UNFPA COUNTRY SUPPORT TEAM
|
The primary purpose of the UNFPA Country Support Team for the South Pacific based in Suva, Fiji, is to provide countries with high-quality technical support services to meet their needs, leading towards national self-reliance in the population field.
Among the functions of the Country Support Team towards this end, the injunction "to provide active and close backstopping to the local pool of national experts" implies more frequent interaction between CST Advisers and national counterparts than is afforded by the occasional in-country technical advisory visit.
This Discussion Paper series has been initiated by the CST, Suva, in an attempt to establish a dialogue among national population programme personnel on the multidimensional aspects of population programmes. The major objective of the series is to help in the conceptualization and development of a more holistic programme approach.
A number of governments in the Pacific have introduced demographic goals into their population policies, invariably seeking to induce a fall in the relatively high levels of fertility being experienced in their countries. A disconcerting feature of most of these policies is the way quantitative demographic objectives, particularly goals of fertility reduction, are often set without adequate attention being paid to their implications for the attainment of a rate of modern contraceptive prevalence and the financial and human resource costs pertaining to the projected level of fertility.
Without advocating in any way the setting of quotas for service providers, the objective of this paper is to illustrate some of the implications of demographic goal setting in the context of a country's official population and development policy. The paper demonstrates how it is possible to incorporate a consistent and well defined set of demographic goals and objectives in a country's population policy and to trace some of their implications in a plan of implementation for an evolving FP programme. Using the Marshall Islands (RMI) as an example, the paper applies the computer software TARGET model to set a national or sub-national demographic goal, or fertility level, which then serves to establish the scope and direction of the nation's FP programme.
The author of the paper would welcome receiving any comments from readers.
19 November 1994
Population and development policies have been adopted in a minority of countries in the South Pacific. Others are currently engaged in drafting multi-sectoral population policies and have requested technical assistance from the UNFPA Country Support Team (CST) in finalising their policy documents and in designing implementation strategies. Those countries which are implementing formal policies include the Federated Sates of Micronesia, Marshall Islands, Solomon Islands and Papua New Guinea. UNFPA has assisted Tuvalu and Niue to begin the process of policy formulation while efforts are underway to revise existing policies in the Marshall Islands and Solomon Islands. Yet, all countries have become increasingly aware of the close interrelationships between demographic variables and the socio-economic milieu, regardless of whether they have adopted formal policies or not. Among the latter, without a formal written policy document, Fiji has a long standing programme of population-related activities.
All current and prospective policy interventions to promote the full integration of population factors into the planning process for sustainable development should give cognizance of the universal principles elaborated and agreed upon at the recent International Conference on Population and Development held in Cairo in September 1994. The following basis of action on family planning was accepted:
"The aim of family-planning programmes must be to enable couples and individuals to decide freely and responsibly the number and spacing of their children and to have the information and means to do so and to ensure informed choices and to make available a full range of safe and effective methods... The principle of informed and free choice is essential to the long-term success of family-planning programmes. Any form of coercion has no part to play ... Government goals for family planning should be defined in terms of unmet needs for information and services. Demographic goals, while legitimately the subject of government development strategies, should not be imposed on family-planning providers in the form of target or quotas for the recruitment of clients'(United Nations 1994, International Conference on Population and Development, Programme of Action, para. 7.12)
Without advocating in any way the setting of quotas for service providers, most governments in the Pacific have introduced demographic goals into their population policies, invariably seeking to induce a fall in the relatively high levels of fertility being experienced in their countries. A disconcerting feature of most of these policies is the way quantitative demographic objectives, particularly goals of fertility reduction, are often set without adequate attention being paid to their implications for the attainment of a rate of modern contraceptive prevalence and the financial and human resource costs pertaining to the projected level of fertility. Two illustrations from Papua New Guinea and the Solomon Islands population policies are revealing.
