UN Population Division, Department of Economic and Social Affairs,
with support from the UN Population Fund (UNFPA)
|
| UN Population Division, Department of Economic and Social Affairs, with support from the UN Population Fund (UNFPA) |
|
Distr.
GENERAL
E/CONF.84/PC/7
17 March 1993
ORIGINAL: ENGLISH
PREPARATORY COMMITTEE FOR THE
INTERNATIONAL CONFERENCE ON
POPULATION AND DEVELOPMENT
Second session
10-21 May 1993
Item 4 of the provisional agenda*
PREPARATIONS FOR THE CONFERENCE
Recommendations of the Expert Group Meeting on Family Planning,
Health and Family Well-being
Report of the Secretary-General of the Conference
SUMMARY
In response to Economic and Social Council resolution 1991/93, the
Expert Group Meeting on Family Planning, Health and Family Well-being was
convened in Bangalore, India, from 26 to 30 October 1992 as part of the
preparations for the International Conference on Population and
Development to be held in 1994. The findings of the Expert Group are
presented in this report for consideration in the context of the review
and appraisal of the World Population Plan of Action by the Preparatory
Committee for the Conference. The Expert Group examined the linkages
between family planning, health and family well-being and emphasized the
need to place family planning in the wider context of quality of life of
women and children, and health and welfare of the family and to shift the
focus of family planning programmes from demographic targets to
individual needs. The deliberations had as their objectives to
contribute to the review and appraisal of the progress made in attaining
the objectives, goals and recommendations of the Plan of Action, to
identify the obstacles encountered and to adopt a set of recommendations
for the next decade in order to support couples and individuals in making
informed and voluntary choices about the timing, number and spacing of
children, through family planning programmes.
* E/CONF.84/PC/3/Rev.1.
93-15551 (E) 150493 /... CONTENTS
Paragraphs Page
INTRODUCTION ............................................. 1 - 7 3
A. Background ...................................... 1 - 3 3
B. Opening statements .............................. 4 - 7 3
I. SUMMARY OF THE PAPERS AND DISCUSSION ................ 8 - 35 5
A. Society and family planning ..................... 11 - 13 6
B. Review of existing family planning programmes and
lessons learned ................................. 14 - 15 7
C. Issues related to the implementation of family
planning programmes ............................. 16 - 25 8
D. Family planning and health ...................... 26 - 28 11
E. Family planning and family well-being ........... 29 - 31 13
F. Future directions: people's involvement in
family planning programmes ...................... 32 - 35 14
II. RECOMMENDATIONS ..................................... 36 - 46 17
A. Preamble ........................................ 36 - 46 17
B. Recommendations ............................................ 19
INTRODUCTION
A. Background
1. The Economic and Social Council, in its resolution 1991/93 of 26
July 1991, decided to convene an International Conference on Population
and Development under the auspices of the United Nations and decided that
the main theme of the Conference would be population, sustained economic
growth and sustainable development. The Council authorized the
Secretary-General of the Conference to convene six expert group meetings
as part of the preparatory work.
2. Pursuant to that resolution, the Secretary-General of the Conference
convened the Expert Group Meeting on Family Planning, Health and Family
Well-being in Bangalore, India, from 26 to 30 October 1992. The Meeting
was organized by the Population Division of the Department of Economic
and Social Development of the United Nations Secretariat in consultation
with the United Nations Population Fund (UNFPA). The participants,
representing different geographical regions, scientific disciplines and
institutions, included 18 experts invited by the Secretary-General of the
Conference in their personal capacities; representatives of the United
Nations Office at Vienna, the United Nations Children's Fund (UNICEF),
the five regional commissions, the United Nations Educational, Scientific
and Cultural Organization (UNESCO), the World Health Organization (WHO)
and the World Bank. Also represented were the following non-governmental
organizations: International Institute for Rural Reconstruction (IIRR);
International Planned Parenthood Federation (IPPF); International Union
for the Scientific Study of Population (IUSSP); Population Council;
Center for Development and Population Activities; Population Institute;
Program for Appropriate Technology in Health (PATH); Association for
Voluntary Surgical Contraception (AVSC); Family Health International
(FHI); Institute of Resource Development (IRD)/Macro Systems; Japanese
Organization for International Cooperation in Family Planning (JOICFP);
Pathfinder International; Population Crisis Committee; and Rockefeller
Foundation.
3. As a basis for discussion, the 16 experts had prepared papers on the
agenda items. The views expressed by the experts were their own and did
not necessarily represent the policies of their Governments or
organizations. The Department of Economic and Social Development
prepared a background paper entitled "Key issues in family planning,
health and family well-being in the 1990s and beyond". UNFPA contributed
a paper on future contraceptive requirements and logistics management
needs. Discussion notes were provided by the United Nations Office at
Vienna, the regional commissions and a number of specialized agencies and
non-governmental organizations.
B. Opening statements
4. Opening statements were made by Ms. D. K. Thara Devi Siddartha,
Union Minister of State for Health and Family Welfare of the Government
of India; Dr. Nafis Sadik, Secretary-General of the International
Conference on Population and Development; and Mr. Shunichi Inoue, Deputy
Secretary-General of the Conference.
5. In her opening remarks, Dr. Sadik noted that India provided an ideal
setting for the Meeting because India was the first developing country in
the world to have a national population programme and had continued its
commitment to planned population growth and voluntary family planning
since 1951. She also commended the efforts of the Government of India in
placing family planning in the wider context of health and family welfare
and agreed with the national strategy which emphasized the development of
human resources rather than controlling human numbers. Ms. Thara Devi
Siddartha reaffirmed the position of the Government of India that, for
the future well-being of the country, the highest priority had been
accorded to population stabilization efforts. In this regard, she noted
that fertility behaviour could not be understood in isolation without
reference to the socio-cultural context, nor could family planning
policies be pursued successfully without promoting conducive socio-
economic conditions such as female literacy, the general quality of life,
reproductive health and family well-being. She further noted that there
was a need to shift the emphasis from quantitative to qualitative
assessment of the population, which would require a holistic approach to
population control. Women's total health must become the central concern
of planning. When a woman was given the opportunity of choosing her time
of conception, the size of her family and the time period between births,
very large benefits were likely to accrue.
