11 such as incentive schemes (Chomitz and Birdsall,<sup>1990) and even, unfortunately, coercive measures to</sup> accelerate fertility decline. Examples of Type<sup>C countries are most of north India, Bangladesh, Zimbabwe,</sup> and Kenya. A growing numbe; of other African<sup>countries are also now beginning to enter</sup><sup>**thlk**. itegory.</sup> 29. Finally, Type D countries are those in which<sup>socio-economic conditions are not conducive to rapid</sup> or sustained fertility decline and where governments<sup>are not prepared to support programs of fertility control</sup> or family planning. Where family planning<sup>services exist, they tend to be provided by the (often very small)</sup> private sector, including NGOs, although<sup>in some cases governments do provide family planning as part of</sup> primary hea:th care or maternal and child health<sup>services. But the services are normally rudimentary because</sup> most of these countries are very poor and<sup>generally are unable to deliver government services effectively.</sup> In the short term, policy dialogue is the<sup>first priority in such countries to try to move them toward Type C.</sup> One often-effective parallel approach to<sup>improved policies is to mount pilot or demonstration family planning</sup> programs to convince policymakers that there<sup>is demand for such services, that they are socially acceptable,</sup> and that they are within the government's capability<sup>to deliver. Over the longer term, of course, collateral</sup> investments to modify the indirect determinants<sup>of fertility will be required to increase overall motivation for</sup> small families. Several Sub-Saharan African<sup>and Middle Eastem countries remain Type D.</sup> 30. This paper is not the place to try to prescribe<sup>specific strategies for dealing with individual Bank</sup> member countries. That work is appropriately<sup>done in Operations. This framework can be helpful, however,</sup> in explaining the importance of devising different<sup>strategic approaches to countries in different, but not</sup> unique, circumstances and for suggesting the outlines<sup>of these approaches. It is also important to reemphasize</sup> here that over the past 20 years, there has been a<sup>major shift toward the upper left-hand corner of the matrix.</sup> Many countries which in the mid- to late 1960s<sup>were clearly Type C or D have moved into Type A. And</sup> many which in the early and mid-1970s were<sup>Type D or B have moved toward or into Type A. Program</sup> effort has been carefully studied by Mauldin<sup>and associates through the 1980s and, in a 1991 paper they say,</sup> "The most notable finding so far from this research<sup>is the marked upward shift in program effort scores since</sup> the early 1980s [the average country score<sup>increased by 34 percent]... The total number of countries with</sup> strong or moderately strong programs increased<sup>from 23 to 43, and the weak and very weak decreased from</sup> 65 to _45"_ (Mauldin and Ross, 1991). A sixteen-cell<sup>matrix in which the authors place countries by program</sup> effort and social setting, along with contraceptive<sup>prevalence, is presented as Table 1. Figure 5 shows the</sup> remarkable increase in contraceptive prevalence<sup>that occurred between 1960-65 and 1983 -- a trend that has</sup> continued into the 1990s. The demand for<sup>family planning, based on both improving living conditions and</sup> stronger governmental efforts to promote small<sup>families, is well established.</sup> 31. The foregoing framework is useful to the extent<sup>that the principal direct intervention it implies --</sup> family planning -- actually works. Does it?<sup>The 1984</sup><sup>_World Development Report_stated: "For the single</sup> goal of reducing fertility, spending on family<sup>planning services turns out to be more cost effective (that is,</sup> it leads to the same fertility reduction at lower<sup>cost) than does spending on education, health (which reduces</sup> fertility by reducing infant mortality), and<sup>other programs." Of course, these other human development</sup> programs (in education and health) also serve<sup>additional goals. Therefore, these programs should not be seen</sup> as alternatives to one another, but rather<sup>as complementary interventions, each of which reinforces the effects</sup> of the others. This is so because the indirect<sup>determinants of fertility (health, education, etc.) must operate</sup> through the proximate determinants (age<sup>at marriage, contraceptive use, exposure to the risk of conception,</sup> etc.), of which contraceptive use is the<sup>most important.</sup> 32. Bongaarts, Mauldin and Phillips (1990) recently<sup>carried out a comprehensive review of the available</sup> evidence on the demographic impact of family<sup>planning programs.</sup> Their conclusion: "... the large international effort to implement family planning<sup>programs has been quite successful in attaining many of its</sup> objectives. By making contraceptives more<sup>readily available and by encouraging smaller families, public and</sup>