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 Front Cover
 Population programs 1985: A growing...
 Effectiveness of a contraceptive...
 Status and roles of women as factors...
 Thailand's field-worker evaluation...














Title: Studies in family planning
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Title: Studies in family planning
Abbreviated Title: Stud. fam. plann.
Physical Description: v. : ill. (part fold.), maps (part col.) ; 28 cm.
Language: English
Creator: Population Council
Publisher: Population Council
Place of Publication: New York
Frequency: quarterly[<1997- >]
monthly[ former july 1963-]
monthly (with combined june/july, aug./sept. issues)[ former ]
bimonthly[ former ]
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regular
 Subjects
Subject: Birth control -- Periodicals   ( lcsh )
Family Planning Services -- Periodicals   ( mesh )
Gezinsplanning   ( gtt )
Régulation des naissances -- Périodiques   ( rvm )
Genre: periodical   ( marcgt )
 Notes
Additional Physical Form: Also issued online.
Dates or Sequential Designation: v. 1- July 1963-
Numbering Peculiarities: Vol. 1- called also no. 1-<25>
General Note: Supplements accompany some issues.
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issn - 0039-3665

Table of Contents
    Front Cover
        Page 1
    Population programs 1985: A growing management challenge
        Page 2
        Page 3
        Page 4
        Page 5
        Page 6
        Page 7
        Page 8
        Page 9
        Page 10
        Page 11
    Effectiveness of a contraceptive education program for post-abortion patients in Chile
        Page 12
        Page 13
        Page 14
        Page 15
    Status and roles of women as factors in fertility behavior: A policy analysis
        Page 16
        Page 17
        Page 18
        Page 19
        Page 20
        Page 21
        Page 22
        Page 23
        Page 24
    Thailand's field-worker evaluation project
        Page 25
        Page 26
        Page 27
        Page 28
Full Text












Volume 6, Number 7 July 1975



CONTENTS OF THIS ISSUE



POPULATION PROGRAMS 1985: A GROWING MANAGEMENT CHALLENGE 178
David C. Korten
Based on extensive interviews, country site visits, and a review and complex, including a growing focus on population policy
of the current literature, the author attempts to identify major issues in development planning and the integration of family
forces that will shape the world population effort over the next planning efforts in broadly based rural development schemes.
decade. He anticipates a growing willingness to directly confront Although the author sees important new opportunities in these
demographic issues, not as a separate specialized activity but developments, he points to the increasingly complex organiza-
as an integral part of the development process. As a result, popu- tional arrangements they will involve and the greater variety and
lation programs may be expected to become increasingly diverse sophistication of the management skills required.


EFFECTIVENESS OF A CONTRACEPTIVE EDUCATION PROGRAM
FOR POSTABORTION PATIENTS IN CHILE 188
Ellen Hardy and Karen Herud
In order to reduce the incidence of repeat abortions, the ma- 1 July 1971 and 28 February 1972, 993 participated in interviews
ternity ward of the Barros Luco-Trudeau Hospital in Santiago, and educational talks given by volunteers, and 491 served as a
Chile, established a contraceptive education program for post- control group. Sixty-seven percent of those in the educational
abortion patients referred to the hospital because of complica- group accepted contraceptives compared with 42 percent in the
tions. The purpose was to inform them about family planning, to control group. In both groups, younger and single women ac-
provide contraceptives, and to refer them to a family planning cepted in significantly smaller proportions than other women.
clinic. Of a total of 1,484 women seen at the hospital between


STATUS AND ROLES OF WOMEN AS FACTORS IN FERTILITY BEHAVIOR:
A POLICY ANALYSIS 192
Adrienne Germain
Demographers and others concerned about high rates of popula- ever, to translate this recognition into concrete programs and
tion growth have recognized the importance of certain aspects policies. In this article, demographic evidence from the Third
of the status and roles of women as determinants of fertility be- World is reviewed, a rationale for fuller inclusion of women in
havior. Development planners and other policy-makers have also national development as agents and beneficiaries is developed,
begun to realize the magnitude of women's various contributions and possible strategies are outlined.
to family income and the national economy. It is difficult, how-


THAILAND'S FIELD-WORKER EVALUATION PROJECT
Yawarat Porapakkham, Peter J. Donaldson, and Thavisak Svetsreni


The results of a two-year study of the performance of different
types of family planning field workers in rural Thailand are sum-
marized in this report. Three types of field workers were em-
ployed: salaried workers, workers paid on an incentive basis, and
volunteers. Field workers did raise acceptance levels, and volun-
teers seemed to do a particularly effective job. Moreover, continu-


ation rates in areas served by field workers were favorable. Al-
though shortcomings in the research design limited the analysis
in several important respects, the report concludes that family
planning field workers would be a valuable addition to Thailand's
National Family Planning Program.


T THE POPULATION COUNCIL, INC., 1975


Studies in


Family Planning


A PUBLICATION OF

THE
POPULATION
COUNCIL







Population Programs 1985: A Growing Management Challenge


DAVID C. KORTEN


Kanagaratnam (1974b) recently referred to family planning
as "the cutting edge of social change." The problem we face is
how for the first time in human history to bring about a planned
worldwide change in a specific set of highly personal human
behaviors for the long-term benefit of mankind. This is a bold
undertaking, to say the least. If the challenge is to be met, man-
agement skill and social science research must be applied effec-
tively in meeting this social-change objective. A brief look at
where we stand in terms of progress to date, an attempt to look
ahead to the targets of the next decade, and an examination of
emerging trends in program concepts and strategies can give us
some clues as to the type of organizational and managerial
capabilities that will be required for success in this venture.

Current Status
The available indicators of progress over the past 10-15 years
in the population/family planning field are impressive. Certainly
few ideas in the history of mankind have spread so rapidly
throughout the world, emerging from the status of taboo topic
to that of high priority policy in little more than a decade.
On the other hand, in view of the need to reduce reproduc-
tion rates and in view of the opportunities offered by family plan-
ning to improve maternal and family health, there are indications
that current progress is not adequate. The facts indicate that the
major accomplishments have been in creating legitimacy for
population as a major social concern and establishing the in-
dividual's right of access to family planning services, while
successful examples of planned reductions in national fertility
rates remain few. Furthermore, considerable concern has been
aroused by a marked drop-off in the rate of family planning
acceptance in some countries, suggesting that the family plan-
ning effort in these nations is faltering. Even the more successful
programs present some alarming trends in that the two contra-
ceptive methods currently growing most rapidly in acceptance
are the oral and the condom, methods with continuing and costly
resupply requirements. Also, an unfortunate paradox remains
in that abortion, probably the most widely used method of fer-
tility control throughout the world and the method most clearly
related to dramatic changes in fertility levels (Berelson, 1974b;
Tietze and Dawson, 1973), continues to be subject to severe
legal restriction in most developing countries, causing unwanted
births and increasing maternal morbidity and mortality. In ad-
dition, the 1974 World Population Conference raised doubts in
some minds regarding the commitment of many developing na-
tions to deal in a forceful way with the population problem.
In this confused and contradictory context, what can be said
about the future of the population effort, let alone the manage-
ment requirements thereof?

Central Forces
There appear to be four major forces that will shape develop-
ment in the population/family planning field over the next


decade: (1) ever-increasing consciousness of and commitment
to the importance of taking firm and constructive action to deal
with population problems as an integral part of the development
process; (2) controversy regarding strategic priorities; (3) the
search for new and more diverse means for dealing with the
population problem; and (4) short-term financial uncertainty
with regard to population funding with a prospect that longer
term emphasis will be on incorporating population activities in
the budgets of a variety of integrated development activities.

INCREASING COMMITMENT
In spite of the continued vocal opposition to population efforts
on the part of a few nations, both awareness of the problem and
support for positive action continue to grow. As of 1974, 91
percent of the population of the developing world lived in na-
tions that had official policies to reduce population growth or
that officially supported family planning activities. This repre-
sents a gradual but continued increase from 87 percent in 1972
and 83 percent in 1971 (Nortman 1972, 1973, 1974).
Other evidence of growing awareness, a basic prerequisite of
commitment, is reflected in a study of the national development
plans initiated between 1960 and 1972 in developing countries
(Stamper, 1973). Overall, Stamper observed that these plans
used few demographic data and even short-term projections of
labor force and school-age populations were rare. Only 27 of 70
development plans analyzed in the study recognized any popula-
tion problems. Stamper's data suggest, however, that these de-
ficiencies are being rapidly overcome. Of the 11 development
plans that went into effect in 1970 or later, only three neglected
population issues while seven included clear policies and pro-
grams relating to population matters.
There are a number of reasons to believe that it will be rare
for any development plan initiated between 1980 and 1985 to
fail to give full attention to demographic considerations:
1. Population will have increasing visibility among national
planners as a result of such factors as the World Population Con-
ference (with its emphasis on the interrelationship of popula-
tion and development), the World Food Conference, the World
Fertility Survey, the African Census Program, the policies and
concerns of major donor agencies, and a growing emphasis on
providing technical assistance in incorporating demographic
analysis and planning in national development plans.
2. Rapid urbanization, with its attendant crowding, and in-
creased political awareness give continually growing visibility
to demographic issues and the service requirements that popula-
tion growth generates.
3. A growing popular and professional literature on popula-
tion matters increasingly supportive of the need for population
limitation keeps the issues ever before the public.
4. Increasingly visible evidence of the limitations of world re-
sources and the dramatic reductions in world food reserves give
increased validity to the argument that there are limits to the
adjustments that can be made to rapidly growing populations.






As a result of these forces, we can expect that the need for
fertility reduction will come to be confronted more openly
and directly. This growing commitment to population concerns,
however, will not necessarily be translated into commitment of
resources to programs concerned exclusively with population or
family planning.

STRATEGIC PRIORITIES

Prior to the World Population Conference at Bucharest, three
major positions were becoming strongly delineated with regard
to priorities in use of population resources. These may be labeled
the family planning, health, and general development positions,
and the arguments for each may be summarized as follows:
1. Family planning as priority: Population is perhaps the cen-
tral current problem of mankind and seriously intensifies and
multiplies other social and economic problems. The available
resources should be devoted to attacking this problem as di-
rectly as possible through such feasible actions as making family
planning services universally, easily, and inexpensively available
and through the creation of the most direct possible incentives
to reduce desired family size. A variety of contraceptives must
be made as readily available as aspirin, cigarettes, and soap.
Commitment, resources, and effective management are the key
needs. The urgency is such that we cannot wait for the develop-
ment of strong, broadly based health systems or for general
development.
2. Health as priority: Control of mortality and morbidity is
the key issue, and with it will come control of fertility. People
do not want to prevent births until they know the children they
have will have a better chance of survival. Furthermore, ac-
ceptance and delivery of family planning services is best achieved
through the larger health delivery system. Thus, family plan-
ning funds are most appropriately devoted to strengthening
health delivery systems where they do exist and to creating such
systems where they do not exist.
3. Development as priority: The desire for large families is a
natural and rational response to the conditions in less developed
countries, where children are a source of labor and old age se-
curity and the costs of child-rearing are minimal. Only with the
achievement of broadly based socioeconomic development can
a fertility decline be expected. Therefore, the funds for family
planning would be better invested in general development pro-
grams. Fertility reduction will naturally follow development,
whether with or without family planning.
Those who argued for the health or development positions
generally maintained that the family planning approach was a
proven failure. On the other hand, the family planning as pri-
ority group argued it was much too early to draw any conclu-
sions regarding the effectiveness of family planning programs,
in part because no country had yet made a well-managed, all-
out effort, effectively using all known and available measures.
The 1974 World Population Conference made a substantial
contribution toward a convergence of these views that may be
expected to influence thinking about population, health, and
development over the coming decade. The lines between these
positions have become less clearly drawn, and a recognition of
the complex interdependence of the three strategies is emerging
(Teitelbaum, 1974). Any effort to achieve one of the three
objectives must now include attention to the other two as well.
The conference also gave visibility to several other closely re-
lated development priorities, including: (1) reduction of in-
equality between rich and poor; (2) improvement in the status


of women; (3) rural development; and (4) rational use of re-
sources, especially by the richer nations. The conference helped
clear the air on a number of issues so that in the future it may
be possible for many developing nations to more directly con-
front the population issue on their own terms. At the same time,
it placed an emphasis on people and on the importance of basic
social change rather than more advanced technology as the
major prerequisite to the solution of mankind's problems in the
areas of population, food, and resources.


MORE COMPREHENSIVE POPULATION STRATEGIES
Not long ago, population programs in most countries focused
almost exclusively on delivering and promoting family planning
through medical clinics. Within the past few years, thinking has
changed dramatically with regard to both the scope and context
of the population effort, reflecting a combination of increased
commitment, capability, and sophistication, as well as the shift
in thinking about development strategies evident at the World
Population Conference.
With regard to the scope of the population effort, the think-
ing now extends to five broad categories of action that govern-
ments can use to reduce fertility: communication, provision of
services, manipulation of family size incentives, changes in
social institutions and opportunities, and coercion (Berelson,
1974a). With regard to context, the thinking has evolved from
a focus on delivering services separately to integrating popula-
tion activities with many other social and economic develop-
ment activities. The first step in this transition was to think in
terms of integration of population with maternal and child
health efforts, then with basic health care, and more recently
with broadly based community-level rural development activi-
ties.
These trends, most of which are already well established in
the more innovative national programs, have very important
consequences for the management of the population effort. We
can understand these implications better by looking closely at
the changes taking place in relation to communication, service
delivery, and social and economic policy in some of the more
advanced national programs.

Communication
Factual information and motivational messages about popula-
tion and fertility-related matters are becoming available through
a growing variety of channels, including schools, literacy train-
ing classes, modern and folk media, satisfied users, and com-
munity organizations. The messages themselves will become in-
creasingly linked with messages concerning such other related
topics as land reform and agricultural productivity, family
health, employment, taxation, education, and religion.


Services
An increasing variety of fertility control methods are be-
coming available through a growing diversity of delivery chan-
nels. Clinical trials are under way with a wide range of new con-
traceptive methods as well as improved established methods
(Segal, 1974). While none of these efforts is expected to pro-
duce the "perfect" contraceptive, continued progress can be
expected in improving effectiveness, safety, and ease of use, and
in reducing side effects, resupply requirements, and the amount
of medical skill and judgment required for safe delivery. This
will mean less dependence on medically based distribution,






greater response to individual needs and concerns, and lower
delivery costs. The present trend toward easing legal restrictions
on abortion means that programs may increasingly incorporate
this method as a regular part of their service program.
Contraceptive services are becoming available not only
through a wider variety of channels but also in conjunction with
a wider variety of other services beyond the traditional family
planning clinic. The channels include specialized centers such as
sterilization and abortion clinics, specialized family planning
field workers or community distributors, maternal and child
health workers, local midwives, agricultural extension agents,
wives of the village chiefs, village clerks, local mothers' clubs,
neighborhood stores, places of employment, private physicians,
street vendors, and others.

