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\'' Populatio
Plannin
Sector
Working
Public Disclosure Authorized

paper
NI CROFI COPPY

Report No.: 11067 Type: (MIS)

Title: POPULATION ELANNING : SECTC)R W(
Autlhor: WORLD BANK
Ext.: 0 Room: Df3pt.-
OLI) SECTOR WORXING PAPER 1972
Public Disclosure Authorized

BANK
WORLD
losure Authorized

march1972
 FOREWORD
This is one of a seriesof World Bankpamphletsdealing with those
sectors(e.g., education,agriculture, power, transportation,popula-
tion, etc.) to which the Bankdirectsits developmentlending. Initial-
ly, theseSectorWorking Paperswere not written with any thought
of publication. They began as an internal exerciseto gain better
perspectiveon the characteristicsof the fieldsof activity coveredby
the Bank'sprojects and to describe the size and philosophy of the
Bank'slending programin eachfield.
The original instructions were to prepare papers that would de-
scribe the distinctive economic, financial, and institutional charac-
teristicsof eachsector; outline the role played by eachsector in the
generalprocess of economic development; review the scale and
approach of World Bank operations in the sector; and summarize
the Bank'sphilcsoph; about how its own operations,together with
the activit;esof other aid donors,cancontribute to building up each
sector-physically, financially, and institutionally-in its member
countries.
Although Bankloans are usually for specificproject. (e.g.,a dam,
a group of schools, a power system)we are convinced that their
merits can be judged only within a broad assessment of their rela-
tion to the developmentof the sector and of the whole economy.
The fixing of priorities among individual projects, and the reform
of policies and institutions to best serve a country's development
needs,require that individual projects be consideredin this wider
context.ThusBankprojects arederived troin -n analysisof the larger
economicsystemsinto which they must fit. In conducting this "sys-
temsanalysis"as a foundation for its project lending, the Bankplaces
primary reliance on field-basedcountryeconomicstudiesand sector
surveys.
The Sector Working Papershave served a useful function at all
levelswithin the Bank; we now feel they may be of similar interest
to r,,pple beyond our own staff and Inanagement. They are there-
fore being published in a seriesof pamphletsthat deal with the in-
dividual sectors in which the Bankis operating.

RobertS. McNamara
President,World BankGroup
March1972
 CONTENTS
Foreword ............................................... 1
Introduction ............................................... 3
Wo.ld Population Trends ...................... 7
World Population Projections ............. .. .................... 10
Economic Effects .............................................. 13
Family Planning Efforts .......................................... 17
The Bank's Program and Approach ........... .. .................. 27

Annexes

1. Population Projections, 1970-2100.........................

41
2. Specific or General Population Targets in 27 Countries ..... ... 53
3. Contraceptive Methods ................ .................. 55
4. Evaluation of Family Planning Programs ....... ............. 63
5. Bilateral, Multilateral and Private Agencies ...... ............ 73
6. Research ........................................... 81

2
 POPULATION
PLANNING
SECTORWORKING PAPER

* Thispaperdescribesthe Bank'seffortsto help membercoun-

tries reduce population growth rates and sets out its future
programof activity in the field, as now envisaged.
To give perspectiveto this discussion,the paper alsooutlines
the economiceffectsof reducingpopulationgrowth in develop-
ing countries and summarizesavailable information on the
global demographic situation, world population trends and
projections,and the accomplishmentsand potential of family
planningprograms.
References to the Bankor the World BankGroup include the
International ievelopmeuit Association(IDA) but not, for pur-
pcsesof this paper,the InternationalFinanceCorporation(IFC).
Money amountsare expressedin U.S. dollar equivalents.The
Baik's fiscalyear endsJune30.

INTRODUCTION
The purposeof economicdevelopmentis to makepossiblehigher
living standardsfor individual men, women and children. A rising
standardof living meansa growing ability to afford both the material
and non-materialbenefitswhich a modernizedeconomy makespos-
sible. For most people in most countries,however,the first require-
mentsare more and better food, improved accessto educationand
healthcare,and more opportunity for gainful employment.
Despite its limitations, one of the best availablemeasuresof eco-
nomic progresstowardthesegoalsis the growth of per capitaincome.
This is the growth of national income,adjusted for growth of popu-
lation. Thusthe relationshipbetweenthe growth of a nation'sincome
and that of its population is fundamental to the improvement of
human welfare.
While neither the causesnor the effectsin this relationshipare fully
understood,one central fact is clear: the higher the rate of popula-
tion growth, the more difficult it is to raiseper cipit- ncome.Today
the world's population is growing much faster than at any time in
history. This simple fact led the PearsonCommissionto say,in 1969,
that "No other phenomenoncastsa darker shadow over the pros-
pects for international developmentthan the staggeringgrowth of
population."

3
 The problemscreatedby the large numbersand high growth rates
of populationconcernboth the world asa whole and individualcoun-
tries. Both more and lessdevelopedcountriesconfront suchuniversal
questionsas the ultimate size of population the world can sustain
and the rate at which the limit will be approached.The earth can
undoubtedly support substantiallymore than the 3.6 billion people
tiow living on it. But there is great doubt about i!s ability to sustain
unlimited numbersat decent standardsof living, which a majority
do not haveeven now.
TheWorld Bank'sconcern,however,is not with ultimate numbers,
but with the developmentalimpact of population growth. Develop-
ment does not mean more people, but higher living standardsand
greaterwelfare for however many there may be. The Bank entered
the field chiefly becauseit becameconvinced that the attempt to
raiseliving standardsin a great manydevelopingcountrieswasbeing
seriously undermined if not thwarted. The Bankhas no fixed ideas
as to how large the population of individual countriesought to be.
But it is convincedthat in the great majority of developingcountries,
the faster the rate of population growth, the slower will be the im-
provementof living standards.Within the last few years,the govern-
mentsof more than 26 countries have indicatedthat they sharethis
belief by adopting official policies to slow their population growth.
There is another important reason for the Bank's entry into the
population field. It concernshuman we.fare,and particularly health.
Thereis strong evidencethat where childien havebeen well spaced,
both theyand their mothersenjoy betterhealthand experiencelower
mortality rates.It doesnot follow, of course,that parentswill neces-
sarily choose to spacetheir children or to have fewer of them, if
given the chanceto do so.
Manygovernmentsfeel, however, that people should be given the
choice if it is possibleto bring it to them, and the Bankis prepared
to help them do so.Experiencesuggeststhat if couplesare given this
voluntary choicetheir own family-sizedecisionswill tend to slow the
rateof populationgrowth.Yet no one canpredictwhetherthe general
responsewill developstronglyor quickly enoughto givegovernments
substantialhelp in attaining their developmentobjectives.

