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NATIONAL SECURITY STUDY MEMORANDUM 200 (NSSM 200) |
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II. Action to Create Conditions for Fertility Decline: Population and a Development Assistance Strategy II. A. General Strategy and Resource Allocations for AID Assistance Discussion: Since inception of the program in 1965, AID has obligated nearly $625 million for population activities. These funds have been used primarily to (1) draw attention to the population problem, (2) encourage multilateral and other donor support for the worldwide population effort, and (3) help create and maintain the means for attacking the problem, including the development of LDC capabilities to do so. In pursuing these objectives, AID's population resources were focussed on areas of need where action was feasible and likely to be effective. AID has provided assistance to population programs in some 70 LDCs, on a bilateral basis and/or indirectly through private organizations and other channels. AID currently provides bilateral assistance to 36 of these countries. State and AID played an important role in establishing the United Nations Fund for Population Activities (UNFPA) to spearhead multilateral effort in population as a complement to the bilateral actions of AID and other donor countries. Since the Fund's establishment, AID has been the largest single contributor. Moreover, with assistance from AID a number of private family planning organizations (e.g., Pathfinder Fund, International Planned Parenthood Foundation, Population Council) have significantly expanded their worldwide population programs. Such organizations are still the main supporters of family planning action in many developing countries. AID actions have been a major catalyst in stimulating the flow of funds into LDC population programs - from almost nothing ten years ago, the amounts being spent from all sources in 1974 for programs in the developing countries of Africa, Latin America, and Asia (excluding China) will total between $400 and $500 million. About half of this will be contributed by the developed countries bilaterally or through multilateral agencies, and the balance will come from the budgets of the developing countries themselves. AID's contribution is about one-quarter of the total - AID obligated $112.4 million for population programs in FY 1974 and plans for FY 1975 program of $137.5 million. While world resources for population activities will continue to grow, they are unlikely to expand as rapidly as needed. (One rough estimate is that five times the current amount, or about $2.5 billion in constant dollars, will be required annually by 1985 to provide the 2.5 billion people in the developing world, excluding China, with full-scale family planning programs). In view of these limited resources AID's efforts (in both fiscal and manpower terms) and through its leadership the efforts of others, must be focussed to the extent possible on high priority needs in countries where the population problem is the most acute. Accordingly, AID last year began a process of developing geographic and functional program priorities for use in allocating funds and staff, and in arranging and adjusting divisions of labor with other donors and organizations active in the worldwide population effort. Although this study has not yet been completed, a general outline of a U.S. population assistance strategy can be developed from the results of the priorities studied to date. The geographic and functional parameters of the strategy are discussed under 2. and 3. below. The implications for population resource allocations are presented under 4. 2. Geographic Priorities in U.S. Population Assistance The U.S. strategy should be to encourage and support, through bilateral, multilateral and other channels, constructive actions to lower fertility rates in selected developing countries. Within this overall strategy and in view of funding and manpower limitations, the U.S. should emphasize assistance to those countries where the population problem is the most serious. There are three major factors to consider in judging the seriousness of the problem: The first is the country's contribution to the world's population problem, which is determined by the size of its population, its population growth rate, and its progress in the "demographic transition" from high birth and high death rates to low ones. The second is the extent to which population growth impinges on the country's economic development and its financial capacity to cope with its population problem. The third factor is the extent to which an imbalance between growing numbers of people and a country's capability to handle the problem could lead to serious instability, international tensions, or conflicts. Although many countries may experience adverse consequences from such imbalances, the troublemaking regional or international conditions might not be as serious in some places as they are in others. Based on the first two criteria, AID has developed a preliminary rank ordering of nearly 100 developing countries which, after review and refinement, will be used as a guide in AID's own funding and manpower resource allocations and in encouraging action through AID leadership efforts on the part of other population assistance instrumentalities. Applying these three criteria to this rank ordering, there are 13 countries where we currently judge the problem and risks to be the most serious. They are: Bangladesh, India, Pakistan, Indonesia, Philippines, Thailand, Egypt, Turkey, Ethiopia, Nigeria, Brazil, Mexico, and Colombia. Out of a total 67 million worldwide increase in population in 1972 these countries contributed about 45%. These countries range from those with virtually no government interest in family planning to those with active government family planning programs which require and would welcome enlarged technical and financial assistance. These countries should be given the highest priority within AID's population program in terms