ISSUES IN BRIEF

U.S. Support for Family Planning Overseas: The Program and the Politics

As the 21st century approaches, U.S. foreign aid is undergoing radical change. Its size is being dramatically reduced and its purposes sharply narrowed. Although the large majority of Americans supports assistance to developing countries on humanitarian grounds, the dwindling U.S. budget for development assistance increasingly will need to be justified on strategic grounds or by the economic benefit that aid returns to the United States. Since international population assistance remains a large component of overall development assistance, it too must prove its value, effectiveness and continued reason for being. Perhaps more than any other aspect of U.S. foreign aid, however, population assistance has been subjected to this level of scrutiny from its beginnings.

A woman's ability to control her fertility has implications not only for herself and her family but globally as well. In recognition of this fact, the U.S. government initiated its population assistance program almost 30 years ago. At the time, the United States was one of only a handful of nations in the world to assert leadership in this area. Even in those quarters where the problems associated with rapid population growth and unwanted childbearing were acknowledged, most were skeptical that anything could be done to ameliorate the situation.

Over the last three decades, a worldwide consensus has gradually emerged, embraced by poor and wealthy countries alike, that population stabilization is critical to a key set of inter-related goals: promoting democracy and enhancing political stability; alleviating poverty and facilitating economic growth; and protecting the global environment. Further, progress during this period has indeed been made in lowering birth rates and improving women's status — and these years of experience are pointing the way toward future progress.

This Issues in Brief outlines the international population assistance program. It examines the program's policy origins and how its structure and priorities are evolving in relation to the consensus of world governments ratified at the 1994 United Nations International Conference on Population and Development and amplified at the 1995 Fourth World Conference on Women. It discusses the impact the program has had over the years relative to critical U.S. economic and foreign policy goals. Finally, it describes the unique and unprecedented public policy challenges the program is confronting as the scope and fundamental tenets of U.S. foreign assistance are being called into question, and as a target of the antiabortion movement and Christian right.

The Origins and Principles of U.S. Population Policy

Governmental emphasis on family planning arose at a time of rising concern about the environment, poverty alleviation and the rights of women — and concurrent technological advances, most notably the advent of the birth control pill and the IUD in the early 1960s. In 1967, as Congress was requiring for the first time that family planning services be made available on a voluntary basis to poor women in the United States, it also added Section 104 to the Foreign Assistance Act of 1961 to specify that funds be allocated to increase "opportunities and motivation for family planning and to reduce the rate of population growth."

While demographic concerns were a driving force in creating the U.S. population assistance program, the authorizing statute also stressed that "good health conditions are a principal element in improved quality of life and contribute to the individual's capacity to participate in the development process, while poor health and debilitating disease can limit productivity." Further, the statute called for coordination of population planning efforts with other programs aimed at "reducing the infant mortality rate, providing better nutrition for pregnant women and infants, and raising the standard of living for the poor."

The formal launching of the program was quickly followed by its real political send-off when President Nixon, in 1969, transmitted an extensive statement to Congress on the critical importance of, and the responsibility of the government to confront, population growth and family planning needs both overseas and in the United States.

Nixon identified population growth as "among the most important issues we face... a world problem which no country can ignore, whether it is moved by the narrowest perception of national self-interest or the widest vision of a common humanity." He called for increased funding for population and family planning services, training and research. He also urged the United Nations to take a leadership role, pledging full U.S. cooperation. Indeed, the United States was instrumental in the founding of the United Nations Population Fund (UNFPA) that same year.

Twenty-five years later, these activities remain a matter of high priority among most members of Congress and within the Clinton administration. The program's structure and programmatic priorities are evolving, however, consistent with new developments and perspectives about the issues. Indeed, in preparation for the 1994 International Conference on Population and Development (ICPD), the U.S. Agency for International Development (AID) adopted goals on sustainable development that elevate the importance of improving the quality of life of individuals and of meeting the long-neglected aspirations and needs of women and girls in the less developed world. These same goals are reflected in the Program of Action adopted in Cairo in September 1994.