"The second phase of the National Population Policy is to achieve the following targets:- To increase the family planning prevalence from three percent now to about 22 percent by 1995 and 63 percent by year 2000; To increase the percentage covered by family planning services and information to all married couples by the year 2000; To reduce the total fertility rate (TFR) per woman from the current 5.4 per woman to 4.4 by 1995 and 3.2 per woman by the year 2000" (PNG, 1991). "To actively encourage the gradual reduction of the fertility rate from the present high level of 6.4 to a more acceptable level of 3 to 4 over the next 10 years period, and to promote a better maternal and child health by increased child spacing strategies"(Solomon Islands, 1988).
While such goal-setting is commendable and an essential ingredient of family planning programme monitoring and management, without a fully-specified plan of implementation, entailing a full costing of the physical and human resource implications of attaining the lower levels of fertility, the policy is often nothing more than an expression of wishful thinking. Evidently, a plan of action is essential to address the fundamental problems and potential constraints which are likely to impede the success of the FP programme. They involve the provision of an adequate number of trained personnel in family planning service delivery and the securing of a regular and adequate quantity of supply of devices and services. This will also entail the integration of FP into the pre-service training of registered nurses, adequate provision for nurses and mid-wives to receive in-service training and up-grading of their skills, and the construction of built-in mechanisms for supervision, guidance and follow-up of trainees after the completion of FP training courses.
To the author's knowledge, no Pacific Island Country (PIC) which has written a formal population policy has developed a fully specified plan of implementation for attaining its national fertility goals. One major contributing factor to this inhibiting constraint is that data collection and record keeping in family planning programmes are grossly inadequate. Most PICs have severely limited knowledge of the current extent of usage of contraceptives and the method mixes, making it an extremely precarious exercise to attempt to forecast the future demand for contraceptives of various kinds.
The objective of this paper is to illustrate some of the implications of demographic goal setting in the context of a country's official population and development policy. The paper demonstrates how it is possible to incorporate a consistent and well defined set of demographic goals and objectives in a country's population policy and to trace some of their implications in a plan of implementation for an evolving FP programme. Using the Marshall Islands (RMI) as an example, the paper applies the computer software TARGET model to set a national or sub-national demographic goal, or fertility level, which then serves to establish the scope and direction of the nation's FP programme.
Section 2 of the paper discusses the nature of the population and development problem in the RMI while section 3 spells out the FP goals in the draft of a revised version of the population and development policy. Section 4 portrays the TARGET-setting model and its conceptual framework which is applied to the RMI in section 5. The financial and human resource implications of the model's results are elucidated in section 6 while section 7 draws some overall conclusions.It is anticipated that this paper will stimulate interest among those responsible for reproductive health, FP and development planning in PICs to employ the TARGET model in their countries as a first step in formalising a plan of implementation for the FP programme, which should be established to meet some of the demographic goals set in the population and development policy. For those countries wishing to employ the model in their planning exercises the Suva-based UNFPA CST is available to assist in this endeavour.
The Republic of the Marshall Islands is composed of 29 coral atolls and 5 islands dispersed across almost two million square kilometres of the central Pacific Ocean. Devoid of natural resources other than those which lie beneath the sea, and relying on the extremely narrow productive base of the economy, the country is heavily dependent on major budgetary support from the United States under the Compact of Free Association. This agreement expires in the early years of the next century, after which the level of resource inflows under a renegotiated agreement remains uncertain and precarious. Evidently, intensifying human resource development must play a principal role in the overall development strategy of the RMI. At present, and for the foreseeable future, the single most intractable development problem facing the country is the alarmingly high rate of fertility, at over 7 births per women, leading to population growth which is estimated to be 4.2 percent per annum. In 1988, the census enumerated 43,380 persons living in this resource-poor country. Without any major change in household demographic behaviour the size of the population will double to over 86 thousand in less than 17 years, or by 2005.
| "If the Government is to undertake a successful transformation of the human resources of the country, the population problem will have to be addressed as a matter of priority as it has adverse effects in many other areas and diverts scarce public resources. National commitment to family planning and population control, through leadership at the very highest levels of government, would go a long way toward redressing years of neglect" (World Bank, 1993). |
In 1994 population size likely approaches 56 thousand, with over two-thirds living in densely crowded conditions in the urban centres of Majuro and Ebeye. While the economy is aid-driven and dominated by the public sector, GNP per capita is relatively high, estimated to be in the mid-range for lower middle-income countries between US$1,236-2,555, but reliable estimates are unavailable.