The Demographic Situation

It took more thani1,800yearsfor the world's populationto increase
from 210 million to one billion. Thesecond billion required about a
centuryand a quarter,and the third only 30 years.It isnow takingonly
15 yearsto add the fourth billion (seeTable 1). If presentgrowth rates

4
 Table1: Worla Population
Trends,Zero A.D. to 1970
A. PopulationSize"'(millions)
About About
Area 0 A.D. 1000 1750 1800 1850 1900 1950 1960 1970
World 210 284 750 960 1,240 1,650 2,518 2,995 3,632
Europe 39 63 120 155 195 293 392 425 462
SovietUnion 30 45 70 130 180 214 243
Asia 138 165 480 630 810 930 1,381 1,660 2,056
U.S.and Canada 1 6 26 81 166 199 228
Africa 100 100 100 150 222 278 344
LatinAmerica 33 56 12 20 35 65 163 213 283
Ot.Žania 2 2 2 2 13 16 19
"-Totals maa not check. due to rounding.

B. AverageAnnualRatesof Growth(%)
Area 1750-1800 1800-1850 1850-1900 1900-1960 1960-1970
World 0.5 0.5 0.6 10 1.9
EuropE 0.5 0.5 0.8 0.6 0.9
U.S.and Canada - 3.0"' 2.3"' 1.5 1.4
SovietUnion 0.6 0.9 1.2 0.8 1.4
Asia 0.5 0.5 0.3 1.0 2.5
Africa 0 0 0.8 1.0 2.4
LatinAmerica 1.0 1.1 1.2 2.0 2.9
Oceania 0 0 0 1.6 2.0
-Includes a high rate ot adult immigration.
So,urce, UIN World Population Conterence, \'ol. II, pp. 21-22; and Population Council. Reports on
Populationfamily Planning. December 1969.

were to continue, the current population of more than 3.6 billion

would double in 35 years,and by the end of this century it would be
increasingat the rateof a billion about everyeight years.
It is becoming increasinglydifficult to raise living standardsand
maintain even the presentquality of life in the face of these huge
annual increasesin population.This is especiallytrue in the develop-
ing countries, where two thirds of the world's population live and
where five sixths of the 1970-80increasewill occur. Such increases
impose heavyeconomicand social burdens.
In the mid-1960s,about two thirds of total annual investmentin a
sample of 22 developing countries was required to maintain per
capita income at a constant level, leavingonly about a third to raise
living standards.The correspondingfiguresfor a representativesam-
ple of 19 developedcountries were one quarter and three quarters.
It is clear that present rates of population growth in developing
countries are penalizing the hundreds of millions who live on the
margin of subsistence.If develcping countries are to achievesus-
tained social and economic development,population growth must
be reduced.

5
 The high ratesof population growth in most developingcountries
resu!t from their traditional high birth ratesand declining mortality
rates. Improved health servicesand medical technology will cause
further mortality declines,which will require fertility ratesto be re-
duced from presentlevelssimplyto avoidfurther increasesin popula-
tion growth rates.
The evolution of populations through the three stagesof (1) high
fertility/high mortality, (2) high fertility/low mortality, and (3) low
fertility/low mortality is what demographersrefer to as the historical
demographictransition. Both the first and last are periodsof modest
population growth; the middle stageis one of rapid growth. It is in
this middle stagethat the world as a whole now finds itself, because
the total rate of growth is hcavily influenced by what is happening
in the less developed countries where two thirds of the world's
population live.
The demographictransition deccribeswhat happenedhistorically
in the now-developedcountries.The causesof fertility declinesthat
carry countrk.s into stagethree are complexand not yet fully under-
stood. They include such influencesas increasesin the age of mar-
riage, urbanizat>-r, the gradualspreadof education,reducedinfant
mortality, the high living standardsthat accompanyrising incomes,
the spreadof old age pensionsystems,the prohibition of child labor,
and risingequality for women.
There is no guaranteethat the sameset of forces affecting deci-
sionson family sizewill emergewith equal for-e in today's develop-
ing countries and lead them inevitably into stagethree. They have
not done so to date. Eventuallythey may, although no one knows
how long it might take.The provisionof family planning servicescan
do much to speed up, perhapsby many decades,a transition that
otherwise might occur only very slowly. The difference in the pace
of this changemight makethe differencebetweendevelopmentand
non-development.
It is important to note that the Bank'sinterest in "population" is
wider than family planning,which is directed at the spacingof chil-
dren and limiting fertilit,. The Bank'sconcern also embracesmany
other aspectsof population and its effectson development.Its peri-
odic analysesof the development prospectsof member countries
normally include the main demographicvariablesof births, deaths,
and migration.Populationissuesarecentral to the Bank'slong stand-
ing interestsin education,employment,and rural development.
These other aspectsof the population question lie outside the
scope of this paper, which is concernedonly with the problem of
limiting fertility and with the Bank'scontribution to that objective.

6
 However,enablingandpersuading
manto limit hisfertility is itselfa
muchbroaderproblemthantheprovisionof familyplanningservices.

WORLD POPULATIONTRENDS
In the pre-industrialera,world populationgrewslowly.Disease,
famineandbreakdowns in thesocialorderresultedin mortalityrates
which were normallyhigh, and occasionallyveryhigh. Epidemics
sometimes wipedout largeproportions of apopulationin a fewyears.
For example,in the two years1348-50,bubonicplague(the Black
Death)reducedthepopulationof Europeby25%.Underthesecon-
ditions,fertility hadto be consistently
highto ensurethe survivalof
familiesand of the population.Societieswhosecultural,religious
and legal codesdid not placea high valueon fertility would not
havesurvived.

The Demographic Transition

Populationgrowth ratesin Europebeganto increaseduring the
late eighteenthcentury.Thiswasthe resultof a declinein mortality
which accompanied the agriculturaland industrialrevolutions,but
whichwasnotmatchedfor manyyearsbyanycorresponding decline
in fertility. Beforethedecline,deathrateswerearound28 to 32 per
thousand.Bythe mid-1800s, deathratesin EnglandandScandinavia
were about10 pointslowerthan theyhad beena centuryearlier.
Thedeclinespreadovermostof thecontinent,andtheratecontinued
to fall until in Europetodayit isabout10 perthousand. Thusin many
European countriesthe transitionto presentdeathratestook more
than 100 years;the transitionoccurredmore quicklyin countries
whereit startedlater.'
Threefactorsareconsidered basicto thehistoricaldeclinein mor-
tality rates:improvednutritionasa resultof higheragriculturaland
industrialproductivity;bettersanitationandpersonalhygiene,which
reducedparasiticand infectiousdiseases, particularlywater-borne
diseases; andimprovements in medicalcare.Asa resultof thediffer-
entialtrendsin mortalityandfertility,the longtermgrowthrateof
Europe'spopulationdoubled,fromabout.5%to 1%.
'One of the more dramatic casesoi a rapid tall in tertility occurred in Japanalter WVorldWar I1.
Both birth and death rates rose between 1875 and 1920: thereatter the birth rate fluctuated at the
intermediate levels of 26-36 per thousand, standing at 33 in 1949. The death rate, on the other
hand, fell to about 12 in 1949, giving Japana rate ot natural increase of more than 2%. Between1948
and 1952, abortion on medical or social grounds was legalized and contraception encouraged by
the passageof new legislation. During the subsequent20 years the birth rate fell 15 points to 18.
and the death rate continued its drop to about seven per thousand in 1969.giving a rate ot natural
increase just over one percent.