of resource allocations and/or leadership efforts to encourage action by other donors and organizations. The form and content of our assistance or leadership efforts would vary from country-to-country (as discussed in 3. below), depending on each country's needs, its receptivity to various forms of assistance, its capability to finance needed actions, the effectiveness with which funds can be used, and current or adjusted divisions of labor among the other donors and organizations providing population assistance to the country. AID's population actions would also need to be consistent with the overall U.S. development policy toward each country. hile the countries cited above would be given highest priority, other countries would not be ignored. AID would provide population assistance and/or undertake leadership efforts with respect to other countries to the extent that the availability of funds and staff permits, taking account of such factors as: a country's placement in AID's priority listing of LDCs; its potential impact on domestic unrest and international frictions (which can apply to small as well as large countries); its significance as a test or demonstration case; and opportunities for expenditures that appear particularly cost-effective (e.g. its has been suggested that there may be particularly cost-effective opportunities for supporting family planning to reduce the lag between mortality and fertility declines in countries where death rates are still declining rapidly). 3. Mode and Content of U.S. Population Assistance In moving from geographic emphases to strategies for the mode and functional content of population assistance to both the higher and lower priority countries which are to be assisted, various factors need to be considered: (1) the extent of a country's understanding of its population problem and interest in responding to it; (2) the specific actions needed to cope with the problem; (3) the country's need for external financial assistance to deal with the problem; and (4) its receptivity to various forms of assistance. Some of the countries in the high priority group cited above (e.g. Bangladesh, Pakistan, Indonesia, Philippines, Thailand) and some lower priority countries have recognized that rapid population growth is a problem, are taking actions of their own to deal with it, and are receptive to assistance from the U.S. (through bilateral or central AID funding) and other donors, as well as to multilateral support for their efforts. In these cases AID should continue to provide such assistance based on each country's functional needs, the effectiveness with which funds can be used in these areas, and current or adjusted divisions of labor among other donors and organizations providing assistance to the country. Furthermore, our assistance strategies for these countries should consider their capabilities to finance needed population actions. Countries which have relatively large surpluses of export earning and foreign exchange reserves are unlikely to require large-scale external financial assistance and should be encouraged to finance their own commodity imports as well as local costs. In such cases our strategy should be to concentrate on needed technical assistance and on attempting to play a catalytic role in encouraging better programs and additional host country financing for dealing with the population problem. In other high and lower priority countries U.S. assistance is limited either by the nature of political or diplomatic relations with those countries (e.g. India, Egypt), or by the lack of strong government interest in population reduction programs (e.g. Nigeria, Ethiopia, Mexico, Brazil). In such cases, external technical and financial assistance, if desired by the countries, would have to come from other donors and/or from private and international organizations (many of which receive contributions from AID). The USG would, however, maintain an interest (e.g. through Embassies) in such countries' population problems and programs (if any) to reduce population growth rates. Moreover, particularly in the case of high priority countries to which U.S. population assistance is now limited for one reason or another, we should be alert to opportunities for expanding our assistance efforts and for demonstrating to their leaders the consequences of rapid population growth and the benefits of actions to reduce fertility. In countries to which other forms of U.S. assistance are provided but not population assistance, AID will monitor progress toward achievement of development objectives, taking into account the extent to which these are hindered by rapid population growth, and will look for opportunities to encourage initiation of or improvement in population policies and programs. In addition, the U.S. strategy should support general activities capable of achieving major breakthroughs in key problems which hinder attainment of fertility control objectives. For example, the development of more effective, simpler contraceptive methods through bio-medical research will benefit all countries which face the problem of rapid population growth; improvements in methods for measuring demographic changes will assist a number of LDCs in determining current population growth rates and evaluating the impact over time of population/family planning activities. 4. Resource Allocations for U.S. Population Assistance AID funds
obligated for population/family planning assistance rose steadily since
inception of the program ($10 million in the FY 1965-67 period) to
nearly $125 million in FY 1972. In FY 1973, however, funds available for
population remained at the $125 million level; in FY 1974 they actually
declined slightly, to $112.5 million because of a ceiling on population
obligations inserted in the legislation by the House Appropriations
Committee. With this plateau in AID population obligations, worldwide
resources have not been adequate to meet all identified, sensible
funding needs, and we therefore see opportunities for significant
expansion of the program.