6. Dr. Sadik emphasized the need to place family planning in a wider
context of quality of life of women and children, health and family
welfare. She also stressed the need to enhance the status of women,
which was crucial for achieving sustainable development. To realize this
goal, women must have equal access to education and equal participation
in social, economic, cultural and political life. These considerations
implied the need for universal access to a wide range of safe, affordable
and effective contraceptive alternatives to meet the vast unmet demand
for family planning. Considering the growing problem of adolescent
fertility, she stressed the necessity of preventing teenage pregnancy and
removing the widespread ignorance among young people of the risks of
unprotected sexual activity. She emphasized the need to involve men in
family planning and to provide them with necessary information, education
and encouragement to take greater responsibility in contraceptive
practice and responsible parenthood. She noted that family planning
programmes could contribute substantially to the reduction of maternal
mortality and the improvement of the reproductive health of women. She
hoped that strategies for the prevention of acquired immune deficiency
syndrome (AIDS) could be found within the framework of family planning
and the Safe Motherhood Initiative, with particular focus on the needs of
women and adolescents. She stressed the importance of a high quality of
services for expanding the levels of acceptance and continuation of
contraceptive practices. She noted that special efforts were needed to
bring high-quality family planning services to vulnerable and/or under-
served sections of the population, including people in minority
communities, rural areas and urban slums. To improve the quality of
care, clients must be given a wide choice of contraceptive methods and
must be treated with dignity and respect by well-trained service
providers. She stressed that more research, development and training
were necessary to widen the range and improve the quality of available
contraceptive methods. It was also necessary to ensure that
contraceptive supplies were available at the right time and place and in
the right quantity. She underscored the necessity of directly involving
local communities to ascertain the family planning needs of communities
with widely different backgrounds and suggested that this "people-centred
approach" might encourage clients to share the cost of services. She
observed that the pool of international resources for development was not
growing as fast as the demand for resources. It was therefore essential
to increase coordination and collaboration between national family
planning programmes, non-governmental organizations, the private sector
and international organizations.
7. Mr. Inoue, while enumerating the notable progress made in family
planning practice in the past decade, noted that the current level of
fertility and the rate of population growth in many developing countries
were still too high and incompatible with the goal of achieving sound
social and economic development. He stressed the importance of women's
choice on the number of children or family size and matching of
individual fertility goals to national goals. He suggested that family
planning should be seen as a means to improve the health and well-being
of the family.
I. SUMMARY OF THE PAPERS AND DISCUSSION
8. In addition to a more general exchange of views regarding the key
issues in family planning, health and family well-being in the 1990s and
beyond, and the linkages between family planning, health and family well-
being, the Expert Group devoted particular attention to the following
areas: society and family planning; review of existing family planning
programmes and lessons learned; issues relating to the implementation of
family planning programmes (quality of services and human resources
development, unreached population groups, adolescent fertility, diffusion
of innovative activities, community-based distribution systems and social
marketing of contraceptives, and future contraceptive requirements and
logistics management needs); family planning and health (safe motherhood
and child survival: the interdependence of services; family planning,
sexually transmitted diseases and AIDS); family planning and family well-
being (family size, structure and child development; fertility decline
and family support system); people's involvement in family planning
programmes (community participation in family planning; cost of
contraceptive supplies and services and cost-sharing; contraceptive
research and development; re-examination of the roles of Governments,
non-governmental organizations and the private sector in family
planning). Both developed and developing country situations were
considered, although the latter dominated the discussion.
9. In formulating recommendations, the Expert Group focused on
identifying practical measures that could be taken to broaden the scope
of family planning programmes in order to make them more effective and
efficient, that would help to meet the unmet reproductive health needs of
women, and that would also have desirable effects on the status of women
and the health and well-being of the family. The Expert Group also
reviewed the state of knowledge about the topics mentioned above and made
recommendations regarding the need for research and data collection.
10. The contributions of family planning towards improving the quality
of life of the population, particularly the health and well-being of the
family, have been the focus of increasing international attention in a
variety of contexts, including human rights and equity and participation
of women in the process of social and economic development. There is
currently an array of international declarations and agreements
concerning the roles of family planning in improving the status of women,
the health of mothers and children, and the environment. These include
the World Population Plan of Action (1974) and the Recommendations for
Further Implementation of the Plan (1984), the Nairobi Forward-looking
Strategies for the Advancement of Women (1985), the Safe Motherhood
Initiative (1987) and the Amsterdam Declaration on a Better Life for
Future Generations (1989). The Expert Group noted that international
declarations and agreements provided necessary support and sound
guidelines for charting the future course of action and urged that
necessary action be taken in implementing them.
A. Society and family planning
11. The Meeting considered the general issues of fertility transition,
women's status and sociocultural milieu and how women's status had
affected the practice of family planning. The status of women needed to
be examined in relation to the social organizations and cultural contexts
which vary from society to society; hence, it remained an elusive
concept, further complicated by varied definitions of status such as
prestige, power, autonomy and rights. It was suggested that the
identification of factors underlying gender inequality might help in
understanding fertility behaviour, because fertility goals were likely to
depend on the extent to which women rely on their male kin and sons for
status and security. It was recommended that removal of gender
inequalities would enhance the status of women, which, in turn, would
have a positive impact on family planning. The Meeting further
considered the reverse side of the relationship, namely the effect of
reduced fertility on women's status. The reduction of time spent in
reproduction and child care allowed women to expand their participation
in the public sphere. It followed that family planning was a major
avenue to improve women's status by providing greater control over
reproductive decisions. It also provided control over fate and thus
empowered women. These independent effects of family planning at
microstructural levels needed to be emphasized.
12. The Meeting also considered issues relating to fertility transition
and socio-economic development, including the status of women and
associated policy questions on investments in social sectors. More
specifically, the questions raised here were: What social sector
investments are likely to strengthen the impact of family planning and
reproductive health services? and How can the design of services be
better tailored to the socio-economic structure in which they all
expected to be effective? The Meeting was of the view that social
development might be contributing more to fertility decline than to
economic development. The Meeting emphasized, however, that there was no
point in presenting socio-economic development and family planning
programmes as competitive or alternative approaches. Changes in
fertility behaviour, stemming from socio-economic development and
increased acceptance of family planning, should be seen as a gradual
process with synergistic effects. It would, therefore, be productive to
identify the linkages between social change, family planning programme
effort and reproductive behaviour. One such linkage was established
through research on "proximate" determinants of fertility, where effects
of socio-economic factors on fertility were usually seen to be mediated
through proximate factors such as use of contraception and rising age at
marriage.
13. A second line of inquiry that had helped to clarify the
understanding of synergies between socio-economic forces and programmatic
variables in accelerating fertility decline was the series of cross-
national studies. These studies showed that fertility declined most
rapidly in countries with high scores with both sets of indicators.
These synergies were also found in country-level studies of fertility
transitions now occurring in many developing countries, particularly in
Asia and Latin America. These studies illustrated that, even in
ostensibly unfavourable conditions, fertility decline could be
accelerated by programme efforts that were sensitive to local conditions,
responsive to community needs and designed to encourage social change.
For instance in Bangladesh, the recruitment of female outreach workers
had contributed to changes in the status of women. In the light of
recent empirical evidence, the Meeting made an important assertion that
the progress of family planning programmes was not dependent upon levels
of socio-economic development, because programmes were more than the mere
supply of contraceptives; they had evolved to respond to the particular
needs of a particular society. Thus, two decades of programme experience
had shown that the linkages between programme effort and socio-economic
setting involved a variety of synergies that needed to be better
understood and strengthened in order to guide social sector investments
in health and family planning, female education and other factors that
improve the status of women.
B. Review of existing family planning programmes
and lessons learned
14. A comprehensive overview of the family planning situations in
various regions of the developing world was presented at the Meeting.