7
 In most Europeancountriesa decline in fertility did not begin until
the second half of the nineteenth century. It has continued, with
minor interruptions, until the present. In the mid-1700sEuropean
birth rates were high (35-40 per thousand in most countries), but
not as high as in manyof today's developingcountries (often40-50).
The sharpestdeclines in fertility occurred between 1870 and 1930,
when they leveled out at around 20, and most Europeancountries
today have ratesbetween 15 and 20.
The motivation for reducedfertility appearsto have arisen from
the spreadof education,the progressof urbanization,and a realiza-
tion that reduceddeath rates would lead to larger families unless
fertility were checked.

Population Trendsin Developing Countries

Prior to World War II, the developing countries also were char-
acterized by high birth and death rates,and thus had low tates of
natural increase.Thedemographictransitionbeganwith a rapid post-
war declinein deavA ratesunaccompaniedby a correspondingdecline
in birth rates.Growth rates beganto increase.Today, the averageis
2.8%, with the level in some countriesas high as 3% and even4%.
Therearewide variations,of course,and differentdevelopingcoun-
tries are at different points along the path of the demographictransi-
tion (seeTable 2). In some,both fertility and mortality remain high.
Table 2: Population Distributionin DevelopingCountries
by Fertilityand MortalityLevels,1970

Deaths Birth - Population

per 1000 per 1000 Atricall Asia'!" Latin America
Stages Population Population Number Percent Number Percent Number Percent
1 (a) High High
(over25) (over25) 27.0 8.0 17.0 1.4 - -
(b) Falling High
(15-25) (over40) 307.0 90.1 978.5 82.6 24.0 8.4
2 (a) Low (less High
than 15) (over40) 5.0 1.5 76.0 6.5 112.5 39.9
(b) Low (less
than 15) Falling 1.5 0.4 112.0 9.5 145.5 51.7
Totals 340.5 100.0 1,183.5 100.0 282.0 100.0
Note: Porulation figures are approximations. For purposesof this table, they have been rounded to
the nearest 500 thousand.
()Excluding five African countries with a total population of 42.4 million.
MExcluding People's Republic of China and four other countries with populations totaling 26.1
million, due to incomplete data.
Sources of basic data: United Nations, Population and Vital Statistics Report. lanuary 1971; Monthly
8ulletinof Statistics, August 1971; and Population Reference Bureau, 1970 World Population Data
Sheet.

8
 In others,mostlyin Asiaand Africa, fertility is high and the death rate
is falling. In still others, notably in countries with two fifths of Latin
America'spopulation, fertility is high and death ratesarealreadylow.
In a few countries of temperateSouth America, EastAsia and parts
of Oceania,death ratesare low and fertility is declining.
The postwardemographicexperiencehasdiffered from the earlier
experienceof developedcountries in severalimportant respects:
* The decline in mortality has been much more rapid, occurring
over one or two decades.For example,betweenthe five-yearperiods
1945-50and 1955-60,life expectancyat birth increasedin India from
32 to 45 years,in the Republicof China from 41 to 61 years,and in
tropical South America from 44 to about 52 years.Consequently,
growth ratesin the developingcountries today are higher than were
ever reachedin Europe.
The difference is not merely in degree, but in kind. A European
country with an annual rateof growth of 1% would double its popu-
lation in 70 years;the averagedevelopingcountrywith a growth rate
of 2.5% will double its population in 28years.If a 1% rateof growth
were reducedto .5%, the doubling time would be extendedby an-
other 70 yearsto a total of 140. But an identical reduction of half of
one percentagepoint when the growth rate is 2.5% would extend
the doubling time by only sevenyears-a tenfold difference.
* Many of today's developing countries lack the open spacesand
wealth of natural resourceswhich characterizedthe areasof Euro-
peansettlementand enabledthem to supporthigh ratesof population
growth more easily.
a To some extent, the earlier growth in today's developed coun-
tries was attributable to adult immigration, leading to significant
differencesbetween their age structureduring developmentand that
of today's developing countries. By 1900, for example, only about
44% of the population of the United Statesand Canadawas below
the age of 20, while in developing countries today that age group
commonly accountsfor 50-55%.
* When mortality beganto decline in manyof today's developing
countries,the levels of economic and social developmentwere not
comparableto those prevailing in WesternEuropebefore the indus-
trial revolution.
* The postwar decline in mortality has been occurring in many
societiesin which non-traditionaleconomic practicesand social atti-
tudes, which normally accompanydevelopment,havenot yet taken
root. Unlike the reduction of fertility, a decline in mortality encoun-
ters no cultural and ideological opposition and does not require a
large measureof continuous and active participation by the popu-

9
 lation. In the earlier experienceof today'sdevelopedcountries,
however,the technologicalmeansfor similartyrapid reductionof
mortalitydid notexist.
Thus,the currentdemographicsituationin the developingcoun-
triesdoesnot havehistoricalprecedents fromwhichtheymighttake
comfort.Theconsiderably morerapiddeclinein mortalityhascreated
a greaterimbalancethan ever existedin the developedcountries.
Thisis the heartof "the populationproblem"in today'sdeveloping
countries.
Thesolutiondependson how fastandby how muchfertilitywill
declinein the next20 to 30 years.Theobjectiveof populationpro-
gramsis to bringaboutdeclinesin fertility morerapidlythanwould
otherwiseoccur,primarilyby supplyinginformationandservices to
thosewilling to usethem.To the extentthatadditionalgovernment
they
policiesandactivitiescaninfluencevoluntaryfertilitydecisions,
too deserveto be consideredas part of a country'spopulation
strategy.Much moreneedsto be learned,however,aboutboth the
effectsandtheefficacyof othe. instruments.

WORLDPOPULATIONPROJECTIONS
Table3 suggests a rangeof possibilitiesoverthe next30yearsfor
the populationof the world,the developingcountriescollectively,
and a numberof largedevelopingcountriesindividually.Theseare
basedon alternativeprojectionsshowingwhat is likely to happen
underoptimisticassumptions (ProjectionA) andveryslowlychang-
ing conditions(ProjectionB).
ProjectionA illustratesa typeof populationgrowthwhichcould
developover t'ie next30 yearsif maximumeffortswere madeto
developfamily planningprogramsand takeany other reasonable
measures that mightbe effectivein curbingfertility.On the basisof
resultsachievedin the mostsuccessful programsto date,a "net re-
productionrate" (NRR)of 1.0couldbe expectedby theyear2000.1
Thisis a possiblebut unlikelyach-evement.
ProjectionB can be conceivedof asan illustrationof population
growthtrendsif familyplann;ngeffortsremainasmodestastheyare
at present.Evenundertheseslowlychangingconditions,somede-
clinein fertilitycanbeexpectedbecause of familyplanningandsome
'The net reproduction rate is a measure of population replacement, in terms of the number of girl
children born over the reproductive life of a hypothetical age group of women, after allowance for
mortality. A population will not stop growing when the NRR of 1.0 is reached. It will maintain
momentum for two or three generations, depending mainly on its age structure. Usually there is
a relatively higher proportion of women in the child bearing ages than would be required for a
stationary (non-growing) population. Therefore, even with a sustainedNRRof 1.0 these populations
would continue to grow for about 60 to 70 years until their age structure became stationary.

