New perspectives on population: lessons from Cairo

The lessons from the 1994 World Population Conference in Cairo, Egypt, are summarized in this publication. The topics of discussion include the evolution of population policies, the changing policy environment, demographic trends, and solutions in the form of gender equity, provision of reproductive health services, and sustainable social and economic development. The program of action supported by 180 governments and targeted for 2015 articulated the goals of universal access to a full range of safe and reliable family planning methods and reproductive health services, a specified level of reduction in infant and child mortality, a specified level of reduction in maternal mortality, an increase in life expectancy to 70-75 years or more, and universal access to and completion of primary education. Other features include goals for improving women's status and equity in gender relations, expansion of educational and job opportunities for women and girls, and involvement of men in childrearing responsibilities and family planning. Steps should be taken to eliminate poverty and reduce or eliminate unsustainable patterns of production and consumption. Population policy must be integrated within social and economic development policies. About $22 billion will be needed for provision of family planning and reproductive health services by the year 2015. Costs will increase over the 10-year period due to the increased population to be served. Per person user costs for family planning alone are higher in countries without infrastructure and technical skills. Actual costs vary with the cost of contraceptive supplies, patterns of use, and efficiency of delivery systems. Although the plan offers 16 chapters worth of advice and recommends 243 specific actions, countries will have to be selective due to cost limitations. The 20/20 Initiative is proposed for sharing social service costs between international donors (20%) and host countries (20%). A separate UN projection of need is for 33% of support from international donors for family planning and related programs. The constraints to the implementation of the action plan are identified as the rate of demographic change, the extent of public support for population limitation and provision of family planning services, and potential conflicts of interests and funding between cooperating agencies. The World Bank has developed guidelines for policy development according to a country's identification as an emergent, transitional, or advanced country.     

Census adjustment and the distribution of federal spending

In 1989, programs that use population counts to determine the distribution of their funds transferred $236 per capita to state and local governments. If the 1990 census were adjusted to reflect undercounting, about 40% of state and local governments would receive increased grants averaging $56 per miscounted person; other jurisdictions would lose an almost equal amount of grant money. The surprisingly small reallocations arise because 1) total funds allocated by population are essentially fixed; 2) allocations depend on other factors in addition to population; and 3) programs vary as to whether they allocate funds in direct or inverse proportion to population.     

A special section for correspondence and controversy

Summary The programs described above cost the state about $1 billion. Other state costs (which are not my responsibility) are incarceration costs for illegals, $400 million. Education cost for children of illegals has been estimated to be $1.7 billion this year. These two alone equal $2.1 billion.Please accept my assurances, and those of Governor Wilson, that we in the administration are not xenophobic or nativistic.I do not know if 8.6 million persons is a reasonable number for our nation of 250 million plus to accept and assimilate. I am convinced that 4.3 million is too many for a single state of 30 million to assimilate effectively. Certainly the costs of doing so are beyond our capacity to absorb without help.I am convinced that our existing assimilation ability is hamstrung by federal practice that ignores our immigration laws by permitting an unchecked flow of illegal immigrants into our country. Over half of this population enters and resides in California.The problem is exacerbated by the almost total failure of the federal government to support itslegal immigration decisions with federal funds to offset the costs of the resultant influx of immigrants.Presented at the Pacific Research Institute Conference on immigration, San Francisco, CA, April 25, 1994.     

Why population matters

Population growth around the world affects Americans through its impact on the economy, the environment, and the world our children will inherit. This explains why population growth is important and why the U.S. government provides assistance (roughly $500 million annually, or $2 per American) for population programs in developing countries. These programs help couples to use family planning when they want to, thereby reducing birthrates, protecting the health of women, and strengthening families.     

The Bangladesh fertility decline: an interpretation

The claim has been made, notably in a 1994 World Bank report, that the Bangladesh fertility decline shows that efficient national family planning programs can achieve major fertility declines even in countries that are very poor, and even if females have a low status and significant socioeconomic change has not occurred. This article challenges this claim on the grounds that Bangladesh did experience major social and economic change, real and perceived, over the last two decades. This proposition is supported by official data and by findings of the authors' 1997 field study in rural southeast Bangladesh. That study demonstrates that most Bangladeshis believe that conditions are very different from the situation a generation ago and that on balance there has been improvement. Most also believe that more decisions must now be made by individuals, and these include decisions to have fewer children. In helping to achieve these new fertility aims, however, the services provided by the family planning program constituted an important input.     

