_17_ _Private sector coverage of the fandly plannWng market_

# percent by health insurance and prepaid plans.

Formal labor force participation and higher income are typically associated with increased contraceptive use and lower fertility. Recent recruits to the formal labor force, however, face a double bind. While their new status motivates them to control their fertility, many do not have the purchasing power to seek medical care outside their prepaid plan. Thus, if the plan does not include family planning, they will either do without or seek out public or subsidized NGO sources. In a survey of all major Peruvian health insurance companies in 1990, none reported covering either prenatal care or family planning, although hospital delivery was included (Foreit 1990); likewise 17 of 28 Brazilian HMOs responding to a 1986 survey reported that they did not offer family planning, but the industry average was even lower (Foreit 1987). With the exception of pioneering efforts in Asia, most notably India, few own-services programs include family planning as a preventive health benefit.

Company-sponsored family planning programs in India date back to the 1930s and include TVS-Lucas (1938), Tata Iron and Steel Company (1950), Alembic Chemicals (1956), and Hindustan Spinning and Weaving Mills, Gujarat Refinery, Godrej & Boyce, and the Tea Plantations (early 1960s). By 1972, 132 plantations and 146 industries were providing family planning (Rinehart et al. 1987). Family planning is offered in the Philippines by the Hawaiian-Philippine Company (1970) and Philacor (1975). By law, all companies in the Philippines that are legally required to provide clinics or infirmaries are required to offer family planning, but not all comply. These programs not only provide family planning services, but also attempt to stimulate demand for fertility control through a series of incentives for adopting family planning (cash payments for sterilization, etc.) and disincentives for large families (limiting maternity leave and benefits for higher-order children). Other employer-sponsored motivational and service delivery programs have been implemented at Jamaican sugar and bauxite companies, coffee growers in Colombia, the P. T. Imbritex textile factory in East Java, Indonesia, and Pertamina Oil Enterprises (Lewis and Kenney 1988).

It appears that these programs have attracted family planning acceptors. A survey of married female workers and wives of male workers at Tata Iron and Steel Company found 84 percent - contraceptive prevalence among women resident in Jamshedpur, where the company is located (Wickstrom et al. 1988), half of which was due to sterilization. Although source of method was not asked, it was assumed that most users were served by the Family Welfare clinics maintained by the company; in addition, the company supplemented the government cash incentive for accepting sterilization.

Labor unions have also been involved in promoting family planning as an employee benefit, in India, Turkey, and Sri Lanka. The International Labor Office, a U.N. organization, subsidizes 70 projects in 35 countries (Rinehart et al. 1983), often in collaboration with UNFPA or international NGOs. Recently, A.I.D. has begun to underwrite organized efforts to enlist employer support for family planning through two world-wide assistance projects, Technical Information on Population for the Private Sector (TIPPS, 1985-91) and the Enterprise Program (1985-91). The A.I.D.-funded OPTIONS projects have addressed policy constraints to greater private sector participation in family planning, and a follow-on to the Enterprise Program (PROFIT) is scheduled to begin in 1991.

A central feature of the A.I.D. employer-based initiatives is the financial argument that the costs to the employer of providing family planning to employees and dependents can be more than offset by savings arising from averting maternity-related service costs. Potential costs and benefits are projected by assessing current levels of fertility and contraceptive prevalence, demand for employer-subsidized family planning, and the costs of providing family planning. Pregnancies,