These Title X funding projections for FY 1976-80 are general magnitudes based on preliminary estimates of expansion or initiation of population programs in developing countries and growing requirements for outside assistance as discussed in greater detail in other sections of this paper. These estimates contemplated very substantial increases in self-help and assistance from other donor countries. Our objective should be to assure that developing countries make family planning information, educational and means available to all their peoples by 1980. Our efforts should include: Increased A.I.D. bilateral and centrally-funded programs, consistent with the geographic priorities cited above. Expanded contributions to multilateral and private organizations that can work effectively in the population area. Further research on the relative impact of various socio-economic factors on desired family size, and experimental efforts to test the feasibility of larger-scale efforts to affect some of these factors. Additional bio-medical research to improve the existing means of fertility control and to develop new ones which are safe, effective, inexpensive, and attractive to both men and women. Innovative approaches to providing family planning services, such as the utilization of commercial channels for distribution of contraceptives, and the development of low-cost systems for delivering effective health and family planning services to the 85% of LDC populations not now reached by such services. Expanded efforts to increase the awareness of LDC leaders and publics regarding the consequences of rapid population growth and to stimulate further LDC commitment to actions to reduce fertility. We believe expansions in the range of 35-50 million annually over the next five years are realistic, in light of potential LDC needs and prospects for increased contributions from other population assistance instrumentalities, as well as constraints on the speed with which AID (and other donors) population funds can be expanded and effectively utilized. These include negative or ambivalent host government attitudes toward population reduction programs; the need for complementary financial and manpower inputs by recipient governments, which must come at the expense of other programs they consider to be high priority; and the need to assure that new projects involve sensible, effective actions that are likely to reduce fertility. We must avoid inadequately planned or implemented programs that lead to extremely high costs per acceptor. In effect, we are closer to "absorptive capacity" in terms of year-to-year increases in population programs than we are, for example, in annual expansions in food, fertilizer or generalized resource transfers. It would be premature to make detailed funding recommendations by countries and functional categories in light of our inability to predict what changes -- such as in host country attitudes to U.S. population assistance and in fertility control technologies -- may occur which would significantly alter funding needs in particular geographic or functional areas. For example, AID is currently precluded from providing bilateral assistance to India and Egypt, two significant countries in the highest priority group, due to the nature of U.S. political and diplomatic relations with these countries. However, if these relationships were to change and bilateral aid could be provided, we would want to consider providing appropriate population assistance to these countries. In other cases, changing U.S.-LDC relationships might preclude further aid to some countries. Factors such as these could both change the mix and affect overall magnitudes of funds needed for population assistance. Therefore, proposed program mixes and funding levels by geographic and functional categories should continue to be examined on an annual basis during the regular USG program and budget review processes which lead to the presentation of funding requests to the Congress. Recognizing that changing opportunities for action could substantially affect AID's resource requirements for population assistance, we anticipate that, if funds are provided by the Congress at the levels projected, we would be able to cover necessary actions related to the highest priority countries and also those related to lower priority countries, moving reasonably far down the list. At this point, however, AID believes it would not be desirable to make priority judgments on which activities would not be funded if Congress did not provide the levels projected. If cuts were made in these levels we would have to make judgments based on such factors as the priority rankings of countries, then-existing LDC needs, and divisions of labor with other actors in the population assistance area. If AID's population assistance program is to expand at the general magnitudes cited above, additional direct hire staff will likely be needed. While the expansion in program action would be primarily through grants and contracts with LDC or U.S. institutions, or through contributions to international organizations, increases in direct hire staff would be necessary to review project proposals, monitor their implementation through such instrumentalities, and evaluate their progress against pre-established goals. Specific direct hire manpower requirements should continue to be considered during the annual program and budget reviews, along with details of program mix and funding levels by country and functional category, in order to correlate staffing needs with projected program actions for a particular year. 1. The U.S. strategy should be to encourage and support, through bilateral, multilateral and other channels, constructive action to lower fertility rates in selected developing countries. The U.S. should apply each of the relevant provisions of its World Population Plan of Action and use it to influence and support actions by developing countries. 2. Within this overall strategy, the U.S. should give highest priority, in terms of resource allocation (along with donors) to efforts to encourage assistance from others to those countries cited above where the population problem is most serious, and provide assistance to other countries as funds and staff permit. 3. AID's further development of population program priorities, both geographic and functional, should be consistent with the general strategy discussed above, with the other recommendations of this paper and with the World Population Plan of Action. The strategies should be coordinated with the population activities of other donors countries and agencies using the WPPA as leverage to obtain suitable action. 