metadata: authors: 0: author: Sinding,Steven W.
docna: 0: docna: Strengthening the Bank's population
            work in the nineties
docty: Policy Research Working Paper
subtopic: Health Care Services Industry,Reproductive Health,Educational Sciences,Family Planning Research
teratopic: Health, Nutrition and Population
abstracts: cdata!: This paper argues that the Bank should
            give renewed priority to population matters and accelerate
            the current upward trend in lending for family planning
            programs in the 1990s. It is timely for two reasons. First,
            the need for bank action in population will increase in the
            1990s as a result of growing unmet demand for family
            planning and stagnant bilateral assistance levels. Second,
            there is evidence that the initial effects of the 1987 World
            Bank reorganization have been to strengthening the potential
            for population work by integrating it more fully with
            economic analysis and overall country programming, but some
            further adjustments would assure that the potential could be
            realized. As the largest and most influential international
            development organization, there is an important leadership
            role for the Bank in promoting population policy analysis,
            dialogue, and in financing family planning programs.
repnme: repnme: Strengthening the Bank's population
            work in the nineties
display_title: Strengthening the Bank's
            population work in the nineties
listing_relative_url: /research/1991/11/699835/strengthening-banks-population-work-nineties
topicv3: Education m1327048 470,Family Planning m1327501 1452,Contraceptives m1327726 1453,Population, Aging and Health m1327736 640,Health m1504661 3480
publishtoextweb_dt: 2010-07-01T00:00:00Z
historic_topic: Health, Nutrition and Population
origu: Pop & Human Resources Department
no_of_pages: 41
author_keys: 0: author_key: 629458
model_extractions: **Policy Research**

**ion, Health, and Nutrition**

# WPS 802

This paper -a product of the Population, Health, and Nutrition Division, Population and Human - Rc"ources Department is part of a larger effort to reiniorce consensus within the Bank about the role of policy dialogue and population lending in the achievement ofdevelopment objectives. Copies are available free from the World Bank, 1818 H Street NW, Washington DC 20433. Please contact Otilia Nadora, room S6-065, extension 31091 (34 pages). November 1991.

In Lhis concise paper, writien for Bank management, Sinding briefly reviews the rationale for Bank involvement in population work. HIe then establishes a conceptual framework for determining appropriate program approaches fbr reducing fertility. Finally he suggests ways to strengthen the Bank's approach to population analysis and program support in the 1990s. Sinding recommends revising Bank strategy, not Bank policy.

The rationale has shifted somewhat, but the Baank's long-standing concern for population and family planning remains compelling. **T'hie** distinction between population and family planning is important because the skills needed to deal witih the two are different. We now know thaL in most settings, family planning - while not a substitute for development -is the most cost-effective approach to reducing fertility. Bank support is particularly important in a critical set of countries (for which Sinding provides an analytical matrix). But in any country, access to family planning improves the lives of the poor in many ways.

Sinding draws two main conclusions from reviews of Bank perfonnance: (1) no satisfactory indicators exist to evaluate Bank performance objectively, and (2) there is scope and opportunity for the Bank to build on receint advanices to improve its efforts in population work. Sinding recommends dhe following:

# _lImnediate_

* Greater attention to analysis of population issues in appropriate country strategy papers and economic and sector work programs.

* Population action plans where analytical work demonstrates a need; consideration of establishing Population Coordinators in each region to monitor and help in analytical work and preparation of action plans: preparation of regior. I population overviews.

* High priority to population training for managers and lead and country economists as well as for technical staff.

* Explicit objectives for population impact in freestanding population projects and in ,opulation componenits of Population, Health and Nutrition projects; careful impact studies.

Certain elements appear to be crucial to the success of Bank programs: government commitment to the program; Bank support of such "software" and recurrent costs as training, transport, management information system11s, and cr,ntraceptive supplies: strengthening of existing institutions rather than development of new ones; involvement of private and nongovemment organizations in the delivery of services; ef fective monitoring and evaluation systems (of the latter, the Bank has done little to 'lte).

# _Longer term_

> * Bank leadership in donor coordination to increase flows and effective use of resources to population activities as part of overall efforts to implement the _Vorld Development Report 1990_ strategy for reducing poverty.

> * Building a consensus for Bank loans to displace bilateral grants to large, more mature populationi and family planning progratns, freeing up grant funds for newer programs that enjoy Iess secure political support.

The Policy, Researcih Working Paper Scricsdisemrinat.s the findings of work ull(ler **way** in ilie Bank. Anobjccuive of **the** series is to get rhese findings ou!t quickly, even ifl'prentation arc iess **than lully** polished. The fin(lings. interpretations, and conclusionc in thcse papers do **not** ncccssarily represent ofhicial Bank policy.

1'roduced by **thc** 1olicy Rescarch Dissemination Ccnter
# TABLE OF CONTENTS

||Introduction|1|
|---|---|---|
||Rationale for Bank Involvement in Population|4|
||The Macroeconomic Consequences of Rapid Population Growth|4|
||The Role of Governrnent|6|
||Conclusion|6|
|II.|Resources and the Demand for Fam;ly Planning|8|
||Table 1. Contraceptive Prevalence in Developing Countries by<br>11c5 Socioeconomic Setting and 1989 Family Planning Program Effort|12|
||Lassons Learned from Family Planning Program Experience|13|
|Ill.|Implications for the Bank|15|
||Incorporating Population More Fully into Economic Work and<br>Policy Dialogue|15|
||Resource Requirements and the Future Role of the Bank|17|
||Specific Proposals for Immediate Action|18|
||Recapitulation of Recommendations|19|
||Figure 1. Population Growth Rate, 1990<br>|21|
||Figure 2. Crude Birth Rates, 1990|21|
||Figure 3. Total Fertility Rates, 1990<br>|22|
||Figure 4. Contraceptive Prevalence Rate, 1980<br>|22|
||Figure 5. Trends in Contraceptive Prevalence, by Region|23|
||References|24|
||Annex: Overview of the Bank's Record in the Population Sector<br>from 1970 to the Present|26|
||Table A-1: Bank Lending for Population, Health and<br>Nutrition (PHN) Projects|31|
||Table A-2: Lending for Population by Region|34|
This paper was prepared by Steven W. Sinding, while he was the World Bank's Population Adviser. Nancy Birdsall contributed substantially to Section 1, 'Rationale for Bank Involvement in Population," on the basis of earlier writings. The Annex is based on work originally done by Anthony R. Measham and Timothy King. Carol Bradford provided extensive editorial assistance and Otilia M. Nadora typed the manuscript.
# FORtWORD

World Bank work on population began two decades ago when popular literature caricatured the problem of rapid population growth with threats of famine and social decay. Thanks to analyses over the past decade, particularly those included in the _World Development Reports_ of i 380, 1984, and 1990, our knowledge about how population dynamics and economic development interact has grown more specific and less apocalyptic. Population growth at rates above two percent per annum exacerbates the problems of development in the poorest countries by limiting poor families' chances to provide good health and education to their children. Moreover, birth spacing and fertility limitation can offer an antidote to poverty as they lessen the burden of chiidbearing on women and result in better nutrition and physical development for children. Experience with family planning programs, and the complementary efforts to enhance the role of women in the development process by offering them better educaticn and work opportunities, demonstrates that governments can take actions that slow popu!ation growth and improve the prospects for development and poverty reduction.

It is within that context that Steven Sinding, Population Adviser at the World Bank from July 1990 through June 1991, prepared the accompanying analysis and recommendations aimed at strengthening the Bank's population and family planning work. The report was discussed at a meeting of the President's Council in June 1991; some of its recommendations are being implemented, and others are under review.