The ICPD ratified an overwhelming consensus among over 180 governments around the world that population-related concerns merit consideration at the highest level; that they must be viewed firmly in a development context; and women and their status are central to sustaining global development efforts. The ICPD was the first international governmental conference to characterize population issues in this way.

In addition, the Cairo conference was a milestone in avoiding the establishment of demographic targets in favor of an approach that responds more directly to individual needs. Similarly, while increased access to contr aceptive services was reaffirmed as a primary intervention, the emphasis is on the delivery of family planning within a broader reproductive health context. This is defined to include "the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning" as well as safe abortion where it is not against the law and "the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant." All of these principles were reaffirmed at the Fourth World Conference on Women, held in September 1995 in Beijing.

The Current Program

The multifaceted U.S. population assistance effort, which is designed to further the broader sustainable development goals of the United States, is funded through several sources. The bulk is administered by AID (about $536 million in fiscal 1995); the U.S. contribution to UNFPA ($35 million in fiscal 1995) is managed by the State Department.

AID is an independent agency with an overall budget of approximately $7 billion; it operates in coordination with the State Department to disburse foreign assistance for humanitarian purposes and to stimulate economic development in poor countries. In this post-Cold War era, AID's traditional focus on promoting economic and political stability has come to define the new U.S. strategic interest in foreign aid, which relies less on military strength.

Based in Washington but relying heavily on its outposts in the developing world, AID's overall philosophy is to promote sustainable development that also serves U.S. interests. Its five primary goals re: strengthening the U.S. economy by creating more U.S. trading partners and more free markets; famine and other crisis prevention; protecting against global threats, such as destabilizing population growth and environmental degradation; strengthening democratic institutions; and maintaining U.S. leadership in foreign affairs.

AID is organized by regional bureau and also according to activity. Along with population assistance, these activities include "child survival" programs, such as immunization and oral rehydration; HIV/AIDS prevention; basic education; "women in development" and microenterprise projects; and food aid, among others. The Office of Population, which is part of the newly created Center for Population, Health and Nutrition, is the locus of the population program worldwide (see Table 1).

Goals and Activities. With its almost 30 years of experience, AID has acquired significant technical expertise, an extensive network of specialized cooperating agencies, a broad field presence and a strong comparative advantage in providing family planning services and information around the world. Indeed, it is viewed by other nations as perhaps the premier governmental source of innovation and technical assistance in this aspect of population assistance efforts. Accordingly, family planning remains the main focus of AID's population program efforts. But the other core element is the focus on reproductive health interventions that benefit the most women and men at the lowest possible cost with the highest public health impact.

The Office of Population's priorities include:

The Office of Population implements these goals with an emphasis on the delivery of family planning services. This has been and remains the crux of the population assistance program. The services component is bolstered by a significant contraceptive commodities effort; research activities (contraceptive development, demographic and operations research); training, information and education; policy development; and evaluation programs (see Figure 1).

Funding and Structure. In fiscal 1995, Congress appropriated $431 million specifically for population assistance, more than one-quarter of AID's overall development assistance fund. In addition, Congress has designated substantial amounts of the Development Fund for Africa (about $75 million) and a portion of the development assistance account ($15 million) for family planning activities in the Newly Independent States (NIS) of the former Soviet Union. Another $15 million was spent for family planning — mainly in Egypt — under the Economic Support Fund.

The Office of Population manages most of AID population assistance funds directly; the rest is administered by AID's regional bureaus and missions. Activities funded through the bureaus/missions basically constitute the government-to-government, or bilateral, aspect of the program, while the central population office tends to work mainly through nongovernmental organizations (NGOs) operating internationally.

AID's population assistance program, either bilateral or through NGOs, reaches into well over 100 developing countries or countries in economic transition (see Figure 2). Priority countries tend to be those with rapid population growth rates, but increasingly countries are also identified based on the unmet need for family planning services. This is particularly true in the NIS, where population growth rates are low but the unmet need for family planning services, as reflected in the high abortion rates there, is significant.