With the income base facing an uncertain future and population growing at a rate unprecedented in the rest of the world, living standards in the Marshall Islands look precarious and seem likely to decline. The extent to which they fall will depend on how successful the authorities are in implementing a revised Population and Development Policy, particularly those elements while relate to inducing a reduction in fertility through a revitalized programme of family planning.In July 1990 the Government of the Marshall Islands adopted a voluminous National Population Policy, approaching 100 pages in length. While the document provides a detailed survey of the way rapid population growth severely impinges on the social and productive sectors of the economy, its major contribution is to provide an unambiguous case for public policy aimed at changing fertility behaviour. It offers an extensive menu of population-responsive policies in the various social and economic sectors. Where it singularly fails, however, is to specify a set of quantifiable and achievable goals, particularly in the area of family planning, against which to judge the success of the pronounced policy during its implementation. Indeed, it seems strange that the policy document should state:
"There is a crying need for RMI national government and all levels of leaders to place family planning and population education as a top priority, clearly directing all government ministries to operate accordingly and in close coordination with each other"(RMI, 1990, p.76).
Such a plea looks incongruous in what is meant to be, after all, government policy. This uncertainty over exactly who was promoting the "policy", and the lack of clear, quantitative goals against which to monitor progress in implementation led to initiatives by the Office of Planning and Statistics, which is responsible for coordinating population policy formulation, to revise the document with UNFPA Country Support Team assistance in 1994.
Some of the initial demographic goals of the draft revised policy have been utilized in this paper. Readers are cautioned, however, that the suggested quantified goals are still tentative since the document has not yet been officially adopted by the Government.
A successfully implemented family planning programme could be expected to induce a fall in RMI's realised fertility for a number of reasons which include: a diminution in the exposure period over the lifetime of each woman; and an expected decline in desired fertility as the health benefits of child spacing lead to a reduction in infant mortality and the realisation on the part of parents that the attainment of their desired family size does not require such a high number of births as is currently realised, where, as noted above, the TFR in 1988 was estimated to be 7.2 children per woman. The infant mortality rate (IMR) is high and estimated to be 63 per thousand live births, among the highest in the Region (SPC, 1994).
The principal purpose of the exercise reported here is to make projections of the Family Planning Programme to the year 2003, in accordance with the fertility and other demographic goals set in the draft revised Population and Development Policy, and particularly to elaborate on the relationship between realised fertility, the necessary contraceptive prevalence rate (CPR) implicit in this level of fertility and the demands for, and costs of, the various services provided.
Family Planning services in the RMI were inaugurated in the mid-1960s under the umbrella of the Federal Maternal Child Health Block Grant, but the programme's success has been limited due to weak planning and management (ADB Health and Population Project, 1993). UNFPA began supporting the programme in 1984 via the World Health Organisation (WHO). The FP programme comes under the direction of the Bureau of Preventive Services within the Division of Public Health. Services are capable of reaching the great majority of Marshallese via a comprehensive health care system, and a series of health centres on each atoll. On Majuro, FP education, counselling and supplies are available at the main hospital and at Laura dispensary. Access to FP is also sometimes available once a week at the Salvation Army Church building. Services are offered at Ebeye hospital and at Outer Island clinics. Urban clinics are staffed by graduate and practical nurses while health assistants and traditional birth attendants (TBAs) dispense services on the Outer Islands. Transient public health teams visit these rural dispensaries several times a year.