Social and Economic Policy
The scope of thinking about population in relation to social
and economic policy is expanding rapidly. Originally, the pri-
mary concern was to urge economic and social planners to take
demographic trends into account in their planning efforts so as
to highlight the significance and consequences of the trends.
Now the concern includes considering social and economic
policy decisions in light of the impact that they will have on
shaping these demographic trends. This concern usually cen-
ters first on creating direct social and economic incentives to
reduce family size through changes in policies relating to ma-
ternity leaves and benefits, family size allowances, tax benefits
or penalties, social security provisions, educational fees, and
direct money payments so as to increase the immediate and evi-
dent cost to the couple of having children. Singapore is well
known for its leadership in this area.
Beyond the more direct social incentives, it is now recognized
that other aspects of social and economic policy may also be
important in determining preferred family size, even though the
relationships are not always well understood (McGreevey and
Birdsall, 1974). Thus, policies relating to such issues as emanci-
pation of women, education, marital status, employment gen-
eration, income distribution, and land reform are under review
for possible demographic implications.

FINANCIAL CONSTRAINTS
We may expect to face greater constraints on the amount of
international funding available to the population effort as such,
as well as new thinking regarding the use of population funds.

Amount of Funds
In the past, the population field has been notable for having
more funds than viable projects and the matter of absorptive
capacity was of major concern to donors (OECD Development
Centre, 1973). A rapid reversal in this situation has been ex-
perienced by a number of agencies just during the past year,
and any that have not experienced it already probably will do
so within the coming year. Three factors are involved. The first
is a sharp increase in quality project requests. The second is the
high rate of world inflation, which requires substantial budget
increases just to maintain existing programs. The third is a re-
duction in the rate of increase of funding, and, in the case of the
United States, at least a temporary cutback in total funds com-
mitted. The Population Council, the Ford Foundation, and the


Rockefeller Foundation also reduced in absolute terms funds
devoted to population activities in 1973 as compared with 1972
(UNFPA, 1974). Ominously in the background is potential,
and in some instances actual, disillusionment with the lack of
visible success in past population efforts.
In spite of the fact that both the United Nations Fund for
Population Activities and the World Bank expect continued
major expansion of their population programs over the next few
years, it seems fairly certain that the days of "easy money" in
the population field are over.


Use of Funds
The themes of the World Population Conference will increas-
ingly affect the population funding situation as the new thrusts
in development thinking make their claims for funds. With the
focus on integrated development, it may be expected that an
increasing portion of population activities will be funded in
conjunction with activities in health, education, development
planning, agriculture, and community development, with spe-
cial emphasis on multisectoral, integrated rural development
projects.


Targets
The conference in Bucharest highlighted the difficulty of ob-
taining international agreement on worldwide targets for the
population effort. Even so, the targets in the World Population
Plan of Action give us a guide to the magnitude of the task to
be faced over the next decade.
The Plan states unequivocally that availability of the informa-
tion, education, and means to decide the number and spacing
of children is a basic human right. Although reliable estimates
of the percentage of the world's population without such access
are lacking, one may assume that insuring such universal access
by 1985 to those persons who are most inaccessible by geog-
raphy, education, language, or custom will be no small task. It
is clear that adequate programs must be developed to serve the
most remote areas, even though costs per acceptor are likely to be
much higher than among more accessible populations. In areas
where no infrastructure exists for providing any type of service
to the population, such an infrastructure will have to be created.
The Plan is more equivocal with regard to targets for birth
rate reduction, although it stresses the considerable effort that
may be required by those nations that wish to reduce their birth
rates to 30 per thousand by 1985. Current birth rates for the
less developed nations average 37.9 per thousand (Nortman,
1974). Achieving a 30 per thousand target by 1985, difficult as
it may be, seems modest considering that a reduction in birth
rate to about 15 per thousand is required to reduce fertility to
replacement levels and that a path leading to replacement fer-
tility by the year 2000 means that world population will reach
5.9 billion by that year and will not stabilize until it reaches 8.4
billion (Frejka, 1973), or about 2.3 times the current world
population.
Berelson (1974a) provides us with a rough rule of thumb
that achieving a birth rate of 30 per thousand means that about
30 percent of eligible couples must be taking active measures
to control fertility. Likewise, he suggests that reaching a birth
rate of 15 per thousand requires that 60 percent of eligible cou-
ples be controlling fertility.
Assuming reliance on contraception as the major means of






fertility control, reaching the 30 percent level of active use
means recruiting 12 percent of all eligible couples as new or re-
acceptors each year, assuming an annual drop-out rate of 40
percent.' To reach 60 percent coverage with the same retention
rate would require maintaining recruitment at 24 percent of
eligibles each year.2 The magnitude of the task is highlighted by
1971 data on 41 developing countries with official family plan-
ning programs. The data indicate that in that year the programs
recruited 8,947,600 new acceptors (Ravenholt, Brackett, and
Chao, 1973; Nortman, 1973), a number equivalent to only 3.8
percent of the countries' estimated married, fertile female pop-
ulations for that year and a rate not substantially higher than the
estimated rate of growth in their overall populations.
Taking median UN projections, which place the 1985 pop-
ulation for the developing world at 3.66 billion (Nortman,
1973), and assuming that 15 percent are married women, 165
million couples from the developing world will need to be con-
trolling their fertility by 1985 to achieve a target of 30 percent
coverage. Creating the desire to limit fertility and providing the
means to do so on so massive a scale present a major challenge
requiring considerable commitment, effective program strategies,
substantial increases in resources, and efficient use of these re-
sources.


Emerging Organizational
and Managerial Requirements
It is quite clear that managing population programs of the
next decade will present many difficult challenges. The require-
ments will be far more varied and complex than those of man-
aging the small clinic-based, single-service contraceptive delivery
program of earlier days. Programs will be larger, more diverse,
more closely interrelated with other development activities and
organizations, and more oriented to relatively less accessible
rural populations. They will be less medically oriented, will rely
on less educated personnel, and, while they will include a major
service delivery component, will give relatively greater attention
to the motivational correlates of limiting family size than in the
past. As a result, they will require more sophisticated organiza-
tional forms, greater managerial expertise, and greater use of
social science research.

ORGANIZATIONAL TRENDS AND REQUIREMENTS

The Evolutionary Stages

Although there are substantial differences between countries
in the specific evolution of their programs in response to unique


In a population of 1,000 eligible couples, we would require 300
contracepting couples at any point in time to meet the 30 percent tar-
get. If 40 percent of these drop out of the program each year, this
means that 120 dropouts, or 12 percent of the total eligibles, must be
replaced each year. Likewise, a program with a 40 percent drop-out rate
recruiting 120 new or reacceptors each year would eventually stabilize at
300 active contracepting couples. This is, of course, a simplified model
in that it assumes no increase in the size of the eligible population over
the year. In fact, an average 2.5 percent growth in this population dur-
ing the year would mean that the recruitment required to maintain a
30 percent level of active use would in fact be slightly higher than indi-
cated in the text, or about 12.4 percent of eligible couples.
2 Given growth in the population, this figure would originally be
nearer to 24.8 percent. As the low-fertility situation is reached, how-
ever, retention rates could be expected to increase, thus reducing the
requirements for maintainance recruitment to below the 24 percent
figure given in the text.


local conditions and program strategies, there does seem to be
a prevailing evolutionary pattern through which many programs
tend to move, with each new stage involving more complex
organizational arrangements. By identifying this pattern, we can
get an idea of the organizational forms likely to be of greater
importance over the next decade and, at the same time, build a
basis for better understanding the management requirements of
programs at different stages of development.3

Stage 1: The Single-Purpose Organization. The single-purpose
family planning organization marked the beginning stage for
most current national population programs. This was most usu-
ally a private organization devoted exclusively to family plan-
ning, with autonomy in budgeting, personnel assignment, and
supervision. The single-purpose organizational form has proven
nearly essential where the broader health infrastructure is weak
or lacks commitment to family planning and therefore cannot
or could not be relied on as an effective channel for family plan-
ning service delivery.

Stage 2: The Multipurpose Health Delivery Organization. As
family planning becomes officially accepted, the next step is nor-
mally to introduce it as one of the services offered by govern-
ment health programs. The degree of actual integration with
other health services varies considerably, however, ranging from
almost total independence to complete integration. An example
of an independent program is the one found in the Nicaraguan
Ministry of Public Health in which family planning services are
offered during separate hours by personnel contracted under a
separate budget and responsible directly to a central office family
planning staff (F. Korten et al., 1975). A completely integrated
program is one in which the family planning services are offered
and supervised by personnel for which family planning is only
one of their duties. This is basically the model of the social se-
curity program in El Salvador (Ickis, 1974). The trend among
countries that are incorporating family planning with other gov-
ernment health programs is strongly in the direction of increased
integration.
The greater the degree of integration, the more the success or
failure of the family planning program depends on the strength
and commitment of the broader health system. With the less
integrated program, the very structure of the clinic schedule and
the work contract provides some assurance that at least minimal
attention will be given to family planning, even in the absence
of staff commitment, effective supervision, and other manage-
ment control mechanisms. With the fully integrated program,
more effective orientation and motivation to family planning are
required along with stronger supervision and control systems to
insure that family planning receives the desired attention. In
general, the greater the degree of integration, the greater the de-
pendence on effective management.

Stage 3: The Population Agency. Stage 3 is normally reached
when the government decides to embark on a more broadly
based population effort involving sectors other than just health.
This often leads to a separation of the planning and implement-

8 It must be stressed that this is by no means intended to represent a
universal model. There is no such model. Some programs skip stages,
enter two stages at once, or arrive at them in a different order. What
is presented here is only one of the more common models and one that
has an internal logic as an evolutionary process. It reflects a direction
of movement toward increasing organizational complexity and pro-
gram integration that does appear to be nearly universal.







ing activities by establishing an independent population office,
board, or commission (subsequently referred to in this paper
as a population agency). Planning and coordination become the
responsibility of the population agency, while implementation
remains the responsibility of a variety of ministries, agencies,
and private organizations with responsibilities in such different
sectors as health, education, rural development, and industry.
The success of the population agency depends on the existence
of the traditions and budgeting mechanisms required to give
clout to a central planning agency, the degree of top-level gov-
ernmental support they receive, and the viability of their structure
and placement within the governmental bureaucracy (Montague
and Thorne, 1974; Kanagaratnam, 1974a). A particularly key
distinction is made by Kanagaratnam (1974a) between the in-
terministerial body, which he finds seldom functions effectively,
and the independent entity with its own authority and budgetary
responsibility, which he finds the most promising arrangement
and the one currently favored by the World Bank in its project
agreements.
The trend toward the population agency is particularly strong
at present. While circumstances vary from country to country,
the reasons are quite compelling:

1. With the growth in the number of government units in-
volved in population activities, it becomes difficult for a single
ministry to coordinate what has become an interministerial
effort.
2. The normal mechanisms for central governmental plan-
ning and coordination, the national economic and social plan-
ning agencies or ministries, lack the required skills or commit-
ment in the population area. Although many have recently
begun to take into account the impact of demographic trends
on economic and social planning, there are few if any such
agencies that have developed the inclination and capability to
review economic and social policy in terms of their impact on
demography or to give major attention to the development and
promotion of a family planning effort.
3. There has been a need to break the dominance in the pop-
ulation effort of the clinically based, medically oriented minis-
tries of health. Often underfunded, poorly managed, and lack-
ing in commitment to family planning and population matters,
these ministries have in many instances proved ineffective for
providing widespread access to family planning services.
4. Some countries have need of an organizational mechanism
through which international assistance can be channeled into a
multidisciplinary program, cutting across conventional organiza-
tional lines.
5. Creation of a population agency can be a way of showing
serious commitment to population issues, in the face of pressures
from foreign donors, without upsetting the existing priorities of
established organizations.

Stage 4: Decentralized Civil Administration. Stage 4 reflects
a growing concern to extend population and other development
activities more aggressively to the rural areas and a resulting
need for mechanisms to achieve decentralized coordination of
rural development activities. Successful rural development must
necessarily recognize the integrity of the local community as
an economic and social unit and requires considerable adminis-
trative initiative, flexibility, and adaptation to local conditions.
Coordination of efforts of the many district- or village-level
workers representing a multitude of government ministries and
agencies cannot be accomplished at the central government level.


Reliance must be placed on a coordinating infrastructure at the
local level with a local decision-making capability. If such an
infrastructure does not exist, it must be created.
The basic model for such an infrastructure is a civil adminis-
trative hierarchy, responsible to a ministry of home affairs, hav-
ing a line of authority running down through provincial or state
governors, district officers, and village heads. Although overall
priorities or targets may be set at the central government level,
the success of this structure depends on considerable local au-
tonomy in implementing decisions. Operational control of de-
velopment programs is generally transferred from the sectorally
oriented ministries, such as health and education, to the gov-
ernors or district officers, whose authority may be augmented
by local taxing powers, as well as by considerable discretion
over budgets and personnel assignments for all governmental
activities within their geographical areas of jurisdiction. Varia-
tions of this structure are found in Indonesia, Taiwan, and
Korea.
Within the Stage 4 organizational framework, responsibility
for fulfilling population program targets rests directly with the
governor or district officer who, in turn, has the authority to in-
tegrate and coordinate population activities with other local
development efforts. This arrangement can be quite effective
in meeting population targets, as it appears to be in Indonesia,
if the civil structure is sufficiently strong and there is sufficient
commitment to population objectives at the central govern-
mental level to insure that they receive the necessary priority
attention.
Where such decentralized administrative structures do not
exist, their creation requires major national administrative re-
form. Since such reform is an almost essential prerequisite to
an effective rural development effort (Owens and Shaw, 1972),
it may be expected that it will receive attention from an in-
creasing number of governments over the coming decade, creat-
ing concomitant opportunities and challenges for the population
program.

Implications of Organizational Evolution
Each time the population program evolves to a more advanced
organizational stage, the management task becomes more diffi-
cult and complex. At Stage 1, the organization has a single con-
cern, the delivery of family planning services, and the lines of
authority and responsibility are relatively straightforward. At
each successive stage, we move further from these basic condi-
tions. As the population program becomes defined in more com-
plex terms and involves more complex strategies, it becomes
dependent on organizations with their own sometimes con-
flicting objectives, and the lines of authority often become am-
biguous. The role of program manager moves from director of
program activities to coordinator, planner, negotiator, technical
advisor, and staff specialist. Furthermore, each of the more ad-
vanced stages is likely to incorporate elements of the earlier
stages as well. For example, in Stage 4, national planning au-
thority for population matters may remain with a central
population agency and the program itself is likely to involve an
integrated program of rural health delivery as well as specialized
clinics for such services as sterilization and abortion.