We were fortunate to have Steven Sinding with us for a year and to have his contribution to Bank work summarized here. He brought to the task twenty years of experience in the fields of population and international donor assistance, most recently, before joining the Bank, as USAID mission director in Kenya. He left the Bank to become the Director of Population Sciences at the Rockefeller Foundation, but his work continues to stimulate useful discussion within the Bank of how best to pursue its population and family planning objectives.

Ann 0. Hamilton Director Population and Human Resources Department
# INTRODUCTION

1. Tb: paper argues that the Bank should give renewed priority to population matters and accelerate the current upward trend in lending for family planning programs in the 1990s. It is timely for two reasons. First, the need for Bank action in population will increase in the 1990s as a result of growing unmet demand for family planning and stagnant bilateral assistance levels. Second, there is evidence that the initial effects of the 1987 World Bank reorganization have been to strengthen the potential for population work by integrating it more fu.ly with economic analysis and overall country programming, but some further adjustments would assure that the potential could be realized. As the largest and most influential internatioual development organization, the.e is an important leadership role for the Bank in promoting population policy analysis ane. dialogue and in financing family planning programs.

2. As is noted in the Annex, which recounts the history of Bank involvement in population, and in Section n, a great deal has been learned about what works and what doesn't in the population field.' This institutiona **l** earning has been translated into considerable improvements in lending for population projects, particularly in recent years. A recent OED review cites several examples of countries -- Indonesia, Bangladesh, Kenya -- in which Bank population operations have improved matkedly as the result of Bank project and program experience as well as experience gained through the efforts of others. The 1987 reorganization has created an environment where population can be much more effectively factored into the analytic work and the lending operations of the Bank -- and this is beginning to happen. At the same time, as Section n notes, global demand for population program resources is at an all-time high, and is growing rapidly. The Bank's resources are needed as never before. Finally, high fertility, both as a cause and as a consequence of poverty, has become a central issue in the Bank's heightened osaiwern with the reduction of poverty and Wth the establishment of environmentally sustainable developmernt. As the Bank gives greater attention to the longer-run development problems and the human development approaches that must be a part of any concerted effort to address them, population will certainly be among the fundamental issues that need to be addressed within both the Bank's policy dialogue and lending operations. For all these reasons, this is an opportune time to examine the Bank's strategy on this critical issue. Thus, this is a strategy paper -- a series of suggestions for improving existing Bank analysis and operations. It does not change existing policy.

3. The word "population," as used here, means population dynamics: specifically rates of change in human fertility, mortality, and migration. Population policies are purposive efforts to modify one or more of these variables, generally because of concerns that present rates are inimical to some other value or set of values (e.g., improvements in living standards, ability to defend the nation, loss of skilled workers). Over the last 25-30 years, many countries, including many developing countries, have officially adopted population policies, usually with specific objectives with respect to one or more of the demographic variables. In nearly all cases, these policies are intended to overcome a perceived imbalance between population changes and development goals and aspirations. In a few cases, these policies are pronatalist, as in France and the Soviet Union. In others, they are intended to promote temporary or permanent out-migration (India, Bangladesh) or internal redistribution (transmigration in Indonesia or efforts to stem the growth of primary cities). But the great majority of population policies in the second half of the 20th century are aimed at reducing the 'A major 'best practice" paper, "Improving Family Planning Effectiveness," which catalogues and evaluates what has been learned, is currently under preparation in PHR. It is intended both to strengthen policy dialogue by demonstrating to policymakers that demographic problems are tractable and to provide practical advice on program design and implementation to program administrators in developing countries, as well as to Bank staff. This paper draws on its preliminary results.
2 unprecedenteu rates of natural increase that have resulted from the steep declines in mortality that have characterized the post-war period, particularly in the developing world. These policies have thus called for reducing fertiiity, usually by means of a combination of family planning programs and the modification of other factors that directly (e.g., age at marriage) or indirectly (e.g., female education) affect the rate of eproduction and completed family size. As used in this paper, "family plann' mg' pr'.grams refer to e.forts to enable couples to determine the number and spacing of their children by providing them information on fertility regulation and contraceptive services.

4. While high fertility has been the primary stimulus to the establishment of family planning programs in some countries, in others family planning programs have been established for non-demographic reasons as well. Because the ipacing and limiting of births have been demonstrated to improve the health and the survival chances of both mothers and children already born, many countries have included family planning in their maternal and child health programs. Because family planning helps women to determine whether and when they wiH bear children, it can provide them with alternatives to childbearing and motherhood. And, because family planning can help families to limit the number of children they bear, it can contribute importantly to efforts to invest in children and to increase per capita well-being. In fact, in the majority of developing countries today, family planning is seen as both a means of reducing high rates of population growth (the macro perspective) and of helping to improve the living conditions of individuals and families (the micro perspective).

S. The distinction between ponulation and family planning is important because the skills needed to deal with each are quite different. The analysis of population-development interactions properly lies substaLtially within the macroeconomic policy analysis and design units. Such units need to examine the extent to which demographic factors are or are tot in balance with other development objectives and, if not, what policy interventions are available to alter theni. Such analysis is normally the province of economists, demographers and other social scientists. Family planning, on the other hand, is one among several pub"-. health program interventions. The design of family planning programs is primarily within the province of health professionals. Where family planning programs are determined to be required to alter demographic rates, the two groups need to work closely together. Often governments establish special population coordinating uni;s to facilitate such cooperation.

6. In the early years of international population program assistance, up to the mid-1970s, donors (including the Bank) were criticized by scholars and by many developing country governments for placing too strong an emphasis on fertility control and on the supply side of controlling fertility, i.e., family planning services. They were accused by these same critics of not taking adequately into account the underlying factors that affect demand for children (and hence, for contraception), and they were urged to direct their attention to such critical underlying factors that affect desired family size as educationa **l** evels, especially of women; infant and young child mortality; land tenure patterns; and women's employment opportunities, especially outside the home. Bilateral donors and international agencies responded after the World Population Conference at Bucharest in 1974 and have, since that time, consistently defined population policies and programs in terms of mortality and migration, in addition to fertility, and in terms of social and economic policies and programs that influence demographic variables, other than family planning.

7. Unfortunately, there was little empirical information available in the years leading up to the Bucharest Conference on how couples, women in particular, would respond to the availability cf low-cost contraceptive services. The intervening 15-plus years of experience have clearly demonstrated that the demand for such services is stronger than many had thought -- not only for purposes of limiting fertility but also because of the control that modern contraception gives women over the timing of births and, thus, many other aspects of their lives, including, perhaps most importantly, their own health and the health of their children. In
3 Section 11 of this paper, the extent of this,demand is demonstrated and it is argued that in most settings, family planning, while not a substitute for development, is the most cost-effective approach to fertility reduction. Because of this, and because of the collateral benefits of family planning, this paper gives especially strong emphasis to family planning and to meeting the unmet demand for contraception, both by urging member governmCnts -- recipients and donors -- to recognize and respond to the demand for such services and by oelping to finance programs that supply contraceptive services. Through its primary health and education lending, in particular, the Bank is contributing to modifying the demand for children. The time is now right to focus a major effort on the supply side. The next two decades represent an historic opportunity for the World Bank to play a central role in: a, helping countries tc define appropriate health and population policies, b) helping to define the resource requirements to implement those policies, and c) mobilizing resources, including Bank resources, to nmeet these needs in the most effective way possible.

8. The paper has three sections. It begins with a review of the rationale for Bank involvement in population. It then reviews the external environmcnt and establishes a conceptual framework for determining appropriate program approaches to fertility reduction. The final section suggests how the Bank's own approach to population analysis and program support in the 1990s might be strengthened. The paper focuses on a few key issues and its intended audience is Bank management. Approaches to different regional and country situations are outlined, but specific strategies and work programs are not included as they are tha responsibility of the Operations Complex.
4

## **1.** RATIONALE FOR BANK INVOLVEMENT **IN POPULATION2**

9. The Bank began to discuss population issues systematically in the late<sup>1960s, and made its first family</sup> planning loan in 1970. J;sp .e a br,%d agreement among governments<sup>and most observers that population</sup> growth has generally negative consequences for many aspects of development,<sup>there is less agreement among</sup> development economists on the effects of rapid population growth<sup>on economic growth in developing</sup> countries. Under these circumstances, what is the rationdle for the<sup>Bank to continue to be corcerned with</sup> this issue?

