 John C. Caldwell is Emeritus Professor of Demography, National Centre for Epidemiology and Population Health, The Australian National University, Canberra. E-mail: jack.caldwell@anu.edu.au. James F. Phillips is Senior Associate, Research Division, The Population Council, One Dag Hammarskjold Plaza, New York, NY 10017. Barkat-e-Khuda is Associate Director and Head, Policy and Planning, International Centre for Diarrhoeal Disease Research, Bangladesh. National family planning programs have been an important instrument in accelerating global fertility decline and in restricting ultimate world population to a level probably below ten billion. They began to come into being after 1950 and will probably go out of existence in most of the world's regions by 2050. The archetypal programs were instituted in Asia and North Africa. The end of the twentieth century is an appropriate half-way mark at which to evaluate the twentieth-century programs and to assess what changes in them will be needed for the twenty-first century. Some changes are necessary because dramatic events have occurred: (1) long-term replacement-level fertility has been attained in most of East Asia and some of Southeast Asia, and accordingly, some programs there are being phased out; (2) mainland South Asian fertility has been slower to decline; (3) international donor funding is diminishing and may not be significant during much of the twenty-first century; (4) the 1994 International Conference on Population and Development held in Cairo called for a radical change in programs away from demographic aims and toward reproductive health and the improvement of the situation of women; and (5) the future family planning frontier will be sub-Saharan Africa, for which radically new types of programs may have to be developed. These issues were discussed in January 2000 at a conference held in Dhaka, Bangladesh. A selection of contributions to the conference is published here. This article provides an overview of the issues based partly on this selection and partly on the discussions that took place at the conference. (Studies in Family Planning 2002; 33[1]: 1–10)
The Global ExperienceJason L. Finkle and C. Alison McIntosh are independent scholars who formerly taught at the University of Michigan at Ann Arbor. Finkle resides in Ann Arbor and McIntosh in Melbourne, Australia. E-mail: jfinkle@umich.edu. Population conferences have evolved through three overlapping stages, each stage reflecting a different perspective on the relationship between national policy formulation and the international system. Initially, at Rome in 1954 and in Belgrade in 1965, participants were invited on the basis of their expertise and were not expected to represent their governments. By the time of the Bucharest Conference in 1974, the United Nations, in an attempt to give conferences a greater role in shaping population policy and to inspire member governments to show greater concern for their own population problems, decided that conferences would be intergovernmental gatherings and that national delegations would be selected by governments. The effect of this change was that governments gave less weight to scientific expertise and, conversely, greater weight to political and bureaucratic considerations. At the present time, although conferences remain intergovernmental gatherings, the door has been opened for nongovernmental organizations-civil society-to play a more active role in the conference process and in deliberations. As conferences have become more inclusive, their focus has veered from what has conventionally been regarded as population concerns. The changing composition of participants at UN conferences has had the effect of altering the policy agenda in the international population field and, as some have argued since Cairo, has redefined the meaning of population. Conferences in the twenty-first century likely will be compelled to confront diverse demographic problems in addition to social issues demanding the attention of the political system at every level. (Studies in Family Planning 2002; 33[1]: 11–23)
John Bongaarts is Vice President, Policy Research Division, and Elof Johansson is Vice President, Center for Biomedical Research, Population Council, New York. E-mail: jbongaarts@popcouncil.org. This study reviews existing methodologies for projecting future trends in contraception, evaluates the validity of the assumptions underlying these projections, proposes methodological improvements, and assesses the prospects for new methods of contraception in the coming decade. Demand for contraception can be expected to continue to rise rapidly for the next few decades as populations continue to grow and fertility declines to approach replacement level. As a result of these trends, the number of contraceptive users in the developing world is expected to rise from 549 to 816 million during the next 25 years, according to the most recent UN projection. An examination of the projection methodology found it to be reasonable. Projecting the future distribution of specific contraceptive methods is more difficult. Method choice is affected by trends in several factors, including access to different methods, user characteristics, and technology. The procedure employed by the Futures Group to project method mix was found to be less than optimally designed, and a new methodology is, therefore, proposed. (Studies in Family Planning 2002; 33[1]: 24–36)
Sarah F. Harbison is Senior Research Advisor, Bureau for Global Health, USAID, Washington, DC. Warren C. Robinson is an economic consultant, 4753 MacArthur Blvd NW, Washington, DC 20007. E-mail: robharbmat@aol.com. Although the world demographic transition from high to low fertility appears to be nearing its completion, observed in perspective, this is the latest in a series of such transitions stretching back into prehistory. A stable new equilibrium is far from inevitable; indeed, it is unlikely. Many countries are experiencing below-replacement-level fertility, and this trend is spreading. Couples are now able to choose their family size, free of the traditional pressures to bear children that was characteristic of most traditional societies. In fact, most societal pressures for the last generation have been distinctly antinatalist, in response to the enormous attention paid by the media to the "population bomb" agenda. This antinatalist attitude is changing, however, and what seems more likely than either a stationary or declining world population is a new growth cycle reflecting a resurgence of fertility as a response to growing material affluence and potential technological mastery of environmental challenges. Societal pressures and policies will play a role in this transition as they did in earlier ones. (Studies in Family Planning 2002; 33[1]: 37–48)