Beyond the Population Agency: Stage 5?
It may prove useful to look beyond currently established
trends to a fifth stage, not yet identifiable as a trend, which might







be labeled "Beyond the Population Agency." Since the popula-
tion agency is currently proving to be such a popular organiza-
tional mechanism, it is important to ask what its future may be
since there is reason to believe that by 1985 it may have proved
to be a necessary, but only transitional, form. The conditions
that may lead to its phasing out include the following:
1. The growing emphasis on rural development and the con-
comitant decentralization of administrative authority mean that
increasingly the more significant coordination can take place at
a subnational rather than a central governmental level. The
central coordination by the population agency will become less
critical.
2. Such village-level organizations as mothers' clubs, which
are becoming prominent in Korea (Kincaid et al., 1974) and
Indonesia, are becoming more heavily relied on as focal points
of initiative in altering family size norms, distributing contra-
ceptive supplies, and encouraging family planning acceptance
and continuation. This means that the need for initiatives at the
central governmental level may gradually be reduced.
3. The development of a stronger, more adequately funded
and managed health program combined with a shift in focus
within the health establishment toward: a) greater acceptance
of family planning as a significant and justified health activity;
and b) growing emphasis on community-based integrated health
activities relying on subprofessional personnel will make the
health system a more effective delivery vehicle. The influence
of the population agency will thus become less crucial.
4. The growing acceptance on the part of government leaders
of the need to slow population growth as a primary objective
of all governmental entities may make a greater diffusion of
responsibility possible. This degree of commitment has been
remarkably slow in emerging, in part because the long-term
consequences of population growth have been easier for govern-
ment leaders to neglect than crises with more immediate conse-
quences. Such commitment has emerged, however, in such
diverse countries as Korea, Singapore, Indonesia, and the Philip-
pines and must ultimately spread as the relationship between
population growth and the more immediate crises becomes bet-
ter understood.
5. A continually growing sophistication within governmental
economic and social planning agencies will create a climate
more favorable to their assuming responsibility for population
policy and program planning. The development of longer term
planning perspectives and increased attention to social policy,
trends that should be reinforced by the outcomes of the world
population and food conferences, may be expected to contribute
to this climate. Further interest should be stimulated by exper-
iences in Singapore, South Korea, Taiwan, and, recently, Indo-
nesia, which suggest that, with effective broadly based programs
and commitment, relatively short-term results are possible from
the population effort. Finally, the continually closer integration
of population with other development activities will create a
greater need for integration of population planning with the
broader development planning effort.
These developments will all serve to reduce the need for a
separate population agency at the national level, and, to the
extent that the population agency is an effective force in further-
ing the national population effort, it may be expected to con-
tribute to achieving this final stage in the organizational evolu-
tion in which its functions will be divided between the planning
board and other relevant institutions. For example, the Family
Planning Coordinating Board in Indonesia is encouraging the


formation of a strong population unit within the national plan-
ning body and the assumption of responsibility for program im-
plementation by the provincial governors. The Population Com-
mission in the Philippines has taken the lead among government
bodies in responding to an order to all government organizations
to regionalize their operations.

MANAGERIAL REQUIREMENTS
The increased size, diversity, and complexity of the programs
create a growing need for more highly skilled management
and more complex and sophisticated management systems to
plan and implement population program activities. Building the
required program management capabilities will be a major un-
dertaking requiring the support and commitment of national
program leaders, donor agencies, research organizations, and
both local and regional management institutes (D. Korten,
1974b; Wickham, 1974). A major problem arises in this un-
dertaking, however, from the trends toward diversification of
program activities and the increasing integration of population
activities with other development programs. As the programs
evolve to the more advanced organizational stages, their effec-
tive management depends increasingly not on persons with an
exclusive commitment to population program objectives but
rather on persons responsible for an integrated health delivery
or community development program, the administration of a
province, or the direction of a national planning board. Man-
agement improvement activities within the population sector in-
creasingly will have to take this reality into account and seek
to strengthen the management of the broader systems in which
the population activity is imbedded.
The diversity of the tasks involved make it difficult to identify
with much specificity the types of managerial skills required.
A few generalizations may be made about the overall program,
however, which will then be followed by more specific observa-
tions on requirements of the service delivery system.

The Broader Context
The basic underlying theme of the current development effort
is creation of the conditions that will allow greater local par-
ticipation in assuming responsibility for the development process
and in reaping its rewards. This means strengthening local or-
ganizational capabilities, changing inhibiting traditional mo-
tivational and interpersonal patterns (D. Korten, 1972), and
redesigning administrative and political processes that centralize
power and create enforced dependence of the village com-
munity on the urban center (Owens and Shaw, 1972). Each
of these activities carries its own requirements for specialized
skills in organization and management of social change pro-
grams and involves processes in which those responsible for
population programs may expect to become increasingly in-
volved.

A Marketing Orientation
Looking more narrowly at the more specialized requirements
of the population program, we can identify two major tasks.
The first is to bring about very difficult changes in a range of
highly personal, yet culturally conditioned, behaviors in broad
segments of the population. The second is to make attractive
and readily accessible a broad line of low-priced fertility con-
trol products and services. Perhaps the closest analogy we have






is to marketing, although the behavior-change component goes
well beyond that of the normal marketing effort.
The contrast between the marketing orientation and the more
traditional medical view, which Rogers (1973) observes has
dominated much of the population effort over the past decade,
should be immediately evident. The doctor's traditional role has
been to treat sick people who seek his attention. He works on
a one-to-one basis exercising individual professional judgment
in making decisions for each patient. He openly promotes his
own services only at risk of professional censure. Seldom are
the services arranged to suit the convenience of the user. The
very term "patient" suggests a passive and dependent status on
the part of the service client.
In the marketing approach, decisions are made with regard
to groups of persons with similar characteristics. Considerable
resources are expended to identify and seek out potential clients
and to identify their perceptions of their own needs. The client
is assumed to be a choice-maker. The marketing task is to in-
fluence the choice process through actions that seek to increase
the attractiveness and accessibility of the fertility control prod-
uct. In the expanded population effort, we define these terms in
a very broad sense. The product is assumed to include the ac-
ceptance of concepts such as delayed marriage as well as contra-
ceptive products or abortion services, and the influence process
is defined to include social incentives and increased opportuni-
ties for women as well as conventional promotional campaigns.
Although medical skills are and will remain crucial in improv-
ing contraceptive technology, delivering clinical services, treat-
ing complications, and providing referrals, conventional medical
skills will become increasingly less relevant to the central re-
quirements of program leadership, and the influence of the med-
ical profession on the population effort may be expected to de-
cline accordingly.


The Planning Level
At the planning level, whether in the population agency or the
national planning agency, the critical skills will relate to: 1)
analyzing complex social systems to identify the most important
fertility-related behaviors and motivations and the major social
and economic circumstances that reinforce them; and 2) plan-
ning strategies for the critical system interventions required to in-
crease the incidence of fertility-limiting behavior. Political skills
will be required in creating coalitions of political power in sup-
port of the required interventions. Also required will be the or-
ganizational skills of the project manager in winning cooperation
of other agencies under conditions where there is often limited
direct formal authority. Special mechanisms will need to be de-
signed for establishing and monitoring relations with these agen-
cies. This need plus the demand for results and for efficient use
of resources when dealing with such a range of organizations
will require special skill in program budgeting and management.


The Implementing Level
The broadly based population program could be defined as
encompassing an almost limitless number of implementing ac-
tivities, each with its own managerial requirements. One of the
major activities, however, will remain that of the direct promo-
tion and delivery of the means to limit fertility. The current trend
in service delivery is quite clearly toward creation of a diversity


of service delivery channels both medically and nonmedically
based, and there is little reason to expect any reversal of this
trend. In fact, it should be strengthened with expected advances
in contraceptive technology that will increase ease of administra-
tion and reduce side effects. By looking at the specific manage-
ment requirements of each of a number of delivery channels,
we can get an idea of the diversity of management skills that may
be required.
Four types of delivery channels, in the probable order of their
future importance, are: commercial distribution, community-
based distribution, integrated preventive services outreach, and
clinic-based distribution. The reasons for ranking them in this
order are quite simple. Those channels ranked higher on the list
tend to offer the greatest convenience to the user while placing
the least financial and managerial demands on government re-
sources. Once established, those channels higher on the list are
relatively self-sustaining because of the natural incentive struc-
ture, and they require minimal maintenance by government
agencies. Continued improvements in contraceptive technology
as well as the current trend toward removal of the prescription
requirements from such methods as the oral will greatly increase
the possibilities for effective use of channels with relatively lim-
ited managerial and financial requirements. Such channels in-
clude commercial and many forms of community-based distri-
bution, which have minimal involvement of medical staffing and
minimal need for special-purpose, government-salaried point of
contact personnel.
Clinic-based distribution has dominated most official family
planning program efforts in their earlier stages. The trend, how-
ever, is moving toward nonclinical distribution, with a few coun-
tries such as Thailand building a major portion of their programs
around nonclinical channels with apparent success. Although
many countries will most likely continue to rely heavily on
clinic-based distribution, by 1985 it may be expected that the
model in the more innovative countries will be to use the clinic
mainly for such methods as sterilization and abortion and for
providing backup for treatment of complications. We must at
least consider the possibility, however, that by 1985 advances in
abortion technique and at least female sterilization may make
safe nonclinical delivery of these services fully feasible and ac-
ceptable. Likewise, improvements in other contraceptive tech-
nologies should further reduce the incidence of complications re-
quiring medical attention. The major management skills required
of the government for each of the four types of channels are dis-
cussed below.


Commercial Distribution. Program actions relating to the
commercial sector normally involve the stimulation of sales
through commercial channels. This involves taking steps to re-
move barriers and introduce incentives or subsidies, publicly
promote privately distributed products, publicize profit-making
opportunities, or introduce new low-cost, well-promoted prod-
ucts into existing channels. The advantages of using the com-
mercial system are that consumers contribute to the cost of
supply, a well-developed distribution system often already exists
even in remote areas, and requirements for program supervision
are minimal. Designing and implementing such programs do
require a thorough knowledge of marketing channels and mech-
anisms combined with an entrepreneurial orientation. These re-
sponsibilities, however, can be contracted to qualified private
agencies and consulting groups, as is the established pattern in







many of the countries that have sought to encourage commer-
cial distribution. Thus, the skills required on the part of the gov-
ernment are mainly those involved in contract administration.

Community-Based Distribution. Community-based distribu-
tion has strong parallels to commercial distribution in that sup-
plies are often sold at a small cost with a return to the seller.
Rather than using conventional outlets, however, the "retailer"
may be a community leader, satisfied program user, small-shop
keeper, hairdresser, or local organization. To the extent that such
programs maintain their own staff of educators, supervisors, and
distributors, management of the system will require a corre-
sponding degree of organizational, personnel development, and
management skill. The community-based scheme also requires
the capability to maintain a supply system, in addition to the
marketing and entrepreneurial skills required in managing the
commercial delivery schemes. Skills in community organization
may prove particularly important to the extent that community
organizations are used. Once established, however, the direct
sales incentive to the distributor makes the system largely self-
sustaining so long as the supply system is adequately main-
tained, and requirements for continued supervision are likely to
be minimal.

Integrated Preventive Services Outreach. One of the key com-
ponents of most of the integrated services delivery schemes is a
community outreach effort in which the client contact is estab-
lished, and basic, mainly preventive, services are provided by
paramedicals, field workers, and indigenous practitioners. If
medical doctors are involved, their roles are as supervisors, con-
sultants, or providers of medical backup. In many ways, these
systems pose a considerable management challenge. They re-
quire sustained independent action by geographically remote
nonprofessional personnel with limited training. They involve a
wider range of services than the community-based family plan-
ning distribution system, and the preventive health tasks, which
are normally their central focus, are in many ways inherently
more difficult than the delivery of curative services in a clinic.
The field workers deal not with the passive treatment of patients
motivated by the discomfort or immediate fear generated by
illness but with matters of nutrition, family planning, hygiene,
and child care where the client must actively exercise self-disci-
pline and break established habits in the absence of any com-
pelling motivating pain. Considerable skill and empathy with
the client is crucial. Maintaining the desired quality and effec-
tiveness of service in such systems may be expected to require
continuous on-the-job training and very effective supervision.
What knowledge and skills are needed to create and manage
such a system? First, there is need for a substantial understand-
ing of the client and skill in the application of attitude and
behavior change techniques. Such knowledge is needed for plan-
ning program strategies, designing training for supervisory and
fieldwork personnel, and designing backup promotional ef-
forts. Second, there is need for organizational skills in building
and maintaining the training and supervisory systems that are
central to making this type of delivery system work. Of course,
those family planning programs that have been built on strong
fieldwork organizations already have considerable experience
in this regard though generally only with unipurpose workers.
Finally, management personnel must be capable of handling
problems of inventory and logistics involved in maintaining such
a system.


A prevailing assumption in many of the integrated service de-
livery models is that the community health workers will report
to the medical director of the nearest clinic. Given the likely and
often necessary differences in orientation between the field per-
sonnel and the clinic personnel and the incompatibility of the
doctor's clinical responsibilities with the responsibilities and re-
quirements of effectively supervising extension personnel, it is
not surprising that this supervisory model often proves inef-
fective. The question of what the appropriate relationship is be-
tween these two activities raises important organizational issues
that must be addressed over the next decade. Particularly as field
workers are trained to service clients in the field by prescribing
oral contraceptives and inserting IUDs and are thus dependent
on clinics only for backup on complications, it is likely the trend
will be toward assigning them to a district or village official, re-
flecting the community orientation of their work. The most ef-
fective supervisory backup on technical matters is likely to be
provided by persons specially trained for this purpose and as-
signed on a full-time regional basis to the supervisory task.

Clinic-Based Distribution. Whether or not the role of the
clinic in the delivery of family planning services changes as an-
ticipated, certain management requirements will persist. Motivat-
ing clinic personnel to take time for family planning education in
the midst of busy schedules will be a major supervisory chal-
lenge, as will the creation of a service orientation among clinic
personnel. Another important need in the clinic will be to apply
operations-management concepts to review norms and organize
client flow in order to increase the speed of client processing and
the size of the client population the clinic can support. Meeting
these requirements is and will remain a major challenge given
the normal difficulties involved in supervising independent pro-
fessionals, especially those with only underpaid, part-time as-
signments in the government clinic.

Information and Research Support Requirements
Making the complex decisions involved in the broadly based
population program will require the availability of program data
and social science knowledge geared to program decision-mak-
ing needs at both the planning and implementing levels. It may
be expected that the topics receiving research attention will be
heavily influenced by the growing interest in the demographic
impacts of development policy, the trend toward integrated
services delivery, and the focus on rural populations. In the plan-
ning and conducting of research, close collaboration will be
needed between the researchers, analysts, and statisticians, who
generate data and knowledge, and the program managers, who
use the data and knowledge for decision-making. Each must un-
derstand the needs, capabilities, and limitations of the others.
The speed with which decisions are being made with regard to
program designs suggests that the more aggressive and innova-
tive program managers are not inclined to wait for years to ob-
tain research results as the basis for decision-making. Closer
links between research and management can be expected to
characterize the more effective programs, reflecting specific at-
tention to the following:
1. Identification by researchers, evaluators, and statisticians
of relevant program managers as the primary clients for their
work, and an effort to address themselves to the decision-mak-
ing needs of those managers.







