Global population growth was among the top concerns in the late1960s. Some projections were that the world’s population was growing so rapidly as to outstrip the resources to sustain it. Something had to be done, and in the era before oral contraceptives and other reproductive technologies, the choices were few. Yet, the need for action was so strong that a few countries launched efforts to try and contain population growth. These efforts were viewed with deep skepticism by many policy makers and health professionals. Change fertility behaviors on a broad scale? Fly in the face of current microeconomic theory that promoting small families, fewer children especially among people living in poverty, was actually counter to the economic incentive and value of having more children? And while the first attempts at controlling population growth were generally regarded as failures, the pressure to do something better led to more experimentation and trials. What happened is that population fertility rates actually began to decline in some countries, and then more. And 30 years later, though the world’s population continues to increase in some regions, population-based methods of behavior change to achieve economic, social and health outcomes have become accepted wisdom. So much so that complacency and neglect has set in.
That’s the story recounted in detail in two publications by The World Bank that were launched at an event today I was invited to attend: The Global Family Planning Revolution: Three Decades of Policies and Programs and Population Issues in the 21st Century: The Role of the World Bank. How did population control programs actually work? One analysis in the opening remarks laid it on two factors:
- Good programs found woman in all societies who wanted to control their fertility, especially after having had 4, 5, 6 or more births. As one discussant put it: “They were tired of being pregnant.” This unmet need surfaced as programs began to be fielded, and coincidentally (?) the application of social marketing in these programs began to take root.
- Well-designed, well-managed programs were found to work in settings where social conditions were more favorable than the initial countries in which population control was attempted (better economic status, relatively higher status of women, higher education levels and low infant mortality rates – that worked to counter the economic value theory).
Several of the panelists emphasized the point that a new theory arose to counter the microeconomic model and explain what was being observed in these successful countries, a sociological one – Theory of Ideational Change. Once the notion of family planning (“you can take control of your life”) diffuses through society, it has an impact on behavior adoption that is independent of the effects of economics. It was a radical (where are the Freakonomics folks?) perspective that behavior can and will change even if living standards (economic incentives and costs) do not. Think about that for a minute: psychosocial benefits can trump financial costs and barriers.
The implication of this next generation of family planning programs was clear: improving welfare, creating supportive norms and offering good family planning services and products can have important impact on fertility behaviors.
As these programs were replicated and expanded into even more countries, global Total Fertility Rates (TFRs) began declining in most parts of the world by the 1970s; yet what we have seen over the past 10 years or so is a plateauing of progress. Discussants pointed to a lessened focus on family planning overall due, they believe, to a focus on other health priorities (notably the big shift in funding to HIV/AIDS prevention and treatment), a preoccupation with individual health outcomes rather than population ones (a familiar theme to our regular readers) and concerns that government programs aimed at socially beneficial outcomes were doing so at the expense of marginalizing some groups and not respecting the individual rights and concerns of others. And while many countries were experiencing moderate to substantial declines in their TFRs during this time, today 35 countries still have TFRs>5 (five or more births in a family) and have shown little change over the past 50 years.
These high fertility countries, 31 of which are in Sub-Saharan Africa, require renewed and increased attention to creating and growing family planning programs that stimulate demand for products and services (and accompanying changes in fertility behaviors), improving access to contraception and reproductive health services, and research to understand and serve the needs of ‘the youth bulge’ in the demographic composition of these countries. As one of the authors of the report later said to me: What we need to do is a better job of segmenting our populations, something we have not been terribly good at up to now.
The program came to a close with a call to return to the original agenda set by the World Bank in the 1960s: population growth is a menace. To do so would mean:
- A return to having evidence-based programs as a norm – where data makes a difference in how programs were funded, developed, implemented and managed. The point was made that political, bureaucratic and religious issues have always been part of the mix of concerns that need to be balanced in this area, but objective data should be the primary driver of decision-making.
- Increasing the historically prominent role that NGOs and civil society have played in research, service provision and advocacy for population issues and programs rather than what has become a reliance on the public sector to do everything – often without the capacity and infrastructure to do so effectively and efficiently.
- Rebalancing and invigorating the role of donors in leading efforts to manage what is still one of the major determinants of social and individual well-being and health. It is a call being echoed by a growing number of groups including a report of hearings held for the UK All Party Parliamentary Group on Population, Development and Reproductive Health (pdf file).
As I look at where social marketing has been, and what we’ve learned over the years outside of the family planning arena, there seems no better time or call for returning to our roots with the new ideas, methods and practices we have been honing elsewhere.
Comments