Changing Programs to Meet Twenty-first Century NeedsJudith F. Helzner is Director of Sexual and Reproductive Health, International Planned Parenthood Federation/ Western Hemisphere Region, 120 Wall Street, Ninth Floor, New York, NY 10005-3902. E-mail: jhelzner@att.net. The 1994 International Conference on Population and Development held in Cairo has generated widespread commitment to changing family planning programs from categorical and medically focused service organizations to reproductive health initiatives that embrace a wide range of social and human services. This article uses qualitative data analysis to review the experience of nine family planning association projects in the Latin American and Caribbean region that have made a successful organizational transition from services focused on family planning to a gender-based and sexual health approach. A conceptual framework is proposed, including factors external to the organization. Factors that can promote a pilot intervention's becoming fully institutionalized include: the need for commitment from high-level staff and members of the board of directors, the creation of partnerships with other agencies, and an emphasis on monitoring and evaluation. Lessons from this experience and their potential relevance to other settings are reviewed and discussed. (Studies in Family Planning 2002; 33[1]: 49–60)
Ruth Simmons is Professor and Joseph Brown is Assistant Professor, University of Michigan School of Public Health, Department of Health Behavior and Education, 1420 Washington Heights, Ann Arbor, MI 48109-2029. E-mail: rsimmons@umich.edu. Margarita Díaz is President, Reprolatina, Campinas, SP, Brazil. In the field of reproductive health, investigation of the transfer of knowledge gained from demonstration and pilot projects to large public-sector programs typically has not been considered a relevant domain for research or other investigation. This article draws on a range of research in the social sciences and presents two frameworks for understanding the critical attributes of successful expansion of small-scale innovations. Seven key lessons are developed using examples from family planning where scaling up was an explicit objective, including the early Taichung Study of Taiwan, the Chinese Experiment in Quality of Care, the Bangladesh MCH–FP Extension Project, the Navrongo Project in Ghana, and the Reprolatina Project in Brazil. Unless small, innovative projects concern themselves from the outset with determining how their innovations can be put to use on a larger scale, they risk remaining irrelevant for policy and program development. (Studies in Family Planning 2002; 33[1]: 61–75)
Regional PerspectivesJohn Caldwell is Emeritus Professor of Demography and Visiting Fellow and Pat Caldwell is Centre Visitor, Health Transition Centre, National Centre for Epidemiology and Population Health, The Australian National University, Canberra, ACT 0200, Australia. E-mail: jack.caldwell@nceph.anu.edu.au. Sub-Saharan Africa will be the family planning frontier of the twenty-first century. Fertility levels and population growth rates are still high, and family planning programs suited to the region are still being developed. Nevertheless, by the end of the twentieth century, fertility transition was under way in Southern Africa and a few countries elsewhere. Successful regional family planning in the twenty-first century will depend upon stronger political leadership, the development of family planning programs that meet the needs of all segments of society and not only currently married women, assistance to the market, and a recognition of the central importance of hormonal methods, especially injectables. Problems include stagnation in economic growth and in child mortality decline, as well as the persistence of the AIDS epidemic. (Studies in Family Planning 2002; 33[1]: 76–86)
Mary Arends-Kuenning is Assistant Professor, Department of Agricultural and Consumer Economics, University of Illinois at Urbana-Champaign, 408 Mumford Hall, 1301 West Gregory Drive, Urbana, IL 61801. E-mail: marends@uiuc.edu. The government of Bangladesh is currently testing and implementing strategies to change its family planning program from a reliance on field-workers who conduct home visits to a conventional fixed-site delivery system. Researchers have made two suggestions: First, the program should encourage women to switch from nonclinical methods delivered by family planning workers to more cost-effective clinical methods such as sterilization, and second, field-workers should not be resupplying nonclinical methods, but should focus their attention on motivating nonusers to practice contraception. Longitudinal data from the Maternal and Child Health-Family Planning Extension Project of the International Centre for Diarrhoeal Disease Research, Bangladesh, are analyzed to show that a better strategy might be to target visits to women according to their educational level and area of residence. For uneducated women living far from clinics, access to contraceptives is likely to be a problem, and home visits for resupply might have a larger impact on the contraceptive prevalence rate than would field-workers' visits to motivate nonusers. (Studies in Family Planning 2002; 33[1]: 87–102)
Isabelle Attané is Researcher, Institut National d'Etudes Démographiques, 133 boulevard Davout, 75980 Paris Cedex 20, France. E-mail: attane@ined.fr. This article provides a broad overview of China's family planning policy during the last three decades, highlighting key trends and goals of the program at national and provincial levels. It focuses on the administrative, economic, cultural, and other factors that have helped or hindered the family planning effort and reviews the impact of the program on the provincial population. A key question is whether the policy of strict fertility control will remain relevant and enforceable as population growth slows, as controlling private life becomes increasingly problematic for the government, and as new demographic problems (for example, aging) emerge. (Studies in Family Planning 2002; 33[1]: 103–113)
Gavin Jones is Professor, Demography and Sociology Program, Research School of Social Sciences, The Australian National University, Canberra. Richard Leete is Chief ad interim, Population and Development Branch, Technical Support Division, United Nations Population Fund, New York. E-mail: leete@unfpa.org. The dramatic demographic changes in Asia during the three decades from 1970 to the end of the twentieth century were matched by major changes in government population policies and programs. Fertility declines occurred in widely different economic, sociocultural, and political settings. The extent to which they were attributable to family planning programs, established in most countries of the region by 1970, is hotly debated. The 1970s were the heyday of family planning programs, which were created in a climate of urgency because of concerns over the "population explosion." Issues faced by programs at that time are discussed. Over time, programs generally have moved to a simpler "service" approach. As increasing numbers of countries reach replacement-level fertility, and as policies are formed against the background of the 1994 International Conference on Population and Development held in Cairo, the role of family planning programs is increasingly debated and questioned. This article examines the responses of Asian countries and the population challenges that remain. (Studies in Family Planning 2002; 33[1]: 114–126)
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