# Thg Maroeconomic Consequences of Rapid Population Growth

10. The assumption that rapid population growth is detrimental to<sup>e,-onomic growth prevailed in the</sup> mains. am development literature for much of the postwar period -- as<sup>long as lack of capital (and savings)</sup> coupled with surplus labor in agriculture were seen as the major constraints<sup>to economic growth. By the late</sup> 1970s, however, with attention shifting to the efficiency of resource use<sup>and policies to promote efficiency,</sup> the strength of this causal link began to be questioned. Analyses<sup>throughout the 1980s have been</sup> characterized as "revisionist" Malthusian: population growth is viewed as<sup>only one among several factors that</sup> slow development, and as a factor the effect of which, though negative,<sup>varies greatly in magnitud. depending</sup> on setting and circumstance.' 11. The more recent view is of population change as the aggregate outcome of<sup>many individual decisions</sup> at the micro or family level, and thus as one aspect of a larger complex<sup>system. The micrD or family-level</sup> decisions are made in response to signals provided by the larger system;<sup>these family decisions should be</sup> presumed to maximize not only individual welfare, but also social welfare,<sup>unless there are clear market</sup> failures. Among economists, di"erences on the negative effects of rapid<sup>population growth depend on</sup> differences about the pervasiveness and relevance of market failures.<sup>The report of the National Research</sup> Council of the National Academy of Sciences (1986), for example,<sup>while noting the ability of the marIket and</sup> institutions to adjust, also emphasizes that in many developing<sup>countries, institutional and market problems</sup> are pervasive and the process may be slow.' The World Bank _World_<sup>_Development Report_(1984) emphasizes</sup> the market and institutional failures. It notes, for example, the effects of<sup>rapid population growth and high</sup> fertility on the "congestion" of government services such as health and<sup>education services, which for other</sup> reasons, tend to be subsidized; and the effects of rapid population growth<sup>in settings where property rights</sup> are poorly defined.

12. So the long debate over population growth and development appears to<sup>be entering a new phase. The</sup> emphasis is now on the interaction of rapid population growth with<sup>market and institutional failures jo</sup> 2 This section draws heavily on N. Birdsall, "Economic Analysis of Rapid<sup>Population Growth,"</sup><sup>_Research_</sup> _Observer,_ January 1989.

3 See for example Kelley, 1988.

4Tbe National Academy of Sciences (NAS) report concludes that rapid population<sup>growth does have some</sup> negative effect on economic growth in developing countries. But it<sup>also notes that these effects, based on</sup> the extremely limited evidence availab<sup>1</sup> e, vary greatly among countries.<sup>The principal conclusion of the NAS</sup> report is that the state of evidence on the consequences of rapid population<sup>growth is poor.</sup>
S particular settings. In Bangladesh, per capita income is low;<sup>population growth rates, while declining, remain</sup> high; and people sccept high physical risks in order to make a living<sup>in cyclone-prone areas, as the death toll</sup> of over 100,000 from the cyclone of April 1991 dramatically<sup>illustrates. In this setting, it seems probable</sup> that the social costs of children exceed their private costs,<sup>and that high fertility is slowing development</sup> progress. In the African Sahel, where the rules regarding<sup>access to common property rights seem to be</sup> breaking down (at least in part due to rapid population<sup>growth), and weak governments have nc-t succeeded</sup> in imposing new more for.nal institutional and legal<sup>arrangements, continued rapid population growth can</sup> only exacerbate the resulting set of problems.<sup>Wherever populations are highly dependent on natural</sup> resources, opportunities for migration are limited,<sup>and policies favoring capital have reduced the retvhns to</sup> labor, rapid population growth is problematic. in many<sup>countries, as tor example the Philippines, Indonesia</sup> and Nepal, population pressures on natural resources<sup>are producing major environmental deterioration.</sup> 13. Thus the issue of population growth neeAs to<sup>be addressed urgently in some countries, but less so</sup> in others. Prudence suggests tha. Bank staff be<sup>alert to the potential negative effects of rapid population</sup> growth in a set of key countries, and be equipped to<sup>discuss the population issue with policymakers in those</sup> countries. In virtually all of Africa (including North<sup>Africa), much of South and Southeast Asia, the Middle</sup> East, and certain parts of Central and South America<sup>(e.g., El Salvador, Nicaragua, Peru, Bolivia), the high</sup> potential costs of continuing rapid population growth, relative<sup>to the low costs of efforts to reduce that growth</sup> (as discussed below), suggest that Bank staff should<sup>urge upon policymakers a precautionary principle: steps</sup> to reduce fertility appear, from a macroeconomic perspective,<sup>to be advisable. This is especially true if one</sup> considers that, in may countries, what is done today will<sup>strongly influence population size 50 years from</sup> now. A delay of even a decade in starting fertility decline<sup>in some rapidly growing countries could mean</sup> that they will have to deal with a population a third bigger<sup>than they would otherwise have by mid-century.</sup> 14. Moreover, the Bank, in virtually all of its policy statements<sup>on population, has emphasized not just,</sup> or even primarily, the effects of rapid population growth<sup>on economic growth. A major emphasis has been</sup> on the effects of large families on the poor, and particularly<sup>on poor women and children.5</sup> These negative effects are pervasive even in countries, including much<sup>of Latin America, where significantly negative</sup> macroeconomic consequences of population growth are not<sup>obvious.</sup> _15._ The negative effects of high fertility in poor households are in part associated<sup>with unwanted fertility.</sup> Survey data clearly show high rates of unwanted fertility throughout<sup>the developing world. A good example</sup> of evidence that unwanted births reduce parental investments<sup>in children comes from a study of twins in rural</sup> India; for families in which the most recent birth was of twins, implying<sup>some element of unwanted fertility,</sup> the children were significantly less likely to be in school.<sup>But even where fertility is wanted, in the sense</sup> that couples had access to but did not use contraceptives, many<sup>and closely-spaced births are associated, for</sup> example, with higher maternal and infant mortality, with reduced<sup>expenditures per child on schooling, and</sup> so on.6 ' The Bank has also emphasized the potential negative<sup>effect of high fertility on the distribution of</sup> income, where at least the theory linking rapid population<sup>growth to greater income inequzity is</sup> straightforward; unless there is perfect substitutability<sup>among factors in production, increases in the supply</sup> of unskilled labor relative to other factors will reduce<sup>the return to unskilled labor relative to other factors.</sup> G See, for example, Knodel, _et al_ (1990).
6

# The Role of Government

16. The effects on the poor of their own high fertility, and the fact that there is unwanted<sup>fertility,</sup> particularly among the poor in developing countries, have provided a critical justification<sup>for pubiic policy</sup> attention to family planning. In the 1984 WDR, the Bank defended public intervention to<sup>reduce ferti!ity on</sup> two grounds: the possible gap between private and social costs of children; and the failure<sup>of markets in the</sup> family planning area. The second justification for public policy concern was also<sup>ewn'hasized in the National</sup> Academy of Sciences report. Information about fertility control is not fully marketable;<sup>for example, there</sup> is no opportunity for profit from informing people about such means of contraception<sup>as rhythm and</sup> withdrawal. There are also like'- failures in the markets for contraceptive services;<sup>for example, where the</sup> demand for modem private health ca . is limited, e.g., in the rural areas of many developing<sup>countries, the</sup> private sector will not provide such contraceptive methods as the pill and the<sup>intrauterine device, since these</sup> are jointly produced with medical services. Or the pill, for example, will be provided<sup>privately through</sup> pharmacies, but without attention to safety and follow-up.

