How effective are family-planning programs at improving the lives of women? Some perspectives from a vast literature

How effective are family-planning programs at improving the lives of women? Some perspectives from a vast literature Shareen Joshi Georgetown University June, 2011

Outline • A brief history of FP programs • A review of the evidence: What do these programs do for women? • Non-experimental studies • Experimental studies • How much do the programs cost? • Broad lessons for policy

A brief history of FP programs • 1950—1975 • Significant scale-up in many countries • 1975—1995 • Weakening of international support, domestic commitment in Asia • 1995—2005 • Near disappearance of FP in international policy-circles • Past few years: A new wave of interest?

1950—1975: Scale up World Bank USAID United Nations Rockefeller Foundation Ford Foundation Amount spent: $200 million Amount spent: $0

1975—1995: Why did international support begin to decline? • Fertility decline indeed occurred in many countries • Intellectual shifts • Population growth not a threat to economic growth • Greater emphasis on technology • Green revolution + absence of major famines • Objections from the ground • Human-rights violations • Evidence of side-effects • Feminist critiques • “Development is the best contraceptive”

1994: International Conference on Population and Development, Cairo • FP was subsumed into a broader agenda • Basic theme: “Reproductive rights” • Broader issues of gender inequality highlighted • 179 governments agreed on the need to ensure universal access to reproductive health services by the year 2015 • Problems: • Controversy about status of abortion as a reproductive right • Agenda was too broad • Not enough evidence of any “economic return” on investments in reproductive health • New challenges: HIV

After Cairo… • International support for FP declined significantly: • The percentage of funding allocated for FP has declined from 43 percent in 1998 to 6 percent in 2008 (UNFPA, 2009) • FP was sidelined from the initial MDGs • In 2007, MDGs modified to include “universal access to reproductive health by 2015” • Progress was to be measured by four indicators: the contraceptive prevalence rate, the adolescent birth rate, antenatal care coverage, and the unmet need for FP (United Nations 2007; UNFPA 2011) • HIV programs have rarely been built on the shoulder of prior FP programs and have rarely prioritized FP services

General approach of measuring impact is quite simple Income Culture Education Mortality Status of women Institutions • Key challenges: • Measurement: • FP programs are diverse • Quality is hard to measure • Omitted variables: MANY OTHER THINGS MATTER ON BOTH SIDES

Two main groups of studies

Non-Experimental > Cross-Sectional Studies Cross-country studies • Typically use data from a cross-section to test whether FP programs impact the TFR, CPR or CBR • Strength of FP programs is quantified • Early studies: measures of service delivery/inputs • Lapham, Maudlin and Phillips (1972) measured “effort” • Policy and stage-setting activities • Service and service-related activities • Record-keeping and evaluation • Availability and accessibility of fertility-control supplies and services. • Levels of socio-economic development are included as controls in multivariable regression frameworks, or in decompositions of fertility decline

Non-Experimental > Cross-Sectional Studies Some conclusions from this literature • FP programs DO have an effect on fertility • Between 1960-65 and 1980-85 fertility fell by 3.1 children per woman in countries that had strong programs • Conservative estimate: On average, impact of FP programs on fertility is small (3—10%) • Socio-economic variables ALSO matter • FP are more effective in environments of strong socio-economic development • Fertility decline may have spillover effects • FP programs may also reduce child mortality by reducing the number of risky births • Policy-implications: Strengthening FP programs, i.e. expanding supply, will reduce fertility in developing countries

Non-Experimental > Cross-Sectional Studies But cross-sectional studies have limitations… • Program quality difficult to measure • Programs not randomly placed • Most studies can not establish causal relationships • Schultz (1997): statistical assumptions matter • Too much emphasis on “supply” • Modern day version of Says Law? • Pritchett (1994): demand is also critical

Schultz (1997) • Cross section of low-income countries in the 1970s and 1980s (1972, 1985 and 1988) • Regressed differences in TFRs over time on differences in FP effort scores • Found that the estimated effect of change in FPE on change in TFR is not statistically significant • Treats the FPE variable as endogenous • Donor funds (planned parenthood) are treated as a subsidy for FPE in the first stage regression • Second stage estimate is not statistically significant • When child mortality is included as an independent variable, the FPE variable diminishes in size (0.05) but is statistically significant