Seven measures for population control announced in Guangzhou

On 7 October 1988, the Municipal Government of Guangzhou, China, announced the following Decision: "First, great efforts should be made to strengthen education on the situation and tasks of the family planning programme. Second, family planning work is included in the target responsibility system of leaders at all levels during their terms of office and whether it is good or bad for the fulfillment of their family planning tasks will be considered as one of the criteria for the assessment of cadres in their work to link up with rewards and punishments. Third, the current family planning policies must be resolutely and unswervingly carried out. For those units where family planning policies have not been well carried out and where family planning work has long been stagnant, competent authorities should send capable cadres to help them improve their work within a definite period of time. Fourth, the principle of 'three priorities' (i.e., priority of publicity and education to economic restriction, priority of contraceptive measures to induced abortions, and priority of day-to-day work to shock work) must be adhered to while technical service and work of transforming the backward situation in some places should be done. Fifth, the family planning organizations at all levels must be perfected and ranks of family planning workers be strengthened with the stress on those at the township, town, and street neighbourhood levels. Moreover, the family planning offices should be set up or full-time family planning workers be staffed for enterprises and undertakings in the cities. Sixth, funds for the family planning work must be guaranteed. Seventh, the management of family planning for [the] floating population must be strengthened and a management group for [the] floating population, which consists of representatives from the Municipal Government and departments concerned, must be established."     

Backing seen of population policy in AID

Congress is almost certain to agree to use of U.S. funds to motivate reduced population growth in developing countries but funding for sterilization abroad emerged as a political issue in the House. In the proposed U.S. AID budget, which in the past has been about 10% funded for direct population programs, a total concern with literacy for women, higher educational levels, and other developmental programs which increase motivation for family planning has been proposed. Zero Population Growth has sent telegrams to Congress supporting this basic development policy. The controversy over sterilization is the result of India's compulsory sterilization legislation. An amendment refusing to allow any U.S. funds to be used for sterilization programs was rejected, but in rejecting it, the members of the House of Representatives expressed their concern that any and all sterilization programs be completely voluntary. In a letter, AID Deputy Administrator Robert Nooter assured Congress that AID has no goals to sterilize any certain number of women around the world and it is not the main purpose of the AID program to to emphasize sterilization as a method of family planning.     

Systematic review on the cost and cost-effectiveness of mHealth interventions supporting women during pregnancy

ObjectivesThe increased integration of digital health into maternity care—alongside growing use of, and access to, personal digital technology among pregnant women—warrants an investigation of the cost-effectiveness of mHealth interventions used by women during pregnancy and the methodological quality of the cost-effectiveness studies.MethodsA systematic search was conducted to identify peer-reviewed studies published in the last ten years (2011–2021) reporting on the costs or cost-effectiveness of mHealth interventions used by women during pregnancy. Available data related to program costs, total incremental costs and incremental cost-effectiveness ratios (ICERs) were reported in 2020 United States Dollars. The quality of cost-effectiveness studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).FindingsNine articles reporting on eight studies met the inclusion criteria. Direct intervention costs ranged from $7.04 to $86 per woman, total program costs ranged from $241,341 to $331,136 and total incremental costs ranged from -$21.16 to $1.12 million per woman. The following ICERs were reported: $2168 per DALY averted, $203.44 per woman ceasing smoking, and $3475 per QALY gained. The full economic evaluation studies (n = 4) were moderate to high in quality and all reported the mHealth intervention as cost-effective. Other studies (n = 4) were low to moderate in quality and reported low costs or cost savings associated with the implementation of the mHealth intervention.Conclusions for practicePreliminary evidence suggests mHealth interventions may be cost-effective and “low-cost” but more evidence is needed to ascertain the cost-effectiveness of mHealth interventions regarding positive maternal and child health outcomes and longer-term health service utilisation.     