This overview highlighted the process of socio-economic changes affecting
different parts of the world in terms of gross national product (GNP) per
capita, literacy, primary and secondary school enrolment, percentage of
men in the non-agricultural labour force, life expectancy, total
fertility rate and infant mortality rate. Particular attention was paid
to the current situation in the least developed countries. In most
regions, there had been socio-economic progress, notably in East and
South-East Asia, with simultaneous progress in the development of family
planning programme efforts. It was apparent that, in general, programme
improvements had not matched the progress in socio-economic development.
Nevertheless, there was a positive relationship between improvement in
socio-economic conditions and programme strength. There were also
exceptions to these relationships, where there had not been much socio-
economic improvement but programmes had become stronger and where
fertility decline was in progress (for example, Bangladesh and Botswana).
On the other hand, notable changes had taken place in socio-economic
conditions among the Arab States; yet fertility decline had not been
observed, owing, in part, to the absence of organized family planning
programmes, with the exceptions of Algeria, Egypt, Morocco and Tunisia.
There is a third set of countries (sub-Saharan Africa) where socio-
economic conditions had not changed to any appreciable extent nor had
programme efforts gained much strength. In most of these regions,
fertility level still remained high and contraceptive practice very low.
The primary impetus to the adoption of policies to reduce fertility in
Latin America had come from the medical profession, which was greatly
concerned about the large number of septic abortions. Governments were
slow to react; hence, the private sector and
non-governmental organizations had played an important role in supporting
the cause of family planning, and also in the provision of services.
Latin America, in general, with better socio-economic conditions compared
to the developing countries in other regions, showed a relatively high
contraceptive prevalence throughout most of the region.
15. The general conclusions drawn from the above broad assessment were
that family planning programmes could have an independent effect on
fertility rates and their effectiveness was greatly enhanced when socio-
economic development occurred simultaneously. Organized family planning
programmes and
socio-economic development together produce synergistic effects on
fertility. In this overview, several important programme characteristics
were identified as crucial for the success of family planning programmes.
A selected few of them drew the attention of the Meeting more than the
others. These were: political commitment and strong leadership, the
adoption of a client's perspective, contraceptive
availability/accessibility, quality of services, wide choice of methods,
modes of delivery of services and information, education and
communication campaigns. It was said that political commitment was
fundamental to the success of the programmes, but its importance
diminished as socio-economic conditions improved. In high socio-economic
settings, favourable to low fertility, political commitment was necessary
only to remove barriers to family planning programmes. It was also noted
that political commitment in the developed countries was necessary to
ensure sufficient international financial aid. Concern was expressed at
the Meeting that the present design and ethos of many family planning
programmes emphasized quantitative aspects of achievement at the cost of
quality of care and clients' needs and preferences, and therefore women's
reproductive health needs were neglected. To raise contraceptive
prevalence further, it would be necessary to increase the participation
of women in the decision-making process for programme design and
implementation. Furthermore, women should be given the choice of meeting
their reproductive goals. It was noted that, as abortion played
important roles in maternal mortality and fertility decline, the question
of abortion could not be put aside.
C. Issues related to the implementation of family
planning programmes
16. The Meeting again stressed the need to improve the quality of
services at all stages of programme development. The success of family
planning programmes had been usually evaluated on the basis of their
quantitative impact on fertility. Under these circumstances, there had
been overwhelming concern for quantitative achievements: number of
clients, births averted and so on. The issue of quality of services had
become all the more important now that it had been recognized that
improvement in the quality of services would result in an increase of
contraceptive use and a subsequent reduction in fertility. The Meeting,
therefore, emphasized that a shift to quality services had emerged as an
important area of programme development in the 1990s. It was often
claimed that calls for greater quality of services could not be met owing
to a lack of resources, but the Meeting observed that the critical
bottleneck with respect to quality was not resources but a lack of
commitment on the part of the top management. A significant part of this
lack of commitment could be traced to the difficulties in defining the
quality of services and the absence of readily measurable indicators of
quality. The Expert Group then considered various elements of quality of
service: choice of contraceptive methods; information given to clients;
technical competence; client/provider relations; mechanisms to encourage
continuity; and appropriate constellation of services. These six
elements were regarded as fundamental but their relative importance and
precise form should be adjusted according to specific country situation.
A first, important step in the right direction would be to shift the
focus from demographic targets to individual needs. With regard to
measures for improvement of quality of services, the Expert Group also
emphasized the necessity of human resources development, with provision
for continuous supervision and a management style that emphasized
enhancement of skills rather than punitive measures. Quality of care and
human resources development were generally linked.
17. The Expert Group noted that, although levels of contraceptive use
had increased substantially throughout the developing countries in the
past decade, there remained many sectors of the population, such as
minorities, remote rural areas or adolescents, that had not been reached
by programmes because of resource constraints and other reasons. More
importantly, men represented the "forgotten 50 per cent of family
planning clientele". The critical constraint in reaching men was the
providers, not men themselves. Men had not received the attention they
deserved. Empirical evidence suggested that men had played a major role
both as facilitators and as inhibitors for female contraceptive use. The
role of men in family planning was becoming increasingly important in the
context of raising contraceptive prevalence and further reduction of the
level of fertility. Men, when approached, were often willing to support
family planning practice, either by practising themselves or by helping
their wives to practise. Therefore, men should be approached with more
assertive motivational campaigns that stress the sharing of contraceptive
responsibility, choices of contraceptive methods and parenthood
responsibilities. This new direction implied more research on male
methods of contraception and male attitudes.
18. A growing concern was expressed in the Meeting about the necessity
of reaching the minority populations with family planning services. The
Meeting recognized that the strategies that had succeeded in increasing
contraceptive use in the majority population might not have much effect
on these special groups. Family planning providers needed to understand
better the barriers to family planning acceptance in these communities
before undertaking vigorous promotional activities. Community and
religious leaders and husbands might be helpful in overcoming the
barriers to contraceptive use in these communities.
19. Another important category that had not been reached sufficiently
constituted the people in remote areas: a neglect that had given rise to
pronounced regional differences in contraceptive use. The Expert Group
noted that every effort should be made to reach these areas in order to
remove regional disparities. The Group also recognized the special unmet
need of young couples, within or outside marriage, to have access to
family planning services. Despite Governments' declared intentions,
access to appropriate services by this particular group remained
problematic. Furthermore, the need for family planning counselling
services (for birth postponement or spacing) for this group could not be
overemphasized.
20. The Expert Group expressed concern about the level of adolescent
pregnancies. Precocious child-bearing continues to be a major impediment
to improvement in the status of women. The social cost of adolescent
fertility was high: it hindered possibilities for educational attainment
and self-fulfilment and led to greater health risk. It was observed that
the percentage of women under 20 giving birth was quite high in many
developing countries. The actual number of teenage pregnancies was
unknown because of the lack of statistics on abortion and miscarriages,
but it was undoubtedly very high. There was ample evidence showing that
much of this early child-bearing - whether within or outside marriage -
was unwanted. High rates of unsafe abortion among adolescent women also
attested to the issue of unwanted pregnancies. Adolescents were, in many
countries, increasingly at high risk of contracting and transmitting
sexually transmitted diseases (STDs), including HIV/AIDS, and they were
often poorly informed about how to protect themselves. It was observed
that many adolescents were sexually active and family planning programmes
should be sensitive to their needs because they were the future users.
