policies.* USAID funded sterilization programs should be
carried out in full cooperation with host country officials, and
particular care must be exercised to avoid undue emphasis on any ethnic,
political or religious minority.

Regulations setting out requirements for inform­ed consent are included
as part of all grants, con­tracts and subordinate agreements between
USAID and implementing organizations. Adherence to these guidelines and
regulations is constantly monitored by USAID to insure full compliance.

\(3\) **Natural Family Planning**

In 1981, Section 104(b) of the Foreign Assistance Act was amended to
ensure that information and services relating to natural family planning
(NFP) methods be included among the popula­tion activities supported by
USAID USAID mis­sions have been informed of this legislative amendment
and of USAID\'s intention to see that natural family planning methods,
defined to include all those methods which rely on periodic abstinence,
are integrated into all relevant forms of population assistance,
including research, training, service delivery and information pro­grams,
wherever this is appropriate to the culture and desires of the recipient
population and its government.

Although natural family planning itself is not a new concept, it has
received increased attention and interest in the last decade. USAID
missions should continue to explore ways of encouraging the inclusion of
natural family planning ap­proaches within the programs of public and
private family planning agencies working in the country. USAID policy
governing the funding of natural family planning activities is based on
the same principles of voluntarism and informed choice which govern
activities related to other methods of family planning. USAID gives
preference in its funding to programs which provide a wide range of
choices in family planning methods (excluding abortion) and strongly
en­courages such programs to include information and/or services related
to methods of natural family planning. All USAID supported popula­tion
programs must demonstrate that they are free of coercion regarding not
only the practice of family planning, but also the choice of a
par­ticular family planning method.

\(4\) **The Relationship Between Population and General Development**

Recognition of the reciprocal links between fer­tility and other aspects
of development led Con­gress to amend the Foreign Assistance Act to
in­clude Section 104(d). This section states that:

\(1\) Assistance under this chapter shall be administered so as to give
particular attention to the interrelationship between (a) population
growth, and (b) develop­ment and overall improvement in living standards
in developing countries, and to the impact of all pro­grams, projects,
and activities on population growth.

Implementation of 104(d) requires USAID to maximize the impact of scarce
development resources, not only by avoiding support to development
programs that appear to work at cross-purposes, but also by building
upon what is known about the links between social and economic progress
and fertility decline. USAID has interpreted 104(d) as a mandate to work
for improvements in the socioeconomic setting within which voluntary
family planning services are provided, (an important development goal in
its own right) in order to support parents\' grow­ing interest in smaller
families as well as their ability to utilize modern, effective
contraceptives to achieve their desired family size. In imple­menting
this mandate, USAID does not seek to tie assistance to fertility
reductions, but rather to coordinate development activities and the
availability of family planning services so that they are mutually
reinforcing.

\(5\) **Contraceptives**

It is USAID\'s general practice to provide to other countries only those
contraceptives approved by the Food and Drug Administration for use in
the U. S.

**III. Factors Affecting Policy Implementation**

Constraints to the achievement of population assistance policy
objectives include:

· weak or inconsistent government policies;

· regulations which inhibit efficient distribution of contraceptives;

· inadequate infrastructures for service delivery; and

· social and economic conditions, e.g., poor health, low educational
levels, and low income levels, especially for women, which militate
against the acceptance or effective use of modern family planning
methods.

There are a variety of government policies and socioeconomic changes
which often tend to en­courage (or at least not discourage) high
fertility; for example, the breakdown of traditional prac­tices which
have served to ensure child spacing; protective labor legislation making
it more difficult for women to work; the lack of regulations

prohibiting child labor; the settlement of nomadic people; and the trend
away from prolonged breastfeeding (one of the most important traditional
means of postponing the next pregnancy) to intermittent breastfeeding
and early weaning. There are also a variety of socio­economic changes
which are associated with higher fertility in their early stages,
although over the long term they are associated with smaller families
(increased female education, improved health and increased family
income, for example).

Most LDCs, often with U.S. or other donor assistance, are currently
investing heavily in development activities in a number of sectors; most
LDCs also have stated policies to reduce population growth. However,
often there is little attention to integrating or coordinating these
development programs and policies so as to max­imize their combined
impact. For instance, in some countries, family planning services are
vir­tually unavailable outside the major cities; at the same time,
governments are investing in family income generation and education
programs in rural areas- programs that are likely to foster couples\'
interest in limiting family size and thereby increase the demand for
modem family planning services. In many areas, family plan­ning services
have not been integrated with ex­isting maternal/ child health programs,
although the former is a critical factor in improving health status in
most LDCs.