The consultant involved in preparing the ADB's Health Sector Review in 1993 attempted to appraise the 1992 FP statistics. The conclusions were that it is not possible to determine the total number of FP acceptors because details of 1991 coverage are not carried over into 1992. Other deficiencies in the data include incomplete reporting from the Outer-Islands such that FP statistics for 1992 may be generally under-reported.
The author was given the following service statistics by the Director of Family Planning for the years 1988, 1992 and 1993. Evidently, a certain skepticism about their accuracy is warranted.
| Method | 1988 | 1992 | 1993 | Discontinuers in 1993 |
|---|---|---|---|---|
| Pill | 122 | 297 | 272 | 30 |
| IUD | 19 | 13 | 13 | 1 |
| Injectitables | 0 | 353 | 540 | 56 |
| Norplant (Stock of Users) |
0 | 813 | 813 | 153 |
| Creams/Foam | 33 | 31 | 32 | - |
| Condoms | 6,434a | 6,998a | 241b | - |
| Tubaligation (Stock of Users) |
250 | 773 | 869 | - |
| Vasectomy (Stock of Users) |
12 | 27 | 41 | - |
The draft Population and Development Policy of 1994 sets the goal of reducing the TFR to 4 children per woman by the year 2005 and a reduction in the annual rate of population growth from 4.2% to 2.6%. Other objectives include a reduction in the IMR from the current 63 per 1000 live births to 38 and an increase in life expectancy from 61 to 66 for men and 64 to 69 for women. The CPR is targeted to rise from under 10% to over 45% and the number of contraceptive service outlets to rise from less than 10 to over 50. These are ambitious goals which are evidently warranted by the extremely large projected imbalances between resources, income and the population should fertility fail to fall significantly in the near future1.
A number of fundamental problems and potential constraints will act as bottlenecks to impede the attainment of these goals. They involve the shortage of an adequate number of trained FP personnel and the securing of a regular and adequate quantity of devices and contraceptive supplies. Major constraints on programme implementation relate to a low-level of knowledge about FP and its benefits, to the high desired family size of Marshallese parents, to the supply and logistics of contraceptive distribution, and to the poor data collection and record-keeping in the programme. The only current donor is UNFPA/WHO.
The Population Council's Target-Setting Model is specifically geared to consider the kinds of problems addressed by the Ministry of Health planners in the Marshall Islands and elsewhere in the PICs2. When it is desired to project a specific quantitative reduction in fertility by some future date, then family planning providers will be faced with the task of estimating the likely number of contraceptive users and acceptors needed to achieve the projected fall in fertility. In its simplest form the model calculates the number of contraceptive users required to achieve this projected future level of fertility. Estimates of the required numbers of acceptors and contraceptive supplies can also be provided by the output generated from the model.
The model and its application are in full accordance with the principles enshrined in the ICPD's Programme of Action. It is unequivocally compatible with the principle of voluntary choice in family planning. Its prime application is in the planning and monitoring of a family planning programme geared to help couples and individuals to meet their reproductive goals in a framework that promotes optimum health, responsibility and family well-being and which respects the right of all persons to choose the number, spacing and timing of births. It is essentially a tool for planners and managers of such a programme.
Levels and trends in fertility have been universally shown to be inversely related to the levels and trends in contraceptive prevalence. However, the degree to which a given contraceptive prevalence level reduces fertility depends on the effectiveness of the method practiced. Evidently, the number of users at a point in time depends on past trends in the number of acceptors; the link between current users and past acceptors depends on the rate at which acceptors discontinue use over time. For a given pattern of acceptors, a low discontinuation rate implies relatively high levels of current use, and vice-versa.
The computerized model initially estimates the level of contraceptive prevalence and use required to bring about the targeted future level of fertility. Once the trend in future users is known, the annual number of acceptors or supplies needed can be estimated. However, the TARGET model explicitly recognizes that other factors also directly influence fertility, including such important proximate determinants as:
The model requires the following input data:
The principal objective of the model, which would seem to have the potential for widespread application in PICs, is to estimate the general use and contraceptive methods use, as well as acceptance trends that are necessary to induce an anticipated fall in fertility. The model projections indicate that contraceptive prevalence has to rise to about 75% of married women of reproductive age to reduce fertility to the replacement level3. Variations in trends in the other proximate determinants, such as marriage, breastfeeding, induced abortions and contraceptive effectiveness, have only a modest impact on the prevalence trend required to lower fertility through the demographic transition.
