(July 2005) The last five decades have seen a revolution in the availability, use, and funding of family planning worldwide—a development many analysts credit with dramatically reducing fertility levels and slowing population growth in developing countries.
However, contraceptive use remains low and need for it high in some of the world’s poorest and most populous places. But after rising to prominence in the 1970s and 1980s, family planning has recently yielded the global policy spotlight as well as substantial amounts of funding to issues such as HIV/AIDS and poverty alleviation. Paradoxically, the perceived successes of family planning might have led to its recent loss of visibility, as policymakers and the public view “the population problem” to have been largely solved. As funding continues to decline and a younger crop of leaders has yet to emerge for the field, many of those committed to family planning are asking hard questions about the movement’s next steps.
To capture the family planning field’s internal dialogue about these issues, researchers Ann K. Blanc and Amy O. Tsui interviewed 27 “key informants”—developing-country program managers, senior staff members of nongovernmental and donor organizations, and prominent researchers, most of whom had at least 20 years experience in family planning or a related field. The researchers also held two focus group sessions with 12 junior and mid-level population professionals from developing countries. All responses were confidential.
PRB asked Blanc (a demographer with Blancroft Research International in New York) and Tsui (professor of population and health sciences and director of the Bill and Melinda Gates Institute of Population and Reproductive Health at Johns Hopkins University) about their findings.
PRB: What was the impetus for your project, and what suspicions did you have about what you would hear? What surprised you, if anything?
Blanc and Tsui: The Gates Institute, which supported the study, is about strengthening population and reproductive health leadership, whether analytic or programmatic. We and our colleagues recognized that, in the decade of the 1990s, the visibility of family planning was changing dramatically. What surprised us was the degree of consensus about the reasons for that declining visibility as well as the differences between developed- and developing-country perspectives.
PRB: According to the informants and focus groups, how much visibility has family planning lost? What were the most important factors they cited regarding that decline?
Blanc and Tsui: There was consensus among the interviewees that family planning has lost visibility on the international development agenda in recent years. As one informant put it: “When you hesitate to say the words ‘family planning,’ something is happening. When you say ‘reproductive health’ and have to be careful, something is happening.”
Informants attributed this loss of visibility to four main factors: a declining sense of urgency about population growth and its consequences; competing health and development priorities; rising political conservatism (especially in the United States); and a lack of international and local leadership. Poverty reduction—as reflected in the Millennium Development Goals—was cited as the primary focus of current development efforts.
PRB: What role did the respondents say the International Conference on Population and Development (ICPD) meeting in Cairo in 1994 played in taking attention away from stand-alone family planning programs?
Blanc and Tsui: The agenda that resulted from the ICPD meeting emphasized the welfare of individual women, the achievement of their sexual and reproductive health and rights, and gender equity. In the view of the population insiders we interviewed, this redefinition of the social problem of population growth in terms of reproductive health, particularly for women, has caused popular consciousness about the problem to ebb, since reproductive health does not carry the same political vitality as a developmental disaster or disease epidemic. As one informant put it: “When reproductive health becomes too big, family planning gets lost. The trouble is that it’s no longer a focused program. It’s difficult for donors to see, to manage and implement.”
Many also believe that the messages emanating from the Cairo agenda are diffuse and more complex than earlier messages about population growth or unwanted fertility. Further, family planning is now required to compete for attention against the other development needs identified at the ICPD and emphasized further at the Millennium Summit.
PRB: Many of the participants thought that HIV/AIDS treatment and prevention programs have deflected international attention and drained funds from family planning efforts. Why has this happened, and is there room for collaboration?
Blanc and Tsui: Among the competing issues, the one mentioned most frequently by respondents was HIV/AIDS, which was seen as competing directly with family planning for donor funding and health system resources. It was clear to many respondents that, compared to the magnitude of the HIV/AIDS epidemic, preventing unintended pregnancies was now perceived internationally as much less compelling and less urgent (see figure).
Percent Distribution of Total Worldwide Population-Assistance Expenditures by Categories
Note: In 1995, family planning received 55 percent of total worldwide population-assistance expenditures, while basic research and reproductive health received 18 percent each and HIV/STIs received 9 percent. In 2003, HIV/STIs received 47 percent of total worldwide population-assistance expenditures, while reproductive health received 25 percent, basic research 15 percent, and family planning 13 percent.
Source: United Nations, “The Flow of Financial Resources for Assisting in the Implementation of the Programme of Action of the International Conference on Population and Development,” Report of the Secretary General E/CN.9/2005/5 (New York: United Nations, 2005).
On the other hand, there was general agreement that collaboration between family planning and HIV/AIDS prevention and treatment programs was natural and appropriate. The dual risk of an unwanted pregnancy and sexually transmitted infection was frequently mentioned as a reason for a natural partnering between the two fields. Yet, many respondents noted the distinct lack of collaboration between the fields.
PRB: There also seemed to be a general sense that the international family planning movement is also lacking new directions and leadership—you described it as “a dearth of new leaders and a cadre of older leaders who maintain outdated views.” One of your interviewees added that the family planning movement now has “managers, not leaders.”
What are some of the specific problems respondents saw with the movement’s leadership? Where are the young people who used to go into family planning going?