10
improvement in socio-economicconditions. Iln this casea NRRof
1.0 would be leached by about 2040.
Thesealternativeprojections,discussedin detail in Annex I, have
the following major implications:
,a) Populationsizeand distribution. World population,which to-
taled more than 3.6 billion in 1970, would reach 5.9 billion under
projection A and 6.7 billion under projection B by the year 2000,a
difference of about 770 million. Under projection A, world popula-
tion would level off during the last quarter of the next century after
having reached8.4 billion. Under projection B, population would
becomestationaryhalf a century later, at about 15.3 billion, or 7.4
billion more than under projection A.
The figuresfor developingcountries alone are not veiy different.
Thesecountries would increasetheir population from 2.5 billion in
1970 to 4.5 billion in the year 2000 under projection A and to 5.3
billion under projection B. The difference is in the neighborhoodof
800 million. The ultimate levels for today's developing countries
would be about 6.7 billion people uwderprojection A and twice as
many, or 13.4 billion, under projectioniB.
(b) The key role of largecountries. What happensto world popu-
lation will depend very much on fertility trends in a few large de-
velopirig countries. Comparing projections A and B for developing
countries, half the difference in population size is accountedfor by
12 of them: sevenin Asia (India, Iran, Malaysia,Pakistan,the Philip-
pines, Thailand and Turkey), two in Africa (Kenyaand Egypt),and
three in LatinAmerica (Brazil,Colombia and Mexico).' Thissuggests
the importanceof giving priority to efforts to reducefertility in coun-
tries wheremaximumimpact canbe achieved.
If projectionA were
trendsandbirthsto be averted.
(c) Fertility
achieved,the birth ratewould be 7.1 per thousandlowerin 1995-2000
thanunderprojectionB (21.1insteadof 28.2).Fordevelopingcoun-
tries,the differencewould be 9.3per thousand(23.7insteadof 32).
To achieveprojectionA ratherthanprojectionB,it would be neces-
saryto ave-rtabout840million more birthsbetween1970and the
year 2000in the developingcountriesthan projectionB assumes;
almosthalfof thesewouldhaveto be in the12countrieslistedabove.
While presentprogramsgivelittle promiseof achievinga NRRof
1.0bytheyear2000,a substantially effortnowshouldbring
increased
thisgoalwithin reachby about2025.To reacha NRRof 1.0by the
year2000would requirea maximumeffort,somethingit is probably
not realisticto expect.
and Nigeria, are omitted Irom this list due to lack of sufficientdata.
'Two large count-;es,Indo,nesia

11
 Table 3: AlternativePopulationProjections," Birth Rates,and BirthsOmitted
Population Birth Rate
(In millions (Pr 1.000Popuaioni Omitted
Arths
Regions and Projec- c. 207, A inns- 1970-2000
Countries tion t9,0 200O c. 212i5f 19J6;7. 20no 2020-25 (in millions'
W'orld Total A 3.652 5,916 8,348 34.0 21.1 16.3 882
B 3,652 6,690 15,306 34.0 28.2 23.1
Developed A 1,122 1,388 1,622 18.8 15.8 14.0 4
B 1,122 1,431 1.931 18.8 17.4 15.6
Developing A 2,530 4,528 6,727 41.8 23.7 17.2 837
B 2,530 5.259 13,374 41.8 33.0 24.6
Asia
India A 536 948 1,402 41.4 23.6 17.1 174
B 536 1.100 2.799 41.4 32.9 24.6
Iran A 28 56 88 45.0 24.3 17.2 13
B 28 68 213 45.0 36.5 26.8
Malaysia" A 9 18 27 36.0 21.2 16.1 4
B 9 21 54 36.0 30.1 22.8
Pakistan A 126 260 408 42.3 24.2 17.0 6
B 126 316 982 42.3 36.4 26.6 62
Philippines A 38 79 122 45.2 24.1 17.3 18
B 38 95 282 45.2 35.9 26.2
Thailand A 37 72 108 41.1 22.4 16.7 15
B 37 86 234 41.1 33.1 24.7
Turkey A 34 62 91 36.0 22.0 16.5 10
B 34 71 173 36.0 30.6 23.2
Africa
Egypt A 33 62 94 44.5 24.0 17.1 13
B 33 74 205 44.5 34.8 25.6
Ghana A 9 17 25 49.2 25.6 18.0 4
B 9 20 58 49.2 37.7 27.4
Kenya A 11 21 31 49.6 25.1 17.6
B 11 25 70 49.6 36.7 26.5
Tunisia A 5 10 15 45.3 24.0 17.4 2
8 5 12 34 45.3 35.8 26.1
LatinAmerica
Brazil A 94 181 273 38.6 22.1 16.5 31
8 94 209 529 38.6 31.1 23.5
Colombia A 21 41 62 38.0 22.1 16.6 8
B 21 48 120 38.0 31.3 23.6
Mexico A 51 109 172 44.6 23.7 17.0 27
B 51 131 397 44.6 35.7 26.1
"'For Projection A, a linear decline in gross reproduction rate 'GRRIis assumedto a level which
corresponds to a net reproduction rate (NRR)= 1 by the years 2000-2005;this decline is equated
with maximum effective fertility control. Projection 8 represents population trends under the
assumptionthat the GRRwill decline linearly to make NRR = 1 in the year 2045;this situation is
considered likely to occur if efforts for fertility control continue at the present levels. Both ptojec-
tions assumethe same mortality which is supposed to have different declines in the future, for
di.rerent countries. The full explanation of the assumptions is found in Frejka'sintroduction to
his projections.
MExcluding Sabahand Sarawak.
Source: The tab!a is computed on the basis of data from Tomas Frejka (Population Council), in
"Alternatives of World Population Growth," a monograph in process of publication.

12
 ECONOMIC EFFECTS
RelativeGrowth Ratesof Populationand Income
Rapidpopulation growth is a comparativelyrecent phenomenon.
It has accompaniedeconomic development,and it is clear that the
possibility for more people to live longer and fuller lives has been
one of development'smore important results.Pasthistory,however,
is a misleadingguide to action, becausethe presentsituation does
not offer a comparablepossibility. As noted above, new forces are
producing unprecedentedlyhigh rates of population growth, while
special circumstanceswhich gave peculiar impetus to economic
growth in the earlier period do not prevail.
Thereis no reasonto believe that current ratesof growth will fall
fast enough to relieve the pressureson developingcountries arising
from the need to use significantand rising proportions of their re-
sourcessimply to maintain the averagestandardof living of growing
numbers,leaving less for further improvement. It is not that coun-
tries cannot have both growing per capita incomes and growing
populations; the growth record of manydevelopingcountries in the
last two decadesshowsthat this is not impossible.What is at issueis
the maintenanceof per capita income growth at acceptablelevels
over longer periods,when the populationmaybe doubling everytwo
to three decades.
The decline of mortality in mostdevelopingcountrieshasresulted
in the survival of more adults, who would otherwise have had a
shorter life span,and an increasein the number of survivinginfants.
The respectivecontributions of these two groups to the postwar
population increasecannot be accuratelycalculated, but probably
they are about equally significant.
The economic impact of their survivalis quite different, however;
more adultsliving longer increasethe potential labor force and create
an immediate demandfor jobs and supporting services.They also
add to the numbersin the reproductiveage group, with a potential
impact upon fertility. More children surviving meana risein the de-
pendencyburden and, at a later stage,a further relative increasein
the reproductiveagegroups.Thuswhile anyfall in the infant mortality
rate is to be welcomedon humanitariangrounds,it addsburdensto
weak economieswhich can be lessenedonly by reducing fertility.
To do so, and thus lessenthe dependencyburden, leads to large
economic benefits.This is the heart of the economiccasein favor of
programsto limit fertility.
The other component in high population growth rates hasbeen
the continued high level of fertility. In the longer run this can be