17. The Bank has for these reasons -- the effects of high fertility on poor women and<sup>children, and the</sup> poor markets for contr?ceptive services in developing countries -- put heavy emphasis on the<sup>logic of public</sup> support for family planning programs. The po.ential for access to finily planning to<sup>improve women's</sup> welfare by increasing their control over their own fate has also been increasingly emphasized;<sup>such an</sup> improvement could have implications for aggregate growth, as well if it were to generate<sup>rew externalities</sup> in terms of women's development of their own human capital and that of their female children.

# Conclusion

18. While the rationale has shifted somewhat over time, the Bank's long-standing concern<sup>for population</sup> and family planning remains compelling.

- A In a critical set of countries, where population growth is rapid, per capita income is low, and institutional, market, and policy failures are clear, rapid population growth adds to the constraints inhibiting economic growth and limiting the government's<sup>ability to promote</sup> human development. In these countries (probably including much of Africa, the poor countries of the Middle East and south Asia and some countries of South<sup>and Central</sup> America) continuing, and in some cases renewed, attention by the Bank to population issues is clearly warranted. In other countries, where there is more room for debate about whether rapid population growth is a small or a serious problem, prudence still<sup>suggests strong</sup> attention; this applies all the more when there are likely negative environmental effects that will be very costly, if not impossible, to rectify. The nature and content of the Bank's dialogue on population issues in these countries needs to be attuned to their particular nteds and circumstances.

- In almost all countries, irrespective of the magnitude of the "population' problem, the potential i' -onsiderable for improving the lives of the poor directly by increasing<sup>their</sup> access to fawily planning, thereby reducing their own high fertility and improving the lives of their children. In all these countries, the nature and content of the Bank's dialogue on population and family planning policy, and its advice and lending for family planning programs, aeeds to be at ied to the particular problems they face. These vary greatly, from limited access to family planning in rural areas because health infrastructure is lacking (in much of Africa); regulatory barrin;rs to the use of low-cost paramedicals to deliver simple
7 family planning services (in parts of Africa and South Asia); an extensive but poorly regulated private market with high costs to the health of poor women (in Brazil); limited k cess to methods the poor may benefit from. including sterilizatior, overemphasis in public programs on one method, such as sterilization in parts of South Asia and abortion in Eastern Europe; high welfare and economic costs of illegal abortion; poor quality of public services; etc.
8

# 11. RESOURCES AND THE DEMAND FOR FAMILY<sup>PLANNING</sup>

19. Profound changes in governments' commitment<sup>to fertility reduction have brought a significan'</sup> turnaround in the relationship between the amount of<sup>donor resources available to support population policies</sup> and family planning programs and the demand for those<sup>resources from governments. Between the mid-1960s</sup> and the late 1970s, donor commitment to fertility<sup>reduction programs exceeded considerably that of</sup> governments in the less developed world. Up to the<sup>mid-1970s, only a few governments, mostly in Asia,</sup> had mounted significant programs to reduce population<sup>growth rates. Because many governments were</sup> reluctant to develop population policies and/or<sup>to mount family planning pr, .ams, donor funds often</sup> supported health programs that were deemed important<sup>to the eventual delivery of family planning services</sup> (e.g., interventions to lower infant mortality<sup>and programs to expand rural clinical facilities) and private</sup> programs that represented innovative approaches<sup>to the delivery of family planning services.</sup> 20. After the Bucharest Conference, many more countries<sup>began to adopt policies to reduce population</sup> growth or, in some cases, simply to provide family planning<sup>services so that "couples may determine the</sup> number and spacing of the children they desire," to quote<sup>from the Bucharest final resolution. By 1985, 70</sup> governments, representing 95 percent of the developing<sup>world's population, had adopted policies that either</sup> explicitly called for fertility reduction or offered<sup>family planning services as part of the broader system of</sup> social services. Simultaneously, the pace of development<sup>in many poor countries meant that incomes were</sup> rising, literacy rates were improving, infant mortaiity<sup>was declining, and the role and status of women were</sup> improving, so that the demand for children was<sup>rapidly declining and the demand for family planning services</sup> was increasing. While it is difficult to chart these<sup>changes precisely, it is generally acknowledged by experts</sup> in the field :hat the demand for resources to support population<sup>and family planning programs began to exceed</sup> the grant funds available from the major donors in the<sup>field (USAID and UNFPA, principally) by the early</sup> 1980s. Grant funds also began to plateau at this<sup>time, a situation that prevailed through the decade. By the</sup> end of the 1980s, it was estimated by UNFPA (van<sup>Arendonk, 1990) that around $550 million per year</sup> (including $125 million in IBRD loans and IDA<sup>credits) was being contributed by donors to the $4.5 billion</sup> being spent on these programs from all sources, including<sup>developing country governments and individual</sup> users of the services.

21. The demand for resources in the future is expected<sup>to continue to grow markedly for several reasons.</sup> First, countries are continuing to adopt, or to strengthen,<sup>existing population and/or family planning policies,</sup> particularly in Sub-Saharan Africa. Second, the demand<sup>by individual couples to control their fertility is</sup> growing rapidly, accurding to the Demographic and<sup>Health Surveys (DHS), as social and economic changes</sup> occur and a- familiarity with the concepts of limiting and spacing<sup>births spreads. As programs directed at</sup> improving these social and economic conditions, and<sup>at poverty reduction generally, proceed and succeed,</sup> the demand for family planning services will continue<sup>to escalate. Even today, according to DHS estimates,</sup> there are 300 million women in the developing world<sup>who say they want no more children or wish to space</sup> the next birth, who are not currently practicing family<sup>planning. In an analysis that was prepared for the</sup> donors late last year, Bongaarts, Mauldin and Phillips<sup>(1990) estimate that 21 percent of current fertility in</sup> developing countries is unwanted; this supports<sup>the argument of unsatisfied demand and the case for</sup> significant increases in funding for programs<sup>that will satisfy it.</sup> 22. There have been several efforts to estimate future<sup>costs of family planning programs (see references).</sup> In one widely accep, ,d analysis, the UNFPA estimates<sup>annual costs at $9 billion per year by the year 2000.</sup> In many countrins, private payments have replaced<sup>government and/or donor subsidies as contraceptive</sup> prevalence has increased (e.g., Thailand, Mexico,<sup>Indonesia, Brazil). While this trend will undoubtedly</sup>
9 prevalence has increased (e.g., Thailand, Mexico, Indonesia, Brazil). While this trend will undoubtedly continue and even accelerate in countries where contraception is already well established,<sup>free or subsidized</sup> contraceptive services will continue to be required in countries which are at early stages<sup>of program</sup> development and/or where a substantial proportion of the population continues<sup>to live in poverty. Thus, no</sup> matter which basis one chooses for estimating future funding requirements,<sup>even assuming substantial</sup> increases in private demand and financing of contraception, it appears certain<sup>that large increases in donor</sup> financing, alongside even more substantial increases in the amounts budgeted<sup>by the countries themselves,</sup> will be required.

