V. Provision and Development of Family Planning Services, Information and TechnologyIn addition to creating the climate for fertility decline, as described in a previous section, it is essential to provide safe and effective techniques for controlling fertility. There are two main elements in this task: (a) improving the effectiveness of the existing means of fertility control and developing new ones; and (b) developing low-cost systems for the delivery of family planning technologies, information and related services to the 85% of LDC populations not now reached.
Legislation and policies affecting what the U.S. Government does relative to abortion in the above areas is discussed at the end of this section.
IV. A. Research to Improve Fertility Control Technology
DiscussionThe effort to reduce population growth requires a variety of birth control methods which are safe, effective, inexpensive and attractive to both men and women. The developing countries in particular need methods which do not require physicians and which are suitable for use in primitive, remote rural areas or urban slums by people with relatively low motivation. Experiences in family planning have clearly demonstrated the crucial impact of improved technology on fertility control. None of the currently available methods of fertility control is completely effective and free of adverse reactions and objectionable characteristics. The ideal of a contraceptive, perfect in all these respects, may never be realized. A great deal of effort and money will be necessary to improve fertility control methods. The research to achieve this aim can be divided into two categories:
1. Short-term approaches: These include applied and developmental work which is required to perfect further and evaluate the safety and role of methods demonstrated to be effective in family planning programs in the developing countries.
Other work is directed toward new methods based on well established knowledge about the physiology of reproduction. Although short term pay-offs are possible, successful development of some methods may take 5 years and up to $15 million for a single method.
2. Long-term approaches: The limited state of fundamental knowledge of many reproductive processes requires that a strong research effort of a more basic nature be maintained to elucidate these processes and provide leads for contraceptive development research. For example, new knowledge of male reproductive processes is needed before research to develop a male "pill" can come to fruition. Costs and duration of the required research are high and difficult to quantify.
With expenditures of about $30 million annually, a broad program of basic and applied bio-medical research on human reproduction and contraceptive development is carried out by the Center for Population Research of the National Institute of Child Health and Human Development. The Agency for International Development annually funds about $5 million of principally applied research on new means of fertility control suitable for use in developing countries.
Smaller sums are spent by other agencies of the U.S. Government. Coordination of the federal research effort is facilitated by the activities of the Interagency Committee on Population Research. This committee prepares an annual listing and analyses of all government supported population research programs. The listing is published in the Inventory of Federal Population Research.
A variety of studies have been undertaken by non-governmental experts including the U.S. Commission on Population Growth and the American Future. Most of these studies indicate that the United States effort in population research is insufficient. Opinions differ on how much more can be spent wisely and effectively but an additional $25-50 million annually for bio-medical research constitutes a conservative estimate.
Recommendations:A stepwise increase over the next 3 years to a total of about $100 million annually for fertility and contraceptive research is recommended. This is an increase of $60 million over the current $40 million expended annually by the major Federal Agencies for bio-medical research. Of this increase $40 million would be spent on short-term, goal directed research. The current expenditure of $20 million in long-term approaches consisting largely of basic bio-medical research would be doubled. This increased effort would require significantly increased staffing of the federal agencies which support this work. Areas recommended for further research are: 1. Short-term approaches: These approaches include improvement and field testing of existing technology and development of new technology. It is expected that some of these approaches would be ready for use within five years. Specific short term approaches worthy of increased effort are as follows:
a. Oral contraceptives have become popular and widely used; yet the optimal steroid hormone combinations and doses for LDC populations need further definition. Field studies in several settings are required.
Approx. Increased Cost: $3 million annually.
b. Intra-uterine devices of differing size, shape, and bioactivity should be developed and tested to determine the optimum levels of effectiveness, safety, and acceptability.
Approx. Increased Cost: $3 million annually.
c. Improved methods for ovulation prediction will be important to those couples who wish to practice rhythm with more assurance of effectiveness than they now have.