13
expectedto declineeverywhere. However,culturalandsocialfactors
are significantenoughto makefor importantdifferencesin fertility
levelsamongareasof the world. In the faceof continuingsuccess
in reducingmortality,no developingcountryhasyet experienced a
fertilitydeclinesufficientto reducethe rateof populationgrowthto
the averagelevelof 1% per annumcharacteristic of the developed
economies of Europe,NorthAmericaandJapan.
Fallingfertility istheonlyfactorthatcanaccomplish sucha reduc-
tion-except, of course,a returnto muchhighermortalityrates.The
issueis notwhetherthe reductionwill takeplace,but howsoon,by
whatmeansandat whatcost.Thequestioniswhetherit canbe initi-
atedandaccelerated throughappropriatepolicyactions,in orderto
reapmore quicklythe economicbenefitsthat can be linked with
lo-.er ratesof growth.

Effecton PerCapita Incomes

Themostcertain,immediate,and measurable benefitof slowing
populationgrowthis the inc-easein per capitaincome.Theimme-
diate impactof falling fertility is a declinein averagefamily size,
reflectedthroughoutsocietyin a smallerdependency ratio.' In the
shortrun thereisno changein thelaborforceor otherresources, so
thatthe samenationalincome will be availableto a smallernumber
of people.At the sametime,proportionatelylessof the nationalin-
comewill haveto be usedto maintainthe capitalstockper person
at a constantlevel,makingit possibleto applymore resources to
increasingcapitalperworker,thusraisingproductivityandpercapita
income.
Thehigherper capitaincomespermithighersavingswhichcould
financehigher levelsof capital accumulation,both physicaland
human.This,in turn,leadsto furtherincreases in thenationalincome.
Thereisnothingautomaticaboutsucha process, however;it ismade
possiblebyfallingfertility,butthepossibilitieshaveto beseizedand
usedfor purposes whichpromoteeconomicdevelopment. Suchde-
velopmentmaybe accelerated asmuchby theinvestmentin human
resources-notably improvements in thequalityof education-asby
otherkindsof capitalimprovements.
Theeffectsof thedeclinein fertilitywill befelt in thelabormarket,
whichwill havefewer entrantsapproximately 15 to 20 yearslater.
The impactof this declineuponthe nationalincomewill depend
'The ratio of people not in the labor force to the total population. Since all personsdepend on the
production of those in the labor force, a lower ratio means that producers do not have to share
their output with as many non-producers. yielding both producers and their dependents a higher
per capita income.

14
mainly upon whether the opportunities made possible by lower
population growth in the previous15 yearsor so havebeen usedto
increasethe quantity and quality of the capital stock. Many factors
are involved, including labor productivity, the composition of the
labor force, and improvementsin health and education made pos-
sible by rising per capita incomes.

Employmentand Income Distribution

Problemsof unemploymentand inequality in the distribution of
income will always be easedby reductions in fertility. Continuing
high fertility results in large numbersof young people entering the
labor force eachyear.Employmentopportunitieshaveto expandfast
enoughto absorbthem. At high ratesof growth of population,where
the numbersinvolved may be doubling every 25 years,the absorp-
tion problem is severe.
Any country with a problem of long run unemploymentcannot
fail to benefit from the slowergrowth in the labor force which results
from reducedfertility. Where large numbersof people are entering
the labor force to compete for jobs, wagesare depressed,while
thosewho own or control capitalearn high returns,as do the owners
of land and other resourcesin fixed supply. In any social or political
system,high fertility tendsto worsen the distribution of income and
wealth.A reductionin the rateof growth of populationmakesit easier
to redresstheseinequities.

Estimatingthe Effects
The longer term cumulativeeconomiceffectsof lowering popula-
tion growth ratesareclearlyprofound,althoughit is difficult to isolate
them from those of other economic forces. Sincethere is no basis
for estimatingsuch effects historically, attemptshavebeen made to
indicate their orders of magnitudeby the constructionof simulation
models.With thesemodels it is possibleto work out the implications
of varying fertility reductionsover severaldecades,and to compare
the resultswith the situationassumingno fertility decline.
While the quantitative results depend upon assumptionsmade
about the economic relationshipsinvolved, they indicate substantial
benefits in growth of per capita incomes,with a cumulative effect
over time. Typically, if fertility is halved in a generation,by the end
of that period per capita incomescan be 20% to 40% higher than if
fertility had remainedconstant.The indicatedbenefitsbecomemore
impressiveas projectionsare extendedinto the future, but resultsin

15
the shorter period are more persuasivein terms of current policy.
This account of the economic benefits to be expectedfrom a re-
duction in population growth rates placesits main emphasison the
attainment of a higher per capita national income. The national in-
come, however,haslong been recognizedasan incompletemeasure
of welfare, even in strictiy economic terms. It needsto be supple-
mentedby taking account of other benefitsof reducedfertility.
Someof theseappearas social benefits, but they haveeconomic
consequenceswhich maythemselvesbe measurable,at leastin prin-
ciple. They include an increasein the spacingbetween pregnancies,
bringing benefits to the family in the form of improved health for
mothersand children, fewer maternaldeaths,and fewer retardedand
handicapped infants. Improved nutrition and family care is more
likely with smallerfamily size. A reduction in the number of illegal
and unsafe abortions also follows as knowledge of contraception
spreads.
It is possible to place many of the above conclusionsin a cost-
benefit framework, relating the value of the benefitsto the costsof
programs required to bring about reductionsin fertility. There is as
yet no fully agreedbasisfor estimatingsomeof the key valuesto be
employed,and eventhe useof this approachhasarousedcontroversy.
But there can be no question that the economic benefits of lower
ratesof population growth are considerable,and would prove to be
all the greater if proper account could be taken of thosewhich are
not easilyquantified. Calculationshaveconsistentlyshowna level of
benefits that exceedcostsby a very wide margin.