However, while a relatively close correspondence between declines in fertility and increases in contraceptive prevalence has been documented, there is no linear relationship with acceptor rates. While the number of acceptors has to rise to accomplish a growth in contraceptive prevalence, there is only a loose connection between acceptor and prevalence rates because the total number of acceptors needed to attain given increments in prevalence depends heavily on the average rate of drop-out. A changing method mix can yield trends in the number of acceptors that fluctuates much faster or slower than the overall number of users.
The TARGET model requires the user to input a number of key assumptions. In this application to the Marshall Islands, the fertility goal specified in the draft Population and Development Policy (TFR of 4 in 2005)4 is reflected in table 2; the rates of effectiveness of various methods, the method mix used and the proximate determinants of fertility are portrayed in tables 3, 4 and 5.
One option in the TARGET model is to input the distribution of contraceptive supplies by source. Currently, all contraceptives are provided through WHO/UNFPA. As the demand for contraceptives grows in time, it may be that the Marshall Islands will need to seek alternative donor sources, at which point this option in the computer model could be utilized.
One required input for the TARGET model is the proportion of women aged 15-49 who are currently exposed to the likelihood of becoming pregnant, or who, in other words, are sexually active. Since we have no knowledge of this precise number it is necessary to make some assumptions, based on related data. The Census of Population and Housing 1988 found 68% of 15-49 year olds are currently married, which forms the lower bound of those sexually active. Furthermore, 80% of all 15-49 year olds have already borne at least one child, but may not be currently sexually active. In the youngest age group, 15-19 years, only 23% are currently married, yet 41% have already borne at least one child. On the basis of this evidence, therefore, for purposes of this exercise, it is assumed that at least 80% of the relevant age group are sexually active (Scenario A). Alternatively, Scenario B assumes 95% of the 15-49 year olds are currently exposed to pregnancy, and this represents the upper limit of women who may be candidates for contraception.
Assuming an annual consumption of 100 condoms per user, the number of women protected by condoms in 1988 from table 1 would be 64 (6434 /100). This implies that the total number of users of contraceptives in 1988 in table 1 was 500. If we assume that 95% of all women between the ages of 15 and 49 are sexually active (8320), then a rough estimate of the CPR in 1988 would be 6%5 (Scenario B). Alternatively, if 80% of the relevant age group are sexually active, or 7006 women, then the 500 users imply that the CPR in 1988 is approximately 7% (Scenario A). Since almost all women in the Marshall Islands are married by the age of 25, and given the very high rate of adolescent pregnancy, the consensus amongst Marshallese members of the multisectoral committee charged with revising the Population and Development Policy, the National Population Coordinating Committee, is that 95% of all women aged 15-49 are sexually active. No doubt, the reality lies somewhere between Scenarios A and B.
| Scenario A | 1988 | 1993 | 1998 | 2003 |
|---|---|---|---|---|
| Total Fertility Rate | 7.20 | 6.13 | 5.07 | 4.00 |
| % Women Exposed | 80.0 | 80.0 | 80.0 | 80.0 |
| Women aged 15-49 (000s) | 8.73 | 10.83 | 13.41 | 16.54 |
| Scenario B | ||||
| Total Fertility Rate | 7.20 | 6.13 | 5.07 | 4.00 |
| % Women Exposed | 95.0 | 95.0 | 95.0 | 95.0 |
| Women aged 15-49 (000s) | 8.73 | 10.83 | 13.41 | 16.54 |
The number of women aged 15-49 is projected from the computer software package DEMPROJ, using 1988 as the base, and assuming the TFR declines linearly to 4 by 2003, and female life expectancy rises from 64 to 69 by 2003, reflecting the goals of the draft Population and Development Policy.