The Group, therefore, emphasized the importance of involving youth in
identifying their special needs and urged Governments to make provision
for sex education, family-life education and HIV/AIDS education, and to
ensure easy access to reproductive health services, including family
planning services. In this regard, non-governmental organizations might
play important partnership roles with Governments in developing
innovative programmes for this segment of the population. The Group
encouraged further research for better understanding of these adolescent
concerns. In considering adolescent issues, the Group also focused on
the related issue of abortion.
21. With regard to the issue of diffusion of innovative behaviour and
information, education and communication (IEC) activities, the Expert
Group noted that there was a substantial amount of unmet need for family
planning; many women who wanted no more children and were exposed to the
risk of pregnancy were not practising family planning. The intervention
most suited to transforming these high levels of need into effective
demand was information, education and communication activities. The
Meeting also noted that two important aspects of IEC activities -
research on development of IEC material, and management and evaluation of
the dissemination process - often were neglected. There was much concern
that IEC materials were designed on the basis of feelings rather than on
research. It was also noted that IEC activities needed to be better
managed, taking into consideration the existing IEC infrastructure,
relevance of different IEC strategies, and the mixing of messages in
appropriate media formats. Another important aspect that drew the
attention of the Group was IEC activities targeted towards providers,
policy makers and informal leaders. For the purpose of
institutionalizing family planning in society, IEC programmes must
identify the motivational needs of health-care providers, policy makers
and informal leaders and must meet those needs; their support was
essential for the effective implementation of programmes.
22. The Expert Group noted that community-based distribution (CBD) of
contraceptives had played an important role in making contraceptives
available to people living in areas not covered by commercial networks or
institutional services. In a related area, social marketing of
contraceptives (SMC) to low-income groups in developing countries had
been met with mixed results. The impact of social marketing of
contraceptives in terms of increased contraceptive prevalence or
fertility decline was still very uncertain, but undoubtedly it
constituted a way to complement other supply channels. Both of these
modes of delivery of supplies (CBD and SMC) had great potential which
needed to be properly evaluated to determine their cost-effectiveness,
scope of their contribution and extent to which subsidies were necessary.
The question of combining these two approaches to reduce cost needed to
be examined.
23. The future contraceptive requirements and logistic management needs
of family planning programmes were considered at the Meeting. To achieve
the United Nations medium-variant population projection by the year 2000,
contraceptive prevalence in developing countries must rise from 51 per
cent in 1990 to 59 per cent in 2000. This meant that an estimated 567
million couples must be using some form of contraceptive at the end of
the century. According to this projection, the following would be needed
in developing countries by the decade 1991-2000: 151 million surgical
procedures for female and male sterilization; 8.76 billion cycles of oral
pills; 663 million doses of injectables; 310 million IUDs and 44 billion
condoms.
24. If the contraceptives required for the period 1991-2000 were
purchased in the market, they would cost about US$ 5 billion. From an
annual cost of US$ 399 million in 1990, the cost for contraceptives would
rise to US$ 627 million by the year 2000. It should be noted that this
total did not include the much larger cost of delivery of services. The
total cost would vary according to the method-mix; for example, wider use
of Norplant implant would increase costs considerably. It was projected
that by the year 2000, Governments' share of the cost would be reduced
from 60 per cent in 1990 to 52 per cent; private sector's share would
remain the same, at 17 per cent, and international donors' share would
rise to 31 per cent from 22 in 1990. Large though these sums were, the
costs of contraceptive supplies constituted only about one fifteenth, or
7 per cent, of the total required by the year 2000 for supporting
population activities, which was set at US$ 9 billion by the Amsterdam
Declaration on a Better Life for Future Generations, adopted by the
International Forum on Population in the Twenty-first Century.
25. Contraceptives were currently being manufactured locally in at least
23 developing countries and local production was under consideration in
four or more countries. It was encouraging to note that in four large
countries (Brazil, China, India and Indonesia), at least three methods
(pills, condoms and IUDs) were produced locally with capacity approaching
or exceeding their respective estimated commodity requirements. External
assistance agencies had been active in supporting the local production of
contraceptives.
D. Family planning and health
26. The Expert Group observed that the issue of safe motherhood should
not be discussed in the context of health only, because motherhood was an
important social function and not a disease. Rather, it should be
considered in the wider context of the role and status of women. Women
who wanted to avoid unwanted pregnancies should be provided with family
planning services, including access to safe abortion, in order to protect
their health and well-being. As family planning contributed
substantially towards child survival and reduction of maternal mortality,
the relevance of family planning in any strategy for safe motherhood and
child survival was undeniable. Another essential component of a safe
motherhood strategy was good maternal care, which was not complete
without preconception and post-partum care, in which birth planning was a
basic component. In this connection, it was observed that progress
towards safe motherhood should be measured in terms of lifetime risk of
maternal death, and not in terms of the commonly used maternal mortality
rate, which measured only obstetric risk. Equally important was the
question of child survival, which was considered a desirable social goal
in itself. Research evidence showed that family planning contributed
substantially towards child survival. Women seeking preventive and
promotive care for their children should have easy access to family
planning care. The Group was of the opinion that reproductive health
care should be provided as an integrated package of services that were
mutually strengthening, cost-effective and convenient to users. An
important point to note in this respect was that users should be the ones
to determine the type of integration that was most suitable for their
needs.
27. The Expert Group focused on the linkages between family planning,
sexually transmitted diseases and AIDS. Family planning is practised by
sexually active men and women of child-bearing age. The same are at risk
of coming into contact with STD as well as heterosexually transmitted HIV
infection. The practice of family planning should play a crucial role in
the prevention of vertical transmission of HIV from mother to child,
through prevention of pregnancy among HIV-infected women. Another
important linkage between family planning and STDs/AIDS was that some of
the contraceptive methods did have a protective effect against these
infections. These important linkages implied the need to widen the scope
of family planning programmes to encompass reproductive health care,
including STD and AIDS control. Efforts to control these diseases could
be enhanced by utilization of the widespread network of family planning
clinics, especially in the rural areas of developing countries. The
facilities offered unparalleled opportunity to reach women of child-
bearing age when the risk of exposure to STD and AIDS was greatest.
Integration of these services would permit optimal use of the limited
resources available in the developing countries for the control of these
infections as well as for family planning.
28. The obvious disadvantage of integration was that services might not
reach men directly. This was an area requiring reorientation of the
family planning approach, which had hitherto relied mainly on contact
with women, to permit more interaction with men. For the purpose of
integration, there was a need to initiate training activities for the
personnel involved in family planning and STD/AIDS control services,
aimed at making them realize the interrelationship between the services
they offered and thereby promoting closer working relationships. The
Meeting, however, cautioned about possible dangers of hasty integration.
It could be an error to integrate STD-control programmes into existing
family planning structures without making sure that current facilities
could provide quality services, that adequate staff were present and that
they had the necessary training and orientation. It was also necessary
to encourage research in sexual behaviour in different cultural settings
to provide information that could be used in intervention programmes.