Radio: a strategic tool for development

Every country should recognize the need to fully involve media leaders in the planning and implementation of population and family planning programs. Broadcasters are the best equipped to understand the "mind-set" of the mass audience and what is needed to bring about changes therein. If there is to be involvement of the media, particularly radio professionals, in the design, development and implementation of population and family planning programs, attention must be given to the inmplications of this in terms of implementing the World Population Plan of Action. Strategies for population communication using radio as the central medium include the following: 1) development of an adequate in-country support structure; 2) development of a sound, well-researched population communication program; 3) on-air programming in the form of instruction rather than entertainment; 4) provision for substantial and continuous feedback from the audience; 5) frequent broadcasts at a prime time of day; and 6) a program commitment of from 5 to 6 years. Radio needs to be recognized as a strategic tool for development; it should be used professionally and should receive sufficient priority by funding agencies.     

Family planning and fertility decline: a global overview

Family planning and development policy concerns are not incompatible. The emphasis on development policies at the 1974 World Population Conference at Bucharest did not mean that world governments had lost interest in the population and family planning issue. Although worldwide attitudes toward family planning have become more and more favorable, this has not yet meant great impact on world demographic trends. The "inertia factor," i.e., the effects of high birthrates in the previous generation, will camouflage declining birthrates for some time to come. The trend of fertility reduction which was perceptible only among small populations a few years ago is also becoming manifest in larger Third World countries. Mortality rate declines have slowed down but there is no rising mortality due to starvation in any country. At present, food demand exceeds availability for 80% of the Third World population. It is predicted that the food deficit will increase 70% by the year 2000.     

Asia's population and development in retrospect and prospect

By 1989 Asia's population will reach 3 billion. That Asia's countries can change the course of population development has been shown by China, whose population growth rate has decreased to 1.2%. 58% of the world's population in 1985 was Asian, and 53% of it was concentrated in 11 Asian countries, of which 37.6% was accounted for by India and China. Asia's population density is 3 times the world average, and the number of persons sustained by a square kilometer of land in Asia is 2.5 times the world average. Asia's population is young (median age 20.3), which means a high dependency burden, a large number of women of childbearing age, and low quality of life, as measured by infant mortality, life expectancy, and literacy. Rapid population growth ensures a low rate of development. Asia's goals are to achieve a 1% growth rate by year 2000, zero population growth and replacement level by 2015 for East Asia and 2020 for South Asia. The World Bank estimates that Asia's population will not stabilize until the end of the 21st century, by which time it will have reached 6 billion. Asia must find a way of achieving both population control and economic development. 5 recommendations are made to the Asian Forum of Parliamentarians on Population and Development (AFPPD): 1) that the AFPPD sponsor the activities of "the Day of 3 billion"; 2) that seminars and conferences on population be held among Asian nations; 3) that high-fertility countries adopt late marriages, few births, and programs for maternal and child health; 4) that organizations for family planning be strengthened and given the resources to upgrade the status of women; and 5) that international cooperation in the area of population be intensified.     

Sub-Saharan Africa: population pressures on development

The population of sub-Saharan Africa, estimated at 434 million in 1984, is expected to reach 1.4 billion by 2025. The birth rate, currently 48/1000 population, continues to increase, and the death rate, 17/1000, is declining. Rapid population growth has curtailed government efforts to provide adequate nutrition, preserve the land base essential for future development, meet the demand for jobs, education, and health services, and address overcrowding in urban areas. Low education, rural residence, and low incomes are key contributors to the area's high fertility. Other factors include women's restricted roles, early age at marriage, a need for children as a source of security and support in old age, and limited knowledge of and access to modern methods of contraception. Average desired family size, which is higher than actual family size in most countries, is 6-9 children. Although government leaders have expressed ambivalence toward development of population policies and family planning programs as a result of the identification of such programs with Western aid donors, the policy climat is gradually changing. By mid-1984, at least 13 of the 42 countries in the region had indicated that they consider current fertility rates too high and support government and/or private family planning programs to reduce fertility. In addition, 26 countries in the region provide some government family planning services, usually integrated with maternal and child health programs. However, 10 countries in the region do not support family planning services for any reason. Unfortunately, sub-Saharan Africa has not yet produced a family planning program with a measurable effect on fertility that could serve as a model for other countries in the region. Social and economic change is central to any hope of fertility reduction in sub-Saharan Africa. Lower infant and child mortality rates, rising incomes, higher education, greater economic and social opportunities for women, and increased security would provide a climate more conducive to fertility decline. Given the limited demand, great sensitivity must be shown in implementing family planning programs.     