Table 3| Annual Rates of: | |||
|---|---|---|---|
| Method | Effectiveness | Discontinuation | Consumption |
| Pill | 0.90 | 0.10 | 13.0 |
| IUD | 0.95 | 0.18 | - |
| Female Sterilization | 1.00 | 0.00 | - |
| Male Sterilization | 1.00 | 0.00 | - |
| Injectibles (Depo Provera) | 0.98 | 0.16 | 4.0 |
| Condom | 0.70 | 0.50 | 100.0 |
| Foaming Tablets/Cream | 0.70 | 0.15 | 50.0 |
| Norplant | 0.98 | 0.19 | 0.2 |
| Method | 1988 | 1993 | 1998 | 2003 |
|---|---|---|---|---|
| Pill | 9.7 | 9.6 | 9.6 | 9.6 |
| IUD | 0.4 | 0.5 | 0.5 | 0.5 |
| Female Sterilization | 31.0 | 30.8 | 30.8 | 30.8 |
| Male Sterilization | 1.0 | 1.5 | 1.5 | 1.5 |
| Injectibles (Depo Provera) | 19.2 | 19.2 | 19.2 | 19.2 |
| Condom | 8.6 | 8.5 | 8.5 | 8.5 |
| Foaming Tablets/Creams | 1.1 | 1.1 | 1.1 | 1.1 |
| Norplant | 29.0 | 28.8 | 28.8 | 28.8 |
| Total (%) | 100.0 | 100.0 | 100.0 | 100.0 |
The 1988 and 1993 method mixes portrayed in table 4 are based on data given to the author by the Director of Family Planning. Lacking any firm indication as to how the relative popularity of the various methods might change over time, it has been assumed that the method mix for 1993 remains constant in each year to 2003. This seems to be not an unreasonable assumption given the actual realized relative constancy of the mix over the 1988-93 period. However, in other country contexts which display a definite trend in patterns of change in the method mix over time, it may be more appropriate to build this trend into the model.
| 1988 | 1993 | 1998 | 2003 | |
|---|---|---|---|---|
| Contraceptive Prevalence Rate (CPR %) |
6.0 | |||
| % Women Exposed: (Scenario A) (Scenario B) |
80.0 95.0 |
80.0 95.0 |
80.0 95.0 |
80.0 95.0 |
| Duration of Post-Partum Infecundity (months) |
11.9 | 11.9 | 11.9 | 11.9 |
| Induced Abortion Rates per 1000 Women 15-49 |
0.0 | 0.0 | 0.0 | 0.0 |
| Pathological Sterility Rates (% Childless at age 49) |
5.0 | 5.0 | 5.0 | 5.0 |
We have no Marshall Islands' specific data on the duration of post-partum infecundity; 11.9 months is suggested by Bongaarts and Stover (1986) from a cross-section of international data. Marshallese staff of the Ministry of Health and Environmental Services assured the author that rates of induced abortion are negligible. The pathological sterility rate is unknown in the Marshall Islands but is approximated here in the following manner. The indicator used to represent the extent of sterility is the percentage of women who are childless at the end of their reproductive years. The proportion of women who are childless after the age of 50, as reported in the 1988 Population Census, rises with age, from 3.9% for women aged 50-54 years to 18% for women over the age of 75 years. This pattern could well be related to higher mortality for women with high parity; yet, not all of these women have ever been married so their zero parity might not indicate sterility. As a result it is assumed that 5% of Marshallese women experience pathological sterility for purposes of this exercise.
The results of these projections are displayed in tables 6 and 7.