4. AID's budget requests over the next five years should include a major expansion of bilateral population and family planning programs (as appropriate for each country or region), of functional activities as necessary, and of contributions through multilateral channels, consistent with the general funding magnitudes discussed above. The proposed budgets should emphasize the country and functional priorities outlined in the recommendations of this study and as detailed in AID's geographic and functional strategy papers. II. B. Functional Assistance Programs to Create Conditions for Fertility Decline Discussion It is clear that the availability of contraceptive services and information, important as that is, is not the only element required to address the population problems of the LDCs. Substantial evidence shows that many families in LDCs (especially the poor) consciously prefer to have numerous children for a variety of economic and social reasons. For example, small children can make economic contributions on family farms, children can be important sources of support for old parents where no alternative form of social security exists, and children may be a source of status for women who have few alternatives in male-dominated societies. The desire for large families diminishes as income rises. Developed countries and the more developed areas in LDCs have lower fertility than less developed areas. Similarly, family planning programs produce more acceptors and have a greater impact on fertility in developed areas than they do in less developed areas. Thus, investments in development are important in lowering fertility rates. We know that the major socio-economic determinants of fertility are strongly interrelated. A change in any one of them is likely to produce a change in the others as well. Clearly development per se is a powerful determinant of fertility. However, since it is unlikely that most LDCs will develop sufficiently during the next 25-30 years, it is crucial to identify those sectors that most directly and powerfully affect fertility. In this context, population should be viewed as a variable which interacts, to differing degrees, with a wide range of development programs, and the U.S. strategy should continue to stress the importance of taking population into account in "non-family planning" activities. This is particularly important with the increasing focus in the U.S. development program on food and nutrition, health and population, and education and human resources; assistance programs have less chance of success as long as the numbers to be fed, educated, and employed are increasing rapidly. Thus, to assist in achieving LDC fertility reduction, not only should family planning be high up on the priority list for U.S. foreign assistance, but high priority in allocation of funds should be given to programs in other sectors that contribute in a cost-effective manner in reduction in population growth. There is a growing, but still quite small, body of research to determine the socio-economic aspects of development that most directly and powerfully affect fertility. Although the limited analysis to date cannot be considered definitive, there is general agreement that the five following factors (in addition to increases in per capita income) tend to be strongly associated with fertility declines: education, especially the education of women; reductions in infant mortality; wage employment opportunities for women; social security and other substitutes for the economic value of children; and relative equality in income distribution and rural development. There are a number of other factors identified from research, historical analysis, and experimentation that also affect fertility, including delaying the average age of marriage, and direct payments (financial incentive) to family planning acceptors. There are, however, a number of questions which must be addressed before one can move from identification of factors associated with fertility decline to large-scale programs that will induce fertility decline in a cost-effective manner. For example, in the case of female education, we need to consider such questions as: did the female education cause fertility to decline or did the development process in some situations cause parents both to see less economic need for large families and to indulge in the "luxury" of educating their daughters? If more female education does in fact cause fertility declines, will poor high-fertility parents see much advantage in sending their daughters to school? If so, how much does it cost to educate a girl to the point where her fertility will be reduced (which occurs at about the fourth-grade level)? What specific programs in female education are most cost-effective (e.g., primary school, non-formal literacy training, or vocational or pre-vocational training)? What, in rough quantitative terms, are the non-population benefits of an additional dollar spent on female education in a given situation in comparison to other non-population investment alternatives? What are the population benefits of a dollar spent on female education in comparison with other population-related investments, such as in contraceptive supplies or in maternal and child health care systems? And finally, what is the total population plus non-population benefit of investment in a given specific program in female education in comparison with the total population plus non-population benefits of alternate feasible investment opportunities? As a recent research proposal from Harvard's Department of Population Studies puts this problem: "Recent studies have identified more specific factors underlying fertility declines, especially, the spread of educational attainment and the broadening of non-traditional roles for women. In situations of rapid population growth, however, these run counter to powerful market forces. Even when efforts are made to provide educational opportunities for most of the school age population, low levels of development and restricted employment opportunities for academically educated youth lead to high dropout rates and non-attendance..." Fortunately, the situation is by no means as ambiguous for all of the likely factors affecting fertility. For example, laws that raise the minimum marriage age, where politically feasible and at least partially enforceable, can over time have a modest effect on fertility at negligible cost. Similarly, there have been some controversial, but remarkably successful, experiments in India in which financial incentives, along with other motivational devices, were used to get large numbers of men to accept vasectomies. In addition, there appear to be some major activities, such as programs aimed to improve the productive capacity of the rural poor, which can be well justified even without reference to population benefits, but which appear to have major population benefits as well. The strategy suggested by the above considerations is that the volume and type of programs aimed at the "determinants of fertility" should be directly related to our estimate of the total benefits (including non-population benefits) of a dollar invested in a given proposed program and to our confidence in the reliability of that estimate. There is room for honest disagreement among researchers and policy-makers about the benefits, or feasibility, of a given program. Hopefully, over time, with more research, experimentation and evaluation, areas of disagreement and ambiguity will be clarified, and donors and recipients will have better information both on what policies and programs tend to work under what circumstances and how to go about analyzing a given country situation to find the best feasible steps that should be taken. Recommendations: 1. AID should implement the strategy set out in the World Population Plan of Action, especially paragraphs 31 and 32 and Section I ("Introduction - a U.S. Global Population Strategy") above, which calls for high priority in funding to three categories of programs in areas affecting fertility (family-size) decisions: a. Operational programs where there is proven cost-effectiveness, generally where there are also significant benefits for non-population objectives; b. Experimental programs where research indicates close relationships to fertility reduction but cost-effectiveness has not yet been demonstrated in terms of specific steps to be taken (i.e., program design); and c. Research and evaluation on the relative impact on desired family size of the socio-economic determinants of fertility, and on what policy scope exists for affecting these determinants. 