A tentative discussion on family planning problems in Xinjiang's minorities]

The Uighur Autonomous region in Xinjiang includes a number of minority groups such as the Uighur, Kazakh and Hui. The question of how to implement family planning in minority areas if of utmost importance. In February 1982, the State Council decreed that family planning policy for minority groups could justifiably be more lax than for the Han people, who comprise a majority of Chinese population. Instead of advocating 1 child per couple, as is the current national policy, urban minority groups are permitted 2 (with exceptions, 3) children per couple and rural villagers are permitted 3 (with exceptions, 4) children. The 1982 National Census showed that the natural rate of growth for Xinjiang was 13.63/1000 (compared to the national rate of 11.45/1000) with individual minority growth rates as high as 20.11/1000. The area's gross output value cannot keep up with this population increase. Over half of Xinjiang's minorities are of the Islamic faith, which teaches that births are not self-willed. It is crucial to inculcate in them that births can indeed be planned. Also, their custom of early marriage (age 15 for girls and 16 for boys) which leads to a high fertility rate, must be changed. Although Xinjiang's land mass is great, only 38.4% is arable, so the common belief that its population can grow without limit is fallacious. When family planning was being implemented nationwide, for minorities it was only propagandistic. After the population growth for the majority Han was under control, the minority groups declared family planning programs would also benefit them. Symposiums were held contraceptive use became voluntary among many women. The birth rate fell from 22.5/1000 in 1981 to 14.09/1000 in 1985. Family planning also received approval from religious leaders. But because population distribution and growth are uneven in Xinjiang, family planning policy must reflect these differences.     

Population growth and poverty in the developing world

The links between rapid population growth and the absolute poverty currently affecting 780 million people in the developing countries (excluding China and other centrally planned economies) were examined. Absolute poverty is defined as having less than the income necessary to ensure a daily diet of 2150 calories per person ($200 per person a year in 1970 United States dollars). Focus is on poverty and demography in the developing world (defining poverty; income, fertility and life expectancy; demographic change and poverty), effect of poverty on fertility, family planning programs and the poor, and the outlook for the future. Rapid population growth stretches both national and family budgets thin with the increasing numbers of children to be fed and educated and workers to be provided with jobs. Slower per capita income growth, lack of progress in reducing income inequality, and more poverty are the probable consequences. Many characteristics of poverty can cause high fertility -- high infant mortality, lack of education for women in particular, too little family income to invest in children, inequitable shares in national income, and the inaccessibility of family planning. Experience in China, Indonesia, Taiwan, Colombia, Korea, Sri Lanka, Cuba and Costa Rica demonstrate that birthrates can decline rapidly in low income groups and countries when basic health care, education, and low-cost or free family planning services are made widely available.     

Thinking about several problems of the research of our family planning strategy]

On the basis of 1982 census data, it is estimated that from 1987-1997 13 million women will enter the age of marriage and child-bearing each year. The tasks of keeping the population size around 1.2 billion by the year 2000 is arduous. Great efforts have to be made to continue encouraging one child/couple, and to pursue the current plans and policies and maintain strict control over fertility. Keeping population growth in pace with economic growth, environment, ecological balance, availability of per capita resources, education programs, employment capability, health services, maternal and child care, social welfare and social security should be a component of the long term development strategy of the country. Family planning is a comprehensive program which involves long cycles and complicated factors, viewpoints of expediency in guiding policy and program formulation for short term benefits are inappropriate. The emphasis of family planning program strategy should be placed on the rural areas where the majority of population reside. Specifically, the major aspects of strategic thrusts should be the linkage between policy implementation and reception, between family planning publicity and changes of ideation on fertility; the integrated urban and rural program management relating to migration and differentiation of policy towards minority population and areas in different economic development stages. In order to achieve the above strategies, several measures are proposed. (1) strengthening family planning program and organization structure; (2) providing information on population and contraception; (3) establishing family planning program network for infiltration effects; (4) using government financing, taxation, loan, social welfare and penalty to regulate fertility motivations; (5) improving the system of target allocation and data reporting to facilitate program implementation; (6) strengthening population projection and policy research; (7) and strengthening training of family planning personnel to improve program efficiency.     