2. Collaborative efforts between manager and researcher in
identifying important program decisions that could be strength-
ened through research inputs and in designing research and its
presentation to be relevant to those decisions.
3. Experimentation, and rapid collection of both formal and
informal feedback on results, as an integral part of ongoing pro-
gram operations, with the experiments under operational con-
trol of program management and the research staff providing
technical support in design and evaluation.
4. The collection and presentation of operating statistics
geared to management decision requirements and designed to
highlight trouble spots needing follow-up attention.
The problems of utilizing social science research in population
program decision-making and the most promising approaches
to their solution are not new. Most of them were identified by
Berelson (1966) some years ago, but dealing with them will
take on greater urgency over the next decade as program deci-
sion-making becomes more complex and demanding. In the
meantime, however, a few examples of effective models for
using research in support of program decision-making are
emerging in such programs as those in Taiwan (Cemada and
Sun, 1974) and Singapore. Progress is being made in identify-
ing steps that must be taken to improve data utilization (D.
Korten, 1974 a and b), and promising efforts have been under-
taken in Central America by a management institute to bring
together program managers with researchers, evaluators, and
statisticians to identify key issues in data utilization, build
mutual understanding of program needs, and plan corrective
actions within their respective program structures (INCAE,
1974).
Although there are signs that some progress may be made in
dealing with problems of research utilization in the population
field, a new set of problems may be emerging for information
and research support activities. When family planning services
were a well-defined activity, there was quite naturally a consid-
erable demand for specialists trained in family planning re-
search, evaluation, and statistics. This situation may change sub-
stantially over the next decade. As the organizations they serve
become multipurpose, the population evaluator, researcher, and
statistician may be under pressure to respond to a wider variety
of problems and issues than in the past, with requirements for
new concepts, skills, and techniques. For example, it is evident
that specialized family planning data systems, costly as they
have been to develop, are poorly suited to managing the work
of multipurpose workers. The demand for narrowly focused
population specialists is likely to level off as the overall concern
for dealing with the population issue continues to increase. The
emerging demand is likely to be less for specialists in demo-
graphic and population policy analysis and more for broadly
oriented social policy analysts, less for specialized family plan-
ning evaluators and statisticians and more for persons prepared
to provide support in the evaluation and management of more
broadly conceived social services and rural development pro-
grams of which population and family planning activities are
only one of several important components.


Conclusion
The agenda for action implied by the foregoing analysis is an
imposing one. Actions are required at the national level to plan
for meeting the specific organizational and managerial require-


ments with which the national program will be faced. At the re-
gional and international levels, mechanisms for documenting
and sharing relevant experience with organizing and managing
new types of programs and alternative distribution channels are
required to speed the learning process that all nations share in
meeting the challenge of this bold undertaking to manage a
planned social change on a global scale.
Although national and regional diversities are likely to be-
come more rather than less pronounced over the next decade,
some fairly universal forces are acting to shape the future of
the population effort in nearly all countries. If these forces are
kept in proper perspective, they can provide a useful guide to
future organizational and managerial requirements. Approach-
ing current problems from such a futuristic perspective may
allow solutions to today's problems that are relevant to tomorrow
rather than yesterday, and, therefore, more viable and lasting.


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ABOUT THE AUTHOR David C. Korten, Ph.D., is a visiting
associate professor at the Graduate School of Business Ad-
ministration, Harvard University.

ACKNOWLEDGMENTS This article is a revised and updated
version of a background paper originally prepared at the re-
quest of the International Committee on the Management of
Population Programmes (ICOMP) for the 1974 Annual Con-
ference held at Harrison House, Long Island, New York,
29-31 July 1974, under the sponsorship of the UNFPA. The
author is indebted to the nearly 100 persons, interviewed in
ten countries during the course of preparing this paper, whose
data and insights have proven invaluable; to the Ford Founda-
tion for its financial assistance; to ICOMP for its institutional
support; and to Frances Korten, Peter Garrucho, and Allan
Rosenfield for helpful suggestions made on earlier drafts. The
opinions expressed are those of the author and do not neces-
sarily reflect the views of any of the supporting institutions.








Effectiveness of a Contraceptive Education Program

for Postabortion Patients in Chile

ELLEN HARDY and KAREN HERUD


As a group, women who are hospitalized as a result of com-
plications of abortion have high fertility rates, are generally
highly motivated to avoid future pregnancies, and run a great
risk of aborting again if another pregnancy occurs (Requena,
1965). Broad experience indicates that patients hospitalized
from complications of abortion are highly motivated to accept
a contraceptive, particularly the intrauterine device (IUD).
Postabortion insertion of an IUD does not entail an increase
in the risk of infection and expulsion or a decrease in method
reliability (Rosenfield and Castadot, 1974).1
This paper evaluates the efforts of an educational program
at the Barros Luco-Trudeau Hospital in Santiago, Chile, in-
tended to inform women hospitalized for abortion complica-
tions about family planning and to persuade them to accept
contraceptives. The health objective of the hospital was to
reduce the incidence of induced abortion by offering these
women the alternative of contraception.
For more than 15 years, the maternity ward of the Barros
Luco-Trudeau Hospital has recognized the seriousness of the
problem of induced abortion and has taken steps toward its
prevention. In 1967, the hospital initiated postabortion insertion
of IUDs for patients who requested it, but family planning
education and information were provided only individually by
physicians or paramedics who were personally interested in the
problem, and there was no formal educational program. Post-
abortion patients discharged without an IUD were not referred
to or informed about family planning clinics.
A review completed at the end of 1969 showed that 12 per-
cent of women coming to the hospital with abortion complica-
tions reported contraceptive failure as the reason for pregnancy,
with two-thirds of them having used the IUD. It was to be
expected that most of those patients would not accept another
IUD insertion postabortion and would discourage other patients
who might have accepted without their influence.
As a result, the hospital decided to institute a formal con-
traceptive education program; to offer other contraceptives in
addition to the IUD; and to provide for a more careful follow-
up of all patients, not only for evaluation purposes but as a
way to reinforce users' motivation and to persuade nonusers
to enter the program.


Recruiting and Training Volunteers
Because the use of professional personnel was beyond the
budget capacity of the hospital, volunteers were recruited for
the educational program. The Asociaci6n Chilena de Protec-


SSee also: Andolsek, 1972; Goldsmith et al., 1972; Tatum, 1972; and
Viel and Lucerno, 1970.


ci6n de la Familia (APROFA) attracted and trained women
of the middle and high socioeconomic groups who were inter-
ested in participating in educational programs on family plan-
ning. All volunteers had secondary or university education,
most were married, and their age varied from late twenties to
sixty. Many were close relatives of physicians.
Volunteers received a two-week training course on contra-
ceptive methods, the possible consequences of illegal abortion,
and the advantages of family planning. Those wishing to par-
ticipate in the Barros-Luco's postabortion education program
received additional instruction on the program objectives, meth-
ods to be used in educating patients-including interview pro-
cedures and use of audiovisual material-procedures for col-
lecting and recording data for evaluations, medical services
rendered, and procedures for follow-up. Before starting the
program volunteers interviewed several patients as a pretest of
the questionnaires and of their skills.
To keep the personnel participating in the program informed
and motivated, circulars reporting on the progress of the pro-
gram were published periodically and displayed in the abortion
and family planning clinic sections of the hospital. At group
meetings, supervisors and volunteers reported on the goals
achieved, discussed the work, and agreed on procedures.


Volunteers' Educational Activities
Every afternoon, from Monday to Friday, the volunteers
gave a recorded talk, illustrated with slides, in the abortion
ward where all but the most seriously ill abortion patients were
located. Immediately after the talk, volunteers held individual
interviews with each patient in order to dissipate possible
doubts, reinforce motivation, and obtain the data requested
for the evaluation. For this last purpose, a preceded form was
prepared including data on name, address, age, education, mari-
tal status, number of living and dead children, previous abor-
tion(s), and interest in the use of contraception.
A potential problem faced was the social distance between
volunteers and patients, and the possibility this might cause
problems in communication. Some effort was spent on trying
to avoid this. Volunteers were instructed to treat patients with
respect and to avoid the familiar "tu," which is often used in
Chile when talking to someone of lower status. No trouble
arising from social differences was reported during the program,
however.
The active volunteers, numbering between 20 and 25, were
divided in five groups, one for each weekday. Each volun-
teer's duty was limited to two to three hours of work a week,
from two to five in the afternoon. The leader of each group-
also a volunteer-distributed among them the different tasks
to be accomplished.







Prescription of Contraceptives
All personnel of the Abortion Section were instructed to offer
contraceptives to each patient at time of discharge from the
hospital. To reinforce this practice, the item "Contraception
at Discharge" was included on the clinic abortion record, which
the doctor filled out when he signed the permission for dis-
charge.
The contraceptives offered were IUDs (Lippes Loop and
Copper-T) and oral contraceptives. IUD insertion was per-
formed at the hospital, immediately after discharge from the
Abortion Section. In the case of pill acceptance, the patient was
given the first tablet of a cycle at discharge and took the re-
maining tablets with her.


Clinic Follow-Up
All patients, acceptors and nonacceptors, were given an
appointment at the obstetrical and gynecological outpatient
clinic of the hospital one week after discharge. Within this clinic
is a family planning clinic. The purpose of the appointment
was twofold: to control any after effects of abortion and to re-
peat the offer of contraception.
All patients referred to the family planning clinic (including
those who did not live in the health area served by the hospital)
were followed up during the year following their discharge.
Patients with a history of repeated abortions were referred to the
fertility section of the clinic. Because the number of such pa-
tients to be followed up was large, the services of a "matrona"2
were contracted for two hours every afternoon especially for
this group, and various doctors volunteered their services as
did all permanent personnel in the family planning section of
the clinic.
On the interview card, the volunteer recorded the date of the
patient's discharge from the hospital, the date of her appoint-
ment at the family planning clinic, and whether she accepted
contraception on discharge. Approximately ten days after a
patient's discharge, the volunteer educator visited the clinic to
ascertain whether the patient had kept the appointment. If the
patient had come in, the volunteer recorded what had occurred
at the visit, and the date of the next appointment.
Follow-up letters were mailed to all patients who did not
come to the clinic during the 15 days following discharge from
the hospital. When a letter was returned because the woman no
longer lived at that address, a search was made for the patient's
card in the general hospital file. If a different address was found
in that file, a second letter was sent there.
Information regarding subsequent visits that a patient made
to the clinic was also recorded on the interview card by the
personnel of the clinic Investigation Center, which was in charge
of program evaluation.

Control Group
To evaluate the possible influence of the educational program
on contraceptive acceptance levels, a control group of patients
was selected, consisting of those hospitalized after 5 pm Friday



2 "Matrona" in Chile corresponds to a trained midwife or obstetrical
nurse elsewhere.


of a given week and discharged not later than noon of the
following Monday. Both control and experimental groups were
offered contraception at the moment of discharge, referred to
the family planning clinic, and sent contact letters if they did not
appear. However, only those who attended Monday through
Friday received the educational talk and personal interview.
Because the patients were in a large common ward of an old
hospital, this arrangement did not eliminate the possible indirect
influence on the control group through contact with patients in
neighboring beds who received information and education. This
"contamination" risk would tend to increase contraceptive ac-
ceptance among the women not interviewed (the control
group), and because of this, the differences in contraceptive
behavior between the interviewed women and the control group
is a conservative estimate of the influence of the educational
program.


Results
EVALUATION OF EDUCATIONAL PROGRAM

The distribution of the patients by acceptance of contracep-
tion for interviewed and control groups, and for the total, is
shown in Table 1. For all patients, 63 percent accepted contra-
ception at discharge or at subsequent clinic visits, 27 percent de-
clined for unspecified reasons, and 10 percent declined because
they desired pregnancy. The difference in the proportion accept-

TABLE 1 Percentage distribution of experimental and control
groups by contraceptive acceptance or nonacceptance
Item Experimental Control Total
Acceptors
Before discharge 42 36 40
On first clinic
visit 22 16 20
On later clinic
visit 3 3 3
Nonacceptors
Reasons unknown 22 36 27
Wishing pregnancy 11 9 10
Total
Percent 100 100 100
Number 993 491 1,484
NOTE: Differences between groups are significant (p = 0.05).


ing contraception between the interviewed women (67 percent)
and the control group (55 percent) is statistically significant
at the .05 level.3 The difference in the proportion desiring a
subsequent pregnancy is not statistically significant in the two
groups.
Table 1 also shows proportions of patients accepting con-
traception by time of acceptance. For both groups, the majority
of acceptance occurred at the time of discharge (42 percent
of the interviewed and 36 percent of the control group) or dur-
ing the first visit to the clinic (22 percent of the interviewed and
16 percent of the control group). In the second, third, and
fourth clinic visits, a smaller proportion began use.
A larger proportion of interviewed women than noninter-



SThe statistical analysis of the differences between the groups was
made using the tests of z or x2, according to the case.







TABLE 2 Percentage distribution of experimental and control
groups by sociodemographic characteristics
Characteristic Experimental Control Total
Age
Less than 20 13 14 13
20-29 53 53 53
30-49 34 33 34
Education-
None 5 4 5
Primary 62 59 61
Secondary or higher 33 37 34
Marital status
Married 81 81 81
Single 19 19 19
Living children
Noneb 17 23 19
1 to 3 58 56 57
4 or more 25 21 24
Previous abortions
None 53 52 53
1 or more 47 48 47
Total
Percent 100 100 100
Number 993 491 1,484

0 Education was unknown in 223 women-139 experimental and 84 control.
b Significant (p = 0.05).



viewed women (61 percent and 48 percent, respectively) at-
tended the clinic on the first appointment date, without being
contacted by letter.


INFLUENCES OF OTHER VARIABLES ON ACCEPTANCE

To determine whether factors other than the educational
talks might be influencing the contraceptive acceptance levels,
the two groups were classified by age, marital status, number of
living children, and history of past abortions, as shown in Table
2. The classification permits a comparison of the two groups,
which is shown in Table 3.
The age distribution of the experimental and control groups
is almost identical. In both the experimental and control group,
acceptance was highest among women aged 20-29 and lowest
among women under age 20. There were significant differences in
acceptance between experimental and control women aged 20
and over but little difference in acceptance among women under
age 20: in the experimental group, 60 percent (600) of the
women accepted, whereas in the control group, 48 percent
(237) accepted.
For the analysis of marital status, the women were classified
as either single (not currently living with a partner) or married
(living in legal or consenual union with a partner present). There
was no difference in marital status between the two groups. In
both groups, married women accepted contraception in larger
proportions than those without partners. The acceptance of con-
traceptives was higher for the interviewed group than the con-
trol group among both women without spouses and women
with spouses, although for the women without spouses, the
difference was not statistically significant.
The control group had a somewhat greater proportion of
women with no children. Since the women with no children had
a lower rate of acceptance, it was possible that this difference
accounted for much of the difference in acceptance levels be-
tween the two groups; however, the higher rates of contracep-
tive acceptance in the interviewed versus noninterviewed


TABLE 3 Percentage distribution and number of cases of
postabortion contraceptive acceptors and nonacceptors
among experimental and control groups, by sociodemographic
characteristics
Experimental Control
Characteristic Acceptors Nonacceptors Acceptors Nonacceptors
Age
Under 20 10 (65) 19 (62) 12 (33) 17 (38)
20-29 56 (370) 49 (161) 55 (149) 49 (109)
30-49 34 (230) 32 (105) 33 (88) 34 (74)
Marital status
Married 84 (560) 75 (245) 84 (228) 76 (169)
Single 16 (105) 25 (83) 16 (42) 24 (52)
Living children
None 11 (72) 31 (103) 11 (30) 37 (82)
1 or more 89 (593) 69 (225) 89 (240) 63 (139)
Previous abor-
tions
None 51 (340) 56 (190) 48 (130) 57 (127)
1 or more 49 (325) 44 (138) 52 (140) 43 (94)
Total 100 (665) 100 (328) 100 (270) 100 (221)

( )= Number of cases.

women were statistically significant both for women with and
without children.
Similar proportions of interviewed and control groups re-
ported previous abortions (47 percent and 48 percent respec-
tively). Examination of the relation of previous abortion history
to acceptance shows that proportionately fewer of the patients
who had had no previous abortions began contraceptive use
than of those with previous abortions (64 percent versus 70 per-
cent in the interviewed group and 51 percent versus 60 percent
in the group not interviewed), and the differences are statistically
significant in both interviewed and control groups. The differ-
ence in acceptance between the interviewed and control groups
was significant in the group with no previous abortions as well
as in the group of patients with one or more previous abortions.