23. This growing unmet demant for family planning services in the face of relatively stagnant<sup>levels of</sup> external assistance means that many countries are seeking, and will likely increasingly<sup>seek, additional</sup> resources. In response, the Bank will have an opportunity to expand its support in<sup>many countries where it</sup> currently has PHN activities and extend it to other countries where such support has not<sup>been provided to date</sup> -- a topic that is addressed in greater detail in Section III below. In developing strategies<sup>for expanded Bank</sup> involvement in the population field, it is helpful to think in terms of a typology of countries,<sup>based on two</sup> broad factors: a) the "social setting" within which population programs operate; and<sup>b) the country's political</sup> commitmen **t** o fertility regulation and its capacity to deliver services -- what Lapham and<sup>Mauldin (1985)</sup> term "program effort." The "social setting" is a term that is meant to describe the<sup>conditions that are</sup> generally known to have the strongest indirect influence on fertility behavior -- particularly the<sup>role and status</sup> of women, including female education and employment outside the home, infant and young child<sup>mortality,</sup> and the distribution of access to economic opportunity (e.g., employment<sup>and services) -- or equity.</sup> Generally, the better a country's record on these social indicators, the more favorable the<sup>social setting will</sup> be in terms of couples' desire to limit family f 'ze, and hence, the demand for family planning services.' In many cases, this demand is confirmed by demographic and household surveys.

24. Program effort is more difficult to define, at least in quantitative terms. It is meant to<sup>characterize</sup> the will of the political leadership to moderate population growth rates and/or to provide<sup>contraceptive</sup> services. But the concept also includes a judgment about the country's ability<sup>to deliver those services</sup> effectively. While political will and administrative capacity are admittedly not the same thing,<sup>they are more</sup> often than not closely linked and, for purposes of the typology, can be combined in a single indicator. It has been pointed out that where political will outstrips the capacity to effectively deliver services, there is the danger that impatient political authorities will attempt to short-cut the administrative difficulties<sup>by turning</sup> to coercive measures or ethically objectionable incentives schemes. In the vast majority<sup>of cases, however,</sup> political will has led to the strengthening of administrative capacity -- hence the appropriateness<sup>of treating</sup> them together.

_25._ This conceptual framework can be presented as a four-fold matrix (the number<sup>of cells is arbitrary</sup> and can be expanded to create a more discriminating typology if desired since, in fact, each dimension<sup>is a</sup> continuum) which can be used to categorize countries (or regions within countries),<sup>as follows:</sup> 7The issue of differentials in contraceptive use is the subject of a PHRHN-sponsored study, "Impediments to Contraceptive Use and Fertility Decline in Different Environments," which is currently<sup>underway, and is</sup> scheduled for completion in 1992.
10

# PROGRAM EFFORT

||Stronger|Weakar|
|---|---|---|
|More|||
|favorable|A|B|
|SOCIAL|||
|SETTING|||
|Less|C|D|
|favorable|||

26. Tyve A countries are those in which both factors are favorable and in which broad and substantial support for family planning programs is warranted. The government is committed and relatively capable of delivering services, and the social setting suggests a strong predisposition on the part of couples to limit family size and to space births. Surveys generally show average desired family sizes of fewer than four children. In such countries, governments should be encouraged to adopt policies which provide incentives to the private sector to meet the rising demand for contraception. Policies such as elimination of duties and tariffs on contraceptives and permitting commercial firms to market resupply methods (pills, condoms) are but two examples of how governments can meet expanding demand by providing incentives to the private sector rather than by expanding public service delivery systems. Examples of countries in this category are China, Thailand, S. Korea, Sri Lanka, parts of south India (e.g., Kerala), Indonesia, Tunisia, and Mexico. Much of East Asia falls into this category, as do a few Latin American countries.

27. Type B countries are those in which the development indicators (and often survey data) suggest a strong interest on the part of couples to limit fertility, wiEh desired family sizes being comparable with Type A countries, but where government lacks the will (and perhaps, but usually not, the ability) to effectively deliver services. Since such countries generally have relatively high living standards, resulting in part from effective public sector performance in some social service areas (e.g., education and health services), it is normally lack of will rather than lack of capability that explains the relative absence of public sector activity in the population field. Often the reason for lack of government commitment is concern about alienating politically powerful groups, such as religious organizations or ethnic minorities. In such cases, the private sector is the obvious channel for responding to the desire of couples to control their fertility. Much of Latin America and some Middle Eastern countries fall in this category.

28. Type C countries are the reverse of Type B: a strong commitment on the part of the government to control population growth (often without commensurate administrative capability because these are generally quite poor countries) in a socio-economic environment that may not be conducive to rapid fertility decline because of high rates of illiteracy, infant mortality, and lack of opportunities for women outside their traditional childbearing and child-rearing roles. Surveys usually show desired family sizes of more than four, and often six or eight, children. Yet, even in such countries, there will be substantial numbers that will be interested in controlling fertility. These are typically urban dwellers and others in the modern sector of the economy, and women who have already borne many children and who want to terminate childbearing. Some years ago, before data from sources such as the World Fertility Survey and the Demographic and Health Surveys were available, demographers generally underestimated the number of such couples. Today, we know that these numbers often are substantial and tha.i if program effort is strong, investments in family planning programs usually will yield significant results. However, it is also true that, even with extremely strong political commitment, fertility is likely to fall more slowly than in Types A and B countries. This is why some Type C countries have been willing to contemplate, and in some cases implement, special efforts
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>
12 Table 1. Contraceptive Prevalence in Developing Countries by 1985 Socioeconomic Setting and 1989 Family Planning Program Effon

||||FAMILY PLAN|NING P|ROGRIAM<br>EFFO|RT|||
|---|---|---|---|---|---|---|---|---|
|SES|STRONG|-|MODERATE<br>**_______**__________<br>___<br>_____|<br>___|WEAK<br>________________O|R|VERY WEAK<br>NONE|Row<br>Total|
|HIGH|Taiwan<br>Korea, Rep.<br>MIexico<br>Sub-total|78<br>77<br>53<br>69|Mauritius<br>Singapore<br>Costs Rica<br>Coloubia<br>Panama<br>Cuba<br>Jamaica<br>Trin.& Tob.<br>Sub-total|75<br>74<br>68<br>63<br>61<br>60<br>55<br>53<br>64|Brazil<br>Jordan<br>Sub-total|65<br>27<br>46||62|
|UPPER<br>MIDDLE|Chiuia<br>Thailand<br>Sri Lanka<br>Tunisia<br>Ind,neiia<br>El Salvador<br>Botawana<br>Sub-total|72<br>68<br>62<br>50<br>48<br>47<br>33<br>54|Malaysia<br>Domin. Rep.<br>Peru<br>S. Africa<br>Ecuador<br>Philippines<br>Zimbabwe<br>Egypt<br>Algeria<br>Guatemala|El<br>50<br>4S<br>48<br>44<br>44<br>43<br>38<br>36<br>23|Turkey<br>Paraguay<br>Sub-total|63<br>44<br>54|||
||||Sub-total|42||||48|
|LOWER<br>MIDDLE|Vietnam<br>India<br>Sub-total|53<br>45<br>49|Honduras<br>Morocco<br>Kenya<br>Ghana<br>Pakistan<br>Sub-total|41<br>36<br>27<br>13<br>7<br>25|Bolivia<br>Haiti<br>Papua.<br>N.G.<br>Nigeria<br>Sub-total|30<br>10<br> <br>5<br>5<br>13|Liberia<br>6<br>Ivory Coast<br>3<br>Sub-total<br>S|22|
||Dangladesh|31|Nepal|14|Togo<br>Senegal|12<br>12|Sudan<br>9<br>Malawi<br>7||
|LOW|Sub-total|31|Sub-total|14|Rwanda<br>Benin<br>Burundi<br>Uganda<br>**Mali**<br>Sierra<br>**Leon**|10<br>9<br>9<br>S<br>5<br>**e**<br>4|Sub-total<br>8||
||||||Sub-total|8||1-|
|Column<br>Total||55||45||20|6|37|

Totals weighted by: UNIT WEIGHTS SnrLce: Maulgin and Ross, 1991
13 private sector programs have increased the use of contraception which in turn has led to reduced fertility and population growth." They go on to say, in much the same manner as the 1984 WDR, that "...[the amount ofl fertility reduction that can be achieved with a given program effort in a particular country depends on the level of development of that country.' They then estimate the effect of family planning programs in terms of the fertility rates that could be expected to have occurred in the developing world in the absence of organized family planning programs, and conclude that such programs reduced actual fertility by 1.2 births per woman during the period 1980-85. Cumulatively, between 1965 and 1990, there were an estimated 412 million fewer births than would otherwise have occurred. Projecting forward on the basis of current information about unwanted births (i.e., 21 percent of current births reported to be unwanted), they calculate that by simply averting unwanted births through effective family planning programs, the global population in 2100 could be 7.8 billion rather than the 10 billion estimated in the Bank's own projections. (In the absence of any organized family planning programs, they estimate that global population would grow to 14.6 billion by 2100.) Of course, it will not be possible to prevent all of the unwanted births, but, according to this analysis, even partially effective programs could produce significant declines in fertility and a much smaller population by the end of the next century than would otherwise be the case.