Our population predicament: a new look

Issued to mark the Population Reference Bureau's 50th anniversary, this issue updates the story of world population presented in its popular predecessor of 1971, "Man's Population Predicament." Estimated at 1/2 billion in 1650, world population reached about 2 billion in 1930, 4 billion in 1975, and is projected to be about 6 billion in 2000. Most of today's rapid growth is occurring among the 3/4 of the world's peoples living in less developed countries where the post-World War II gap between high birth rates and falling death rates has only recently begun to narrow. This growth, coupled with high consumption in developing countries, is putting tremendous pressures on the Earth's resources, environment, and social fabric. New evidence on Europe's population transition and from China, Indonesia, and Thailand in the 1970s suggests that well-designed family planning programs can speed fertility decline but rapid worldwide attainment of replacement level fertility will also require special development efforts and measures that go beyond family planning. Current projections of the world's ultimate peak population range from 8 billion in the mid 21st century to 11 billion in about 2125, depending on when replacement-level fertility is reached. China's drive for a drastic birth rate reduction and the oil crisis might change fertility behavior more rapidly than most demographers have heretofore thought likely.     

Population and housing

The analysis described here was carried out in response to a political crisis in Australia. In 1994, a Member of Parliament who opposed the use of foreign aid funds for family planning programs blocked the passage of the national budget. The impasse was resolved through a compromise. The use of foreign assistance for population activities was frozen pending an independent inquiry into the impact of population on economic development. A team of nine researchers prepared background papers on population and economic development, health, education, food supply, housing, poverty, the environment, family planning, and human rights. The overall conclusion of the inquiry was that slower population growth will yield more rapid development in most countries, especially in relatively poor, agricultural nations. The purpose of this contribution to the inquiry was to assess how population growth was affecting the housing sector and, in turn, economic development. Among other questions, does population growth increase the demand for residential land, housing, and urban infrastructure? Demographic methods were critical to answering the questions, especially assessing the impact of population growth on the demand for housing.     

Perceived factors of family planning clinic performance and service quality

As part of a larger operations research project, this 1990 study analyzed the performance of the Philippine Department of Health's (DOH) family planning (FP) clinics. Specific study objectives were 1) to measure acceptor targets, servicing capacity utilization, outreach, and costs; 2) to determine what providers believed affected performance; 3) to record which quality indicator providers use; and 4) to determine the perceptions of acceptors about clinic personnel, the clinic as a FP outlet, FP service processing, and FP service quality. Data were gathered from clinic records and from sample surveys in 25 clinics in four specified locations. Eight clients were sampled from each of the 100 clinics. It was found that clinic staff accepted low attainment of FP acceptor targets and that clinic capacity utilization levels were at 25% of capacity. Providers were unaware of the number of potential FP acceptors in their areas and had no information about the costs of running their clinics. The FP clinic managers identified 34 major determinants of clinic performance, but more than half reported that they had very little control over these determinants. The providers described quality service from the point of view of the acceptors and described the quality of a clinic in terms of the minimal physical characteristics required. The acceptor survey revealed that acceptor satisfaction depends upon 1) clinic accessibility and lay-out, 2) intensive personal contact, and 3) clinic infrastructure. The study uncovered a need for the DOH to institute management training programs for clinic managers and to provide managers with the resources and personnel to shift priorities in favor of FP coverage and prevalence. Managers, who are resource allocators, must also receive information about the costs of FP services in their clinics. In addition, the DOH's determination that its FP program would be facility- rather than community-based should be modified to incorporate community outreach elements. The DOH can also make a big impact on perceptions of quality (of both providers and acceptors) by improving clinic conditions to meet basic standards. Once these basic needs are met, additional needs of acceptors can and must be addressed.     

Withdrawal in Pakistan: new insight into an old method

Although family planning programs pay almost no attention to the validity of coitus interruptus (withdrawal), it is a traditional method of family planning widely used to regulate fertility in Pakistan. Large-scale quantitative studies conducted in recent years in Pakistan by the Population Council have indicated that withdrawal is the most popular temporary method of fertility regulation in the country, second among all methods only to female sterilization. Pakistani couples use withdrawal mainly because they believe that modern methods are unsafe for women and unreliable. They have some fears and misconceptions about modern methods. The method may work well in Pakistan also because users seem to feel that they own it. Withdrawal is therefore a reasonable option given Pakistanis' beliefs and circumstances. Those who use withdrawal in Pakistan practice the technique with considerable efficacy and tend to continue using it. Furthermore, couples which use withdrawal have discussed their family planning preferences and decided together to use the method. However, in order to improve the use of modern methods of contraception, information provision, counseling, and interpersonal communication must be improved.