Where the constraints to acceptance or effective use of modem
contraception are rooted in the lack of improvement in basic living
conditions and economic opportunities, USAID is careful to coordinate
its development activities in other sectors with its support for family
planning programs so that the two are mutually reinforcing. USAID also
works with LDC countries to help them analyze and strengthen their
policies, which may in some cases include modification of regulations
that inhibit contraceptive distribu­tion, and in others focus on improved
maternal and child health or education opportunities for females. Where
infrastructures are weak or in­adequate, USAID supports institutional
develop­ment activities or works with the private sector which often has
more efficient channels for delivery of services than the government.
The major priority emphases of the Agency -an ex­panded role for
government-to-government discussions on country policies, the private
sec­tor, institutional development, and technology transfer-are
particularly relevant to overcom­ing major constraints to successful
implemen­tation of U.S. and LDC population policy objectives.

**A. Host Country Policies**

USAID\'s experience has been that family plan­ning programs are most
successful where govern­ments support strong service delivery systems,
are committed to curbing excessive population growth through provision
of voluntary family planning services, and where this commitment is
translated into a clear population policy, backed by policies stressing
improved education, health and employment opportunities, especially for
women. In countries where continued high population growth rates appear
to be eroding economic development, A. 1. D. includes this fac­tor in its
policy discussions with the government. While the U.S. does not and will
not make development assistance conditional on the host government
adopting a particular population policy, USAID will continue to seek and
respond to opportunities for policy-level discussions on voluntary
family planning. Indeed, many of the family planning program
\"successes\" in Asia and Latin America involved not only substantial
bilateral support for expansion of quality family planning services, but
also a continuing official dialogue on the policy and institutional
reforms needed to improve the quality and coverage of the programs.
USAID\'s application of Section 104(d) of the FAA is an important
element in ongoing discussions on population and develop­ment policies.
In addition, A. 1. D. will continue to sponsor the development and use
of a variety of tools for analyzing and demonstrating the im­pact of
rapid population growth on economic progress, making these programs
available to interested LDC governments as they examine the full range
of their development objectives, pro­grams and problems.

**B. Private Sector**

In most countries, the distribution of contracep­tives began through the
private sector: private physicians prescribed contraceptives for their
pa­tients; some methods of family planning were available over the
counter; and private volun­tary organizations offered services, most
often in urban areas. The private sector has acted as an important
\"supply side\" force, responding to demands for services and also
demonstrating to the government how efficient contraceptive distribution
systems could be implemented. After governments begin to provide
services, there remains a mix (which varies by country) of public and
private sector delivery systems. In a number of countries, the
government relies on the private sector to provide all or a large
pro­portion of the services available.

Over the past several years, A. 1. D. support to private voluntary
organizations has amounted to roughly one-third of the population
assistance program - This support is channeled for the most part through
large U.S. based or international in­termediaries that implement programs
in LDCs through or in collaboration with local organiza­tions.

Family planning service delivery, whether private or public, has
typically involved clinic-­based physician-oriented services. Although
ef­fective, such programs are costly and often biased toward urban
consumers. In an effort to reach the rural population, and the poor in
par­ticular, modified programs have been developed to meet the needs and
circumstances of isolated areas. Increasing the number of distribution
points and types of contraceptive methods of­fered is critical to
expanding the accessibility of services. In an attempt to increase
services and stimulate greater private sector involvement in the
delivery of family planning USAID is placing greater emphasis on
community based distribu­tion involving paraprofessional and volunteer
personnel. Additionally, in many developing countries, USAID supports
commercial retail sales (CRS) programs under which family plann­ing is
delivered through the commercial sector. USAID will stress the need for
family planning delivery systems to become less dependent on ex­ternal
resources, by systematically encouraging greater local fundraising,
voluntarism and com­munity participation, fee-for-services, and im­proved
management efficiencies in all programs. The Agency will also support
efforts by U.S. private firms involved in the manufacture and
distribution of contraceptives to promote similar development in LDCs.
To the extent practicable, the methods, research, and experiences of
such firms should be adapted and utilized in develop­ing countries.

**C. Institutional Development**

Strengthening and fostering the direct involve­ment of local institutions
in the development process will continue to be actively pursued under
the USAID population assistance program. Both public and private
institutions are involved in the delivery of family planning services in
LDCs. The magnitude of effort needed to make services available to all
individuals who want them, and the inadequacy of infrastructures to
deliver such services in the majority of countries, point to the
importance of strengthening a vari­ety of types of local institutions
which are or could be effective service providers.