2. Research, experimentation and evaluation of ongoing programs should focus on answering the questions (such as those raised above, relating to female education) that determine what steps can and should be taken in other sectors that will in a cost-effective manner speed up the rate of fertility decline. In addition to the five areas discussed in Section II. B 1-5 below, the research should also cover the full range of factors affecting fertility, such as laws and norms respecting age of marriage, and financial incentives. Work of this sort should be undertaken in individual key countries to determine the motivational factors required there to develop a preference for small family size. High priority must be given to testing feasibility and replicability on a wide scale. 3. AID should encourage other donors in LDC governments to carry out parallel strategies of research, experimentation, and (cost-effective well-evaluated) large-scale operations programs on factors affecting fertility. Work in this area should be coordinated, and results shared. 4. AID should help develop capacity in a few existing U.S. and LDC institutions to serve as major centers for research and policy development in the areas of fertility-affecting social or economic measures, direct incentives, household behavior research, and evaluation techniques for motivational approaches. The centers should provide technical assistance, serve as a forum for discussion, and generally provide the "critical mass" of effort and visibility which has been lacking in this area to date. Emphasis should be given to maximum involvement of LDC institutions and individuals. The following
sections discuss research experimental and operational programs to be
undertaken in the five promising areas mentioned above. Discussion There is fairly convincing evidence that female education especially of 4th grade and above correlates strongly with reduced desired family size, although it is unclear the extent to which the female education causes reductions in desired family size or whether it is a faster pace of development which leads both to increased demand for female education and to reduction in desired family size. There is also a relatively widely held theory -- though not statistically validated -- that improved levels of literacy contribute to reduction in desired family size both through greater knowledge of family planning information and increasing motivational factors related to reductions in family size. Unfortunately, AID's experience with mass literacy programs over the past 15 years has yielded the sobering conclusion that such programs generally failed (i.e. were not cost-effective) unless the population sees practical benefits to themselves from learning how to read -- e.g., a requirement for literacy to acquire easier access to information about new agricultural technologies or to jobs that require literacy. Now, however, AID has recently revised its education strategy, in line with the mandate of its legislation, to place emphasis on the spread of education to poor people, particularly in rural areas, and relatively less on higher levels of education. This approach is focused on use of formal and "non-formal" education (i.e., organized education outside the schoolroom setting) to assist in meeting the human resource requirements of the development process, including such things as rural literacy programs aimed at agriculture, family planning, or other development goals. Recommendations 1. Integrated basic education (including applied literacy) and family planning programs should be developed whenever they appear to be effective, of high priority, and acceptable to the individual country. AID should continue its emphasis on basic education, for women as well as men. 2. A major effort should be made in LDCs seeking to reduce birth rates to assure at least an elementary school education for virtually all children, girls as well as boys, as soon as the country can afford it (which would be quite soon for all but the poorest countries). Simplified, practical education programs should be developed. These programs should, where feasible, include specific curricula to motivate the next generation toward a two-child family average to assure that level of fertility in two or three decades. AID should encourage and respond to requests for assistance in extending basic education and in introducing family planning into curricula. Expenditures for such emphasis on increased practical education should come from general AID funds, not population funds. II. B. 2. Reducing Infant and Child Mortality Discussion High infant and child mortality rates, evident in many developing countries, lead parents to be concerned about the number of their children who are likely to survive. Parents may overcompensate for possible child losses by having additional children. Research to date clearly indicates not only that high fertility and high birth rates are closely correlated but that in most circumstances low net population growth rates can only be achieved when child mortality is low as well. Policies and programs which significantly reduce infant and child mortality below present levels will lead couples to have fewer children. However, we must recognize that there is a lag of at least several years before parents (and cultures and subcultures) become confident that their children are more likely to survive and to adjust their fertility behavior accordingly. Considerable reduction in infant and child mortality is possible through improvement in nutrition, inoculations against diseases, and other public health measures if means can be devised for extending such services to neglected LDC populations on a low-cost basis. It often makes sense to combine such activities with family planning services in integrated delivery systems in order to maximize the use of scarce LDC financial and health manpower resources (See Section IV). In addition, providing selected health care for both mothers and their children can enhance the acceptability of family planning by showing concern for the whole condition of the mother and her children and not just for the single factor of fertility. The two major cost-effective problems in maternal-child health care are that clinical health care delivery systems have not in the past accounted for much of the reduction in infant mortality and that, as in the U.S., local medical communities tend to favor relatively expensive quality health care, even at the cost of leaving large numbers of people (in the LDC's generally over two-thirds of the people) virtually uncovered by modern health services. Although we do not have all the answers on how to develop inexpensive, integrated delivery systems, we need to proceed with operational programs to respond to ODC requests if they are likely to be cost-effective based on experience to date, and to experiment on a large scale with innovative ways of tackling the outstanding problems. Evaluation mechanisms for measuring the impact of various courses of action are an essential part of this effort in order to provide feedback for current and future projects and to improve the state of the art in this field. Currently, efforts to develop low-cost health and family planning services for neglected populations in the LDC's are impeded