# Lessons Learned from Family Planning Program Experience

33. As is noted above, a great deal has been learned about the design and implementation of effective population projects in recent years. The vast literature which has accumulated on family planning program effectiveness will soon be available in summary form through the family planning effectiveness study referred to in footnote 1. Also, the recent OED study of Bank performance in several countries will soon be available. What follows is a brief overview of some of the most important lessons learned, which can guide the design of an enhanced Bank effort in the population field.

34. The quality of family planning services is crucial. Simply providing contraceptives is not enough. The more closely such services are linked to maternal and child health and nutrition programs, and the more care is taken in training administrators, supervisors, and field workers to respond to clients' perceptions and needs, the more acceptable and effective family planning services will be. The most successful programs in the longer term are those which emphasize comprehensive counselling on contraceptive methods and which assure informed choice among a reasonably broad range of methods in a completely non-coercive atmosphere.

35. Government commitment, both as stated in public pronouncements and as manifested in allocation of administrative and financial resources, is important. This commitment becomes more important the less capable the private sector is of catering to the demand for family planning services. Bank projects have tended to be most successful in countries whose governments were fully committed to effective programs. In many countries, the Bank has played an important role in encouraging such commitment. Examples are Rwanda, Kenya, Zimbabwe, Bangladesh, Nigeria and Mexico.

36. While the Bank has a comparative advantage in such infrastructure components of population programs as the construction of physical facilities, the most successful projects have been those where Bank resources have also financed such "software" and recurrent costs as training, transport, management information systems, and contraceptive supply. The recently completed OED reviews of the Bank's contributions to the population programs in Indonesia, Bangladesh, and Kenya strongly support this conclusion.

37. It is generally better to attempt to strengthen existing institutions than to try to bypass them by creating new ones. Even a weak Ministry of Health can do a great deal to undermine the effectiveness of a new agency that is established to administer family planning services. The slower s.art-up of a program
14 that depends upon substantial institutional strengthening<sup>is more than offset by subsequent performance. The</sup> examples of Pakistan and the Philippines, where separate,<sup>paralle! agencies were created to administer</sup> implementation of family planning services, and which<sup>are documented in recent sector reviews, support this</sup> conclusion. (The successful case of Indonesia,<sup>where a separate agency, the BKKBN, was created solely to</sup> manage the population program, appears to be unique.) 38. Private and nongovernmental institutions play a<sup>particularly important role in most countries in the</sup> delivery of primary health care and family planning services.<sup>Where family planning remains a politically</sup> sensitive topic, as in much of Latin America, Africa, and the<sup>Middle East, these organizations often play the</sup> leading role as service providers. In such countries,<sup>Bank projects tend to be more successful to the extent</sup> they involve such organizations. Support for NGOs has been<sup>successfully incorporated in many second and</sup> third generation Bank population projects, among<sup>other places in Kenya, Bangladesh, and Zimbabwe.</sup> 39. The most successful population programs (e.g.,<sup>Indonesia, Thailand, Colombia) are those which</sup> include effective monitoring and evaluation systems. The<sup>Bank has done comparatively little in this field ar.d,</sup> as is suggested below, should consider doing a<sup>good deal more. Effective monitoring and evaluation systems</sup> not only help managers track performance and impact, they<sup>also can contribute importantly to institutional</sup> morale and esprit.
15

# Ill. IMPLICATIONS FOR THE BANK

40. In recent years there have been several reviews of Bank performance in population. They are summarized in the Annex. Two main conclusions can be drawn from those reviews that bear directly on future activities. First, no satisfactory indicators exist to evaluate objectively the Bank's performance -- a major reason for the lack of consensus about this performance. Performance can be measured in tertns of both "level of effort" (number of projects, volume lent, numbers of population sections of analytical reports, etc.) and "impact" (numbers of new service delivery sites established, numbers of new acceptors of family planning services, contraceptive prevalence, fertility change, etc.). Since, to date, Bank population projects have not consistently set their objectives at this "impact" level, it is very difficult to judge performance by that criterion. That leaves "level of effort," but most would agree that the indicators here are seriously deficient because techniques tor measurement are flawed by the lack of definition of what constitutes "population" lending, and very little effort has been made to measure it separately.

41. Even more problematic is how to judge the impact of non-PHN lending on fertility objectives. It seems sensible not even to attempt this in the case of lending for agriculture and industry, or for infrastructure projects in general, since the links between employment and productivity gains, on the one hand, and fertility on the other, are impossible to quantify. The links between social sector lending and fertility are more direct, but similarly difficult to measure quantitatively.

42. Notwithstanding these definitional and methodological problems, what can be said about the Bank's performance in the population field? Granted the difficulty in comparing achievements over time in a constantly changing and often difficult external environment, the evidence from recent OED work is that the Bank's overall contribution in population improved over the 1970-1987 period. Since the 1987 reorganization, the overall trend remains one of modest improvement (at least in sector work and lending). OED-sponsored reviews of individual countries conclude that in some -- Indonesia, Bangladesh, Kenya -- the Bank's projects became more focused on those elements which have emerged from experience as the most critical for increased contraceptive use and decreased fertility. training, especially of field staff; transport and logistics; management information; and contraceptive supply. Moreover, this improvement in quality has taken place while both lending for population and the number of population projects have been increasing (see Appendix Table A-2 for detail on FY86-FY91 population lending). Population, as a specific program area, has grown and PHN as a whole has expanded even more.

43. The second conclusion is that there is both scope and opportunity for the Bank to build upon these recent advances to enhance its efforts in the population field. A broad consensus exists on this point between Bank critics, management, and staff: external need and Bank potential both argue for an expanded and more effective effort in population and family planning. Recent substantial increases in lending are indicative of strong demand from borrowers for population program assistance as the gap between demand and the traditional sources of funding -- bilateral donors and the UNFPA -- widens. The recommendations that follow are thus offered in the context of a strengthening record of performance. They are intended to reinforce this record and to point to ways in which the Bank can be even more effective as its resources become more central to the achievement of countries' population policy objectives.

# Incorporating Population More Fully Into Economic Work and Policy Dialogue

44. The Bank has a potentially major role to play in bringing population issues to the fore in policy analysis and policy dialogue. In many countries, rapid population growth continues to undermine government efforts to improve education and health, to preserve the environment, and to create enough jobs to
16 accommodate the rapidly swelling<sup>work force. While apocalyptic predictions such as those in The Population</sup> Bomb and The Limits to Growth<sup>have not materialized and are unlikely to do so, populations which are</sup> growing at between 2 and 4<sup>percent per year -- doubling every 17 to 35 years -- are in many instances</sup> overwhelming governments' abilities<sup>to maintain current living standards, much less make progress.</sup> _45._ The devolution of program strategy<sup>development to Country Departments, with support from</sup> Technical Departments and PRE,<sup>provides an opportunity for the Bank, as never before, to deal with</sup> population as an integral component<sup>of country operations. In the large number of countries where it is an</sup> important development issue, population<sup>should be trea.ed as a key component of country economic work,</sup> and not left entirely to sector staff, whose<sup>expertise and responsibilities generally relate to health and family</sup> planning services. In addition, PRE<sup>should give high priority to cross-national research, particularly on such</sup> still poorly understood questions<sup>as the consequences of rapid population growth for environmental</sup> sustainability.