Finally, future research in contraceptive technology development should
focus on methods that might have additional benefit in the prevention of
STD/AIDS, and especially on those methods that were women-controlled.
E. Family planning and family well-being
29. Under the theme of family planning and family well-being, the Expert
Group considered two important issues: (a) changes in family size and
structure; and (b) fertility decline and family welfare systems. The
Meeting recognized the importance of the family as a fundamental unit of
society. The characteristics of the basic family types found in the East
and in the West were discussed and compared. The families in the East
were characterized by a "feedback model" of intergenerational relations,
in which the older generation initially fostered the younger generation
but was then cared for by the younger generation. The Western model was
described as a "continued linear model", in which there was usually no
feedback from the younger to the older generation. Consequently, the
typical family pattern of Western society was the so-called nuclear
family, consisting of husband, wife and unmarried children. In many
Eastern societies, married children did not necessarily leave their
parental home to form nuclear families and thus three-generation families
were common in the East. The family size was, therefore, relatively
larger than that of the West.
30. As elsewhere in East Asia, the traditional Chinese family had
undergone substantial transformations in the past half century. Both
family size and family structure had been affected by the process of
modernization and by the profound structural changes experienced by the
Chinese society. The average family size was 5.3 until the 1950s, it
declined to 4.43 by the 1982 census and decreased further to 3.97 by the
1990 census. The decline in family size during the 1950s and the 1960s
was mainly associated with social structural changes, such as land
reform. By contrast, family-size reduction in the 1970s and the 1980s
could primarily be attributed to fertility decline, although other
factors such as improved housing supply and census underenumeration had
also played a role. A process parallel to the decline in family size had
been the trend towards family nuclearization. However, although the
proportion of extended families had been decreasing substantially for the
past five decades, the three-generation family still comprised about 20
per cent of Chinese families, and it was not certain that it would
experience further reduction in the near future. Although there was no
officially stated policy that promoted three-generation families, this
family form had been viewed as beneficial for old-age care. However, the
rapid fertility reduction would undoubtedly affect family structure in
the coming years. When the children born under the current low-fertility
regime reached the age of family formation, some elderly parents would
not be able to live with married children, if they had only one married
daughter, assuming that current cultural practices persisted. It was
also noted that the policy, with respect to number of children a couple
could have, led to large differences in fertility levels and family sizes
between rural and urban areas, and between minorities and the Han
majority. The Chinese case-study served as an illustration of how
government policies, along with changing socio-economic conditions,
affected the size and structure of the family. The attention of the
Meeting was drawn to some undesirable consequences of the rapid fertility
reduction experienced in the Chinese society: one child was sometimes
raised as a "little emperor", with yet unknown consequences for the
child's development, and a strict one-child policy might lead to sex-
selective abortion practices. The impact of rapid decline in fertility
on child development was not yet fully known.
31. Lower fertility levels resulting in smaller families were thought to
benefit both parents and their children directly. This view assumed that
decisions about family size and family welfare were made simultaneously
at the start of child-bearing. In recent years, this conventional wisdom
had been increasingly challenged. The Meeting, therefore, examined the
linkages between reduced family size and family welfare systems,
including the economic well-being of the family, welfare of the children,
wife's employment opportunities, and parental old-age security. Whether
the number of children was positively or negatively correlated with the
economic well-being of the family would vary with the life-cycle stage of
both the parents and the children, as well as the existing social
settings. A study in a village in Bangladesh found that male children
became net producers at age 12, and could compensate for their cumulative
consumption by age 15. Similar results were found in northern Ghana.
Other studies had shown that in a peasant society, at the aggregate
level, the net worth of children was negative. A large family gained
economic benefits from its size only at certain stages of the family life
cycle. These studies, however, did not show the cumulative effect of
actual family size on the economic well-being of the family. In a recent
study in Thailand, where rapid socio-economic development was taking
place, an assessment of the impact of a reduced number of children on
family economic well-being was carried out by comparing couples whose
reproductive years corresponded with the period of decline of fertility
in Thailand but who had small and large families. The study found
reduced family size to have positive effects on a couple's ability to
accumulate wealth, participate in new forms of consumption and thus have
more material possessions and better quality houses. In terms of welfare
of the children, empirical evidence, from both developed and developing
countries, showed a negative link between the educational attainment of
the children and the size of the family. This relationship was also
found to be true in Thailand. It was important to remember that, in the
process of development, Thailand was experiencing rising costs of living
and costs of raising children. Thai parents also had high aspirations
for their children in terms of educational attainment. It could be said,
therefore, that economic benefits were not the only guiding factors in
family-size decisions. The nature of the linkages between fertility and
women's employment varied according to a number of factors. Role
incompatibility between reproduction and production was found to be
stronger in urban areas as compared to rural areas. A recent study on
parental care in Thailand showed that fertility decline did not
significantly reduce the proportion of the elderly who would co-reside
with an adult child. It was generally felt that there was a serious
scarcity of research to explore the linkages between fertility decline
and family welfare systems and this was an important area for future
research.
F. Future directions: people's involvement in
family planning programmes
32. In the 1960s, most of the public sector family planning programmes
were centrally organized with a vertical delivery system and quantitative
demographic targets rather than welfare goals. During the past 15 years,
there has been an appreciable shift away from target-oriented vertical
programmes. In its place, a growing concern has arisen that family
planning services should be tailored to meet the needs and preferences of
the clients who use them. The concept of "user's perspective" gradually
came into prominence with the attendant emphasis on community
participation. In the early 1980s, community participation had received
strong endorsement as a cornerstone of family planning programmes. At
the Meeting, the recurrent themes of discussion included such issues as
community participation, individual needs and preferences, quality of
care rather than quantity, and the welfare aspect of programmes. All of
these themes had direct or indirect bearing on community participation.
The essential ingredient of the community participation concept was
empowerment: the notion that communities should have a degree of control
over the nature of development goals and implementation of activities.
The participation of the community in planning, decision-making and
programme implementation was its underlying and fundamental feature. The
application of the concept in family planning had led to various forms of
participation. Contributory participation, where communities assisted
pre-set programmes by means of labour (volunteers), cash or provision of
other resources such as land, was relatively common. The second most
common form found was organizational participation, where formal or
informal structures existed to facilitate contributions by the community.
The limited empirical evidence suggested that genuine community
participation in family planning in terms of "empowerment" was still
extremely limited. The following reasons for this were discussed:
family planning was perceived to be a need of a small fraction of the
community; inflexibility of centralized programmes did not allow for
local variations; family planning might lack a ready appeal to community
elites, typically older men whose wives had passed beyond the
reproductive age span; and family planning as an innovation might create
antagonism based on religious beliefs, moral issues etc. Participatory
programmes were often found in the private sector and they had met with
relatively greater success, because non-governmental organizations tended
to be more adaptable and accommodating to community wishes than were
government departments. It was interesting to observe that, in the non-
governmental organization programmes, integration was a common
characteristic of community participation projects that involved family
planning. It seemed reasonable to conclude that an integrated package of
services with a decentralized programme development mechanism and the use
of local institutions would ensure greater participation of the community
in family planning and related activities, and would make family planning
services more responsive to people's needs. However, the Group observed
that it was also necessary to make serious objective evaluations of these
activities, particularly in terms of cost-benefit analysis.