because of the lack of international commitment and resources to the health side. For example: A. The World Bank could supply low-interest credits to LDCs for the development of low-cost health-related services to neglected populations but has not yet made a policy decision to do so. The Bank has a population and health program and the program's leaders have been quite sympathetic with the above objective. The Bank's staff has prepared a policy paper on this subject for the Board but prospects for it are not good. Currently, the paper will be discussed by the Bank Board at its November 1974 meeting. Apparently there is some reticence within the Bank's Board and in parts of the staff about making a strong initiative in this area. In part, the Bank argues that there are not proven models of effective, low-cost health systems in which the Bank can invest. The Bank also argues that other sectors such as agriculture, should receive higher priority in the competition for scarce resources. In addition, arguments are made in some quarters of the Bank that the Bank ought to restrict itself to "hard loan projects" and not get into the "soft" area. A current reading from the Bank's staff suggests that unless there is some change in the thinking of the Bank Board, the Bank's policy will be simply to keep trying to help in the population and health areas but not to take any large initiative in the low-cost delivery system area. The Bank stance is regrettable because the Bank could play a very useful role in this area helping to fund low-cost physical structures and other elements of low-cost health systems, including rural health clinics where needed. It could also help in providing low-cost loans for training, and in seeking and testing new approaches to reaching those who do not now have access to health and family planning services. This would not be at all inconsistent with our and the Bank's frankly admitting that we do not have all the "answer" or cost-effective models for low-cost health delivery systems. Rather they, we and other donors could work together on experimentally oriented, operational programs to develop models for the wide variety of situations faced by LDCs. Involvement of the Bank in this area would open up new possibilities for collaboration. Grant funds, whether from the U.S. or UNFPA, could be used to handle the parts of the action that require short lead times such as immediate provision of supplies, certain kinds of training and rapid deployment of technical assistance. Simultaneously, for parts of the action that require longer lead times, such as building clinics, World Bank loans could be employed. The Bank's lending processes could be synchronized to bring such building activity to a readiness condition at the time the training programs have moved along far enough to permit manning of the facilities. The emphasis should be on meeting low-cost rather than high-cost infrastructure requirements. Obviously, in addition to building, we assume the Bank could fund other local-cost elements of expansion of health systems such as longer-term training programs. AID is currently trying to work out improved consultation procedures with the Bank staff in the hope of achieving better collaborative efforts within the Bank's current commitment of resources in the population and health areas. With a greater commitment of Bank resources and improved consultation with AID and UNFPA, a much greater dent could be made on the overall problem. B. The World Health Organization (WHO) and its counterpart for Latin America, the Pan American Health Organization (PAHO), currently provide technical assistance in the development and implementation of health projects which are in turn financed by international funding mechanisms such as UNDP and the International Financial Institutions. However, funds available for health actions through these organizations are limited at present. Higher priority by the international funding agencies to health actions could expand the opportunities for useful collaborations among donor institutions and countries to develop low-cost integrated health and family planning delivery systems for LDC populations that do not now have access to such services. Recommendations The U.S. should encourage heightened international interest in and commitment of resources to developing delivery mechanisms for providing integrated health and family planning services to neglected populations at costs which host countries can support within a reasonable period of time. Efforts would include: 1. Encouraging the World Bank and other international funding mechanisms, through the U.S. representatives on the boards of these organizations, to take a broader initiative in the development of inexpensive service delivery mechanisms in countries wishing to expand such systems. 2. Indicating U.S. willingness (as the U.S. did at the World Population Conference) to join with other donors and organizations to encourage and support further action by LDC governments and other institutions in the low-cost delivery systems area. A. As offered at Bucharest, the U.S. should join donor countries, WHO, UNFPA, UNICEF and the World Bank to create a consortium to offer assistance to the more needy developing countries to establish their own low-cost preventive and curative public health systems reaching into all areas of their countries and capable of national support within a reasonable period. Such systems would include family planning services as an ordinary part of their overall services. B. The WHO should be asked to take the leadership in such an arrangement and is ready to do so. Apparently at least half of the potential donor countries and the EEC's technical assistance program are favorably inclined. So is the UNFPA and UNICEF. The U.S., through its representation on the World Bank Board, should encourage a broader World Bank initiative in this field, particularly to assist in the development of inexpensive, basic health service infrastructures in countries wishing to undertake the development of such systems. II. B. 3. Expanding Wage Employment Opportunities, Especially for Women Discussion Employment is the key to access to income, which opens the way to improved health, education, nutrition, and reduced family size. Reliable job opportunities enable parents to limit their family size and invest in the welfare of the children they have. The status and utilization of women in LDC societies is particularly important in reducing family size. For women, employment outside the home offers an alternative to early marriage and childbearing, and an incentive to have fewer children after marriage. The woman who must stay home to take care of her children must forego the income she could earn outside the home. Research indicates that female wage employment outside the home is related to fertility reduction. Programs to increase the women's labor force participation must, however, take account of the overall demand for labor; this would be a particular problem in occupations where there is already widespread unemployment among males. But other occupations where women have a comparative advantage can be encouraged. Improving the legal and social status of women gives women a greater voice in decision-making about their lives, including family size, and can provide alternative opportunities to childbearing, thereby reducing the benefits of having children. The U.S. Delegation to the Bucharest Conference emphasized the importance of improving the general status of women and of developing employment opportunities for women outside the home and off the farm. It was joined by all countries in adopting a strong statement on this vital issue. See Chapter VI for a fuller discussion of the conference. Recommendations 1. AID should communicate with and seek opportunities to assist national economic development programs to increase the role of women in the development process. 