Appropriate institutions range from local women\'s groups, to private
family planning associations, to Ministries of Health. In many countries
it is important to have family planning services included as part of
government maternal and child health (MCH) services, due to the real as
well as perceived links between MCH and the spacing or limiting of
births. Increased effort is also being directed to the involvement of
local community organizations in the delivery of ser­vices as well as in
the dissemination of information and education about both the concept of
family planning and contraceptive methods. The mobilization of community
resources (labor, materials, money, leadership) as a contribution to
government-financed or private sector pro­jects is an important means of
encouraging com­munity interest in a service, as well as fostering
initiative and building local management capabilities.

The population assistance program seeks not only to involve local
institutions in service delivery, but also to build or strengthen the
capacity of local demographic and social science research institutions,
government units responsible for policy analysis and development,
train­ing institutions, and systems through which in­formation, education,
and communications about family planning reach potential clients.

The effectiveness of local organizations depends on such things as sound
allocation and use of resources; quality of leadership; clarity of
ar­ticulated goals and programs; and flexibility in implementation of
programs. Improving organizational effectiveness may require changes in
structure and function, in management systems, or in people\'s knowledge
and skills. For this reason, greater attention must be given to building
management and skills-training capacities into local organizations.

While it is generally understood that public policies affect the success
of development efforts, less well understood are the ways in which
government policies may handicap the effec­tiveness of local
institutions. For instance, govern­ment policies may regulate the import
and/or distribution of contraceptive supplies, fix prices at levels that
militate against cost recovery, or define, in a limiting way, the role
and functions of a private organization.

**D. Technology Transfer**

One of the strengths of the U.S. population assistance program has been
the transfer of U.S. scientific and technological know-how to LDCs
implementing family planning programs. The U.S. has led the way in
developing, testing and disseminating the most widely used
contracep­tives and family planning delivery systems. USAID is increasing
the amount of its support for the development of promising new
contraceptive methods and for research on the safety and effec­tiveness
of contraceptives tested under actual LDC conditions. In addition to the
transfer of technology directly applicable to the delivery of
contraceptives, USAID has sponsored the development and dissemination of
a variety of technologies for analyzing and demonstrating the impact of
rapid population growth on economic progress, making these tools
available to LDC governments as they examine their ­policy and program
goals. Demand from LDCs for technologies developed by the U.S. continues
to be high. Our ability to transfer technology ap­propriate to various
country needs has given the U.S. a longstanding leadership role in this
field.

**IV. Conclusion**

Population Assistance will continue to be an essential element of U.S.
development assistance. The content and direction of the U.S. program is
guided by a number of factors:

· the commitment to helping LDCs achieve self-­sustaining economic
growth;

· the belief that individuals and couples should be able to decide
freely the size of their families;

· the conviction that sustained economic de­velopment and the achievement
of a decent life for all LDC citizens can only occur when popula­tion
growth no longer outpaces economic pro­gress;

· the evidence that voluntary family planning programs are needed and
wanted by citizens of the developing world;

· the belief that it is in line with U.S. strategic as well as
humanitarian interests to help LDC governments achieve national economic
goals, and to support the efforts of their citizens for a better life
for themselves and their children; and

· the growing evidence that the U.S. has unique strengths in this area
of International develop­ment assistance.

Strengthening and fostering the direct involve­ment of local institutions
in the development process will continue to be actively pursued under
the USAID population assistance program. USAID will capitalize on the
flexibility and in­novativeness of the private sector in the search for
new and better ways to make safe, effective and acceptable
contraceptives widely available. There will be increased attention to
the needs and interests of the consumer of the services, so that the
services will meet, to the fullest extent possi­ble, the cultural
preferences of both current and potential users. Finally, USAID will
strew in its programming the integration of family planning services
with health and other development activities.

**V. Annex**

**PD-3 (September 1982)** *(Formerly PD-70 June 14, 1977)*

**USAID Policy Guidelines on Voluntary Sterilization**

**1. Overview**

*The World Population Plan of Action* of the World Population Conference
of 1974 observed that; \"All couples and individuals have the basic
right to decide freely and responsibly the number and spacing of their
children, and to have the in­formation, education and means to do
so\....\"

The Foreign Assistance Act (FAA) of 1961 (as amended) reflects
additional considerations:

\(1\) the process of economic and social develop­ment which is in turn
affected by the pace, magnitude and direction of population growth; and,

\(2\) in many LDCs high rates of population growth limit attainment of
broader development goals, contribute to economic hardship and hazardous
health conditions, and deny op­portunities for improved quality of life
for many parents and their children.