OtherImplicationsof PopulationSize
Much of the concernabout current population growth stemsfrom
anxietyaboutits implicationfor the future sizeof population,whether
in the world or in a particular country, in relation to the availability
of natui. I resources.The growth of population, however, accounts
for only about half the growingannualdrain on the world's resources.
The other half,or more,arisesfrom the growth of per capita incomes.
Thus,except perhapsin the caseof food, it is both rising levelsof
income and expandingpopulationsthat create pressureson the use
of natural resources.Theseseembound to intensify even if popula-
tion growth slows down, despite man's ingenuity in overcoming
technologicalproblemswith new agriculturalmethods,new sources
of energy,new waysof combatingpollution, and new, increasingly
dense modesof urban living.
Even if many of the difficulties concerningthe environment and

16
 resourceavailability stem as much or more from income growth as
from population growth, the wealthier a country is in per capita
terms,the easierit will be to mobilize resourcesin order to copewith
such problems.For example,an economy of 20 million people with
an averageincome of $2,000might havethe sameproblemsof pollu-
tion or scarcityof resourcesas one of 400 million with a per capita
income of $100.Thereis little doubt that the smaller country could
moreeasilytacklesuchproblems,becauseof its greatertaxingpower
and the more developed researchand production capabilitiesthat
are associatedwith higher incomes.
Againstthe disadvantagesof larger population size one potential
advantageis sometimesmentioned: countrieswith largepopulations
may be able to take advantagemore readily of the economiesof
scalethat undoubtedlyexist in manyactivities,particularly in manu-
facturing. Market size, however, is more a question of aggregatein-
come than of populationsizeper se.Theremayhistoricallyhavebeen
countries which could have been consideredunder-populated,in
terms of the economy'sability to make effective use of its natural
resources.Perhapsthe UnitedStateswas in this positionat somepoint
in the past.However,instanceswhen the addition of more peopleto
the labor force led to increasesin labor productivity and incomeper
head must have been few in the past and are virtually nonexistent
today. Developingeconomieswill be able to increaseper capita in-
comesmore rapidly if their populationgrowth is low than if it is high.

FAMILYPLANNINGEFFORTS
While efforts to reduce population growth ratesare still dwarfed
by the magnitudeof the problem, there hasbeen a notable-even
dramatic-increase over the last decadein both public and govern-
mentalinterest,concernand action. In 1960,only three countrieshad
official policies designedto slow the rate of population growth; by
1971,26 countries,with more than two thirds of the population of
developing areas,had announcedsuch policies or started official
programs;and some 24 others,with 12% of the developingworld's
population, supportedprivate family planning programswithout an-
nouncing official policies (seeTable 4).
By1970, 30 headsof governments,including thoseof 19 develop-
ing countries,had signedthe U.N. Declarationon Population,which
characterized"unplanned population growth" as one of the world's
"great problems" and called on national governmentsto recognize
family planning as one of their "vital interests."

17
 Table4: OfficialPositions of 48 DevelopingCountrieson FamilyPlanning
PopulationSize Supportbut No
,Millions) Policyand/orProgram Announced Policy
400and more People'sRepublicof China (1962)
India (1952,reorganizedin 1965)
100-399 Indonesia(19681
Pakistan(1960,reorganizedin 1965)
25-99 Egypt(1965)
Iran (1967)
Republicof Korea(1961)
Nigeria (1969)
Philippines(1970)
Thailand (1970)
Turkey (19651
15-24 Morocco (1965) Colombia
SouthAfrica
10-14 Republicof China (1968) Ceylon
Kenya (19661 Tanzania
Malaysia(1966) Venezuela
Nepal (1966)
Lessthan 10 Barbados(1967) Bolivia
Botswana(1971) Chile
Dominican Republic (1968) CostaRica
Ghana(1969) Cuba
lamaica(1966i Dahomey
;1auritius (19651 Ecuador
Puerto Rico(1970) ElSalvador
Singapore(1965) The Gambia
TrinidadandTobago(1967) Guatemala
Tunisia(1q64) Haiti
Honduras
Hong Kong
Nicaragua
Panama
Rhodesia
Senegal
WesternSamoa
source:Lapham.
R.J. andMauldin XV.P., "AnAssessment
of NationalFamilyPlanningProgrammes,"
unpublished paper presented to OECD's Fourth Annual Population Conference, October 1971.

ProgramResults
About 20 million women in 18 countries with programs, or 10%
of the married women of reproductive age in those countries, have
become "acceptors" during the last five years, the average period the
programs have been in effect (see Table 3). It is important to distin-
guish between the total number of "acceptors" and the annual in-
crease in that number (and to distinguish between the gross and the
net increase, i.e., after allowing for those who cease their participa-
tion). The figure of 20 million acceptors overstates the number of
women practicing contraception, because in every country many

18
acceptorsleave the program and those who reenter are again re-
corded as "new acceptors."
Countries with population programsusually establishpopulation
goals, or targets.They may aim at reducingthe existing crude birth
rate to a specified lower rate over five to 10 years,or at recruiting
specific numbers of acceptorsinto the program (sometimeseven
classifiedby methods)over a certain numberof years.'
An examinationof these targetswill show that a number of the
programswhich beganfive or more yearsago, after declinesin fer-
tility for a few years,appear now to have reachedan annual peak
of acceptors;the numberof new acceptorsseemsto havestabilized,
while the decline of the birth rate ap[ -ars to haveslowed down or
'See Annex2 for population targets.

Table 5: Numberof Acceptorsby Method, andCoverageAchieved by

Programsof 18 Countries(000s)
All Program
Methods as
Oral Other All a Percentage
Contra- Sterili- Program Program of women
Country Year IUDs ceptves zation Methods Methods 15-44"'

Ceylon 1966-69 68 55 18 19 160 >8.2

Colombia 1965-70 209 97 u 11 316 U
Ghana 1969-70 5 3 0 3 11 1-2
Hong Kong"' 1964-70 76 55 4 149 284 51.
India 1964-70'"'3,799 0 8,659 2,098's' u 14.9
Indonesia 1968-70 88 59 0 28 175 u
Iran 1966-70 36 627 0 u 662 >9.3
Kenya 1969-70 49 24 u u u 2.
Korea,Rep.of 1964-70 1,713 597 150 u u 42.
Malaysia" 1967-70 3 196 9 12 220 8.
Morocco 1964-70 41 25 0 0 67 3.
Pakistan"' 1964-70 3,277 6 189 u u 4.
Philippines"' 1970 84 193 - 85 362 u
Singapore 1965-69 10 82 4 51 147 35.
China,Rep.of 1964-70 779 150 1 u 979 44.
Thailand 1964-70 248 207 34 0 489 >9.6
Tunisia 1964-70 66 24 9 20 108 12.
Turkey 1965-70 250 32 0 0 282 u
Symbols:u, unknown; >, greater than total.
('iNon-sovereign territory.
"'Excludes Sabahand Sarawak.
"'Annual number of acceptors is an estimate basedon units of contraceptivessupplied, the assumed
relationship being one acceptor equals 130 units per year. Becauseof the arbitrary bias ot th.s
estimate, the cumulation of acceptors is not considered warranted.
4
'Acceptors for years prior to 1970when a population policy wasannounced represent clients attend-
ing clinics that currently participate in the government program.
"'To March 31, 1971.
"'Users of conventionat contraceptives,basedon figuresof distribution.
O)This column refers to current acceptors of all program methods as a percentageot women aged
15-44as of lanuary 1q71except for India, for which the date is lanuary 1970.
Source. Population Council, Population and family Planning Programs: A Factbook, No. 2 (1971
edition), lune 1971, New York