Blanc and Tsui: Young people who used to be attracted to the family planning field when it was seen as a critical social need are reportedly going into fields that are perceived to be more urgent today, such as HIV/AIDS, safe motherhood, and poverty alleviation. The lack of funding for advanced training in the sub-fields that have traditionally produced leaders in family planning—such as public health training in family planning service provision, demography, and other social sciences—was mentioned as contributing to the leadership problem. A few informants also pointed to the strong opposition from abortion opponents as a disincentive to work in the family planning field.
Family planning has also lost some of its experienced leaders to other fields. Some older, experienced leaders who formerly worked in family planning are now working on AIDS, safe motherhood, and other public health issues. Many skilled developing-country clinicians have been lost in the generalized “brain drain” from the developing to the developed world. As sociologist Armand Mauss points out, leadership requirements tend to change as movements evolve; the charismatic leaders necessary for mobilizing initial action become less important, while those leaders with organizational and technical skills become more important.
Among institutions, UNFPA was singled out by several respondents for moving away from its leadership role in family planning and contributing to the declining visibility of family planning within the United Nations system and internationally.
PRB: Speaking of Mauss, you use his five-stage model of the “natural history” of social movements to analyze the history of the modern family planning movement. Of the model’s five stages—incipiency, coalescence, institutionalization, fragmentation, and demise—you strongly suggest that the family planning movement today is somewhere between fragmentation and demise. Did your interviewees agree?
Blanc and Tsui: Mauss defined “demise” as the final stage of a social movement, noting that this stage is probably inevitable but often not recognized by members. The stage may even be perceived by insiders as “success,” by virtue of the movement achieving its major goals. Or it may be defined as a temporary setback for a movement that is still vital. A movement in the demise stage is seen as having only “mopping up” tasks left to do.
Although the international family planning movement fits some of the characteristics of a movement in decline, there was not consensus on this point among the interviewees. Some felt that the movement would continue, but that the locus of action would shift from the broad donor world to the developing world—particularly in those countries that have major contraceptive needs, a rapidly growing population, and a policy commitment to slowing growth.
Others felt that in the developing world as a whole—although not necessarily in every individual country—women’s motivation to control fertility is so strong (and the social norm of family planning so well established) that contraceptive use will continue to rise no matter what happens to family planning programs. We need to wait and see what the future brings before we are able to write the full history.
PRB: How did these key informants and focus-group participants think that family planning could best be revitalized?
Blanc and Tsui: First, not all informants thought that the family planning movement was in its demise and, among those who did, not all thought it could be or even should be revitalized.
Those who offered suggestions for revitalization focused their ideas around four themes. The first was to form strategic alliances with other movements, in particular HIV/AIDS, as we discussed earlier. The second was to redefine or reposition the messages of family planning to mobilize and strengthen support, especially from the donor community. Third, some informants believed that improving existing services would revitalize support for family planning. And finally, nurturing and inspiring new individual and institutional leadership was seen as important, especially for enabling and encouraging developing countries to assume future responsibility for the movement.
PRB: Was there a consensus about repositioning the family planning message to link up with poverty alleviation or other health or development issues?
Blanc and Tsui: Suggestions for recasting the central message of family planning centered on three areas: (1) addressing an unfinished agenda of unmet contraceptive need, unwanted fertility, stalled fertility decline, and shortages of contraceptive supplies; (2) highlighting family planning’s benefits for reducing abortion and improving women’s status and health; and (3) demonstrating family planning’s relevance in reducing social inequity.
Developing-country informants were the strongest in articulating the last theme. Many cited the risks of increased poverty, poor health, and higher mortality as a result of high fertility and population growth rates. As one developing-country informant put it, “The population theme is both a threat and an opportunity. It needs to be better utilized, not for Malthusian reasons, but in order to rise above poverty.”
PRB: In your opinion, what’s going to make the difference for this movement between demise and revitalization? Does the solution rest with donor countries, developing countries, or both?
Blanc and Tsui: As the population concerns of the faster-growing developing countries diverge from those of the slower-growing or shrinking developed countries, the core of the family planning movement seems likely to become concentrated in the former. Ironically, in developed countries that have been the strongest supporters of the movement, policymakers and others are increasingly turning their attention inwardly to the consequences of negative population growth.
The longevity and success of the family planning movement has left a rich legacy of transnational infrastructure, mostly in the form of human and institutional capital in the numerous nongovernmental organizations that participated in the family planning movement. National policies that are consistent with the norms of the movement are in place, and there is a well-defined set of globalized beliefs and values that encourage the world community to act on poverty alleviation and public health improvements.
We believe that the international family planning movement will be substantially changed in the future, and that it will likely be defined primarily by the capacity and commitment of leadership originating from those populations with the greatest contraceptive needs.
Robert Lalasz is a senior editor at PRB.
For Further Information
Lori S. Ashford, “What Was Cairo? The Promise and Reality of ICPD” (Washington, DC: Population Reference Bureau, September 2004), accessed online at www.prb.org on July 12, 2005.
Ann K. Blanc and Amy O. Tsui, “The Dilemma of Past Success: Insiders’ Views on the Future of the International Family Planning Movement,” paper delivered at the 2005 Population Association of America annual conference, March 31-April 2, 2005, Philadelphia, accessed online at www.jhsph.edu/gatesinstitute on July 13, 2005.
Dara Carr and Marya Khan, The Unfinished Agenda: Meeting the Need for Family Planning in Less Developed Countries (Washington, DC: Population Reference Bureau, 2004).