2. AID should review its education/training programs (such as U.S. participant training, in-country and third-country training) to see that such activities provide equal access to women. 3. AID should enlarge pre-vocational and vocational training to involve women more directly in learning skills which can enhance their income and status in the community (e.g. paramedical skills related to provision of family planning services). 4. AID should encourage the development and placement of LDC women as decision-makers in development programs, particularly those programs designed to increase the role of women as producers of goods and services, and otherwise to improve women's welfare (e.g. national credit and finance programs, and national health and family planning programs). 5. AID should encourage, where possible, women's active participation in the labor movement in order to promote equal pay for equal work, equal benefits, and equal employment opportunities. 6. AID should continue to review its programs and projects for their impact on LDC women, and adjust them as necessary to foster greater participation of women - particularly those in the lowest classes - in the development process. II. B. 4. Developing Alternatives to the Social Security Role Provided By Children to Aging Parents Discussion In most LDCs the almost total absence of government or other institutional forms of social security for old people forces dependence on children for old age survival. The need for such support appears to be one of the important motivations for having numerous children. Several proposals have been made, and a few pilot experiments are being conducted, to test the impact of financial incentives designed to provide old age support (or, more tangentially, to increase the earning power of fewer children by financing education costs parents would otherwise bear). Proposals have been made for son-insurance (provided to the parents if they have no more than three children), and for deferred payments of retirement benefits (again tied to specified limits on family size), where the payment of the incentive is delayed. The intent is not only to tie the incentive to actual fertility, but to impose the financial cost on the government or private sector entity only after the benefits of the avoided births have accrued to the economy and the financing entity. Schemes of varying administrative complexity have been developed to take account of management problems in LDCs. The economic and equity core of these long-term incentive proposals is simple: the government offers to return to the contracting couple a portion of the economic dividend they generate by avoiding births, as a direct trade-off for the personal financial benefits they forego by having fewer children. Further research and experimentation in this area needs to take into account the impact of growing urbanization in LDCs on traditional rural values and outlooks such as the desire for children as old-age insurance. Recommendation AID should take a positive stance with respect to exploration of social security type incentives as described above. AID should encourage governments to consider such measures, and should provide financial and technical assistance where appropriate. The recommendation made earlier to establish an "intermediary" institutional capacity which could provide LDC governments with substantial assistance in this area, among several areas on the "demand" side of the problem, would add considerably to AID's ability to carry out this recommendation. Income distribution and rural development: The higher a family's income, the fewer children it will probably have, except at the very top of the income scale. Similarly, the more evenly distributed the income in a society, the lower the overall fertility rate seems to be since better income distribution means that the poor, who have the highest fertility, have higher income. Thus a development strategy which emphasizes the rural poor, who are the largest and poorest group in most LDCs would be providing income increases to those with the highest fertility levels. No LDC is likely to achieve population stability unless the rural poor participate in income increases and fertility declines. Agriculture and rural development is already, along with population, the U.S. Government's highest priority in provision of assistance to LDCs. For FY 1975, about 60% of the $1.13 billion AID requested in the five functional areas of the foreign assistance legislation is in agriculture and rural development. The $255 million increase in the FY 1975 level authorized in the two year FY 1974 authorization bill is virtually all for agriculture and rural development. AID's primary goal in agriculture and rural development is concentration in food output and increases in the rural quality of life; the major strategy element is concentration on increasing the output of small farmers, through assistance in provision of improved technologies, agricultural inputs, institutional supports, etc. This strategy addresses three U.S. interests: First, it increases agricultural output in the LDCs, and speeds up the average pace of their development, which, as has been noted, leads to increased acceptance of family planning. Second, the emphasis on small farmers and other elements of the rural poor spreads the benefits of development as broadly as is feasible among lower income groups. As noted above spreading the benefits of development to the poor, who tend to have the highest fertility rates, is an important step in getting them to reduce their family size. In addition, the concentration on small farmer production (vs., for example, highly mechanized, large-scale agriculture) can increase on and off farm rural job opportunities and decrease the flow to the cities. While fertility levels in rural areas are higher than in the cities, continued rapid migration into the cities at levels greater than the cities' job markets or services can sustain adds an important destabilizing element to development efforts and goals of many countries. Indeed, urban areas in some LDCs are already the scene of urban unrest and high crime rates. Recommendation AID should continue its efforts to focus not just on agriculture and rural development but specifically on small farmers and on labor-intensive means of stimulating agricultural output and on other aspects of improving the quality of life of the rural poor, so that agriculture and rural development assistance, in addition to its importance for increased food production and other purposes, can have maximum impact on reducing population growth. Discussion Present efforts at reducing birth rates in LDCs, including AID and UNFPA assistance, are directed largely at adults now in their reproductive years. Only nominal attention is given to population education or sex education in schools and in most countries none is given in the very early grades which are the only attainment of 2/3-3/4 of the children. It should be obvious, however, that efforts at birth control directed toward adults will with even maximum success result in acceptance of contraception