19
 even to have been reversed.The long-establishedprogramsin the
Republic of China, Hong Kong,Republicof Koreaand Singaporeare
in this situation.
In a number of countries-India, Malaysia,Pakistanand Tunisia
among others-programs have been in operation for five or more
yearsand a substantialoperational infrastructurehasbeen built up;
however, performancehasbeen unevenand there hasnot yet been
a significantor demonstrableimpact on their fertility rates.But even
in the caseof the moresuccessfulprograms,it isclearthat moreeffec-
tive education and motivation efforts and more and better family
planning services could increase significantly the proportion of
women practicing family planning, with consequentlylower fertility
levels.
Other countriesare just beginningtheir programsand the number
of acceptorsis still increasing.Thesenewer programsinclude those
in Ghana,Indonesia,Iran, Philippinesand Thailand.
in addition, many countries are moving gradually from limited
voluntary efforts in urban centers to a larger scaleof servicesbut
without any national population policy, although governmenthealth
facilities mayoffer family planning services.Astheir scaleof activities
expands,these countries can learn from the experienceof others
and develop not only their delivery systemsfor contraceptivesbut
also their programsof information, education,and the evaluationof
results.Suchcountriesinclude manyof the 34 which havepioneering
private associationsaffiliated with the International PlannedParent-
hood Federation(IPPF).
One estimateof the number of births avertedby family planning
programswas made by the DevelopmentCenterof the Organization
for EconomicCooperationand Development(OECD)in 1970.It indi-
catedthat 2.3 million births hadbeenavertedin 1968.Comparedwith
what is needed to bring down the rate of population growth to
acceptablelevelswithin a reasonableperiod, this is far from adequate.
Approximately4.8 million births would haveto be avertedannually
between 1970and 1975,and more than ten times that many,or 60.5
million annually, between 1995 and 2000 if the population of de-
veloping countries were to reach a net reproduction rate of 1.0 by
the year 2000 (Annex1, Table 6).

Constraintson Family Planning

There is considerableunevennessin the strengthof commitments
to population control in developing countries, ranging from mere
pronouncementsto firm policiesand programswith varying degrees

20
 of budgetarysupport.This mayreflect in part someof the difficulties
which have limited the effectivenessof many family planning
programs.
Politically, there is sometimesconcern that support of population
programsmay be a liability, especiallysince the resultsof anf pro-
gram will not be immediately demonstrablebut unfavorable mis-
conceptionsmay be widespread:a belief, for example,that there is
a correlation betweenpopulation sizeand military power; a fear that
ethnic balanceswithin a country will be upset; or a suspicionthat
the advocacyby rich countries of lower growth ratesfor the poor is
merely a new form of colonialism and an excusefor not providing
adequatedevelopmentaid.
Culturaland religiousobjections to familyplanningare still serious,
even in areas where national programsexst. In some countries a
family planning program would imply a complete reversalof prac-
tice, tradition and mores.Furthermore,where infant mortality is high
and children are neededfor the family work force, high fertility is
to be expected.
Various administrativeand organizational difficulties commonly
besetgovernmentsin launchingnew programs.Theseare often seri-
ous limitations. No matter how earnestthe political commitment,a
famiiy planningprogramcannotbe effectiveunlessthere isan organi-
zational structure capable of bringing the available technology to
thosepreparedto makeuseof it. Familyplanningprogramsareinher-
ently difficult to administer,sincetheymustmaintaincontinuing con-
tact with married couplesover a long period.
Thedifficulty is increasedwhen servicesmustbe carried to a widely
dispersed,and often illiterate, rural population. Moreover, there is
seldom enoughtrained personnelto carry out a programof the re-
quired magnitude. Finally,there is the handicapof limited adminis-
trative experienceon the part of many personsin the medical and
social serviceprofessions,who in most developingcountries are re-
sponsiblefor administeringfamily planning programs.
Thereare also important technologicalconstraints.Although con-
traceptivetechnology hasmade considerableprogressin the last 15
years,so far there is no perfect contraceptive:highly effective,safe,
inexpensive,easily used and reversible,and one which would not
necessarilyhave to be delivered under medical surveillance.Oral
contraceptivesand the intrauterinedevices(IUDs)are likely to be the
best available means of contraception for some time to come, al-
though experiencehasdemonstratedthat both havetheir limitations.
While researchisproducingvariationsand refinementsof both "the
pill" and the IUD, anyradicallynew techniqueof fertility control must

21
 come from basic researchin reproductive physiology,which is ex-
pensive,complex and uncertain. For the present, family planning
programswill have to operate with essential"' the same methods
known today. Improvementsare on the hor; , but radical break-
throughstoward the "ideal" are not expectedsoon (seeAnnex 3).
Family planning programsnormally include educationand infor-
mation components,although the exacttype of activitiescarried out
must be carefully tailored to allow for cultural sensitivitiesand reli-
gious beliefs. Educationconsistsof the preparation of curriculum
materialson family life and sex and their introduction into school
curricula after suitable testing and training of teachers.The target
group is principally the next generationof potential acceptors.
Information, or communication,activities are directed mainly to
the presentgenerationof potential acceptors.Thesemay be reached
through variousforms of masscommunication(radio,cinema,news-
papers,posters,etc.), as well as through face-to-facecontactsestab-
lished by health personnel,social workers, or speciallytrained field
workers. The educationand information componentsare vital parts
of any well conceivedfamily planning program.
A final constraint on effectivenessis inadequateevaluation.Al-
though considerablework has been done on the measurementof
resultsof family planning programs,there is everywhere long way .

to go before adequatereporting systemsexist to provide information

for managementdecision-makingand program evaluation. Inade-
quate evaluation machinerylimits assessment of a program'seffec-
tivenessin reducingfertility, the ultimate test of its success.
An adequate information system for evaluation would address
itself to three questionsin particular: (a) The structureand level of
demand, to provide guidance for determining the priorities of the
program'sefforts among areasand population groups; (bi The effect
of varying the level and mix of variousprograminputs, to suggestthe
combination likely to achievebest results; and (c) The effect of the
programon reducingfertility, to provide a measureof effectiveness.'

ProgramCosts
.nancial expenditureson family planning programs have been
modest in relation to national budgets(averagingabout 1%) and, as
noted in the previous section,very low in relation to the economic
benefits of reducedfertility. To date, external assistancehascarried
a sizable proportion of the costs,usually more than 30%. Tables6
and 7 give data for selectedcountries.The relatively low costsare
'See Annex 4 tor discussion of a desirable managementinformation and evaluation system.