46. High fertility is not only a macroeconomic<sup>issue, as pointed out earlier. It I e.s tremely important</sup> implications at the family level<sup>as well and, therefore, for efforts to reduce poverty.</sup> _.s_ not sufficient to focus tbe policy dialogue exclusively<sup>at the macro level. A strong case can be made about the benefits of</sup> reduced fertility for the family,<sup>in terms of the health of the mother and the children already born, their</sup> nutritional status, access to education,<sup>family income, alternative opportunities for women (such as</sup> employment outside the home),<sup>and other reasons.</sup> 47. Because population-development<sup>relationships are multi-faceted and complex, they must be handled</sup> in a country-specific way. Operations,<sup>indeed, the Country Departments, have primary responsibility for</sup> defining population issues and<sup>for designing appropriate population strategies. Africa, for example, has</sup> undertaken a whole series of initiatives,<sup>including the Long-TLrm Perspectives Study, the Capacity-Building</sup> Initiative, the McNamara speech to<sup>the African Leadership Forum, the "agriculture, environment, population</sup> nexus" work, the establishment<sup>of its regional popuiation task force, and the recent decision to add several</sup> population staff positions in the<sup>Technical Department. In addition, it has prepared a regional population</sup> strategy and a series of very specific<sup>country action plans. Its analytic work and policy dialogue have</sup> contributed importantly to policy<sup>change in Nigeria, for example. Asia has produced a discussion note on</sup> future population lending and has<sup>embarked on an ambitious regional sectoral review. It has produced an</sup> excellent population sector study<sup>on the Philippines.</sup> EMENA has within the past year<sup>produced a</sup> comprehensive population strategy<sup>for the Maghreb countries and an analytical piece on Islam and family</sup> planning.

48. LAC's approach advocates that<sup>where population is a politically sensitive subject, or where fertility</sup> rates are not excessive, the Bank<sup>should not insist upon demographic objectives but rather should promote</sup> family planning as an important<sup>health measure, as a basic right of couples, and as a measure to help alleviate</sup> poverty. Sector work in Brazil<sup>has linkeA family planning and women's health in a powerful and imaginative</sup> analysis.

49. Whether or not general fertility<sup>reduction is a politically acceptable or developmentally essential</sup> objective, discussing family planning<sup>as an aid to individual families in realizing their family size objectives</sup> is important and fully justified.<sup>In addition, wherever possible, and where the Bank's own analysis clearly</sup> indicates that population growth<sup>is seriously undermining a country's ability to achieve other development</sup> objectives, the Bank should not<sup>hesitate to share these views with policymakers in the borrowing countries.</sup> High fertility is both a macro<sup>and a micro issue.</sup>
17 _50._ Because a few governments, pressed hard by perhaps overly zealous<sup>advocates in earlier years,</sup> instituted population policies that crossed over the threshold of voluntarism<sup>and into the realm of coercion,</sup> there is today considerable concern about strong advocacy in favor of reduced population growth. Some critics, including many in donor countries, equate such advocacy with infringement of individual freedoms. In fact, because in most high fertility countries demand for contraceptives and family<sup>planning services is</sup> stronger than was generally supposed 10-15 years ago, it is possible to advocate strong demograihic policies in a purely voluntary program context. The ideal approach for the Bank today is<sup>to attempt to persuade</sup> governments that, by responding to the felt needs of their people, especially women,<sup>for the means to control</sup> their own reproduction, they will have also taken the first major step toward<sup>reducing the rate of population</sup> growth. By linking the social goal of fertility reduction with the individual<sup>goal of reproductive freedom,</sup> the Bank can help to reduce the likelihood that member countries will resort to coercive measures. Indeed, successful voluntary programs today will substantially reduce the probability<sup>that govermments will feel</sup> compelled by circumstances to introduce coercive programs tomorrow. Similarly,<sup>there are countries where</sup> population is a serious problem where the subject has not entered into the highest-level<sup>policy dialogue</sup> between the government and the Bank.

# Resource Requirements and the Future Role of the Bank

5i. Resources are scarce, particularly concessional aid flows. The primary responsibility<sup>must, of</sup> course, lie with the developing countries themselves. But, beyond leadership in policy<sup>dialogue, the Bank</sup> will have a large role to play in both mobilizing additional grant funds (e.g., via donor<sup>coordination and co-</sup> financing) and in direct financing. There is also substantial evidence that more Bank resources could usefully be devoted to family planning programs, as Part II of this paper indicates and as recent<sup>increases in lending</sup> levels confirm. Country Departments, Rcgional leadership, and the President, can play an important role in activelv encouraging developing country governments and other donors to increase funding<sup>for family</sup> planning programs as part of increasing aid flows and redirecting resource use to<sup>efficient, high priority</sup> activities. This is consistent with the approach set forth in the 1990 WDR on poverty and<sup>subsequent Bank</sup> policy statements.

_52._ Countries which by now have strong antinatalist policies and well established family<sup>planning</sup> programs are especially strong candidates for World Bank financing -- IDA credits and IBRD<sup>loans. Most</sup> of these are in Asia and are already borrowing a portion of their external financing<sup>for family planning</sup> activities from the Bank, although the bulk of grant money for population also still goes to Asia.<sup>The Bank</sup> can assume a leadership role in opening discussions with these countries and with the<sup>major donors about</sup> increasing grant and near-grant resources for other countries -- those less able and/or willing<sup>to borrow for</sup> family planning but where funds are urgently required. The beneficiaries of such<sup>an increase would be</sup> primarily in Africa, with some EMENA (e.g., Yemen, Afghanistan, Pakistan)<sup>and a couple of LAC countries</sup> (Bolivia, Haiti) also benefitting. This is not to suggest that IDA reduce<sup>its population efforts in Africa or</sup> in the other high fertility areas mentioned above. Rather, it is to suggest that<sup>the Bank use the process of</sup> donor coordination to help rationalize the allocation of global population resources<sup>in a more efficient and,</sup> ultimately, more effective manner. If, in addition, the Bank were to try to<sup>increase bilateral grant co-</sup> financing or parallel financing of its family planning operations in Asia and in other countries<sup>with well-</sup> established policy commitment and programs, this might well result in an overall increase<sup>in total</sup><sup>**grant**</sup> resources for family planning. The DAC would probably be an appropriate forum for this<sup>discussion. Thus,</sup> as in all sectors, lending for family planning should be designed to gradually<sup>phase out, first as the</sup> government and the private sector assume responsibility for recurrent local costs, and<sup>ultimately as they</sup> assume responsibility for foreign exchange costs as well.
18

# Specific Proposals for Immediate Action

_53._ First, Country tXpartments should be sure that country strategies include attention to population issues wherever demographic pressures are a problem. It would be useful for Country and Technical Departments to work together to see what additional things should be built into work programs to strengthen analyses, dialogue, or lending. (An assessment of the treatment of these issues in recent Country Strategy Papers and ESW would be helpful in this regard.) Such analysis would include assessing the impact of population change on other development parameters and examining the policy options for bringing demographic factors into balance with development objectives -- in other words, treating population as a macroeconomic variable. In most cases, it would mean examining the impact of high fertility and rapid population growth on the development aspirations of the member country and examining the potential demographic impact of alternative programs in such areas as agriculture (e.g., land inheritance systems), health (e.g., maternal and infant mortality), and education (e.g., female primary education). But in other cases, population movement, or mortality, or age structure may prove to be of greatest significance. The point is that population dynamics -- changing demographic variables -- are extremely important in planning for economic development, whether one is looking at Haiti's high fertility, or Uganda's rapidly rising mortality because of AIDS (which is having increasingly important demographic consequences in many countries), or Hungary's aging population, or rapid urbanization in Cote d'lvoire. Obviously, where such analysis has already been competently done by others (e.g., the countries themselves, USAID, UNFPA), it need not be duplicated by Bank staff.