Pritchett (1994) • Shows that most of the variation in TFR across countries is driven by desired fertility (DF) and the number of wanted births (WB) • R-squared in the regression with DF is 0.91, N=66 • R-squared in the regression with WB is 0.85, N=47 • Unwanted fertility, or the fraction of births, which at the time of conception are reported as unwanted, does not explain much of the cross-country variation in TFR • Conclusion: • FP programs do not matter much! • If FPE were to increase in low-income countries from its indexed value of zero to the average level in his sample of countries (i.e., 31.4), holding desired fertility fixed, this major policy revolution would reduce TFR by only 0.22 to 0.37 births

Non-Experimental Another Approach: Case-studies • These focus on a single country over time, and use a mix of quantitative and qualitative methods to assess impact of FP programs • Hundreds of these exist covering countries, regions, states or even individual programs • Most of them find that FP programs make a difference • "FP programs contribute to fertility decline, often substantially" (Ahlburg and Diamond 1996: 319). • A question: Is there publication bias?

Non-Experimental A third approach: Panel studies • Examine impact of an FP program on CPR, TFR, CBR, etc. in one particular country/region over time • Typically control for initial conditions and omitted variables (through fixed-effects) • Often address program placement • Because individuals or communities are tracked over time, the effect of FP programs can be “separated” from other socio-economic trends such as improvements in education, income, employment, etc. • Some interesting studies: • Schultz (1973) and Montgomery and Casterline (1993)– Taiwan • Gertler and Molyneax(1994) -- Indonesia • Rosenzweig and Schultz (1982) • Miller (2009) – Colombia

Gertler and Molyneaux (1994) • Focus on Indonesia for the years 1982 through 1987 • Model: • Relates changesin fertility to changes in behavioral choices (contraceptive use, age at marriage). • also relates changes in behavioral choices to changes in women's education and wages, men's wages, and family-planning resources (e.g., number of clinics or field workers per capita), etc. • Results: • 75% of fertility decline was attributable to a large rise in contraceptive use (as opposed to other choices, such as postponement of marriage). • 87% of the increase in use was attributable to changes in educational and economic factors • Only 5% was attributable to changes in the availability of family-planning services. • BUT…. They acknowledge that demand and supply went hand in hand

Non-Experimental > Panel Studies Some key results • FP programs do have an impact on fertility • Effect is about 5—15% decline in fertility • Socio-economic variables ALSO matter • FP programs can only “explain” a small percentage of fertility decline (4-8% in Indonesia and 6-8% in Colombia) • Lots of evidence of spillover effects • FP programs “reinforce” other types of programs (Rosenzweig and Wolpin, 1982, and Duraiswamy and Malathy, 1991) • Family size and child-health can indeed be substitutes (Rosenzweig and Wolpin, 1986) • Lower fertility (as a result of FP programs) can increase female education and employment (Miller, 2009) • Policy implications: Again, FP can lower fertility

Another approach: Experimental Studies • Idea: units of study (individuals, regions or clinics) are randomly allocated to different “treatment” arms, a control arm is chosen to provide a benchmark for progress and both treatment and control are tracked over time • The difference between the treatment and control groups, over time, can provide the most confident inference about a program’s impact • The approach has become enormously popular in recent years but there are many examples of FP programs that were designed this way 30+ years ago • Taichung, Taiwan (1963—1969) • Matlab, Bangladesh (1977 onwards) • Navrongo, Ghana (1994 onwards)

Experimental Studies Evidence from Matlab, Bangladesh Impact over 30 years • Benefits to women: • 15% reduction in fertility = 1 less child • Improved weights and BMI’s • Lower mortality risks • Increased labor-market participation & wages • Benefits for children • Better health (vaccinations) • Higher schooling attainment for boys • Benefits for families • Increased resources (drinking water) Program Details: • Women with 8+ years of schooling were trained as “Health workers” • Visited a set of married women in their own village every 2 weeks in their homes • Provided key functions: • Choice of services and follow-up support • Referred women to the hospital for pre-natal and ante-natal care medical care • Distributed “safe delivery” kits • Prenatal and ante-natal care • Tetanus inoculations • Children’s immunizations • Treatment for simple diseases (diarrhea, respiratory diseases, etc.) Source: Phillips et al. (1988), Sinha(2005), Joshi and Schultz (2007), Chowdhuryet al. (2007), Schultz (2008), Menken, Duffy and Kuhn (2003)