Table 6| Scenario A | 1988 | 1993 | 1998 | 2003 |
|---|---|---|---|---|
| Contraceptive Prevalence (%) No. of Users/Acceptors of which: Pill* IUD** Female Sterilization** Male Sterilization** Depo Provera* Condom* Foaming Tablets/Cream* Norplant** |
7.0 489 47 2 74 3 94 42 5 109 |
20.4 1765 170 3 104 6 339 150 19 196 |
33.7 3621 348 4 154 8 695 308 40 347 |
47.1 6236 599 6 205 11 1083 530 69 508 |
| Scenario B | ||||
| Contraceptive Prevalence (%) No. of Users/Acceptors of which: Pill* IUD** Female Sterilization** Male Sterilization** Depo Provera* Condom* Foaming Tablets/Creams* |
6.0 498 48 2 87 4 96 43 6 124 |
19.5 2009 193 3 122 7 386 171 22 227 |
33.0 4210 404 5 182 9 808 358 46 406 |
46.6 7318 703 7 244 13 1405 622 81 599 |
| Scenario A | 1988 | 1993 | 1998 | 2003 |
|---|---|---|---|---|
| Pill 1. IUD 2. Female Sterilization 3. Male Sterilization 3. Depo Provera 4. Condom 5. Foaming Tablets/Creams 6. Norplant 7. Total |
250 2 740 30 301 76 27 665 2091 |
884 3 1040 60 1085 270 104 1196 4642 |
1810 4 1540 80 2224 554 218 2117 8547 |
3115 6 2050 110 3466 954 376 3099 13176 |
| Scenario B | ||||
| Pill 1. IUD 2. Female Sterilization 3. Male Sterilization 3. Depo Provera 4. Condom 5. Foaming Tablets/Creams 6. Norplant 7. Total |
250 2 870 40 307 77 33 756 2335 |
1004 3 1220 70 1235 308 120 1385 5345 |
2101 5 1820 90 2586 644 251 2477 9974 |
3656 7 2440 130 4496 1120 441 3654 15944 |
Table 6 shows that, if the TFR should decline to 4 children per woman by the year 2003, the number of contraceptive users will need to grow by a factor of between 12 and 14, as the CPR rises to 47%. The increase in the commodity costs of contraceptive supplies is reported in table 7. While the total commodity cost rises by a factor of over 6, the absolute maximum amount, approaching US$16,000 by 2003, is not prohibitive6.
The World Bank reports that the estimated total unit cost per contraceptive user is about US$20 in a typical developing country context (World Bank, 1992). This includes overhead costs, including training of health personnel. Therefore, as the fixed programme costs are spread over an increasing number of users, the total unit cost can be expected to fall, only to rise again eventually, as the programme reaches out to the more inaccessible Outer-Island groups. In this case, using US$20 as the fixed unit cost per user, the annual total cost of the family planning programme in the Marshall Islands would rise from about US$10,000 in 1988 to US$146 thousand in scenario B and to US$125 thousand in scenario A. The budgetary implications are clearly much greater than when only commodity costs are considered, particularly when health services and contraceptive supplies are free to users.
More significant constraints on an expanding family planning programme in the RMI relate to the logistics of organizing a regular and dependable supply of contraceptives, and to the need for an expanded programme of training for health personnel in the various aspects of family planning provision. The Asian Development Bank has recently reviewed the health and population sector in the Marshall Islands and made a series of recommendations which would further the attainment of the targets contained in this paper (Asian Development Bank/Republic of the Marshall Islands, 1993). The ADB review proposes, inter alia, the following:
This involves improved baseline data on target populations and contraceptive users, where deficiencies have been noted above; the identification of optional points of access, such as hospital-based clinics, outreach, dispensaries, education institutions etc; the setting of FP targets (which has now been undertaken in the draft of the revised Population and Development Policy); and the ability to evaluate the effectiveness of programme activities against set programme targets.
The ability to generate data on family planning acceptor rates by specific target group and geographic area is essential for planning and evaluating the FP programme. Such data are non-existent in the Marshall Islands and, to the author's knowledge, the great majority of the countries in the South Pacific region.
In order to overcome part of the constraint relating to the limited number of service providers, the ADB proposes that FP should be integrated with MCH, child welfare and immunization services. In Majuro the number of staff involved in FP would increase from four to twelve. Such an integrated approach would allow each nurse to deal with all of the client's needs, including post-natal, well-baby, immunization, FP and health education.