54. Where such analysis demonstrates that population growth represents an important obstacle to the achievement of other development objectives, where high fertility is shown to have deleterious effects on large numbers of households, and where governments are deemed to be doing too little in response, population action plans could be prepared.

_55._ Second, Regions could take steps to further encourage, assist, and monitor regional performance. Unless this is done, it is unlikely that the recommendation for strengthened analytical work and strategy formulation will fare any better now than it did following the 1976 Freedman and Berelson report (see references), which made essentially the same point. To this end, each Region could consider establishing a senior population position. These senior regional population staff would contribute substantially to an increase in the level and quality of population work. (This seems less necessary for Africa which already has, de facto, such a position and a very active program.) 56. Third, population training for country and lead economists would be useful to carry out thie increased and improved analytic work. A Bank-wide training program for both economists and managers began in the spring of 1991 and merits strong continuing support.

57. Fourth, we need to begin to think more consistently about population objectives. As is pointed out above, for years the effectiveness of many of the Bank's population projects has been difficult to assess because their objectives have not been made explicit. Rather than being preoccupied with the volume of lending or the number of projects in the population field, or the proportion of each **PHN** project th%at is actually for population, the Bank needs to focus on impact. Do these projects, whatever one calls them, contribute to increased availability of services, increased prevalence of contrac._ptive use, and, ultimately, reduced fertility, maternal and infant mortality and morbidity? Appropriate PHN projects should be carefully reviewed to be sure that they have explicit population objectives, consistent with those of the country itself. It is not easy to attribute fertility decline, or even increased contraceptive prevalence, to a single project, but if the project represents a substantial element of a country's population program (as Bank projects usually do), it is not unreasonable to infer that a substantial share of any observed change is attributable to the
19 project. Making careful provision for data collection and analysis (e.g., strengthened service statistics systems and periodic surveys) can be helpful in this regard. An impact evaluation component in population projects could also assure greater attention to basic objectives.

58. Fifth, a strengthened analytical base and strategy will need to be operationalized. A potentially useful tool to assist Regions and Country Departments in assigning priorities and allocating resources would be a regional population overview that: (a) categorizes countries according to population policy and program status, (b) evaluates demographic objectives for each country and, where they don't exist, suggests realistic objectives for the short (5-10 year) and medium (10-20 year) terms, (c) spells out the Bank's role in helping to achieve these objectives, both within and beyond family planning measures, and (d) identifies the resources, financial and human, required to achieve them. If such an approach were followed, the staff development and staff enhancement implications of each strategy would emerge from the analysis itself. In practice, these additional needs would have to be weighed against competing priorities in each CD and Region, as part of the ongoing process of developing work programs. It would also be useful, for this as for other sectors, to measure total demand for extra resources before these tradeoffs are made, to live within existing tightly constrained budgets. But, as a minimum, unless there are compelling arguments to the contrary (e.g., no countries in the Department with demographic problems), each PHR SOD probably ought to have one population specialist and each TD at least two.

**_59._** Finallv, the Bank has been criticized for its Headquarters-based style of project management, especially in the social sectors. The critics argue that, even more than in other areas, social sector projects require close and continuous monitoring. Some of the Bank's more successful population and health projects have, in fact, included provision for resident management staff (e.g., Bangladesh and Kenya). The experience of other donors also suggests a strong relationship between the intensity of in-country management effort and the effectiveness of the projects. A recent set of papers prepared for an OED review of the Bank's population work concludes, nearly unanimously, that the Bank could have been considerably more effective had it deployed specialized staff in resident missions to assist in implementing these projects. Notwithstanding the apparent high cost of doing so, some Country Departments have put PHR staff in Resident Missions; this may be feasible in other cases. There are also other ways of addressing this issue where using Bank staff is unnecessary or infeasible, by building funding into projects to hire people for this purpose or by using other donor staff, through co-financing mechanisms or otherwise, to monitor and assist in project implementation. Over the longer tun, the Bank must continue to help develop the local country capacity to manage population programs, but, in the interim, resident advisers can be very helpful both to assure effective program implementation and to transfer the skills through which local capacity is built. The long-term benefits would be significant and the cost small in comparison.

# Recapitulation of Recommendations

# Immediate

1. Strong analysis of population issues in appropriate CSPs and in ESW programs, including selected CEMs.

2. Population action plans where analytical work demonstrates a need; consideration given to establishment of Population Coordinators in each region to monitor and assist in analytic work and preparation of action plans; prepare regional population overviews, including staffing implications.

3. High priority to population training for managers and lead and country economists, as well as to technical staff.
20 4. Explicit population impact objectives in free-standing population projects and in population comporants of PHN projects, and careful impact evaluation, _5._ More use of resident advisers in the field to assist in and monitor implementation of population projects.

# Longer Term

6. Bank leadership in donor coordination to increase flows and effective use of resources to population activities as part of overall efforts to implement the WDR poverty reduction strategy. Also, build a consensus for Bank loans to gradually displace grants to larger, more mature population and family planning programs, freeing up grant funds for newer programs which enjoy less secure political support.
FIGURE 1 21 IBRD 23326

# POPULATION GROWTH RATE 1990

<!-- Start of picture text --> POPULATION<br>OROWTH RATE 1990<br>mUnder I% _<br>Ml%to >2% _<br>2% to39 3%a ><br>O--NO 396 or MoreDatalg3; 3<br><!-- End of picture text --> OCTOBER 1 991 <!-- Start of picture text --> FIGURE 2<br><!-- End of picture text --> <!-- Start of picture text --> 23325<br><!-- End of picture text -->

## CRUDE BIRTH RATE 1 990

<!-- Start of picture text --> CRUJDE BIRTH<br>Under 20 wr<br>0 20to> 30<br>- 30 to 40 x><br>40 or More<br>F- No Data<br><!-- End of picture text --> <!-- Start of picture text --> _,,, .<br>J<br>: ,dl j ,,,<br><!-- End of picture text --> OCTOBER 1991j
IBRD 23328 22 FIGURE 3 <!-- Start of picture text --> TOTAL FERTILITY RATES 1990<br>RATES 1990<br>TOTAL FERTIUlY a _..t<br>Udr3%to>45<br>4.5% to >6% VP D<br>U 6% or More<br>WNo Data > &-.<br>OCTOBER 1991<br><!-- End of picture text --> FIGURE 4 IBRD 23327 CONTRACEPTIVE PREVALENCE RATE 1980's <!-- Start of picture text --> CONTRACEPWVE<br>PREVALENCE RATE 1980's<br>[e Under 20%<br>- 20% to ' 40%<br>U 40% to >60% r<br>U 60% or More<br>W No Datc<br><!-- End of picture text --> OCTMBER 1991
23

# FIGURE 5: TRENDS IN CONTRACEPTIVE PREVALENCE, BY REGION

<!-- Start of picture text --> 1960-65 1983<br>80 74<br>Percent<br>practicing<br>contraception<br>60 56<br>45<br>40 34<br>20 14<br>9 7<br>5<br>0<br>All East Ltin South Africa<br>Developing Asia America Asia<br>Countries<br><!-- End of picture text --> <!-- Start of picture text --> Source: United Nations, 1989<br><!-- End of picture text -->