USEFULNESS OF CONTACT BY MAIL

A contact letter was sent to almost all the patients who did
not come to the family planning clinic.4 Fifty-five patients were
sent two letters, and eight were sent three. A greater proportion
of the letters sent to noninterviewed women were returned be-
cause of a wrong address compared with the letters to inter-
viewed women (38 percent and 30 percent, respectively). If we
assume that the letters not returned by mail were received by
the patients, 32 percent of the women who were given definite
appointments in the letters came to the clinic. There was no dif-
ference in the proportion of interviewed and noninterviewed
women who came to the clinic because of an appointment made
by letter.


Conclusion
Although acceptance of contraception does not imply con-
tinued family planning practice (Faundes et al., 1968; Ramos,
1972), it gives an idea of the effectiveness of the educational
efforts carried out. Higher acceptance levels among the women
receiving the educational talks were found almost consistently

4 No letter was sent to 20 women in the control group and 10 in the
interview group because of incomplete or no address.







when the two groups were broken down by age, marital status,
number of living children, and number of abortions. Thus, on
the basis of the available data, it seems valid to conclude that
the educational activities and interviews held by the volunteers
had a positive effect on the acceptance of contraception by the
patients.
Considering the other factors that influence acceptance, it
also may be concluded that there is a greater resistance to using
contraceptives on the part of the not married and younger
women, characteristics that are closely correlated. This resis-
tance to acceptance is made more evident by the fact that these
groups of young and single women are the only ones for whom
no significant differences were found between the interviewed
and control groups; in other words, in these groups, the educa-
tional activities and the interview did not have the significant
positive effects they had on the rest of the patients.
Although we do not have data on this issue, our experience
with individual cases leads us to postulate that this resistance
derives from the honest conviction that "I will never have sexual
relations again," no doubt caused by having been abandoned
by the boyfriend, or by reaction to the experience of abortion.
The numerous cases of patients with these characteristics who
have been readmitted for subsequent abortions, and the greater
gravity of the abortions in this group of women (Faundes,
1973), reveal that we must consider this smaller level of ac-
ceptance by single and younger women as a partial failure of
the program and as an area in which it is necessary to redouble
the educational efforts.
Another finding is that the large majority of patients who
accept contraception do so at the moment of discharge, and that
the rate of acceptance during the later clinic visits is far lower.
This confirms previous findings that high risk women are
most motivated to accept contraception during hospitalization
(Potter and Masnick, 1971). To fully take advantage of this
motivation, it is necessary to make methods other than IUDs
available in the Abortion Section.5 A related observation, unfor-
tunately not properly documented, is that patients who did not
receive a contraceptive during their first visit to the family plan-
ning clinic because of lack of attention or because the appoint-
ment coincided with their menstrual period, seldom returned
for a subsequent appointment.
Finally, in reviewing the practice of setting up appointments
by mail, about one-third of the women who may have re-
ceived a letter came to the clinic. Although this proportion may
seem relatively small, we think that the considerably smaller
cost of contact by mail compared with the alternative of home
visits makes such contact a worthwhile initial step if a function-
ing postal system exists.
The results presented show the important role volunteers may
play in a program of abortion prevention and family planning.
The volunteers showed great motivation and dedication to their
work, which was nurtured and reinforced through informative
meetings and individual conversations. Even more important is
the fact that the volunteers were very aware that the hospital
personnel, from the head of the maternity ward to the clinic
auxiliaries, recognized the importance of the work that they


STo some extent this was done at the time of the study. Oral con-
traceptives, among other methods, were offered, but a breakdown by
method was not possible in the analysis.


carried out. Based on our experience, we suggest that volun-
teers should be under the supervision of someone who will
motivate them; observe the quality of their work; assist them
when they have problems; and convince the staff of the con-
tribution that the volunteers are making so that their efforts
are recognized.


References
Andolsek, L. 1972. "Experience with immediate post-abortion
insertion of the IUD." In Abortion Techniques and Services.
Edited by S. Lewit. Amsterdam: Excerpta M6dica Foundation,
International Congress Series N-255.
Faundes, A. 1973. "Aborto y shock s6ptico." (Abortion and septic
shock.) In Fisiologia de la Reproducci6n y Atenci6n Integral de
la Madre. Edited by L. Sobrevilla. Lima, Perli: Universidad
Peruana Cayetano Heredia.
Faundes, A., G. Rodriguez, and E. Hardy. 1968. "Aceptaci6n de
anticonceptivos en Am6rica Latina." (Acceptance of contra-
ceptives in Latin America.) Boletin de la Asociacion Chilena
de Protecci6n de la Familia, N-5: 2.
Goldsmith, A., R. Goldberg, H. Eyzaguirre, and L. Lizana. 1972.
"Immediate post-abortal intrauterine contraceptive device in-
sertion: A double-blind study." American Journal of Obstetrics
and Gynecology 112: 957.
Potter, G. R., and G. S. Masnick. 1971. "The contraceptive po-
tential of early versus delayed insertion of the IUD." Demog-
raphy 8: 507.
Ramos, R. M. 1972. "Patient motivation at Jos6 Fabella Me-
morial Hospital." West African Post-Partum Seminar. Ibadan,
Nigeria, 1972. (Mimeograph.) Circular N-660. The Population
Council, Postpartum Program.
Requena, M. 1965. "Social and economic correlates of induced
abortion in Santiago, Chile." Demography 2: 23.
Rosenfield, A. G., and R. G. Castadot. 1974. "Early post-partum
and immediate post-abortion intrauterine contraceptive device
insertion." American Journal of Obstetrics and Gynecology
118: 1104.
Tatum, H. J. 1972. "Intrauterine contraception." American Jour-
nal Obstetrics and Gynecology 112: 1000.
Viel, B., and S. Lucero. 1970. "An analysis of 3 years' experience
with intrauterine devices among women in the Western Area
of the City of Santiago, July 1, 1964 to June 30, 1967."
American Journal of Obstetrics and Gynecology 106: 765.


ABOUT THE AUTHORS Ellen Hardy is a consultant for the
Dominican Republic's National Fertility Survey, which is
part of the World Fertility Survey. During 1969-1973, she
was a sociologist at the Center for Research in Reproduction,
Barros Luco-Trudeau Hospital in Santiago, Chile. Karen
Herud, who is a sociologist, was an assistant to Ms. Hardy
at the Center for Research in Reproduction, Barros Luco-
Trudeau Hospital during 1972-1973.

ACKNOWLEDGMENTS A study on the effect of age, parity,
and the spacing of children on mother and child mortality and
morbidity, of which the research described in this paper was
a part, was assisted by a grant from the Population Council
to the University of Chile.







Status and Roles of Women as Factors in Fertility Behavior:

A Policy Analysis

i. ADRIENNE GERMAIN
it


Family planning programs in the Third World were devel-
oped on the assumption that subsidized provision of contracep-
tive education, information, and services would increase con-
traceptive use, help reduce national fertility, and encourage
economic and social development. But family planning pro-
grams at best have had a marginal impact on societal fertility.
This paper explores the hypothesis that the traditional definitions
of women's roles as well as the treatment of women in the
modernization process have been factors that have retarded
progress toward reduced fertility, national development, and
achievement of social justice. The paper is based on the premise
that a fuller understanding of both the socioeconomic deter-
minants of population trends and the consequences of these
demographic trends for development requires recognition of the
relationship between women's status and population trends as
well as understanding of the current and potential roles of
women in national development.'

Background
There is increasing concurrence that contraceptive informa-
tion and service activities have helped many couples have fewer
children but that societal fertility has been too little affected.2
Two explanations for this have been: (a) that family planning
programs could be substantially more effective if better planned
and administered; or (b) that family planning programs can-
not reduce societal fertility since contraceptive motivation is
constrained by cultural, social, and economic conditions that
demand high fertility. This dichotomy has led to rather unpro-
ductive debate that has tended to emphasize either provision of
services or social change. In fact, both are probably necessary
for sustained and significant societal fertility decline (say, re-
duction in the crude birth rate by 15 points in one generation).
In the next decade or two, family planning programs will con-
tinue and be improved and alternate delivery systems will be
tried, aided by broader health and motivation programs that



SThis paper deliberately focuses on fertility in the conviction that
pragmatic arguments in this area may encourage expanded efforts in all
development programs. While recognizing that standards of social jus-
tice require fuller integration of women in national life, it emphasizes
pragmatic economic issues.
2 For example, family planning program user rates among married
women of reproductive age ranged in 1973-1974 from 1 to 27 percent,
with most rates at the lower levels (Nortman, 1974). This is barely
sufficient to keep pace with the annual increase in the number of those
women. Although some encouraging developments have taken place in
several countries, many national family planning program personnel are
dismayed that more progress is not being made. Even in countries with
notable success, such as South Korea and Taiwan, there is increasing
concern that the young age structure of the population may inhibit
efforts to reduce fertility levels for some time to come.


take into account traditional contraceptive behavior (such as
taboos on intercourse). Scholars and program planners, how-
ever, are also asking whether additional alterations in popula-
tion program strategies are justified and feasible. The World
Population Plan of Action adopted at the 1974 World Popula-
tion Conference, for example, recognizes that reduction in na-
tional population growth rates will greatly depend on broad-
based socioeconomic change, including modifications in the
status and roles of women.
In the past decade, a number of studies have sought to docu-
ment the relationship between fertility and indicators of the
status and roles of women, but research results have done little
to influence population or development policy and program de-
cisions. To date, most development programs that have reached
women, including family planning programs, have dealt with
women mainly as reproductive agents and have focused on
domestic science, nutrition, child care, and so on. Furthermore,
where other special programs (such as literacy training) exist,
women usually have less access to them than do men. Proposals
to improve or change women's status and roles usually have
been met with pessimism (Berelson, 1969). Nonetheless, the
proposition will be developed here that programs focusing on
women-aimed at changing pronatalist cultural norms and
practices, creating alternatives to childbearing, and reducing
dependence on children-are necessary and feasible next steps
in achieving faster progress toward reducing societal fertility
levels. Generation of program and research activities along
these lines is required as a complement to current population
and development programs, not as a substitute for them.
A multidimensional approach defined by national conditions
would include at least two basic types of action: (1) fuller in-
tegration of women in current education and other develop-
ment programs; and (2) creation of special programs, where
appropriate, that take into account women's particular needs,
daily schedules, and so on. In many societies the immediate
goal will be increasing the productivity of women's current
activities to (a) release time for them to pursue education or
training, and (b) increase their economic security and standard
of living. The longer term goal is expansion of women's roles
and options in society, which, in turn, will enable them to
choose to have fewer children. Clearly, there are humanitarian
justifications for such a strategy. Are there demographic justifi-
cations?

Justifications
On the basis of available evidence, what changes in the
status and roles of women should nations and agencies con-
cerned about fertility seek to attain? What changes can reason-
ably be expected given national and international resources?







EDUCATION AND FERTILITY

Data from developed countries indicate that higher educa-
tional levels for women and increased opportunities for "satis-
fying" work outside the home are associated with lower fer-
tility. The relationship is less clear for developing countries.
A review of evidence from the past decade indicates that in
most developing countries where research has been done there
is a reasonably strong negative association between women's
educational levels and various fertility measures (birth rate,
number of living children, ideal and expected family size), al-
though the relationship is not always inverse and is sometimes
curvilinear. The amount of education necessary to encourage
reduced fertility varies among countries, depending on the rate
of illiteracy, the strength of pronatalist norms and practices,
the age of the women, and urban/rural residence.3
The effect of education on fertility is also likely to depend
on whether it leads to activities other than childbearing. Edu-
cation is often associated with later age at marriage; in fact,
some studies indicate that the difference in average age at
first marriage between women of higher and lower educational
levels may account for most of the differentials in completed
family size correlated with education (Caldwell, 1971b; Freed-
man, Hermalin, and Sun, 1971; United Nations, 1973b). Sev-
eral cross-cultural and KAP studies indicate that education of
the woman is positively related to contraceptive knowledge and
practice, although the relationship may be confounded by so-
cioeconomic status.4
There is contradictory evidence about the relative importance
of the wife's and the husband's education. Studies in Taiwan
and Thailand, for example, provide evidence that the educa-
tional level of the wife is more strongly correlated with mea-
sures of the couple's fertility and contraceptive use than is the
educational level of the husband (Schultz, 1973b). On the
other hand, studies in Nigeria and urban areas of some Latin
American countries seem to imply that the fertility impact of
the wife's education is limited by the husband's education or
occupation (Miro, 1966; Ohadike, 1968). Several studies in-
dicate that both the husband's and the wife's education are
important, depending on the fertility and family planning prac-
tice measures used (Freedman and Takeshita, 1969; Mueller,
1972).