33. With regard to the cost of contraceptive supplies and services and
cost-sharing, the evidence presented at the Meeting pointed to some
important conclusions. First, the reproductive age cohort was increasing
rapidly even as overall population growth declined. Simultaneously,
donor resources were not expected to increase as rapidly as the increase
of women/couples in the reproductive ages. Secondly, more works needed
to be done to accurately measure the extent of the unmet need for
contraceptives in the developing countries because available data were
inadequate and measures were yet to be perfected. As a result,
projections of unmet needs must be viewed as orders of magnitude.
Thirdly, cost data were also troublesome because of the assumptions
underlying them and the inaccuracy built into equating costs and
expenditures. Determination of financial needs in the future, therefore,
was complicated by the data limitations just mentioned. However, under
the assumption that resources would be constrained in the future, efforts
should be made to assess alternative financing arrangements and to
improve resource allocation and efficiency of service delivery.
Available evidence suggested that among the countries that charged for
family planning, fees were a small proportion of per capita GNP.
Moreover, studies showed that upward adjustments to modest fees had
little effect on utilization, indicating the possible scope for
establishing or raising fees for family planning. In addition, third-
party payers (e.g., insurance companies) for health care represented
another potential financier to share costs with Governments and users.
The Meeting had observed that cost and unmet need data deserved more
consideration and more careful interpretation to guide decision-making
processes to promote efficiency and appropriate targeting for subsidies.
To promote cost-sharing, Governments must have better information on the
price sensitivity of consumers. By removing impediments to private
investment in family planning, Governments should encourage private
sectors to expand their share of service delivery. Innovations in modes
of delivery of family planning services were essential.
34. In the agenda item on contraceptive research and development, the
Group reviewed the most important existing contraceptive methods with
respect to safety and efficiency, emphasizing their effects on women's
reproductive health. The Meeting noted that women in their different
life-cycle stages had different needs for different types of
contraceptive methods. The current research agenda on contraceptive
methods included the relation between hormonal methods and neoplasia,
barriers methods for protection against STD/HIV, breast-feeding and
contraceptive methods, and the use of modern IUDs with high efficiency
and few side effects. Through the collaboration between national and
international agencies and non-governmental organizations, promising
research was continuing on anti-fertility vaccines, methods for the
regulation of male fertility and antiprogestins for early pregnancy
termination. Research needs were identified which would be critical in
the future. In the light of this review and discussion, a few
conclusions were reached at the Meeting. First, there had been a general
decline in expenditures on research in fundamental reproductive
physiology, new contraceptive methods and safety evaluation. Secondly,
there had been a large reduction in the involvement of pharmaceutical
companies in contraceptive research for various reasons: belief that the
market was already "mature"; the long time required to develop a new
method, and the even longer period before there was any return on
investment; and the regulatory problems imposed by drug administrations
and the legal liabilities. To encourage future research in new
contraceptive methods, these barriers needed to be removed. Thirdly,
non-governmental organizations had an important role to play in
contraceptive research by creating a global partnership of scientists who
would work together in the development of new methods, thus filling the
gap left by Governments and the commercial sector. Fourthly, there
should be an emphasis in research on new methods for men.
35. In re-examining the role of Governments, non-governmental
organizations and the private sector in family planning, the Meeting
observed that, despite recent progress in family planning, there were
still many challenges, including a growing demand for services.
Governments must at least sustain, or increase, support for family
planning and try to remove legal and other barriers to expanding
services. They should aim to be flexible, recognizing the needs of
adolescents, and replicate successful models of service delivery. The
existing role of non-governmental organizations in innovative service
delivery should be extended to offer appropriate reproductive and sexual
health services to those most in need, to improve the quality of care and
community involvement, to demonstrate cost-effectiveness and address
women's concerns. Non-governmental organizations still had an advocacy
role, particularly to reduce unsafe abortions and to increase services
for young people. The private sector must cooperate with Governments and
non-governmental organizations, price contraceptives for retail
distribution on the basis of the price sensitivity of consumers, and
participate in community-based distribution and social marketing.
II. RECOMMENDATIONS
A. Preamble
36. The World Population Plan of Action, adopted by consensus at the
World Population Conference, held at Bucharest in 1974, affirms that all
couples and individuals have the basic right to decide freely and
responsibly the number and spacing of their children and to have the
information, education and means to do so. This right should be assured
in all countries, irrespective of their demographic objectives.
37. The use of safe and appropriate fertility regulation methods has
immediate benefits for the health, well-being and autonomy of women.
Family planning also promotes the health and welfare of children,
adolescents and men, and the well-being of the family as a unit.
Finally, family planning contributes to achieving other societal goals
such as the advancement of women, improvements in overall health status,
the stabilization of population growth, preservation of the environment,
sustainable economic and social development, and the overall quality of
life. Indeed, as stated in the report of the United Nations Children's
Fund, State of the World's Children, 1992, the responsible planning of
births is one of the most effective and least expensive ways of improving
the quality of life on Earth, both now and in the future, and one of the
greatest mistakes of our times is the failure to realize this potential.
38. Empirical evidence reaffirms strong linkages between socio-economic
development and fertility trends. Family planning programmes tend to be
most successful where social and economic conditions encourage the
adoption of small family norms. Recent experience, however, has
demonstrated that even in poor socio-economic conditions, considerable
desire to regulate family size exists and fertility has fallen in
countries with well-organized programmes. Individuals in all settings
should not be denied access to the information and means to regulate
their fertility and improve the quality of their lives.
39. In the past two decades, a reproductive revolution has occurred.
Countries have made dramatic progress in expanding the availability of
family planning services, increasing the use of contraception and
accelerating the pace of fertility decline beyond that which would have
occurred in the absence of services. Based on data for women of
reproductive age, 53 per cent of couples are now estimated to be using
contraception; however, there are enormous disparities in levels of
contraceptive use between regions. The availability of family planning
services has itself contributed to a dramatic downward adjustment of
desired family size in many countries. In the less developed regions,
where fertility has been the highest, total fertility rates have declined
from approximately 6.1 in the 1950s to close to 3.7 currently.
40. Despite this progress, major challenges remain. As a consequence of
earlier high fertility in the developing countries, more and more men and
women are entering their reproductive years, and the need for family
planning services in these countries will therefore continue to increase
rapidly. During the decade of the 1990s, just to maintain current levels
of contraceptive use, approximately 100 million more couples will need
family planning services. If fertility declines according to the medium
variant of the United Nations population projections, then a further 75
million couples will need access to family planning information and
services by the year 2000.
41. In addition, large disparities remain both within and among
countries in the practice of family planning. Socio-cultural, economic
and other institutional constraints often prevent couples and individuals
from making informed decisions concerning child-bearing. Millions of men
and women of reproductive age in both the developed and the less
developed regions still do not have access to safe and effective methods
of fertility regulation, as well as information on how to use them. In
many countries, these conditions are reflected in high abortion rates.