Approx. Increased Cost: $3 million annually.
d. Sterilization of men and women has received wide-spread acceptance in several areas when a simple, quick, and safe procedure is readily available. Female sterilization has been improved by technical advances with laparoscopes, culdoscopes, and greatly simplifies abdominal surgical techniques. Further improvements by the use of tubal clips, trans-cervical approaches, and simpler techniques can be developed. For men several current techniques hold promise but require more refinement and evaluation.
Approx. Increased Cost $6 million annually.
e. Injectable contraceptives for women which are effective for three months or more and are administered by para-professionals undoubtedly will be a significant improvement. Currently available methods of this type are limited by their side effects and potential hazards. There are reasons to believe that these problems can be overcome with additional research.
Approx. Increased Cost: $5 million annually.
f. Leuteolytic and anti-progesterone approaches to fertility control including use of prostaglandins are theoretically attractive but considerable work remains to be done.
Approx. Increased Cost: $7 million annually.
g. Non-Clinical Methods. Additional research on non-clinical methods including foams, creams, and condoms is needed. These methods can be used without medical supervision.
Approx. Increased Cost; $5 million annually.
h. Field studies. Clinical trials of new methods in use settings are essential to test their worth in developing countries and to select the best of several possible methods in a given setting.
Approx. Increased Cost: $8 million annually.
2. Long-term approaches: Increased research toward better understanding of human reproductive physiology will lead to better methods of fertility control for use in five to fifteen years. A great deal has yet to be learned about basic aspects of male and female fertility and how regulation can be effected. For example, an effective and safe male contraceptive is needed, in particular an injection which will be effective for specified periods of time. Fundamental research must be done but there are reasons to believe that the development of an injectable male contraceptive is feasible. Another method which should be developed is an injection which will assure a woman of regular periods. The drug would be given by para-professionals once a month or as needed to regularize the menstrual cycle. Recent scientific advances indicate that this method can be developed.
Approx. Increased Cost: $20 million annually.
IV. B. Development of Low-cost Delivery Systems
DiscussionExclusive of China, only 10-15% of LDC populations are currently effectively reached by family planning activities. If efforts to reduce rapid population growth are to be successful it is essential that the neglected 85-90% of LDC populations have access to convenient, reliable family planning services. Moreover, these people -- largely in rural but also in urban areas -- not only tend to have the highest fertility, they simultaneously suffer the poorest health, the worst nutritional levels, and the highest infant mortality rates. Family planning services in LDCs are currently provided by the following means:
1. Government-run clinics or centers which offer family planning services alone;
2. Government-run clinics or centers which offer family planning as part of a broader based health service;
3. Government-run programs that emphasize door to door contact by family planning workers who deliver contraceptives to those desiring them and/or make referrals to clinics;
4. Clinics or centers run by private organizations (e.g., family planning associations);
5. Commercial channels which in many countries sell condoms, oral contraceptives, and sometimes spermicidal foam over the counter;
6. Private physicians.
Two of these means in particular hold promise for allowing significant expansion of services to the neglected poor:
1. Integrated Delivery Systems. This approach involves the provision of family planning in conjunction with health and/or nutrition services, primarily through government-run programs. There are simple logistical reasons which argue for providing these services on an integrated basis. Very few of the LDCs have the resources, both in financial and manpower terms, to enable them to deploy individual types of services to the neglected 85% of their populations. By combining a variety of services in one delivery mechanism they can attain maximum impact with the scarce resources available.
In addition, the provision of family planning in the context of broader health services can help make family planning more acceptable to LDC leaders and individuals who, for a variety of reasons (some ideological, some simply humanitarian) object to family planning. Family planning in the health context shows a concern for the well-being of the family as a whole and not just for a couple's reproductive function.