In carrying out a comprehensive population assistance program
*authorized by the FAA,* USAID has responded to the growing num­ber of
LDC requests for assistance and has helped to make the various methods
of family planning permitted by our legislation available on a broader
scale to the rural and urban population for use on a strictly voluntary
basis.

More recently, LDC governments and non­government organizations have
requested assistance to extend the availability of voluntary
sterilization (VS) services.[^4] Such requests are partially in response
to the preparatory work conducted by various organizations which have
received USAID support, including the Associa­tion for Voluntary
Sterilization (AVS), the Pathfinder Fund, the International Fertility
Research Program (IFRP), and the Johns Hopkins University Program for
International Education in Gynecology and Obstetrics (PIEGO) as part of
its broad program of ad­vanced training in obstetrics and gynecology.
These organizations have contributed to significant advances in the
development of new surgical techniques which make sterilization safer,
simpler and less expensive as an outpatient procedure. They have
developed specialized equipment and given LDC medical personnel
specialized training in the practice of obstetrics and gynecology,
including endocrinology, iden­tification of cancerous conditions,
maternal care, and the management of infertility and fertility,
including sterilization procedures.

In providing support for sterilization services, USAID must reaffirm its
long-standing and com­plete commitment to the basic principle of
volun­tary acceptance of family planning methods and determine basic
conditions and safeguards within which USAID support for sterilization
activities can be provided. These conditions and safe- ­guards are needed
because of the special nature of sterilization as a highly personal,
permanent surgical procedure and to ensure that the needs and rights of
individuals are scrupulously pro­tected.

The official positions of national governments are mixed. While
voluntary sterilization has become a basic part of comprehensive family
planning services in many countries, in some there is only unofficial
approval for action by non-government agencies while in other coun­tries
there is opposition to the method. A.I.D ­staff and USAID-funded grantees
and contractors must be fully aware of national sensitivities and must
receive USAID/W and mission approval before making any commitments on
commenc­ing support for sterilization activities in any context.

**II. General Guidelines**

USAID acknowledges that each host country is free to determine its own
policies and practices concerning the provision of sterilization
services. However, USAID support for VS program ac­tivities can be
provided only if they comply with these guidelines in every respect.

A. **Informed Consent**: USAIDassistance to VS service programs shall be
contingent on satisfac­tory determination by the USAID (bilateral
pro­grams) and/or USAID-funded grantees or con­tractors that surgical
sterilization procedures, supported in whole or in part by USAID funds,
are performed only after the individual has voluntarily Presented
himself or herself at the treatment facility and given his or her
informed consent to the sterilization procedure.

Informed consent means the voluntary, knowing assent from the individual
after he or she has been advised of the surgical procedures to be
fol­lowed, the attendant discomforts and possible risks, the benefits to
be expected, the availability of alternative methods of family planning,
the purpose of the operation and its irreversibility, and his or her
option to withdraw consent anytime prior to the operation. An
individual\'s consent is considered voluntary if it is based upon the
exercise of free choice and is not ob­tained by any special inducements
or any ele­ment of force, fraud, deceit, duress or other forms of
coercion or misrepresentation.

Further, the recipient of USAID funds used all or in part for
performance of all procedures must be compared to document the
patient\'s informed consent by (a) a written consent document in a
language the patient understands and speaks, which explains the basic
elements of informed consent, as set out above, and which is signed by
the individual and by the attending physician or by the authorized
assistant of the attending physician or (b) when a patient is unable to
read adequately a written certification by the atten­ding physician or by
the authorized assistant of the attending physician that the basic
elements of informed consent were orally presented to the patient, and
that the patient thereafter consented to the performance of the
operation. The receipt of the oral explanation shall be acknowledged by
the patient\'s mark on the certification and by the signature or mark of
a witness who shall be of the same sex and speak the same language as
the patient.

Copies of these informed consent forms and cer­tification documents for
each VS procedure must be retained by the operating medical facility, or
by the host government, for a period of three years after performance of
the sterilization procedure.