EMPLOYMENT AND FERTILITY
The relationship between women's employment and fertility
is even more complex than the relationship between education
and fertility both within and across nations. Several authors
have reviewed research in developing countries and have con-
flicting opinions about the existence of a relationship, its di-
rection, the causes of the relationship, and the utility of efforts
to expand women's nondomestic roles as a means of encourag-
ing reduced fertility.5 Nonetheless, there is a negative associa-


See Dixon, 1975; Freedman, Coombs, and Chang, 1972; Heisel, 1972;
Hermalin, 1973; Miro and Mertens, 1968; Schultz and DaVanzo, 1970;
United Nations, 1973b. More extensive references for this entire sec-
tion are available from the author on request.
'See Berelson, 1966; Caldwell, 1971a; Goldberg and Litton, 1969;
Lapham, 1970; Ross et al., 1972.
'See Collver and Langlois, 1962; Concepci6n, 1974; Dixon, 1975;
Gendell, 1967; Heer and Turner, 1965; Maurer, Ratajcyak, and Schultz,
1973; Miro and Mertens, 1968; Schultz, 1973a; Stycos and Weller, 1967.


tion in many cultures between certain nonfamilial activities for
women and their fertility. Education, urban/rural residence,
fecundity, age, and marital status are also important factors
(Hermalin, 1973; Speare, Speare, and Lin, 1973), and more
adequate studies would need to control for such other variables
as age at marriage and availability of contraception.
Various theories have been advanced to explain inconsistent
research results. The best known and most intensively pursued
is the so-called role conflict theory. Very simply, this postulates
that, in order to have a fertility effect, a woman's work must
directly conflict with her role of mother so that she has to
choose between the two. Fertility is not likely to decrease where
women work in or near the home or can easily make arrange-
ments for child care, where cultural norms dictate that women
should be mothers of large families even if they do work, and
where the work available offers little reward to compensate
for having fewer children.6 Recent studies go beyond the role
conflict theory to argue that the employment-fertility relation-
ship depends on such factors associated with modernization as
the wife's motivation for working, her approval of nondomestic
roles for women, the division of labor and decision-making in
the family, and the amount and type of education she has re-
ceived.7
The obvious conclusion from such diverse findings is that
each country situation should be systematically evaluated in
order to design and implement effective policies. Unfortunately,
however, such evaluations are not often available and do not
have high priority. Moreover, the kinds of programs necessary
to encourage fertility reduction depend not only on population
staff and funds but also on broader development policies. Such
programs might include: functional education for women com-
bined with practical agricultural training in societies where lit-
eracy is low; or vocational training to directly encourage
women to apply their education outside the home in societies
where many women have completed primary education. This
suggests that both population and development planners must
be given a strong rationale for paying attention to the issues con-
cerning women's roles and status.


Theoretical Rationale
There are several fertility-related arguments in support of the
proposal to broaden women's role options:
1. Even where women have full access to family planning
services, they still often do not have access to education, em-
ployment, and roles other than or in addition to motherhood.
Without such opportunities, women's status and roles depend
largely on their number of living children. Furthermore, most
women are socialized from childhood to be mainly or solely
mothers (Mead, 1949). Programs offering acceptable sup-
plementary or alternative roles to motherhood might influence
natality by encouraging postponement of marriage, postpone-
ment of the first birth, or earlier cessation of childbearing. In-
creases in the age at marriage or changes in the percentage of
women who are married accounted for a major portion of re-


6 See Boserup, 1973; Gendell, Maraviglia, and Kreitner, 1970; Gold-
stein, 1972; Hermalin, 1973; Jaffe and Azumi, 1960; Miro and Mertens,
1968; Stycos and Weller, 1967.
SSee Blake, 1965; Easterlin, 1974; Hill, Stycos, and Back, 1959;
Rosen and Simmons, 1971; Safilios-Rothschild, 1972; Schultz, 1971.







cent declines in the birth rates in Hong Kong, Japan, Korea,
Singapore, Sri Lanka, and, reportedly, the People's Republic
of China (Ross et al., 1972). Changes in other determinants
of women's status such as dowry customs or freedom of choice
of spouse would also influence fertility levels if these determi-
nants functioned to delay age at marriage.
2. There is a strong theoretical basis for assuming that well-
planned and executed efforts to (a) increase the education and
economic productivity of women and (b) open alternative or
expanded roles to them reduce the value of children as sources
of labor and old age security. Such programs could lead to
childbearing practices that encourage changes in sex role defi-
nitions in the next generation (Dodd, 1968). One might ex-
pect as well that as both women and men are drawn into the
modernization process, some of the noneconomic (for example,
ritual, psychological) functions of children will be diminished
as traditions change, or that these functions can be fulfilled by
fewer children. Furthermore, education for women will prob-
ably increase their aspirations for their children, increasing the
costs of raising children; this also may lead to reduced fertility
in one or more generations.
3. When women have an education and access to better liv-
ing conditions, their children's chances for survival should be
considerably improved. As more children survive, the number
of births required to achieve desired family size will be re-
duced. Needless to say, it may take one or more generations
for couples to realize that more children are surviving. (There
is relatively little information on people's perceptions of changes
in mortality and even less on how to educate them on the re-
lationships between parity and mortality [Polgar, 1972; Rut-
stein, 1974].)
4. Changes in the status and roles of women may bring
changes in family structure, for example, a change from the
extended family with power vested in the mother-in-law to a
nuclear family with more freedom to make its own fertility
decisions. Perhaps more important, changes in the roles of
women might change the dynamics of the marital relationship,
enabling women to have an equal voice in family decisions,
especially fertility decisions (Rosen and Simmons, 1971).
Studies of married couples in predominantly urban areas in
both developing and developed countries indicate that the more
equal the division of labor and decision-making in the mar-
riage, the more likely it is that couples will (a) communicate
with one another about sex, family size desires, and birth plan-
ning; (b) express a desire for small families; and (c) practice
effective contraception.
5. Activities focused on expanding the roles of women and
increasing their productivity may be more feasible and palat-
able than other "beyond family planning" proposals. Major
suggestions for beyond family planning activities have focused
on directly decreasing the economic values of children. Sug-
gestions have included compulsory schooling, which would
lessen children's labor value; provision of alternative sources
of old age income, such as government pensions; or incentive
and disincentive schemes designed to increase the costs of chil-
dren. Such proposals have been considered to be impractical
at the national level, in the short run at least, because of their
high cost, lack of necessary administrative infrastructure, and
so on. On the other hand, programs to increase the economic
productivity of women and expand their roles could have simi-
lar fertility effects. At the same time, such measures could in-


crease women's economic contributions to the family and the
nation, offsetting some of the initial costs of training and edu-
cation. Prevocational and vocational training, literacy, and agri-
cultural programs may be less expensive and more feasible than
the beyond family planning programs mentioned above: they
can build on existing programs; they do not require the ex-
pensive infrastructure of a formal educational system or a na-
tional social security system; and they do not have the rather
negative implications of programs designed to reduce more di-
rectly the value of children.


Questions and Objections
There are a number of possible questions and objections to
expanding population and development programs to focus on
altering women's status and roles. The first three cited below
relate directly to the relevance of the status and roles of women
for fertility behavior; the next four deal with the feasibility of
such programs.

RELEVANCE OF STATUS AND ROLES OF WOMEN
FOR FERTILITY BEHAVIOR
1. Some have argued that there is no more justification for
adding programs focused on education, employment, and in-
creased social and political participation for women than there
is for adding general programs in education, employment, or
nutrition. All of them, in the long run, would probably encour-
age fertility reduction. The fertility-related arguments and data
outlined above, however, justify a special concern with women's
status in addition to family planning programs and need not
preclude other program strategies.
2. It has also been argued that changes in the status and
roles of women should not be undertaken solely as a means of
fertility reduction. This is certainly true, but it does not invali-
date the fertility framework or the need to convince particular
policy-makers that the issues are important for their programs.
Since faster progress toward societal fertility reduction is not
likely to occur in the absence of changes in the roles of women,
population programs should include attention to such changes.
3. It might reasonably be said that population programs,
through their focus on contraceptive information and services
and their provision of employment for women, are already
doing their share to improve the status of women. However,
providing contraceptive technology will not necessarily result
in reduced fertility if strong cultural supports for large families
exist. Many women in the Third World have not sought con-
traceptive services because their status and often their survival
depend on motherhood; those who do accept contraceptives
(in national family planning programs, at least) have tended
to be older (25 years or older) or higher parity women already
settled into the role of mother. Family planning programs by
themselves do not help increase age at marriage, nor do they
necessarily create contraceptive motivation.

FEASIBILITY OF PROGRAMS
1. There are those who argue that changes in the status and
roles of women will come with socioeconomic development
and that it is not possible to rush the process. Where develop-
ment has begun to take place, however, women by and large







have been left behind. Although educational gaps between men
and women are closing, they are still substantial in most coun-
tries. Youssef (1971 and 1974) and others have shown that
increased female labor force participation is also not an auto-
matic concomitant of economic development but must be de-
liberately planned for. Female employment may be inhibited
by cultural factors, such as systematic seclusion and exclusion
of women in Muslim societies, as well as by supply factors,
such as the demographic composition of the female popula-
tion and the level of education. Perhaps more important, Bose-
rup (1970), among others, has argued that development pro-
grams that focus on men as breadwinners frequently cause a
decrease in the traditional status and economic productivity of
women (village women in particular) as men alone are drawn
into the modem sector through education, job training, and so
on. More empirical study would be necessary to document this
thesis adequately, but data indicate that this is the case in many
countries.8 Because such patterns are likely to encourage con-
tinued high fertility, intervention on the part of those com-
mitted to fertility reduction is advisable.
2. A common argument against increasing women's eco-
nomic activity, especially in the developing world, is that un-
employment and underemployment are already high among
men and attempts to employ women would compound rather
than ease the problem. There is not yet sufficient evidence to
document or refute this claim; however, several arguments for
widening women's economic activity can be made. As indicated
above, women in many societies have traditionally contributed
to the economic survival of their communities; it makes no
sense to ignore them in the course of development and thereby
lose their potential contribution. Women would not invariably
take jobs away from men-they might provide labor in areas
from which men are culturally excluded (for example, health
care for women in Muslim countries). Furthermore, in many
countries, especially those in the early stages of development,
the majority of men and women cannot realistically expect
wage employment; rather they will need to generate an income
through self-employment, cottage industry, small-scale cash
cropping, and so on, all areas in which women have tradition-
ally been active. Boserup (1970) has pointed out that when
more intensive cultivation of land is required (as a result of
increasing population density), both men and women must put
in hard labor to support their families; it seems only natural
to educate both in more efficient techniques.9 In many coun-
tries (for example, Chile, Colombia, and Kenya), at least 25
percent of households are headed by women (due to migration,
death, desertion, or polygamy), which makes their employ-
ment crucial to the family's survival. The immediate goal, then,
should be increased productivity among both men and women
regardless of the availability of wage employment. This would
be fully consistent with the emerging interest in reexamining


8For instance, development planners and advisors, assuming that
farming is man's work, have usually given opportunities to acquire new
agricultural techniques to men even where women have traditionally
done most of the farming. On the other hand, in countries or in sec-
tors of the economy where the supply of skilled and professional work-
ers is low, trained women may face relatively little employment dis-
crimination (Durand, 1973; Mueller, 1973).
9 The assumption seems to have been made that men would pass on
to their wives what they learn in extension education programs. Recent
findings have suggested that this does not necessarily happen. (Butler,
1973; United Nations, 1970).


the design of economic development. The United Nations Sec-
ond Development Decade places emphasis on the social and
economic welfare aspects of modernization, problems of mass
unemployment, and the need to focus on full utilization of
human capital: ". as the strategy of development is re-
examined, it is essential to consider how the total labor force,
both male and female, is best utilized. It is small profit for a
developing economy if the gains made in male productivity are
neutralized by losses in the productivity of females" (de Vries,
1971, p. 8).
3. It is generally agreed that universal formal education and
full employment are not feasible or reasonable goals in many
countries in the short run (say 10-15 years), especially for
women. Furthermore, allocation of scarce resources to these
sectors is conditioned by political factors not easily manip-
ulated. Nations are hard-pressed to keep up with the growth
in school enrollment caused by population growth; this exacer-
bates the difficulties of increasing enrollment for girls.10 These
constraints increase rather than negate the need to pursue al-
ternative means to increase the options available to women.
Employment and education, in the long run, must provide al-
ternatives to childbearing; in the short run, increasing even
slightly the economic status of women (through simple inno-
vations and training that increases their productivity) may do
much to broaden their view of themselves. Even the relatively
small move from illiteracy to literacy often has some influence
on family size.
Some of the immediate impediments to action in these areas
may not require massive inputs of resources or personnel but
rather some creative ideas or interim measures. For example,
if women are already so tied down by domestic or farm chores
that they cannot find time for even informal education pro-
grams, perhaps the radio (if widely available as in Colombia)
can be used. If universal education is not possible, perhaps
training in more efficient agricultural methods would be feasi-
ble as a first step. Formation of a national commission on the
role of women in development, a permanent women's bureau,
changes in program or government hiring, consultants judi-
ciously used to pinpoint possible areas for action, and many
other interim measures might be pursued as a start. Most coun-
tries have active voluntary women's associations, unions, and
marketing cooperatives that could be used to establish pilot
training programs for women.
4. Another frequent argument against programs aimed at
changing the status and roles of women, especially those pro-
grams supported by international agencies, is that they are
culturally imperialistic, imposing a Western definition of what
women should be. Programs directed at changes for women
need not be any more culturally disruptive than existing de-
velopment programs. There is considerable literature on the
kinds of social and cultural change agricultural innovations re-
quire; programs of mass literacy and education foster substan-
tial changes in thinking and behavior; and health improvements
have been a cause of great social changes from the disappear-


Despite progress in school enrollment between 1960 and 1968, the
absolute total of children not enrolled in school increased, and more
recent enrollment statistics imply a general trend in developing regions
toward a decrease in expansion of enrollment rates (United Nations,
1973a). In Asia, for example, an increase of over 50 percent in school
facilities is required in about 15 years just to maintain enrollment ra-
tios in primary schools at existing levels (ECAFE, 1972).






ance of the medicine man through the increased pressures of
population growth. Furthermore, indigenous tendencies already
favor change in women's status and roles: many govern-
ments pay lip service at least to the proposals made here
through adoption of various United Nations declarations (such
as the Declaration on the Elimination of Discrimination against
Women) and through statements in development plans (Beyer,.
1972; Stamper, 1973). Many countries have active women's
organizations that seek change. There is evidence that even in
Islamic societies upper-class girls have begun to have increased
access to secondary and higher education, as parent's aspira-
tions for their children go up and as the traditional modesty
code is altered (Dodd, 1973).
Many countries that have endorsed broad goals of the United
Nations Declaration on the Elimination of Discrimination
against Women have religious and secular traditions that are
not compatible with this Declaration. Thus, the specific goals
of programs aimed at improving the status and expanding the
roles of women will differ among countries. The potential bene-
fits from them as efforts (a) to achieve basic human rights
(education, health, and employment) for all people; (b) to
allow freer reproductive choices by lifting existing pronatalist
coercions; and (c) to encourage more rapid achievement of
national development goals should be carefully considered.
Cultural traditions should not be used as a justification for in-
action but as a means of defining clear and intelligible goals and
developing sensitively designed and well-executed programs.

Program Options
The above arguments justify commitment by governments
and international agencies concerned about national fertility
levels to explore program possibilities designed to broaden the
range of role options available to women. The nature and mag-
nitude of that commitment will be determined by cultural pat-
terns and available resources. The effort must involve popula-
tion and broader development planning and policies. Much of
the action suggested, in fact, may fall outside the current man-
date, funding, and expertise of most family planning programs.
Significant contributions, however, can be made by governments
and agencies concerned with fertility reduction:
1. Research: policy-oriented, country-specific research on the
relationship between fertility and aspects of the status and roles
of women; more applied work directed toward the definition,
cost, design, and implementation of specific policies and pro-
grams.
2. Action programs: innovative pilot projects to investigate
the relationships between fertility and roles by linking the pro-
vision of family planning services to role options for women
(for example, a village project that offers employment in a tex-
tile plant along with family planning); modification of existing
family planning program educational materials and activities
to recognize women in roles other than that of mother and en-
courage them to broaden their self-image.
3. Internal policy appraisal: regular evaluation by each op-
erating agency of the impact of all programs to insure that
those programs consider women's needs and provide the fullest
opportunities possible for them; systematic exploration of policy
options to determine possible areas for innovative work; review
of hiring policies.