The Program's Impact and the Challenges Remaining

AID's population assistance program has contributed significantly to improvements in the quality of life in many developing countries — which ultimately benefits people everywhere. Contraceptive use in these countries has risen, on average, from 10% of married couples in the early 1970s to 50-60% by the late 1980s. The average number of children per family has dropped, overall, from six to four (and even more sharply in some countries), more closely approximating desired family size. A woman's ability to control her fertility allows her greater opportunity to continue her education and increase her prospects in the labor market, as well as protect her own health and that of her children.

Family planning saves lives. Each year, 500,000 women die of pregnancy-related causes, a large proportion associated with unsafe abortion. It is estimated that greater access to preventive family planning services alone could avert 25% of maternal deaths in the developing world by helping women avoid high-risk pregnancies.

Further, family planning is an integral component of any child survival strategy. In developing countries, children born within two years of the mother's last birth are twice as likely to die in infancy as those born after a longer interval.

Clearly, sustainable development must begin with sustainable families, and family planning is an essential ingredient. Therefore, improving access to quality family planning services not only benefits the individuals directly involved but the society in which they live. Successful family planning programs overseas also are directly related to the economic, strategic and humanitarian interests of the United States (see Table 2).

Despite the notable accomplishments of international population assistance programs, many challenges remain. According to UNFPA, one-third of the illness among women of reproductive age in the developing world is associated with pregnancy, childbirth, unsafe abortion, HIV and reproductive tract infection. Reproductive health programs that prevent unwanted pregnancy and protect women and men against disease will need to be enhanced in order to respond to these public health problems.

Worldwide, 230 million women lack access to modern and effective family planning. This, in part, is reflected in the 52 million abortions that occur each year, about 40% of which are performed illegally or under unsafe conditions that often result in infection, chronic pain, infertility and an estimated 67,000 deaths.

In addition, the worldwide incidence of sexually transmitted disease is increasing — with about 250 million people contracting an STD each year. An estimated 1.5 million people became infected with HIV in the last half of 1994 — most live in developing countries with the rate of infection among women far exceeding that among men.

In most regions of the developing world, a gap exists between the number of children women say they want and the number they actually have. Closing the divide between reproductive aspirations and reproductive realities for these women will require dramatic improvements in access to effective contraceptive methods accompanied by complete and accurate information and counseling, all delivered in an environment that emphasizes genuine choices. Also, more men must become engaged as supportive and responsible partners in choosing and using a family planning method.

To the extent that unwanted births can be avoided, this not only contributes toward individual well-being but also slowing the global rate of population growth. Current estimates indicate that if all unwanted births were prevented, the global number of births would drop from 139 million annually to 122 million-almost a 20% reduction in the worldwide population growth rate.

The Political Climate and Policy Issues for the Future

AID's population assistance program is under scrutiny from at least three angles. Among professionals and women's groups directly involved, there is debate about how comprehensive the program should be. The traditional focus has been on increasing contraceptive use, but there is new pressure to consider a much broader reproductive health, even a women's empowerment, approach. At the same time, the program is under renewed attack from antiabortion and Christian right activists for ideological reasons that lately have gone beyond mere opposition to abortion to include more and more overt attacks on family planning itself.

Superseding both of these controversies is the larger one in which the value of U.S. foreign aid generally is being questioned and the essential components of a vastly scaled-down effort are being hotly debated.

Implementing Cairo. The worldwide consensus achieved in Cairo — which received strong backing from the United States — anchors population stabilization at the center of the global economic development agenda, but it abandons macro-demographic targets in favor of empowering individual women, men and communities to attain greater self-sufficiency. Enhancement of the status and role of women at all levels of economic, political and social development is now seen to be central to reducing rapid population growth. Attainment of reproductive health is considered a crucial prerequisite.

For some, AID has not gone far enough towards a reproductive health approach; for others, it is deviating too far from its historic programmatic emphasis on increasing contraceptive prevalence. For now, AID has indicated that it plans to devote at least 21% of its total development assistance budget specifically to family planning (approximately the current amount), while some funds will begin to be used for nontraditional population activities, such as female education and empowerment designed to enhance the demand for and use of family planning services in the near term.