for the reduction of births only to the level of the desired family size -- which knowledge, attitude and practice studies in many countries indicate is an average of four or more children. The great necessity is to convince the masses of the population that it is to their individual and national interest to have, on the average, only three and then only two children. There is little likelihood that this result can be accomplished very widely against the background of the cultural heritage of today's adults, even the young adults, among the masses in most LDCs. Without diminishing in any way the effort to reach these adults, the obvious increased focus of attention should be to change the attitudes of the next generation, those who are now in elementary school or younger. If this could be done, it would indeed be possible to attain a level of fertility approaching replacement in 20 years and actually reaching it in 30. Because a large percentage of children from high-fertility, low-income groups do not attend school, it will be necessary to develop means to reach them for this and other educational purposes through informal educational programs. As the discussion earlier of the determinants of family size (fertility) pointed out, it is also important to make significant progress in other areas, such as better health care and improvements in income distribution, before desired family size can be expected to fall sharply. If it makes economic sense for poor parents to have large families twenty years from now, there is no evidence as to whether population education or indoctrination will have sufficient impact alone to dissuade them. Recommendation 1. That U.S. agencies stress the importance of education of the next generation of parents, starting in elementary schools, toward a two-child family ideal. 2. That AID stimulate specific efforts to develop means of educating children of elementary school age to the ideal of the two-child family and that UNESCO be asked to take the lead through formal and informal education. General Recommendation for UN Agencies As to each of the above six categories State and AID should make specific efforts to have the relevant UN agency, WHO, ILO, FAO, UNESCO, UNICEF, and the UNFPA take its proper role of leadership in the UN family with increased program effort, citing the World Population Plan of Action. II. C. Food for Peace Program and Population Discussion: One of the most
fundamental aspects of the impact of population growth on the political
and economic well-being of the globe is its relationship to food. Here
the problem of the interrelationship of population, national resources,
environment, productivity and political and economic stability come
together when shortages of this basic human need occur. This is not to say that the LDCs need face starvation in the next two decades, for the same projections indicate an even greater increase in production of grains in the developed nations. It should be pointed out, however, that these projections assume that such major problems as the vast increase in the need for fresh water, the ecological effects of the vast increase in the application of fertilizer, pesticides, and irrigation, and the apparent adverse trend in the global climate, are solved. At present, there are no solutions to these problems in sight. The major challenge will be to increase food production in the LDCs themselves and to liberalize the system in which grain is transferred commercially from producer to consumer countries. We also see food aid as an important way of meeting part of the chronic shortfall and emergency needs caused by year-to-year variation at least through the end of this decade. Many outside experts predict just such difficulties even if major efforts are undertaken to expand world agricultural output, especially in the LDCs themselves but also in the U.S. and in other major feed grain producers. In the longer run, LDCs must both decrease population growth and increase agricultural production significantly. At some point the "excess capacity" of the food exporting countries will run out. Some countries have already moved from a net food exporter to a net importer of food. There are major interagency studies now progressing in the food area and this report cannot go deeply into this field. It can only point to serious problems as they relate to population and suggest minimum requirements and goals in the food area. In particular, we believe that population growth may have very serious negative consequences on food production in the LDCs including over-expectations of the capacity of the land to produce, downgrading the ecological economics of marginal areas, and overharvesting the seas. All of these conditions may affect the viability of the world's economy and thereby its prospects for peace and security. Recommendations: Since NSC/CIEP studies are already underway we refer the reader to them. However the following, we believe, are minimum requirements for any strategy which wishes to avoid instability and conflict brought on by population growth and food scarcity: (1) High priority for U.S. bilateral and multilateral LDC Agricultural Assistance; including efforts by the LDCs to improve food production and distribution with necessary institutional adjustments and economic policies to stimulate efficient production. This must include a significant increase in financial and technical aid to promote more efficient production and distribution in the LDCs. (2) Development of national food stocks [1] (including those needed for emergency relief) within an internationally agreed framework sufficient to provide an adequate level of world food security; (3) Expansion of production of the input elements of food production (i.e., fertilizer, availability of water and high yield seed stocks) and increased incentives for expanded agricultural productivity. In this context a reduction in the real cost of energy (especially fuel) either through expansion in availability through new sources or decline in the relative price of oil or both would be of great importance; (4) Significant expansion of U.S. and other producer country food crops within the context of a liberalized and efficient world trade system that will assure food availability to the LDCs in case of severe shortage. New international trade arrangements for agricultural products, open enough to permit maximum production by efficient producers and flexible enough to dampen wide price fluctuations in years when weather conditions result in either significant shortfalls or surpluses. We believe this objective can be achieved by trade liberalization and an internationally coordinated food reserve program without resorting to price-oriented agreements, which have undesirable effects on both production and distribution; (5) The maintenance of an adequate food aid program with a clearer focus on its use as a means to make up real food deficits, pending the development of their own food resources, in countries unable to feed themselves rather than as primarily an economic development or foreign policy instrument; and (6) A strengthened research effort, including long term, to develop new seed and farming technologies, primarily to increase yields but also to permit more extensive cultivation techniques, particularly in LDCs. _______________ Notes: 1. The Department of Agriculture favors U.S. commercial interests holding any national stocks in an international network of stockpiles.
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