USAID Missions should note their responsibility to monitor
USAID-assisted VS programs-whether such programs are funded bilaterally
or by USAID-funded grantees or contractors- to en­sure continuing
adherence to the principle of in­formed consent. In order to carry out
this monitoring function effectively, all proposed programs-either
bilaterally funded or funded by USAID-supported intermediaries-shall be
approved by the mission and USAID/W prior to any commitment of funds or
promise to commit funds for VS activities. In carrying out this
responsibility, USAID staff should be thor­oughly familiar with local
circumstances and government administrative patterns and be able to
communicate effectively with host country representatives.

**B. Ready Access to Other Methods:** Where VS services are made
available, other means of fam­ily planning should also be readily
available at a common location, thus enabling a choice on the part of
the acceptor.

**C. Incentive Payments:** No USAID funds can be used to pay potential
acceptors of sterilization to induce their acceptance of VS. Further,
the fee or patient cost structure applied to VS and other contraceptive
services shall be established in such a way that no financial incentive
is created for sterilization over another method.

**D. Quality of VS Services:** Medical personnel who operate on
sterilization patients must be well-trained and qualified in accordance
with local medical standards. Equipment provided will be the best
available and suitable to the field situations in which it will be used.

**E. Sterilization and Health Services:** To the fullest possible
extent, VS programs-whether bilaterally funded or conducted by USAID
funded private organizations- shall be con­ducted as an integral part of
the total health care services of the recipient country and shall be
per­formed with respect to the overall health and well-being of
prospective acceptors. In addition, opportunities for extending health
care to par­ticipants in VS programs should be exploited to the fullest.
Consideration must also be given to the impact that expanded VS services
might have on existing general health services of the recipient country
with regard to the employment of physi­cians and related medical
personnel and the use of buildings or facilities.

**F. Country Policies:** In the absence of a stated affirmative policy
or explicit acceptance of USAID support for VS activities, USAIDs should
take appropriate precautions through consulta­tion with host country
officials in order to minimize the prospect of misunderstandings
con­cerning potential VS activities. In monitoring the consistency of
USAID-supported VS programs with local policy and practices, USAIDs and
USAID-funded donor agencies shall also take particular note of program
activities among cultural, ethnic, religious or political minorities to
ensure that the principles of informed consent discussed under \"A\"
above are being observed and that undue emphasis is not given to such
minority groups.

**Addendum to PD-3** *(formerly Addendum to PD-70, 2/9/81)*

**Additional A.I.D Program Guidance for Voluntary Sterilization (VS)
Activities**

1\. INTRODUCTION: The previously provided Policy Determination No. 3
(PD-3), remains in effect. However, in light of several years
ex­perience, additional clarification of a number of points relating to
the application of PD-3 and specific interpretation of its provisions
appears to be needed.

2\. APPLICABILITY OF PD-3: PD-3 states \"USAID support for VS program
activities can be provided only if they comply with these guidelines in
every respect\". This means that the provisions of PD-3 must be applied
if USAID funds are used for whole or partial direct support of the
performance of VS activities. However, as also noted in PD-3, \"USAID
acknowledges that each host country is free to determine its own
policies and practices concerning the provision of sterilization
services\". The provisions of PD-3 do not apply if USAID provides
support for popula­tion and family planning programs within a country and
provision of VS services is not called for in the support agreement,
i.e., VS activities may be a part of the host country\'s program, but
USAID funds are not used to support such ser­vices. For example, if USAID
support for VS pro­gram activities is geographically confined to
par­ticular parts of a.country, PD-3 applies only to those areas with VS
program activities supported by USAID PD-3 does not apply if activities
and projects are only peripherally related to provi­sion of VS services,
for example, USAID support for construction of multipurpose buildings or
broad-based training in reproductive health which includes VS
techniques. Finally, in USAID supported population and family planning
pro­grams in host countries which use USAID funds for activities other
than VS and support VS ac­tivities; with their own or other non-USAID
funds, PD-3 does not apply.

3\. INFORMED CONSENT: The recipient of A.1 -D support used fully or in
part for per­formance of VS procedures must obtain and document voluntary
informed consent as part of the conduct of any VS procedure. USAID does
not require any specific format for this pro­cedure. However, the
elements of the procedure described in PD-3 (i.e., an explanation of the
nature of the procedure, the attendant risks and benefits, availability
of alternative methods of family planning, that the procedure is
irreversi­ble, and that the patient may withdraw consent) all must be
part of the process of obtaining in­formed consent.