42. The adoption of family planning has contributed to safe motherhood
and child survival. However, the death and suffering of women in
fulfilling their child-bearing responsibilities continues to be a major
scandal. Each year more than 500,000 women lose their lives for causes
related to pregnancy and childbirth. There has been very little progress
towards the goal of reducing maternal mortality by one half by the year
2000. Avoiding unwanted pregnancies and proper planning of births lowers
maternal mortality. However, safe motherhood will only be achieved
through concerted national and international efforts to make quality
maternal health services, including safe abortion, readily accessible to
all women. This should be a high priority for the next decade.
43. The quality of family planning services is also uneven. A major
challenge in the coming decade will be to expand currently available
contraceptive choices for individuals in many countries and to improve
the interpersonal skills and technical competence of family planning
providers. There is also an urgent need to develop new and improved
contraceptive methods.
44. The revolution in contraceptive technology has stalled because of
the inadequate allocation of resources and the retrenchment of the
pharmaceutical industry. Concerted efforts are needed to launch a second
revolution in contraceptive technology to provide a new generation of
contraceptives for the twenty-first century.
45. One of the most serious problems of the coming decade is the spread
of the AIDS pandemic, which jeopardizes the well-being of mankind.
Family planning programmes have an important role to play in the
prevention of HIV.
46. The Expert Group Meeting on Family Planning, Health and Family Well-
being, having reviewed the progress made in achieving the goals and
objectives of the World Population Plan of Action, adopted the following
recommendations, which are intended to reaffirm as well as extend or
update previous recommendations adopted by Governments in various
international forums. They seek to identify actions that Governments can
take to support couples and individuals in making informed and voluntary
choices about the timing, number and spacing of children, through family
planning programmes and other social policies. Because these issues are
of global concern, the recommendations are also addressed to
intergovernmental and non-governmental organizations as well as to the
donor community.
B. Recommendations
Recommendation 1
Governments are invited to note the growing evidence that all
individuals and couples, regardless of their socio-economic status, value
the opportunity to space and limit their families, and that family
planning can be promoted successfully where levels of socio-economic
development are low, provided that the design of services takes into
account the socio-cultural setting. Family planning programmes should be
regarded as a cost-effective component of a broader development strategy,
one that has significant independent effects on family well-being and
individual and social welfare, particularly of women.
Recommendation 2
Governments should strive to develop social and political
institutions and norms that are oriented towards providing women
opportunities, through formal and informal education, for personal
development and greater autonomy both within the family and the society
as a whole. Governments should support the involvement of women at all
levels of the public policy process and especially in the design,
management, implementation and evaluation of social welfare, health and
family planning programmes.
Recommendation 3
Recognizing the fundamental role of the family in reproduction and
in the socialization of future generations, Governments are urged to
support the family through public policies and programmes, taking into
consideration changes in family forms, size and structure. Governments
should promote family life education for responsible parenthood for both
men and women, high quality child-care arrangements to enable individuals
to combine their dual roles as parents and workers, and adequate support
for the children of single parents.
Recommendation 4
To save the lives of mothers, children and adolescents and to
improve their general health, Governments and the international community
are urged to increase their investment in family planning and
reproductive and maternal and child health (MCH) services. Governments
are also urged to monitor the progress in safer motherhood and child
survival and to take the necessary actions to enhance the effectiveness
of the interventions.
Recommendation 5
Governments and donors are urged to increase their support to the
social sectors, foremost among them health and education, to a level
where basic human rights in these areas can be satisfied.
Recommendation 6
Governments and intergovernmental and non-governmental organizations
are urged to recognize that abortion is a major public health concern and
one of the most neglected problems affecting women's lives. Women
everywhere should have access to sensitive counselling and safe abortion
services.
Recommendation 7
Given the high prevalence of sexually transmitted diseases and the
AIDS pandemic, which threatens the well-being of men, women and children,
family planning programmes need to widen their scope to include
reproductive health care, including STD/HIV education and prevention.
Recommendation 8
Political leaders at all levels should play a strong, sustained and
highly visible role in promoting and legitimizing voluntary adoption of
family planning, and in ensuring a legal and regulatory climate that is
favourable for the expansion of family planning services of high quality.
National and local leaders should translate their commitment to family
planning into the allocation of substantially increased budgetary, human
and administrative resources required to meet the increasing demand for
services.
Recommendation 9
Family planning programmes at both the national and the local level
should seek to increase awareness of the importance of family planning
and commitment to the expansion of good quality family planning services
on the part of key influence groups, including the media, women's and
voluntary organizations, local and religious leaders, and the private
business community. The involvement of non-governmental groups in these
advocacy efforts, wherever feasible, may greatly facilitate the process
of consensus and coalition-building in support of family planning
efforts.
Recommendation 10
Family planning programmes should aim to help individuals to achieve
their reproductive goals, and should be based on voluntary, free and
informed choice.
Recommendation 11
Governments should establish family planning goals on the basis of
the unmet demand and need for information and services. Demographic
goals, while legitimately the subject of government policies and
programmes to achieve sustainable development, should not be imposed on
family planning providers in the form of targets or quotas for
recruitment of clients. Family planning services should be framed in the
context of the needs of individuals, especially women. Over the long
term, meeting unmet needs appears to be the best strategy for achieving
national demographic goals.
Recommendation 12
At the national level, the major institutions involved in family
planning should periodically undertake a systematic examination of the
strengths and weaknesses of family planning efforts, including the
competence of national and regional managers. This process should
include an assessment of how major programme elements are contributing
cost-effectively to overall goals, and result in the development and
implementation of coordinated strategies for programme improvement.
Recommendation 13
Family planning programme managers should consult with and encourage
the participation of local community groups in the design, financing and
delivery of family planning services, wherever feasible. Promising
strategies for increasing community participation include the following:
increased involvement of social organizations such as men's, women's and
youth groups, cooperatives and religious organizations and the use of
local volunteers; greater decentralization of decision-making to local
administrative structures that are better placed to respond to community
needs; and increased pluralism of institutions in the delivery of
services.
Recommendation 14
Governments and non-governmental organizations are urged to improve
the quality of family planning services by incorporating the user's
perspective and respect for the dignity and privacy of the client.
Programmes should provide the broadest possible range of contraceptive
methods; thorough and accurate information to enable clients to make
informed choices; systematic follow-up; easy availability of and
accessibility to services; and technically competent service providers
who receive proper training and supervision, with additional emphasis on
communication and counselling skills. Unnecessary medical and regulatory
barriers restricting access to services should be removed. Strategies
should be carefully designed and tailored according to local conditions,
and the cost of services and contraceptives should be subsidized for
people who cannot afford the full cost.
Recommendation 15
Governments, donors and non-governmental organizations are
encouraged to increase the provision of family planning services through
multiple channels to unserved and underserved populations, such as
adolescent, minority, migrant and refugee groups. Effective outreach
approaches include promotional activities, community-based strategies,
and local health and commercial networks.