22
 partly explained by the use of existing health servicesas the main
delivery system.
In many cases,evenwhen a population policy exists,programex-
penditure is too little in relation to the need. Becausenational family
planning efforts are so recent, costtrends are availablefor only a few
countries; in some (e.g.,India, Republicof China) expendituresare
increasing;in others the data show decreases.Cost p:ojections and
the level of foreign assistanceneededin the next decadecannot be
assessedwith confidence on the basisof such limited experience,
but informed estimateshave been made which uggestorders of
magnitude.
Table 6: BudgetatyPosition of FamilyPlanning Programs
in SelectedCountries,1968-1969
(LIS$millions)
Foreign familv
Fo,reign Aid a, '. Farmili Planning
famils Aid tor *, Famrly Planniny. as ", of
Njijonal Health"' Planning Famils Planning a, '. o. National
Countr% Budget Program Program Pl,!nning Budge-t Health Budget
China, Rep. of 823.0 64.4 0.6 0.5 87.1 1.0 0.1
India 3,141.9 70.8 49.3 18.9 38.3 41.1 1.6
Indonesia 646.3 n.a. 4.Ca' n.a. 92.5 n.a. 0.1
Jamaica 218.3 18.5 0.5 0.2 31.7 2.9 0.3
Korea, Rep. of 984.8 7.7 4.1 2.0 48.8 52.8 0.4
Pakistan 996.6 46.0 19.1 14.9 77.9 41.5 1.9
Trinidad and
Tobago 188.6 13.5 0.1 0.03 30.2 0.8 0.1
"'These data are not comparable on a count, oasis. Some countric'sdo noit shts !amily planning
costs independent ot expenditures tor health programs or do so to varying degrees. In some
countries it is considered politically inadvisable to publish preriie figures. Alio. the dt.i do not
include the costc of prisate programs.
"iData tor 1q70-71.

In a staff study, the United Nations Fund for PopulationActivities

(UNFPA)has estimatedthat it would be necessaryfor developing
countries,if theywere to carry out reasonablycomplete family plan-
ning programson a broad national basis,to spendapproximately65
U.S.cents per capita per year. This figure increasesto $1 per capita
if the costsof educational,motivationaland systemevaulationactivi-
ties are included.Tilese amountsare not small when translatedinto
the proportionsof national budgetsthey would represent,e.g.,some-
where around5%. Fivepercentis a muchlower proportion than most
governmentsnormally spend on education (15% to 30%) or on
national security,but it is about the proportion of total Ministry of
Health expendituresin manylow income countries.
Not even the most committed governmentswith the most suc-
cessfulprogramsare spendingas much as half the per capita figures
mentioned in the UNFPAstudy, and most are spending much less.

23
 Table 7: AnnualPer CapitaExpenditure
of Selected
FamilyPlanningPrograms"'
(UScents)
China,Republicof 6.0 (1971)
India 7.72 (19681
Indonesia 4.1 (1970)
Jamaica 37.0 (1968)
Korea,Republicof 10.4 (1969)
Pakistan 9.4 (1969)
Tunisia 16.8 (1969)
on funds fromall sources-government,
'MBased international,bilateral,and private.
Source.PopulationCounc.l,Populationand FamilyPlanningPrograms: A Factbook.' . 2 (1971
editioni, June 1971, New York.

It is clear that population programs require important shifts in gov-

ernment priorities, which will frequently require fairly significant
changes in budget allocations. Successful programs require substan-
tial increases in both national and international inputs, public and
private.

The Potentialfor FamilyPlanning

How successful can family planning efforts be in reducing fertility
over the next generation? No one knows. Not enough experience to
serve as a guide has been accumulated in existing programs, most of
which began only four or five years ago. Large areas of ignorance
surround such key questions as the potential number of acceptors,
since relatively little is known about the determinants of family size
decisions and how open to change they may be among various
social groups.
There is much debate among experts as to whether the present
numbers of acceptors can be increased (a) primarily through the ex-
tension of services (an approach which assumes the existence of large
numbers waiting to participate); (b) whether much more intensive in-
formation, communication and family life education activities would
be more productive; or (c) whether much larger numbers of accep-
tors can be recruited only after basic socio-economic changes have
taken place. Both research and further experience are needed to
throw light on this fundamental question. Some inferences may )e
drawn, however, from recent experience:
* There does appear to be a correlation between a national pro-
gram's supply capacity (i.e., the number of service facilities) and the
number of women who make use of thte program. This suggests that
as a program's capacity is increased, it does gain additional acceptors,
particularly in the early stages when those who can be most easily
recruited are becoming acceptors. But there is also evidence that

24
 programsin which insufficientattentionis givento educationand
motivationdo notsucceedin recruitinganythingliketheproportion
of womenneededto reachnationalpopulationgoals.It seemsclear
thatgovernments will haveto giveequalattentionto boththesupply
anddemandsidesof theproblem.
* Everywhere thereareconstraints to programexpansionbecause
of the alreadyheavydemandson the medicalservices,inadequate
numbersof traineapersonnelat all levels,inadequate andinsufficient
physicalfacilities,etc. Butgiventhe politicalwill, suchproblemsare
not insurmountable overthe long run (and,asindicatedin the next
section,theseareareasin whichthe Bankcanassist). Overtheshort
run,therearepossibilities for makinguseof non-medical personnel,
in particularsocialworkers,andusingparamedical personnelmore
effective!yin providingfamilyplanningservices.
* As to long term demandfor family planningservices,three
kindsof evidencesuggest that it existsor can be developed:
(1)Variousknowledge,attitude,and practice(KAP)surveysindi-
catethat mostcouplesin developingcountrieswant fewerchildren
thanthey now have.Theaveragenumberof childrenthat a family
"desires"is betweenfourand4.5,comparedto actualfamilysizeof
five to 5.7.In particular,manyfamilieswhichalreadyhaveat least
threechildrendo notwantmore:in HongKongandsevendevelop-
ing countries,'60% of respondents who alreadyhadthreechildren
and70%of thosewith four saidtheydid not want to increase their
families(seeTable8).
Thesesurveyshavetheir limitations.For example,the repliesof
older respondents are influencedby their actualreproductivehis-
tory. Moreover,an expressedpreferencefor a given numberof
childrendoesnot necessarily meanthat contraceptives will be used
on the requisitesustainedbasis.Nevertheless, studiessuggestthat
youngerandbettereducatedwomenwantsmallerfamiliesthantheir
mothersdid. If theevidenceof thestudiesisaccepted, it doesappear
that there is an unsatisfieddemandfor expandedfamily planning
services.
(2) Theappallinglyhigh incidenceof illegalabortionsin many
countries,particularlyin LatinAmerica,clearlyindicatesan unmet
needfor familyplanningservices.
(3)Themostsuccessful familyplanningprogramsto date-in the
Republicof China,HongKong,Republicof KoreaandSingapore-
havebeenconductedin countriesweresocialpressures andthe level
of socio-economic development hadalreadyled to somedecli.iein
'Hong Kong 1967;Thailand 1965;Philippines(urban) 1969;Turkey1963; Republicof Korea (urban)
1964;Tunisia1964; India 196061; Indonesia1963.

25