349. Paper Prepared in the International Development Cooperation Administration1
INTERNATIONAL POPULATION/HEALTH INITIATIVE
Rationale
Even allowing for continued moderate slowdown in the rate of growth, world population is almost certain to exceed 6 billion by the year 2000, an increase in only two decades equal to the entire world population as recently as 1930. Ninety percent of this growth will occur in low income countries. With present trends, the two-child family will not occur world-wide until the year 2020, and the world’s population will not stabilize until 2090—at 10 billion, compared to today’s 4.4 billion.
The demographic situation is serious but not hopeless. Worldwide population growth rates are no longer rising. Growing evidence from disparate cultures and economies demonstrates that fertility can be reduced by determined efforts to provide family planning services and information—in conjunction with efforts to build community and family support for family planning, particularly by improving women’s opportunities outside the home. Over the past decade, understanding of the seriousness of the population problem has grown, and many countries have begun to address population issues. Indeed, for the first time LDC government requests for population assistance substantially exceed the existing contributions of population donors. The U.N. World Population Conference in 1974, Conference on Primary Health Care in 1978, and International Women’s Conferences in 1975 and 1980 all called for provision of family planning services and information to all countries. The International Development Strategy also does.
Providing family planning also improves maternal and child health. The principal threats to health in developing countries are malnutrition and common infections, particularly among young children. These threats are exacerbated by close birth spacing. Maternal mortality (and abortion) is also very high.
[Page 1165]The Initiative
Given (1) urgent population pressure and related health needs in many areas, (2) growing LDC requests for assistance; and, (3) the ability of the major population donors to mount effective and complementary population programs that respond to country-specific opportunities, IDCA and State propose an initiative to:
a. extend high-quality family planning and closely related maternal and child health services as a first step toward primary health care;
b. promote programs that build motivation for small families, particularly by improving opportunities for women and by giving recognition to couples that limit their family size;
c. strengthen political will by clarifying the extent and seriousness of the population problem at both leadership and community levels.
The initiative aims primarily at doubling family-planning practice in the developing countries by 1985, as a step toward lower birth rates. (It also aims at improving basic primary health care, particularly in maternal and child health.) It estimates roughly the expenditures on “population” needed to do this—assuming other development policies are conducive to smaller families and assuming adequate expenditures for other aspects of health.
At present, total spending for population is approximately $1 billion, of which $450 million comes from international donors. Of this, the United States now provides about half. At this level of spending, we know that something like 1/5–1/4 of the couples of reproductive age use some form of contraception,2 and that birth rates in the developing countries (outside China) are roughly 35 per 1,000. To reduce birth rates to something around 25–28 per 1,000 (still far from a two-child norm) contraceptive user rates must at least double; roughly 1/2 of couples must practice family planning. This will only happen when most couples have access to safe, effective and affordable family planning services, and when they are motivated to use them. A doubling of population resources is the minimum necessary to achieve these important targets. This would imply about $2 billion in total spending (real dollars), including at least $1 billion in assistance. (Doubling resources may not quite achieve a doubling of practice, if programs hit diminishing returns. We have already reached some of the “easier” acceptors. But programs get more effective as they go along. On balance, the marginal cost per acceptor may rise, but modestly.)
This initiative, which accords with the recent Declaration of the International Parliamentarians’ Conference sponsored by UNFPA and [Page 1166] with a resolution just passed at the U.N. Mid-Decade Conference on Women, would require a concerted international effort supported by UNFPA, WHO, UNICEF, the World Bank, country donors, and the concerned LDCs.
Other donors interested in increasing population assistance may wish to consider making or increasing contributions to the following institutions:
— UNFPA
The United Nations Fund for Population Activities, active in over 120 countries, has a current budget of about $150 million and a substantial backlog of projects needing support. It primarily funds government projects. As of August 31, 1980, the UNFPA had funded 2,863 projects of which 1,135 has been completed.
— IPPF
The International Planned Parenthood Federation, a private organization also active in many countries, has a budget of about $50 million annually and also a substantial backlog of projects. Like other private organizations, it specializes in innovative ways of initiating and extending family planning services, particularly where open government support is not yet appropriate. (But IPPF often works with government health programs.)
—Other private organizations such as the Population Council active in this field.
Of course several donors, e.g., the Scandinavians, Canada, and the UK, have bilateral programs they may wish to expand.
FYI ONLY: Strategic Program Objectives for I.D.C.A.
1. Sharply increase A.I.D.’s level of funding from about $200 million in FY 1979–80 and continue pragmatically on a country-by-country basis, emphasizing its strongest areas: combining supply of family planning services with support of programs aimed at building demand for those services. Such efforts principally include policy work particularly to increase LDC national leadership commitment; training especially of outreach workers from local communities, and other methods of community involvement; provision of commodities; management support; and biomedical and operations or policy research which tests practical combinations of population, health, and other development measures affecting fertility. We will press other donors—bilateral and multilateral—to support other fields of population assistance. On that basis when AID proposes efforts in those other fields, it will obviously bear a stronger burden of persuasion.
2. Within the above framework, develop and emphasize AID’s capacity for innovation and evaluation activities.
3. Infuse population concerns into all AID health activities while maintaining AID’s health initiative focusing on primary health care.
[Page 1167]4. In other development sectors, emphasize those policies and programs that build motivation for smaller families (especially by expanding women’s employment and education opportunities). This should be a major effort of AID (required by Section 104 (d)),3 but it should be pursued at the UN, the MDB’s and elsewhere.
5. Encourage the World Bank to expand its projected budget for population faster, given the Bank’s strong public calls for more attention to population. Recognize that the Bank has demonstrated a strong interest in population/health infrastructure. Continue to support the Bank’s efforts to broaden the range of its population activities and to exert more leadership in consortia and Consultative Groups on population.
6. Support higher budgets for UNFPA, especially via other donors (who now channel most of their population assistance through UNFPA). Recognize that UNFPA has demonstrated a strong interest in policy development, information, and demographic activities, a sensitive issue; urge UNFPA to give greater and more effective support to a full range of family planning activities (including family planning services) wherever possible; encourage UNFPA to be responsive to opportunities in countries where other donors do not have population programs; and encourage UNFPA to help press other UN agencies to consider the effects of their programs on population.
7. Encourage co-financing of projects among AID, UNFPA, and the World Bank.
8. Press the regional development banks to initiate substantial population assistance. (IDB expects a proposal from Brazil; ADB is interested.)
9. Encourage the NGO’s to give more attention to family planning and to the effects on population of their other programs.
10. Continue to press for more attention to population through the IDS, GA, Special Session, OECD, and such.
- Source: Carter Library, National Security Affairs, Staff Material, Special Projects—Hazel Denton, Box 63, Population: 9–10/80. Drafted by Herz; cleared by Benedick and Van Dusen. Herz sent an earlier version of the paper to Denton under an August 20 covering memorandum. (Carter Library, National Security Affairs, Staff Material, Special Projects—Hazel Denton, Box 63, Population: 8/80)↩
- These data take account of breastfeeding and abortion (often illegal and dangerous). [Footnote in the original.]↩
- Reference is to Section 104(d) of the Foreign Assistance Act of 1973; see footnote 12, Document 308.↩