Recommendation 16
Governments are urged to recognize the special needs of the young
and adolescent population and to strengthen programmes to minimize the
incidence of high-risk and unwanted pregnancies and STD/HIV infection.
Special efforts need to be made to reach this target population with
information, education and motivational campaigns through formal and
informal channels, including the involvement of young people themselves.
In view of the fact that adolescents tend to avoid or underutilize
MCH/family planning and STD services, often with disastrous consequences,
it is important that service providers be trained to be more receptive to
adolescents, and that legislation not inhibit the use of services by
adolescents. Programmes should provide confidential services to
adolescent men and women without regard to marital status or age. Young
people should be involved in the planning, implementation and evaluation
of programmes designed to serve them in order for services to be
sensitive to their needs.
Recommendation 17
Governments, donors and non-governmental organizations are called
upon to provide resources for social marketing of contraception in order
to create a demand for family planning services, especially in
underserved areas and among traditional communities and population groups
where demand is low or
non-existent. Emphasis should be placed on using consumer-oriented
approaches such as careful targeting and segmentation of unserved
populations, proper design of education and communication strategies
based on research, and an appropriate mix of media and interpersonal
communications.
Recommendation 18
Governments, donors and non-governmental organizations should
encourage greater involvement in and responsibility for family planning
on the part of men, through research on male attitudes and motivation,
messages specifically tailored for men, strategies to encourage
responsible fatherhood, sharing of responsibilities between men and
women, research on male methods of contraception, and innovative clinical
services adapted to the needs of men.
Recommendation 19
Governments and non-governmental organizations are encouraged to
support information, education and communication (IEC) activities in
order to increase awareness of the benefits of family planning for both
individuals and the larger community, through comprehensive education
efforts utilizing a wide variety of communications channels. Such
programmes have played a crucial role in bringing about the
transformation of traditional attitudes and social behaviour necessary
for the adoption of modern contraception. Public education programmes
should develop a clear communications strategy based on empirical
research on social values and reproductive behaviour.
Recommendation 20
Governments and education administrators are called upon to expand
and strengthen population and family life education at all levels of
formal education as well as literacy programmes. Such programmes should
be designed to help children and youth in making informed decisions
regarding their sexual behaviour, responsible parenthood and family
planning. Special emphasis should be placed on training teachers and
developing relevant communication methodologies.
Recommendation 21
Governments and international organizations are urged to increase
their support to non-governmental organizations working in family
planning, particularly in two ways. First, by facilitating the
development of public/non-governmental organization partnerships aimed at
expanding access to family planning services. Secondly, by supporting
these organizations to address in innovative ways such important issues
as the reproductive health of adolescents, women's empowerment, community
participation, broader reproductive health services, quality of care and
outreach to marginalized groups. Once shown to be effective and
acceptable, new approaches can then be integrated into wider national
family planning programmes.
Recommendation 22
Non-governmental organizations are encouraged to coordinate their
activities at the national and international level and to continue to
emphasize their areas of comparative advantage, including voicing to
policy makers the real concerns and needs of women and local communities
regarding sexual and reproductive health.
Recommendation 23
Governments should identify and remove legal and regulatory barriers
that impede private sector involvement in family planning, including
regulations that constrain contraceptive options; tax and importation
policies; advertising and promotion restrictions; patent and trade mark
laws; pricing policies; and restrictions on fees charged by non-profit
organizations.
Recommendation 24
Governments and non-governmental organizations should support
public/private partnerships aimed at expanding access to family planning
services. Such arrangements include financing private services through
insurance or other third-party mechanisms, and facilitating commercial
enterprises to provide family planning as part of the health benefit
plans provided to employees. Public sector programmes should seek to
complement the existing family planning activities of the private non-
profit and commercial sectors, including private health-care providers.
Recommendation 25
Governments, non-governmental organizations and donors are urged to
improve forecasting of contraceptive requirements based not only on
current use but also on plans for future programme directions and
priorities. Increased efforts must be directed at coordinating planning
for contraceptive needs, putting systems in place that minimize the need
for emergency responses, as well as helping countries to reduce their
reliance on donors.
Recommendation 26
In meeting future contraceptive requirements, the partnership
between the public and the commercial sectors should be strengthened.
The role of the commercial sector should be expanded in producing,
procuring and delivery of contraceptives.
Recommendation 27
National Governments and international and non-governmental
organizations are called upon to provide additional resources for family
planning in order to satisfy the rapidly increasing demand for services.
With a view to reaching the United Nations medium-variant population
projections, the cost of contraceptive commodities alone has been
estimated at US$ 627 million in the year 2000. The associated logistics,
management and service delivery costs are likely to increase this figure
as much as tenfold.
Recommendation 28
In order to better address the quantity of resources required,
further work is needed to estimate all the component costs of family
planning programmes. At the same time, more attention must be paid to
cost-effectiveness, efficiency, cost-recovery, cost-subsidization,
community-resource mobilization, local production of contraceptives,
where appropriate, and other mechanisms to ensure the optimum use of
existing resources, thereby lowering costs, targeting subsidies and
promoting financial solvency.
Recommendation 29
Governments of developed and developing countries and
intergovernmental organizations are thus urged to increase significantly
their proportions of development assistance for family planning to meet
resource requirements. In so doing, it should be noted that costs of
programmes and sources of financing will vary by such factors as social
and economic setting, programme maturity, programme coverage and delivery
modes, including the extent of involvement of the private and non-
governmental sectors.
Recommendation 30
Governments and donors are urged to increase support for research on
improving existing contraceptive technology as well as developing new
technology that will be affordable in developing countries, focusing on
methods that may have additional benefits in the prevention of STD/AIDS,
male methods to increase men's involvement in family planning, and
methods appropriate for breast-feeding women. Efforts should be made to
remove constraints hindering progress in this area, including
inappropriate litigation practices and unjustified regulatory
requirements, and to enhance the involvement of private industry in this
effort.
Recommendation 31
Governments and donors are encouraged to support social science
research on human sexuality and sexual behaviour in different cultural
settings to provide information useful in intervention programmes to
prevent unwanted pregnancies and STD/HIV infections.
Recommendation 32
In order to improve the efficiency of the limited resources
available for family planning programmes, Governments and donors are
urged to support field studies at the subnational level in different
cultural settings to ascertain the relative cost-effectiveness of various
approaches.
Recommendation 33
Governments, non-governmental organizations and donors are urged to
support ongoing applied research efforts in family planning. Special
emphasis should be given to evolve definition, standards and indicators
of quality of services appropriate to a country/programme setting; and to
include quality of service in the description, monitoring and evaluation
of family planning programmes.
Recommendation 34
In view of the importance attached to the role of family planning
programmes in enabling individuals to achieve their reproductive goals,
Governments and donors should support research efforts to develop
indicators of programme performance to capture this crucial dimension.
Recommendation 35
Governments are urged to attach higher priority to the utilization
of available data and information for programme planning and
implementation; to the collection of timely and reliable data and
information, especially on cost; and to the strengthening of human
resources in various countries in order to facilitate data collection,
analysis and utilization for programme planning and implementation.
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