4\. METHODS OF PAYMENT: All acceptor and/or provider payments in cash or
kind beyond VS service costs as well as fees charged for VS and other
contraceptive services shall be established in such a way that no
financial incen­tive is created for sterilization over another
con­traceptive method.

**(A) Payment of Acceptors:** It should be noted that guidance differs
for payments which may be made to acceptors of VS as contrasted to
pay­ment to providers of VS (guidance applicable to providers of VS
services is described in para 4.B. below). As stated in PD-3, para C,
\"no USAID funds can be used to pay potential acceptors of sterilization
to induce their acceptance of VS\". Further, USAID support generally
cannot be pro­vided to VS services which include incentive payments paid
to potential acceptors. For exam­ple, a VS program supported by USAID
cannot be supplemented with acceptor incentives to in­duce acceptance of
sterilization services. Deter­mination of what constitutes an incentive
must be made locally based on thorough knowledge of social and economic
circumstances of potential acceptors. In general, recompense to
acceptors for legitimate, extra expenses related to VS pro­gram services
such as transportation, food dur­ing confinement, medicines, surgically
related garments and dressings and the value of lost work are not
considered incentive payments and are eligible for USAID support. It
should be emphasized that these payments must be of a reasonable nature
and aimed at making VS ser­vices equally available at the same cost as
other contraceptive services. For example, payment for lost work must
correspond to a reasonable estimate of the value of lost labor over a
reasonable duration of convalescence.

**(B) Payment of Providers of Services:** In light of experience, it
seems desirable to modify the previous USAID program guidance relating
to reimbursement for VS services as defined in USAIDTO Circular 393
(10/27/77), page 6, section 3, \"operating service costs\", para. 4. The
sug­gested prohibition of reimbursement to providers of VS services on a
per-case basis has not proven practical in that payment per case or
procedure is the time honored method of paying for surgical procedures
both in developed and less developed countries. Reimbursement of
physicians, paramedical and other service personnel on a per-case basis
can be an acceptable procedure. Compensation to providers for items such
as anesthesia, personnel costs, pre and post­operative care,
transportation, surgical and ad­ministrative supplies, etc., on a
per-case basis is also generally acceptable. These payments to providers
must be reasonable relative to other medical and contraceptive services
provided so that no financial incentive is created for the pro­viders to
carry out VS procedures compared to provision in other methods of family
planning. As in the of payments to acceptors, this is a judgment which
will have to be made on a country and program specific basis. However,
in both cases, USAID in Washington will provide assistance and guidance
in making such determinations, and decisions relating to application of
PD-3 should be submitted to USAID/ Washington for review. Even though
payment on a per-case basis is often customary, USAID Missions are
advised to encourage patterns of service delivery and methods of payment
which do not unduly em­phasize VS procedures compared to other methods of
fertility control. For example, if physicians who carry out the surgery
are paid on a per-case basis and they have no role in the selection or
counseling of patients, these service providers cannot induce additional
patients to accept sterilizations over other contraceptive methods.
Payments of physicians on a per­session rather than a per-case basis may
also serve the same function. Since payments on a per-case basis do
raise questions, often of a com­plex nature, beyond those raised by other
types of compensation, where a mission can persuade a government to use
such other frameworks for payment, whether immediately or phased-in, it
should do so.

**(C) Payment of Referral Agents:** In some coun­tries fieldworkers are
employed to inform and refer potential acceptors of contraceptive
methods including VS. When extra expenses are incurred in informing and
referring VS accep­tors, a per-case payment of these costs is accep­table.
Again, as is the case with payments to pro­viders and/or acceptors, a
country or program specific determination that the payment is for
legitimate extra expenses or activities associated with VS referral must
be made. The aim is to make all available contraceptive methods
available at the same cost to the acceptor.

[^1]:     ^?^The initial result of lower infant mortality may be a
    higher number of living children per woman since more infants
    survive. Fertility declines follow this initial rise.

[^2]:     ^?^Rural to urban migration and the problem of refugees are
    population related issues, but they are being addressed in separate
    policy papers.

[^3]:     ^?^Policy Determination (PD) 3 *(formerly PD-70)* summarized
    below is attached as an Annex.

[^4]:     ^?^VS service programs include those activities which are
    primarily intended to provide voluntary male and female
    sterilizations to persons requesting this type of contraceptive
    procedure. For purposes of this discussion, however, VS training
    programs are included, since training generally requires that
    trainees conduct supervised procedures on patients who have
    voluntarily presented themselves at a service/training facility for
    sterilization.