The ADB report recommends that FP education should be the responsibility of all health staff engaged in pre-and post-natal clinics, the communicable disease clinic, outpatients and the maternity and paediatric wards of Majuro and Ebeye hospitals. In this manner, the number of persons making contact with FP advisers would multiply significantly, and reduce the staffing constraint on the FP programme. Such a strategy would, of course, entail training in FP for many more health personnel.
Following this approach the ADB report recommends that public health and hospital-based staff involved in operating post-natal clinics, MCH-related clinics, STD clinics and outpatient departments undergo FP training.
The ADB report goes on to argue that accessibility to FP services in urban areas requires an extension of outreach activities to supplement services delivered at Majuro hospital.
Since most Health Assistants, who are responsible for the activities of the FP programme on the Outer Islands, are currently male, it is recommended that more female health workers are trained as Health Assistants or Traditional Birth Attendants.
As noted earlier, a dependable logistics system providing a reliable supply of contraceptive commodities is central to the success of the FP programme.
The ADB report recommends that those institutions engaged in IEC/FLE activities, namely the Ministries of Social Services, Education and Health, as well as the NGO Youth-to-Youth in Health, should be linked through the Health Education Council. Following this proposal, the draft Population and Development Policy indicates an intention to assign overall responsibility to the Health Education Unit of the Ministry of Health and Environmental Services for coordinating IEC/FLE activities.
This demonstration of an application of the TARGET model to the Marshall Islands can serve as an important input into reprogramming exercises for family planning activities throughout the Pacific region. From these results for RMI much more detailed planning work is required, including a strategy to increase the number of health workers able to counsel and provide FP services. In addition, the assumptions contained in our application of the model can be changed from time-to-time, as more current information becomes available, e.g., a changing method mix. Thus, FP programme planners in Pacific Island countries may wish to utilize the TARGET software as an additional tool of analysis to meet the tremendous challenge they are likely to face in the years to the end of the present century and beyond.
While this paper has had the limited objective of illustrating the application of the computer software TARGET model to the Republic of Marshall Islands' family planning programme it has extensive possibilities for use in all Pacific countries. With the benefit of the methods of projection contained here, it is possible to estimate more accurately the future financial needs of a country's FP programme. If the kinds of quantitative demographic goals set out in the RMI's draft Population and Development Policy are to be met, the model has illustrated the extent to which financial expenditures will need to increase. In the case of the expected demand for increased infrastructure and human resources, projections are much more difficult to make. Because family planning activities form only a part of the overall work of paramedical personnel, it is extremely difficult to relate the additional demand for the requisite manpower to the projected growth in demand for FP services.
Nevertheless, the limitations imposed on expanding the number of health personnel by public sector budgetary constraints necessitates that ways and means be sought to ensure that all existing paramedics be fully involved in disseminating FP information and services. Given the anticipated growth in the FP programme, however, an expansion in training facilities and FP personnel seems inevitable. Determining training and personnel requirements in a more precise and quantitative manner should be a priority activity for planners in the Office of Planning and Statistics and the Ministry of Health and Environmental Services in the Marshall Islands, as elsewhere throughout the region.
1The Compact Agreement entitles Marshallese unrestricted access to live and work in the USA, but few have taken this opportunity to out-migrate and relieve the intensity of population pressure at home, perhaps because of their poor educational attainments and lack of marketable skills. Whether Marshallese citizens will retain such access after the current Compact Agreement terminates or under the terms of a new agreement is unknown at present.
2Bongaarts and Stover (1986)
4Because our base year data are for 1988, and the Target software requires data for 5-year intervals, the terminal year in the is 2003, which does not quite coincide with the target year of 2005 in the population policy.
6The total cost of contraceptive supplies grows less than the number of users because of the importance of such methods as sterilization and Norplant, which incur a once-only cost (sterilizatin) or a 5-yearly (Norplant)