Funding Constraints. The availability of funds is much more at issue now, however, than during the last several years when Congress steadily increased population program funding. Congress is currently reconsidering abolishing AID altogether in a move to streamline the existing foreign policy apparatus; development assistance would, in theory, be administered by the State Department instead. Whether or not such a radical proposal is approved, funding for development assistance — including population — could decline by as much as 40% this year.

Further, the budget-cutting climate has forced a re-examination of the underlying rationale for foreign aid. Policymakers repeatedly assert that if foreign aid has any purpose, it should be defined by the economic and strategic self-interests of the United States, not by altruism. The reality is that this has been the premise of foreign aid all along, especially during the Cold War era, but foreign aid became perceived instead, mainly by its detractors, as an international welfare program. They insist that foreign aid is a luxury that the United States cannot afford and that eliminating it is a necessary step towards reducing the budget deficit.

A 1995 survey conducted by the University of Maryland found that most Americans indeed believe that U.S. spending on foreign aid is excessive, but that belief is based on the faulty assumption that the United States spends 15 times more on foreign aid than it actually does. When asked what the appropriate amount for foreign aid should be, the median response was 5% of federal expenditures; 3% was deemed to be the point considered to be too little. In fact, total foreign aid expenditures constitute a mere 1% of the federal budget. The approximately $7 billion currently being spent on humanitarian and development aid (of which population assistance is one small part) amounts to only one-half of 1%. (The other half is consumed by aid to Israel and Egypt.)

Abortion Politics.Finally, international family planning, along with domestic family planning, is being drawn into the vortex of abortion politics even though both programs have long-standing statutory prohibitions against the use of federal funds for abortion services or advocacy.

During the Reagan and Bush administrations, the international program was subject to an administrative policy announced at the 1984 U.N. population conference in Mexico City. The Mexico City policy declared population growth to be a neutral phenomenon; to emphasize the administration's opposition to abortion, the policy also prohibited the transfer of any U.S. population funds to any foreign NGO that with non-U.S. funds provided abortion-related information or services.

During the same period the Mexico City policy was in effect, the Reagan and Bush administrations maintained a boycott of UNFPA. Their attack on the world's largest family planning organization, which provides critical reproductive health care to women in 140 poor countries, centered on its small program in China. UNFPA's program in China tainted the Fund by association — notwithstanding a finding by the Reagan administration itself that UNFPA neither supports abortion services nor condones coercion under any circumstances.

Both the abortion-related restrictions and the UNFPA boycott remained in effect contrary to the will of a majority of Congress by the force of administrative fiat or veto threats. In the meantime, Congress continually reaffirmed its commitment to a strong international population assistance effort by steadily and substantially increasing the program's annual appropriations and by preserving a separate, identifiable population "account." By fiscal 1993, when the Mexico City policy finally was revoked and UNFPA funding restored, overall U.S. expenditures for population assistance had doubled from its fiscal 1980 level.

The antiabortion and Christian right agenda includes defunding UNFPA again, as well as Planned Parenthood Federation of America's international division (Family Planning International Assistance, which has programs in 17 countries) and the London-based International Planned Parenthood Federation, an affiliation of nonprofit family planning associations operating in 125 countries. The rhetoric lambastes family planning organizations for "promoting" abortion; the reality is that their overriding agenda is to provide high-quality family planning services, which would have the inevitable effect of decreasing the need for abortion.

Indeed, the combination of attacks on effective family planning organizations and the prospect of severe funding reductions for family planning programs overseas can only have the effect of increasing-not decreasing-recourse to abortion.

The Role of Congress. Both fiscally and politically, the U.S. population assistance program is being challenged as never before, and its future viability is very much at stake. In considering its future, Congress has a responsibility to examine the factual record that defines the U.S. effort-what the program has accomplished over the years and what remains to be done. Equally important, Congress must recognize that a continuing U.S. leadership role in population-related activities — even as it improves the quality of life of individual women and families in other countries and enhances other countries' prospects for sustainable development — is in the enlightened self-interest of the United States itself.