Finally, providing integrated family planning and health services on a broad basis would help the U.S. contend with the ideological charge that the U.S. is more interested in curbing the numbers of LDC people than it is in their future and well-being. While it can be argued, and argued effectively, that limitation of numbers may well be one of the most critical factors in enhancing development potential and improving the chances for well-being, we should recognize that those who argue along ideological lines have made a great deal of the fact that the U.S. contribution to development programs and health programs has steadily shrunk, whereas funding for population programs has steadily increased. While many explanations may be brought forward to explain these trends, the fact is that they have been an ideological liability to the U.S. in its crucial developing relationships with the LDCs. A.I.D. currently spends about $35 million annually in bilateral programs on the provision of family planning services through integrated delivery systems. Any action to expand such systems must aim at the deployment of truly low-cost services. Health-related services which involve costly physical structures, high skill requirements, and expensive supply methods will not produce the desired deployment in any reasonable time. The basic test of low-cost methods will be whether the LDC governments concerned can assume responsibility for the financial, administrative, manpower and other elements of these service extensions. Utilizing existing indigenous structures and personnel (including traditional medical practitioners who in some countries have shown a strong interest in family planning) and service methods that involve simply-trained personnel, can help keep costs within LDC resource capabilities.
2. Commercial Channels. In an increasing number of LDCs, contraceptives (such as condoms, foam and the Pill) are being made available without prescription requirements through commercial channels such as drugstores.17 The commercial approach offers a practical, low-cost means of providing family planning services, since it utilizes an existing distribution system and does not involve financing the further expansion of public clinical delivery facilities. Both A.I.D. and private organizations like the IPPF are currently testing commercial distribution schemes in various LDCs to obtain further information on the feasibility, costs, and degree of family planning acceptance achieved through this approach. A.I.D. is currently spending about $2 million annually in this area.
In order to stimulate LDC provision of adequate family planning services, whether alone or in conjunction with health services, A.I.D. has subsidized contraceptive purchases for a number of years. In FY 1973 requests from A.I.D. bilateral and grantee programs for contraceptive supplies -- in particular for oral contraceptives and condoms -- increased markedly, and have continued to accelerate in FY 1974. Additional rapid expansion in demand is expected over the next several years as the accumulated population/family planning efforts of the past decade gain momentum.
While it is useful to subsidize provision of contraceptives in the short term in order to expand and stimulate LDC family planning programs, in the long term it will not be possible to fully fund demands for commodities, as well as other necessary family planning actions, within A.I.D. and other donor budgets. These costs must ultimately be borne by LDC governments and/or individual consumers. Therefore, A.I.D. will increasingly focus on developing contraceptive production and procurement capacities by the LDCs themselves. A.I.D. must, however, be prepared to continue supplying large quantities of contraceptives over the next several years to avoid a detrimental hiatus in program supply lines while efforts are made to expand LDC production and procurement actions. A.I.D. should also encourage other donors and multilateral organizations to assume a greater share of the effort, in regard both to the short-term actions to subsidize contraceptive supplies and the longer-term actions to develop LDC capacities for commodity production and procurement.
Recommendations: 1. A.I.D. should aim its population assistance program to help achieve adequate coverage of couples having the highest fertility who do not now have access to family planning services.
2. The service delivery approaches which seem to hold greatest promise of reaching these people should be vigorously pursued. For example:
a. The U.S. should indicate its willingness to join with other donors and organizations to encourage further action by LDC governments and other institutions to provide low-cost family planning and health services to groups in their populations who are not now reached by such services. In accordance with Title X of the AID Legislation and current policy, A.I.D. should be prepared to provide substantial assistance in this area in response to sound requests.
b. The services provided must take account of the capacities of the LDC governments or institutions to absorb full responsibility, over reasonable timeframes, for financing and managing the level of services involved.
c. A.I.D. and other donor assistance efforts should utilize to the extent possible indigenous structures and personnel in delivering services, and should aim at the rapid development of local (community) action and sustaining capabilities.
d. A.I.D. should continue to support experimentation with commercial distribution of contraceptives and application of useful findings in order to further explore the feasibility and replicability of this approach. Efforts in this area by other donors and organizations should be encouraged. Approx. U.S. Cost: $5-10 million annually.
3. In conjunction with other donors and organizations, A.I.D. should actively encourage the development of LDC capabilities for production and procurement of needed family planning contraceptives.
Special Footnote: While the agencies participating in this study have no specific recommendations to propose on abortion the following issues are believed important and should be considered in the context of a global population strategy.