Experimental Studies Evidence from Navrongo, Ghana (1/2) Two treatment arms: • Deployment of community volunteers: • Chiefs, lineage heads and women’s social networks were approached • Community Health Compounds were jointly built • Relocation of nurses from sub-district clinics to community locations: • Vaccinations • Treatment of common ailments • FP options: injectable contraception, oral contraceptives and condoms, referrals for clinical procedures Impact : • Higher health coverage • Improvements in child health • Emerging changes in reproductive behaviour • Steady FP uptake Source: Pence, Nyarko, Phillips, and Debpuur(2007), Phillips, Bawah and Binka (2006)

Experimental Studies Navrongo, Ghana (2/2)

Experimental Studies Some results from this literature • FP programs do have an effect on TFRs • Again, effect is small (5—15%) • In a meta-analysis, Bauman (1997) estimates that FP programs explain no more than 1% of the variation in outcomes. • Clearest evidence yet of spillover effects (mainly from Matlab, Bangladesh) • Child health • Child mortality • Children’s education and labor-force participation • Female health • Female employment and wages • Living standards more generally

Experimental Studies Recent studies also illustrate how they can empower women within households • Ashraf, Field, and Lee (2010) experiment in Zambia: • Treatment Arm 1: Married women receive a voucher to receive free contraceptives ALONE • Treatment Arm 2: Couples receive a voucher to receive free contraceptives • Control Group: Received only information • Results • Women in Arm 1 are 28% more likely to use concealable contraception, 57% reduction in unwanted births • Couples arm was 15% more likely to use contraception but unwanted births was identical to the control group • Need more experiments that test the power structures of households! Source: Adongo (2009)

Costs Both costs and benefits are hard to measure • Most available data pertains to average costs which vary substantially: • Scale of the program • Accounting systems used • Method mix offered to couples • Existing level of infrastructure • Existence of complementary programs • Variations in salaries and costs of other personnel • Benefits are also difficult to measure: • Number of people who use a service? • Births averted? Deaths averted?

Costs Some cost estimates in the literature • Levine et al. (2006) • Contraceptive supplies: $1.55 per person per year • Program costs: $2--$35 per person per year • Halperin, Stover, and Reynolds (2009): average cost of $20 per person per year • Temporary methods: $6 to $24 per acceptor • Long-term methods: $9 to $60 per acceptor • Female sterilization: $30 to $100 per acceptor • The World-Bank’s Disease Control Priorities Project for example, estimates the cost of FP at $117 per DALY • Estimates are constructed from 3 studies that provide IUDs, voluntary sterilization, condoms and other barrier methods, implants, and oral contraceptives to a target population that includes all adult women of child-bearing age • Costs are higher for experimental programs such as Matlab • Costs per prevented birth are about $180 with a range of $150-$220 (Simmons et al. 1991)

Costs Cost-benefit estimates from Levine et al. (2006) • These benefit-cost ratios exclude the broader “spillover” benefits of FP programs • Costs can be further lowered by “bundling” FP with HIV prevention and treatment • programs

Policy Implications Why should we invest in FP programs? • Impact on fertility is generally small, but… • Small declines can “scale up” at the level of a population • Cross-effects on female education, health and employment are often significant • Benefits increase over time • FP is just one more investment in female human capital • Enables women to make choices and attain their own goals • Complements other programs aimed at investing in female human capital (education, health, etc.) • Lots of spillovers! • Expensive? Maybe not….

Policy Implications What should FP programs looks like today? • Voluntary • Long-term support and coordinated funding • Provide a full-range of services to women and adolescents • Mobilize and actively involve local communities (both in design and implementation) • Evidence-based approach towards program design and implementation

Appendix

Three main types of countries • Examples: China, India, Pakistan, Korea, Indonesia • Strong national commitment • Emphasis on low-cost “permanent” methods • Strong incentives to lower fertility • Complementary policies: health, public-health, education • Examples: Latin America, (maybe) Bangladesh • National commitment (strong in some cases) • Emphasis on reduction of unsafe abortions • Focus on maternal & child health, longer birth intervals, etc. • Emphasis on voluntary participation, temporary methods • Examples: Many countries in Sub-Saharan Africa • Small-scale programs run by donors • Problems with both demand and supply • Insufficient coordination • Programs not integrated into health systems

Navrongo: Cells in the experimental design (2/3) Mobilizing Ministry of Health outreach Mobilizing traditional community organization No Yes No Comparison 4 Zurugelu only 1 Yes Combined 3 = 1 & 2 Community health nurses in village locations 2

How effective are family-planning programs at improving the lives of women? Some perspectives from a vast literature