Table 1

New AID Center Promotes Womens' Health and Education

Last year, AID reorganized and created a new Center for Population, Health and Nutrition to foster greater program and policy coordination among these related sectors. An overarching principle guiding the Center and other AID activities is the importance of girls' education and the empowerment of women. Additionally, AID is committed to working in partnership with non-governmental organizations to achieve mutual goals more effectively and often with greater innovation. The Center's specific objectives are that:

Table 2

Population Assistance Overseas Yields Benefits at Home

The social and economic benefits accruing to developing countries as a result of U.S. population assistance are self-evident: reductions in maternal mortality, improved child survival rates, enhanced literacy rates and stronger economies. Often overlooked, however, is how the U.S. benefits from providing the population aid that helps bring about these changes throughout the developing world.

Rapid population growth represents a serious threat to a developing country's ability to pursue and maintain democratic governance and economic growth. In an increasingly interdependent world, one country's political and economic woes affect not only its neighbors, but the global community as well. Comprehensive population and development programs address the root causes of rapid population growth—lack of access to family planning services, low levels of education and few economic opportunities—and, ultimately, help avert the need for costly disaster relief and peacekeeping efforts.

Moreover, by assisting countries to reduce their rapid population growth rates and by investing in key social sectors-health, education, sustainable agriculture-the United States has gained thriving export markets as well as strategic alliances around the globe. Indeed, on economic grounds alone, population and development assistance are lucrative investments for the United States:

U.S. population assistance, in conjunction with other development initiatives, is not only preventive medicine on an international scale, it enhances our own economic and political security over the long run in an increasingly competitive arena.

A Portrait of Three Countries

Thailand
U.S. population assistance to Thailand, which ended in 1990 when the Thai government assumed primary responsibility for financing the family planning program, was instrumental in helping couples reduce their average family size to 2.1 children per woman-about one-third its 1960 level. Today, Thailand has already imported more in U.S. goods than it received in population and development aid; from 1992-1993, Thailand spent $7.8 billion on U.S. exports-more than double the $3.4 billion in U.S. assistance it received over 20 years.

Colombia
Similarly, U.S. family planning assistance to Colombia, which is expected to end in 1996, has helped couples achieve the smaller families they desire, resulting in the average family size declining from 6.6 children per woman—one of the highest in Latin America—to 2.7 children. As its fertility rate gradually declined, Colombia's efforts to democratize succeeded and its economy began to soar. In the span of two years, from 1992-1993, Colombia imported $6.5 billion in U.S. goods and services, considerably more than the total U.S. aid it received over two decades, which totaled $5.3 billion.

Egypt
Another major recipient of U.S. population assistance, Egypt, has also achieved remarkable success in slowing rapid population growth. From 1980 to 1992, average family size dropped from 5.3 to 3.9 children. Beyond Egypt's strong economic appetite for U.S. exports, the North African country has emerged as a valuable political ally in a volatile region where the United States has vital strategic interests. Clearly, U.S. population and related development assistance has strengthened diplomatic relations between the two countries and has served long-term U.S. foreign policy objectives in the Middle East over the last 17 years.

© 1996 by The Alan Guttmacher Institute

Major Sources

The Alan Guttmacher Institute, Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences, New York, 1995.

United Nations International Conference on Population and Development, Programme of Action of the Conference, October 18, 1994.

U.S. Agency for International Development, Office of Population, Overview of USAID Population Assistance, FY 1994, John Snowe, Inc., April 1995.

"Evaluating Reproductive Health Programs: Perspectives of the USAID," presentation by Elizabeth Maguire, USAID, Population Association of America annual meeting, San Francisco, April 1995.

United Nations Population Fund, The State of World Population, 1995, New York, 1995.

For more information about the data presented in this Issues in Brief or about other AGI publications, contact the Washington Office at (202) 296-4012. Multiple copies may be purchased for a small charge.

© 1995 by The Alan Guttmacher Institute

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