The aid of agencies that are not population related, universi-
ties, and so on will have to be enlisted. Feasibility studies that
indicate the costs, benefits, and means of integrating women
more fully into national life have yet to be done in the fields of
agriculture, education, rural development, and employment.
Given the evidence summarized in this paper, those concerned
about fertility levels should exert what leverage they can to see
that appropriate studies and programs are undertaken in these
fields.

CLOSING RESEARCH GAPS

There is considerable need for policy-oriented, country-spe-
cific research on the current condition of women and its im-
pact on fertility, as well as more applied work directed toward
the definition of remedial measures. A number of authors
have reviewed the literature and catalogued basic research gaps
(Chaney, 1973; Kantner, 1967; Ridley, 1967). Some of the
more important of these are reviewed below from a policy
standpoint.
Conceptualization and measurement of "status" and "roles"
are far from adequate." Education and labor force participa-
tion have been the indicators used to date, but indicators of
legal status, political participation, membership in voluntary
associations, roles in the family, as well as the woman's moti-
vation for working would undoubtedly provide a better pic-
ture. Although a composite index might yield more insight
(Stycos and Weller, 1967), improvement in the definition and
measurement of individual indicators would also help.
The few studies that have been made on the determinants
and consequences of changes in women's status and roles in
the Third World have not succeeded in establishing a causal
order among the various factors in change. (For example, does
education lead to employment, or vice versa?) The order of
change is especially important when concern is with the effects
of these changes on fertility. There are also the severe data
problems that constrain most demographic research. (For ex-
ample, the focus on women's status and roles necessarily im-
plies an interest in change over time and a need for longitudinal
studies; however, such studies are expensive, and most data are
cross-sectional.) Reasonable policy formulation will depend on
further country-specific investigation of factors that determine
the relationships between fertility, employment, and education
under different societal and economic conditions. (For instance,
if a rise in the age at marriage appears to be a major correlate
of reduced fertility in a particular country, special research
would seek to determine the causes of the rise.)
Action-oriented studies could (a) convince policy-makers
that it would be efficient, economic, and feasible to examine,
expand, and capitalize on contributions that women make to
development; and (b) identify the areas in a particular culture
where modest inputs (technology, funds, and personnel) could
do most to increase the participation of women in development,
expand their role options, and thereby encourage reduced fer-
tility. Such research could determine, for example, what kinds


"Currently, there seems to be agreement only on a basic dichotomy:
"status" is a relative term referring to ranking of social position; "roles"
has to do with the expected and actual pattern of behavior. They are
not mutually exclusive.







and levels of training, education, and employment would sig-
nificantly increase women's contributions to family income and
the national economy as well as the costs and benefits of special
programs that reach females.

PILOT PROJECTS
Exploratory pilot projects including a research component
might be generated in the following areas, depending on local
conditions and needs.12
Raising the economic productivity of women by including
women in current agricultural training projects; providing pre-
vocational and vocational counseling; subsidizing industries
that train and hire women; forming marketing cooperatives to
eliminate the middleman and allow women to share profits di-
rectly; introducing quality control, management, credit systems,
and marketing for handicrafts and small industrial products;
and training for leadership of women's organizations. These
kinds of programs should be offered in all areas of the coun-
try and be relevant to local needs.
Improving women's educational levels, especially through
nonformal educational programs, by creative use of mass
media, voluntary associations, marketing cooperatives, and the
like; translation and distribution of relevant literature; and spe-
cial seminars for academicians and policy-makers. It is impor-
tant that women be educated in such subjects as accounting,
science, economics, and agriculture, which are likely to in-
crease their productivity and facilitate their participation in na-
tional planning and development.
Undertaking legislative changes in age at marriage, rights
within marriage, access to contraceptive information and ser-
vices, hiring, education, training, and employment. In many
countries these changes are likely to be token, at least initially,
due to an inability to enforce them; however, they may help
legitimize and encourage new social and economic patterns.
How much effect legislation can actually have on increasing
the age at marriage, for example, remains to be seen. There
may be cultural and attitudinal obstacles to change, insufficient
administrative infrastructure, and so on. Furthermore, the in-
crease in the average age at marriage would probably have to
be fairly substantial (perhaps as many as five years) to have
a measurable demographic impact (Lesthaeghe, 1973; Yaukey,
1973). On the other hand, if even a relatively short delay
occurs before marriage and if a woman goes to school or works
during that time, she might begin to be more aware of role
alternatives and want to pursue them.
Changing the traditional image of women as wife and mother
through programs for adolescent girls in women's organizations
would help raise girls' self-esteem, provide alternatives to early
marriage, and encourage them to change their self-images. Be-
cause public opinion and attitudes tend to be reinforced and
perpetuated in the mass media, an essential factor in changing
attitudes and alleviating discriminatory practices in all coun-
tries is likely to be women's images in these media. In some
countries different images are beginning to appear in the press
with an increasing number of articles written about women who

12 Such projects are appropriately undertaken for their own sake, cer-
tainly not just because they are likely to have an impact on fertility.
This should not preclude participation by those interested in fertility
reduction, however.


have achieved higher professional and educational status. Al-
though such articles may provide women with role models, the
achievements cited are not realistic goals for most women. Such
articles combined with radio broadcasts by political or industrial
leaders, articles on working-class women, posters, and new
school texts presenting different images of women, for example,
should help begin to change perceptions.

COUNTRY-SPECIFIC PROGRAMS

In each country the broad range of program and research
possibilities has to be narrowed through a systematic review of
existing education, training, and employment opportunities and
policies for effective action. Consider three examples.
In country X, 85-90 percent of the population are rural and
as many as 65 percent of rural households in some areas are
headed by women; women produce most of the food crops but
have traditionally been excluded from access to agricultural ex-
tension workers and simple innovations; laws insure that women
have few rights within the family or in matters of property;
and women's access to literacy and education programs is
limited. Initial program attempts might focus on training female
agricultural extension workers and providing simple, relatively
inexpensive agricultural innovations and training in cooperative
marketing techniques. A women's bureau in the department
of labor could help evaluate the special needs of women,
analyze their contributions to the national economy, and help
change laws and current training programs.
In country Y, on the other hand, most women have com-
pleted at least primary education; fewer women work in agri-
culture and more work in domestic service and the unskilled
echelons of modern industry; and national economic develop-
ment is further along. The necessary first steps might be better
documentation of the current contributions of women to the
economy; analysis of the costs and benefits of increasing their
participation in the modern sector; concerted attempts at legal
change to insure adequate salaries and working conditions;
establishment of vocational training programs for light indus-
tries, especially those in which men do not normally work; and
creation of training programs for paramedical and other health
workers, particularly where cultural norms demand that women
be treated only by women.
In country Z, women have traditionally been secluded in
their homes; attitudes of both men and women may preclude
direct measures designed to increase the contributions of women
to national development.13 Mobilization of public opinion
through various media may be the most appropriate and feasi-
ble first step. In addition, opportunities for participation in an
activity that may increase the economic independence of the
women and that can be done at home or in groups of other
women (for example, handicrafts) may begin to change at-
titudes about female roles. (Dodd [1973] asserts that the at-
tainment of literacy in such societies provides opportunities
for women to learn about alternative life styles and consider
changes in their behavior codes.) It should be noted that even


13 Some common attitudes are (a) that a woman's place is primarily
in the home; (b) that women are not expected to be the family's source
of economic support; and (c) that men should be the decision-makers
in family and society, especially in public office and such professions
as medicine, science, and engineering (United Nations, 1970).







in societies whose ideologies mandate seclusion of women in
their homes, women in the poorest strata often provide a sub-
stantial portion of the nation's labor, especially in agriculture
and food processing. It is therefore important to reach them in
their roles as producers.


Defining the Target Population

The particular target women for action programs as well as
the feasible short- and long-term goals will depend on the coun-
try situation (for example, resources, current status of women)
and the action priorities of policy-makers. Within the fertility
reduction framework, the best focus might be on encouraging
young unmarried women to delay marriage and young married
women to postpone their first birth or space and limit their
children, to allow them time to undertake the training and edu-
cation necessary for achieving alternative roles. Special empha-
sis could be given to programs aimed at hard-to-reach rural
women, since these women are the majority in most Third World
countries, have a great potential contribution to make to mod-
ernization of the rural sector, and are most likely to be left
behind in the modernization process. In more urbanized coun-
tries, a target of particular importance might be women who
live in the marginal areas of cities and who do not have access
to education, cannot find work, or work under adverse condi-
tions.
Various authors, arguing that urban areas are cores of change
that affect the larger society, assert that change programs
should focus on urban elite women, since they are most likely
to have political power and are the most easily reached. On
the other hand, these women are usually quite removed from
the problems of rural and even urban poor women; programs
designed to broaden the elites' roles would have little in com-
mon with the needs of the rural masses (United Nations, 1972).
Elite women, especially those in high-status public positions,
may nonetheless help create new attitudes toward women and
effect changes.


Summary
This argument for programs directed at improving the status
and broadening the roles of women is based on the assumption
that such programs may, through their impact on fertility mo-
tivation, help make further progress toward societal fertility
reduction and expedite national development. Several points
should be reiterated:
* Women's status and roles in developing countries tend to be
defined largely in terms of their fertility, but most women in
most countries also have economic roles that are ignored in
development programs. Recognizing and encouraging those
roles ought to have some impact on lowering fertility. How
much, how soon, and in what manner this can be brought
about is not yet well known. Nevertheless, the broad trends
are clear, and answers to specific policy questions should be
seriously pursued by those interested in fertility reduction.
* The proposed programs should not be justified only as a
means of achieving fertility reduction. The fertility relation-
ships, however, lend urgency and impetus to proposals for
broadening women's options in society. Exploration of the
field and initiation of programs under a population rubric
may encourage broader involvement by governments and
international agencies.


* The proposed measures will require redefinition of popula-
tion and development policies and priorities, but the benefits
of promoting such changes in social organization are far
broader than their direct effect on birth rates and justify allo-
cation of resources.
* Expanded roles and opportunities for women may mean hard
work and different kinds of problems for women; this must
be balanced against gains for the individual and the nation
that encourage reduced fertility and more equal participation
by women in development.
* This is not a proposal to impose a Western definition of what
women should be but rather to take into account in develop-
ment planning all of women's actual as well as potential
roles. The proposal is not intended to define what women
should do but rather to broaden their range of choices. Be-
cause women, to date, seem to have been under different
restraints than men and because they have not had equal
access to development programs in education, training, and
employment, it is appropriate that programs focus specifi-
cally on women.
* The mandate exists for women's fuller participation and in-
tegration in the political, social, and economic aspects of
national life and for abolition of existing laws, customs, reg-
ulations, and practices that discriminate against women and
help perpetuate high fertility. The key problem remains to
generate more active and substantial commitment to basic
and applied research on the issues as well as to encourage
changes in broad population and development strategies. As
Berelson has said about population policy research and ex-
ternal donor action generally, "The task is to clarify social
choices identify the issues, analyze them scientifically
and keep in the forefront of attention the fundamental
human values that are at stake ." (1971, p. 182).

References
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Chicago: University of Chicago Press, pp. 655-669.
1969. "Beyond family planning." Studies in Family Plan-
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ABOUT THE AUTHOR Adrienne Germain is currently pro-
gram officer in the Population Office, International Division
of the Ford Foundation. On completion of her masters de-
gree in sociology, University of California at Berkeley, she
worked as a staff associate in the Technical Assistance
Division of the Population Council.
ACKNOWLEDGMENTS The author gratefully acknowledges
insightful comments by Oscar Harkavy and Stephen Salyer
as well as invaluable research assistance by Marjorie Horn.







Thailand's Field-Worker Evaluation Project

YAWARAT PORAPAKKHAM, PETER J. DONALDSON, and THAVISAK SVETSRENI


Thailand's national family planning program has become
well known in large part because of the success that charac-
terized the early years of its operation. New acceptors of con-
traception increased from approximately 57,000 in 1968, the
first year the Ministry of Public Health began opening family
planning clinics throughout the country, to over 450,000 in
1974. The performance of the Thai program is especially note-
worthy because no incentives, targets, or field workers were
employed until recently and to date these have functioned
largely on an experimental basis.
For the past several years, it has been clear that additional
inputs would be required to maintain the high level of perfor-
mance established during the early stages of the program. The
Ministry of Public Health's five-year plan (1972-1976) noted
that: "At the present time, the Family Planning Project utilizes
existing health personnel, almost entirely, to motivate and then
provide services for those women in need of contraception. It
is believed that an increased motivational effort will be needed
in the future, efforts that will be impossible for the health per-
sonnel to do alone because of their heavy work load. It is there-
fore recommended that a category of field workers be created"
(Ministry of Public Health, 1972: Annex 4, p. 5). A feasibility
study of the most appropriate kind of field worker for the Thai
program was begun in July 1971.

Selection of Field Workers and Sample Areas
Unlike several other East Asian family planning programs,
such as those in Korea and Taiwan, which make use of special
family planning personnel, Thailand's program is completely
integrated within the health services network. The field work-
ers to be employed in Thailand would differ from others en-
gaged in family planning activities in that they would be almost
exclusively concerned with family planning. Moreover, unlike
the country's auxiliary midwives, who have been used exten-
sively especially to prescribe and supply oral contraceptives,
field workers would concentrate on motivational activities.
Several elements fashioned the decision regarding what type
of field worker to evaluate. Obviously, field workers employed
during the evaluation attempt should resemble, as closely as
possible, the kind of persons that could be employed in the fu-
ture. Moreover, it was important to include a range of realistic
patterns for a large-scale, nationwide, field-worker program
and, at the same time, to avoid evaluating field workers unlikely
to perform well. For the Thai program the most important
element was considered to be conditions of employment, that
is, whether a full-time salaried worker, a worker paid on an
incentive or commission basis, or a volunteer worker would
perform best.
Thus, three types of field workers were recruited and trained.
Type A field workers were full-time salaried personnel who


received 450 baht, about US$22.50, per month; type B work-
ers were full-time workers paid on a commission basis; type C
workers were part-time volunteers who received a monthly fee
of 100 baht, about US$5.00, to cover expenses. Thirty-nine
field workers were recruited: 15 type A workers; 11 type B;
and 13 type C. Some workers of types A and B were selected
at random to be given motorcycles in order to allow for the
measurement of the impact of improved mobility on their per-
formance.
All the field workers were women who lived in the area where
they worked. Field workers were recruited by local Ministry of
Public Health officials. Slightly more than half of them were
married at the start of field work. Approximately two-thirds
were aged 25 or under. Two-thirds of the field workers had
between 8 and 12 years of schooling, with the rest having less.
Several of the volunteer workers, although able to read and
write, had never attended school.
Training of the field workers was carried out during Septem-
ber 1971 at four regional centers by instructors from the Ma-
ternal and Child Health Division of the Ministry of Public
Health. Field workers began their assignments in October 1971
and continued working until April 1973. This report is con-
cerned with field workers' performance during the first year of
field activities from November 1971 to October 1972. The main
responsibility of the field workers was to motivate eligible
women to practice contraception. Operationally, performance
was measured in terms of new acceptors of contraception and
their continuation rates.
Study sites were selected by means of a three-stage sampling
process employing the procedures as well as the sampling frame
developed and maintained by the Institute of Population Studies
at Chulalongkorn University' (Institute of Population Studies,
1971). The original design called for a total of 48 field workers,
16 of each of the three types, to work in 12 sample areas.
During the early stages of the research, however, only 39 field
workers could be recruited. One of the 12 sample areas had
to be dropped because of a lack of local cooperation. The target
population of the study was currently married women aged
15-45 living in nonmetropolitan areas of Thailand.
Data for this report were obtained from both the field work-
ers and from women who accepted contraceptives during the
study period. Before the start of motivational activities, field
workers completed a household enumeration in each of the
sample areas. Data on the number of eligible women-cur-
rently married women between the ages of 15 and 45-their
characteristics and their history of contraceptive use were col-
lected. Each month thereafter field workers filed monthly re-

SThe sampling frame did not include provincial urban districts,
Bangkok-Thonburi, or four predominantly Muslim provinces in Thai-
land's southern region. Certain politically sensitive areas were also ex-
cluded from the sampling frame.






ports with the Ministry of Public Health detailing the number
of eligible women visited during the previous month, listing
new acceptors by method, and reporting on the continuation
of contraception begun by the sample women earlier in the
study period. The data from these monthly reports form the
basis of the present evaluation.


