World Bank Document

successes. In Thailand contraceptive and well-trained practitioners, be referred for further help.use increased from 11 to 35 percent making programs heavily depend- Several countries have greatlyof rural married women between ent on the health system. increased the number of places1968 and 1975, and from 33 to 49 This has caused difficulties for where pills and condoms can bepercent of urban married women. many countries where medical bought, often at subsidized rates.In Indonesia the government facilities and personnel are too But simple and safe barrier methodsexpanded its service in 1974 from limited to provide adequate family (condoms, diaphragms and spermiaclinic-based approach, to one planning coverage. But if they cides) are still neglected in manybased in villages. It currently has operate within the framework of developing countries despite their3,500 clinics, 25,000 village depots the health service, middle-level renewed popularity in developedand 40,000 village family planning health staff and people specially countries. Their use could sensiblygroups. The proportion of married trained in family planning have be encouraged; research into wayswomen using modem contraceptives proved effective substitutes for of making them more practical inincreased from 7.4 percent in 1974 medical specialists. In Thailand developing country settings isto 18 percent in 1977; it was 0.2 and South Korea the use of para- needed (see box).percent in 1970.medical personnel for screeningNor need a population policy patients and supplying contracep- FUTURE PRIORITIES. Progress inbe confined to the support of tive pills led to increased acceptance reducing fertility will partly dependfamily planning programs. A few of these pills. Family planning aides on increasing the demand for concountries-mostnotably Singapore- in Pakistan and Bangladesh have traception-primarily through socialhave used tax and housing policies leamed to insert IUDs, and in India and economic development thatto discourage large families. Direct to carry out menstrual regulation successfully reaches the poor, butpayments for sterilization have been (inducing abortion of possible but also through the growing underanimportant part of the Indian unconfirmed pregnancies at an standing that fertility is a matterprogram. China, which for several early stage). On a trial basis, they of individual choice. It will alsoyears has emphasized that later have been trained to perform depend on providing effectivemarriage and small families are sterilization. family planning services. Both willpatriotic, recently announced Separate family planning services be facilitated if contraceptives canbonuses and preferences for one- have not been so successful. The be made more convenient and lesschild families, and tax and housing ad hoc systems (in Pakistan, for prone to complications that needpenalties for families with more example) have at times involved medical attention. And the importhantwo children. Raising the ambitious programs of regular tance of political commitment tolegal minimum age at marriage home visits to persuade people a population policy should not be(the median among all countries to plan their families, and to supply underestimated. Countries with ais still only 15) might also help, contraceptives. But without a sat- dual concem for social and economicalthough efforts to date have not isfactory health network, it may advance and for family planningbeen particularly successful (with be difficult to supervise the staff will be able to cut fertility ratesthe possible exception of China). and provide more specialized substantially in the rest of thisadvice or assistance to the few century, and beyond.IMPROVING ACCESS TO CONTRACEP- people who develop complications.TION. Before 1960 family planning A promising altemative approach The seamless webservices were provided largely by is to use other administrative netvoluntaryassociations. Most works. From time to time, India Chapter 4 stressed that education,programs were small and offered has had government personnel, health, nutrition and fertility sigservicesthrough health centers such as teachers and tax collectors, nificantly affect the incomes of theand private clinics, promoting recruiting people for sterilization poor. This chapter has consideredsimple barrier methods (foam, -although this became unpopular separately each of these main areascondoms and diaphragms) and through abuse. The successful of human development, with sperhythm.In the 1960s oral contra- family planning program in Indo- cial emphasis on the causes ofceptives and the intrauterine nesia (see box on page 80) has change and the policies that candevice (IUD) became available- taken advantage of strong com- bring it about. But it is worth reitandsterilization and legal induced munity organizations and made erating that the different elementsabortions became more common. extensive use of village workers, of human development are keyThese required clinical support with clinics to which people can determinants of each other.68