The Year's Experience
A total of 11,149 eligible women were enumerated in the
sample areas served by the field workers during October 1971.
At the time of the household enumeration approximately 10
percent of the women said they were currently practicing some
method of birth control with over half of them using oral con-
traceptives. During the 12 months of active field work, from
November 1971 to October 1972, the field workers reported
that 2,304 women, about one-fifth of those not practicing family
planning at the start of the project, accepted some method of
contraception.
Slightly more than two-thirds of the new acceptors started
using oral contraceptives, nearly 20 percent accepted an IUD,
and an additional 5 percent were sterilized; 8 percent began
using a variety of other methods. These figures reflect the pref-
erences of women at large and mirror the pattern found in data
from the national family planning program (Alers et al., 1973).
Oral contraceptives were especially popular among women liv-
ing in areas served by the field workers in part because full-time
workers (types A and B) were able to resupply pills after their
initial prescription by the local physician or government mid-
wife.


Performance by Type
The three types of field workers served different numbers of
women. The 15 full-time salaried workers, type A, were each
responsible for between three and eight villages, with a total of
6,190 women. The 11 commission payment workers, type B,
also each responsible for between three and eight villages, served
4,906 women. The 13 volunteer workers, type C, were each
responsible for only a single village and served 516 eligible
women.
Prior to the start of field activities, 12 percent of the women
served by type A field workers were practicing family plan-
ning. The corresponding figures for types B and C were 7 per-
cent and 16 percent. During the 12 months of field work, type
A workers recruited 25 percent of those not practicing at the
start of the program; type B workers recruited 18 percent of
those not practicing and type C workers recruited 32 percent
of those not practicing.
Another calculation, perhaps somewhat more appropriate, is
the number of acceptors per thousand eligible women per month
of field work. This takes into account that one-third of the
field workers left their assignments at various times during
the study and could not be replaced before October 1972.
The number of months of field work refers to months worked
by the original field workers.2 For type A workers the number
of acceptors per thousand eligible women per month of field
work was 1.57, for the type B workers 1.49, and for the type C
field workers 2.15.
Based on these data, the performance of type C field workers


appears especially good, certainly much better than might be
anticipated, given the lack of institutionalized "volunteers" in
Southeast Asia and the fact that, unlike salaried and commis-
sion workers, the volunteer workers could not resupply pills.
The commission payment workers, type B, on the other hand,
performed less well than expected.


Failure of an Incentive System
We think that the performance of type B workers was espe-
cially poor because of the incentive system employed during the
study. The failure of the incentive system illustrates what may
happen when ideas of proven utility are misapplied.
Commissions for the type B workers were based on their per-
formance relative to other field workers in the same sample
area in the same month. The procedure involved first determin-
ing the total amount of money available for field workers in
each sample area. (It had been figured that, over the course of
the project, commission fees would be roughly equal to the
salary of the full-time paid workers.) This amounted to a
monthly figure of 450 baht times the number of field workers.
This amount was divided among the field workers, each of
whom received 250 baht per month regardless of perform-
ance and an increment depending on her performance relative
to other field workers in her area in a given month. Such a sys-
tem has two shortcomings that make meaningful comparison
between workers paid on this system and the salaried or volun-
teer workers almost impossible.3 The system did not function
as a incentive payment scheme in that all type B workers were
not rewarded equally in a given month for equal performance.
Since payment was made on the basis of a field worker's per-
formance relative to other field workers in her area, one worker
could get more or less than a commission worker in another
area depending only on how her performance compared with
that of other field workers in her area. Likewise, field workers
within a particular sample area were not rewarded equally for
identical performance in various months. The amount they re-
ceived depended on how their performance compared with
others in a given area during a particular month. Thus, a field
worker could receive more or less for the same work in two
different months depending on how the other field workers in
her area performed.
The evidence available from previous research concerned
with incentive payments to field workers indicates clearly that
performance is affected by the payment of such an incentive
(Rogers, 1971). The system of payment employed by the Min-
istry of Public Health doubtless had some impact. Overall, it

2 The original type A workers worked a total of 159 months. If all
15 of the initial type A workers had remained on the job throughout
the study they would have worked 180 months. Type B workers worked
119 months instead of the expected 132 months. Type C workers
worked 148 months instead of 156' months. Although there are many
complicating factors, it is worth noting that the volunteer workers ap-
pear to have the best employment records. This should be a considera-
tion, perhaps not a major one, in deciding which field workers perform
best. Retraining is expensive and time consuming, and high dropout
rates often mean long periods in which women are without the services
of a field worker.
8The correlation among type B workers between performance, as
measured by a credit system devised by the Ministry, and salary was
0.03. Under a more appropriate system, one would obtain a high posi-
tive correlation between performance and salaries among commission
payment workers.







TABLE 1 Number of new acceptors per thousand eligible
women per month by field-worker type, age, education, and
marital status

Field-worker type
Field-worker A C
characteristic Salaried Volunteer
Age
25 and under 1.74 4.74
26 and over 12.29 3.39
Education (years)
0-4 7.95 2.45
5-7 16.52
8-12 1.87
Marital status
Single 2.22 4.18
Married 4.81 4.34
Total 1.57 2.15

= There were no field workers in this category.


appears to have lessened the performance of type B workers.
When controls for education, age, and marital status are intro-
duced, field workers paid on a commission basis performed less
well than the volunteer or salaried workers.
Because of the problems in deciding the precise impact of
the commission payment system, we cannot consider the ef-
fect of commission payment on performance and conclude
which type of field worker performed most successfully. It is
clearly not appropriate to conclude on the basis of the present
study that an incentive payment scheme of the type employed
in other family planning programs would be less successful in
Thailand than a system of regular salaries or volunteer work.


The Effect of Field-Worker Characteristics
Table 1 presents data on the performance of full-time, sal-
aried and volunteer field workers expressed in terms of the num-
ber of new acceptors per thousand eligible women per month of
field work. Because of our inability to judge the impact of the
incentive payment scheme employed in this study, we have
omitted detailed consideration of the commission payment
workers, type B. We consider separately the impact of three
field-worker characteristics: age, education, and marital status.
It is important to remember the large difference in the number
of eligible women served by the two types of field workers.
Type A field workers served a population over ten times as
large as that served by volunteer field workers. Although pre-
senting the field workers' accomplishments as a rate per thou-
sand eligible women standardizes the number of women served,
it does not, by any means, control for the impact of sampling
and measurement error over the small population served by
type C workers. Thus, meaningful subgroup comparisons are
almost impossible.
When field-worker type is controlled, only marital status has
the same effect among both groups. Married field workers per-
formed better than single field workers. The difference is fairly
small among the type C, volunteer workers, but fairly large
among the full-time, salaried workers. The two other character-
istics, age and education, exert opposite influences depending
on the type of field worker. Among volunteer workers, the
younger workers performed better than the older workers, and
the well-educated workers performed better than the less-edu-


TABLE 2 First-method cumulative life-table continuation
rates among 1,124 acceptors in the field-worker evaluation
project and 2,582 acceptors in the national follow-up survey
Continuation rate (percent)
Field-worker evaluation National sample
project, 1973 survey, 1971"
Ordinal month IUD Pill IUD Pill
1 99 92 97 93
6 90 70 85 79
12 85 59 76 69

SOURCE: Alers and Suvanavejh, 1974, Table IV.


cated; among full-time salaried workers, the older workers and
the less-educated workers performed better. The differences by
age among the type A workers are especially strong. The per-
formance by educational attainment is less straightforward be-
cause of the decline in performance among the better educated
type A workers. It may be that education up to a certain level
improves performance and beyond that point serves to increase
the social distance between field workers and eligible women
and thus lessens performance.


Follow-up Survey
A follow-up survey of women who accepted oral contracep-
tives or an IUD during the study period was carried out during
April and May 1973. Because the total number of women who
accepted either pills or an IUD was relatively small, we tried to

carry out a complete follow-up of all those who accepted either
of these methods during the study period. The continuation
rates presented refer only to program acceptors during the first
year of the study, of whom over 60 percent were successfully
followed-up. (The relatively low follow-up rate is due, in part,
to problems of reaching women in politically sensitive and re-
mote areas.)
The first-method cumulative life-table continuation rates,
based on 1,124 completed interviews, are shown in Table 2.
The data suggest that the presence of field workers may improve
continuation rates. For the IUD, the rates in areas served by
field workers are a good deal higher than those found in the
national program. Although pill continuation rates in field
worker areas are lower than in the country as a whole, the data
refer to a period during which there were major problems with
the distribution of oral contraceptives, and, thus, they cannot
be usefully compared with the earlier experience of the na-
tional program (Alers et al., 1973).
Data on continuation by type of field worker point to the
successful performance of volunteer workers, whose continua-
tion rates were better, on the average, than those of other field
workers. However, evaluation of the success of field workers,
and volunteers in particular, in improving continuation rates
must remain tentative at this stage because of the small sam-
ple size.


Implications for the National Program
Ideally, one would like to compare the national family plan-
ning program's achievement in control areas without field







workers to that in areas where field workers were employed.
Although data available for areas in which field workers were
used are not available for areas without field workers, sufficient
material is available for a general comparison.
Although it is a crude indication of the impact of field work-
ers, it is of some interest to consider the number of new ac-
ceptors the national program would have had if the rate of new
acceptance found in areas served by field workers prevailed
throughout the country. In 1972, there were approximately 4.7
million married women between the ages of 15 and 45; of these
roughly 19 percent, about 879,000 women, were reported to
be practicing contraception. If the national program were able
to recruit one-fifth of those not practicing, approximately what
the field workers were able to do, there would have been over
750,000 new acceptors, a minimum of 300,000 more than the
reported 1972 total of 450,000 new acceptors. Such figures
doubtless exaggerate the potential impact of field workers.
Nevertheless, their contribution to the family planning program
would probably be substantial.
As is often the case with program-oriented research of the
type represented by Thailand's field-worker evaluation project,
results have not yet led to any changes in the program. In part
this is due to suspicion regarding the utility of volunteer work-
ers (and the reliability of our findings regarding their perform-
ance). In part it is due to the problems of introducing new po-
sitions of any kind into the Thai health services network. More-
over, since the study was not well designed, researchers lacked
a position of strength from which to argue for the employment
of field workers. Field workers served too few women; the com-
mission system was misapplied and, at 39, the total number of
field workers was too small. The extent to which field workers'
performance may have been affected by such exogenous factors
as unusually high or low receptivity to family planning also
biases our results.
Nevertheless, some new inputs will surely be required in the
future to sustain the past performance of the Thai national fam-
ily planning program. Field workers will doubtless be among
alternatives considered. Based on the data from the present
project, volunteer workers appear to perform far more success-
fully than originally anticipated. Thus, this type should receive
special consideration in the development of a field worker pro-
gram. A carefully planned and carried out program to recruit,
train, and supervise selected village women to support the ef-
forts of the family planning program on a volunteer basis would
probably add to its success. Based on the experience of other
family planning programs that employ field workers, a system
of incentive payments to field workers seems an idea worth
pursuing. Clearly that idea has not received a satisfactory test
in the present project. Thus, a second recommendation would
be that, whatever mix of salaried and volunteer field workers
is employed, serious consideration be given to hiring field work-
ers paid on a proper commission basis and to examining the im-
pact of such a system of payment on performance.
The use of either volunteers or incentive payments to field
workers in a program that has relied almost exclusively on ex-
isting health personnel to recruit family planning acceptors will
not be without administrative and organizational problems. In-
centive payments may cause jealousy, especially among the
country's auxiliary midwives who currently recruit most of the
program's acceptors. Volunteers, because they would be un-
paid, may be perceived as being outside the control of the Min-
istry of Public Health.


The family planning program's difficulty in maintaining the
momentum of its early years requires that some attempt be
made to increase the number of new acceptors (Alers et al.,
1973). Field workers, while not the only solution, would doubt-
less help. At the same time, it is important to remember that the
pattern of acceptance in areas served by the field workers re-
flected the performance of the national program. Field workers
are no panacea. Much more will have to be done to guarantee
continuation of the success of the Thai family planning effort.


References
Alers, J. Oscar, et al. 1973. "Thailand." Studies in Family Plan-
ning 4, no. 5 (May):124-127.
Alers, J. Oscar, and Chaichana Suvanavejh (eds.) 1974. Continua-
tion of Contraceptive Practice in Thailand: The 1971 Follow-up
Survey. Bangkok: National Family Planning Program.
Ministry of Public Health. 1972. Five Year Plan: National Family
Planning Program, Ministry of Public Health, Thailand, 1972-
1976.
Rogers, Everett M. 1971. "Incentives in the diffusion of family
planning innovations." Studies in Family Planning 2, no. 12
(December) :241-248.


ABOUT THE AUTHORS Yawarat Porapakkham, M.D., is a
member of the Department of Biostatistics in the Faculty of
Public Health and a research associate at the Institute for
Population and Social Research (IPSR), Mahidol University,
Bangkok. Peter J. Donaldson, formerly research associate at
the IPSR, is on the staff of the Population Council currently
assigned to the Research and Evaluation Unit of Thailand's
national family planning program. Thavisak Svetsreni, a
research associate at the IPSR, is on leave at the Department
of Anthropology, American University, Washington, D.C.

ACKNOWLEDGMENTS The research reported here was sup-
ported mainly by the Agency for International Development
under contract number AID/csd 2507. The authors thank
their colleagues at the Institute for Population and Social
Research (IPSR) and on the staff of Thailand's national family
planning program for their help throughout the project.


A6-07


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