OpenForum – a blog by the Health and Human Rights community

[Editor's note: This is a guest post written by Stephanie Psaki.]

Last month, the World Bank published a review of its health, nutrition, and population programs from 1997 through 2007, totaling US$17 billion in support. The review found that a third of the projects in this portfolio did not meet their objectives, and that, “none of the projects with explicit fertility or population objectives achieved them.”

The Bank’s current (2007) Population Strategy does not promise much greater success. Amidst a general endorsement of past approaches, the report states that they will target high fertility countries, where total fertility rates (average number of children born to a woman over her lifetime) exceed 5.

However, this strategy does not appear to take into account the level of unmet need – the proportion of women who no longer want to have children but lack access to contraception – in these countries. From an economics perspective, this is analogous to trying to sell a product to a new market with no indication that anyone wants to purchase it.

In fact, there is reason to believe that most people in these high fertility “markets” do not currently want to use contraception.

In a 1994 paper, Dr. Lant Pritchett – a World Bank economist – famously pointed out that worldwide 90% of differences in total fertility rates could be explained by differences in desired fertility. In other words, in most cases women and couples are having children because they want to have children. While Pritchett’s conclusions have been the subject of heated debate, the distinction between wanted and unwanted fertility remains crucial.

In discussing the Bank’s future population strategy, the report notes in passing that, “both demand and supply-side activities are important.” In public health terms, this refers to increasing access to acceptable and effective contraceptive methods (supply) while also promoting a decrease in desired fertility rates (demand).

As the Bank seeks more effective investments in its population portfolio, this distinction warrants additional discussion.

“Supply-side” approaches to population programs are much easier to implement and track than demand-side approaches. And in cases where there is unmet need, distributing condoms or other contraceptive interventions alone may in fact reduce fertility rates. However – and this is key – “supply-side” approaches must target communities with high unmet need, not just high fertility.

While “demand-side” approaches are more difficult to implement, they are also more likely to address the broader needs of high fertility populations, such as disparities in access to education and healthcare. In order to effectively transform attitudes about fertility, “demand-side” programs must be guided by a broader empowerment approach – emphasizing expanded access to information and opportunities – rather than a blunt goal of reducing fertility rates.

The Program of Action resulting from Cairo’s 1994 International Conference on Population and Development underlined the importance of empowering couples, seeking to infuse a rights-based approach into population program design:

The aim of family-planning programmes must be to enable couples and individuals to decide freely and responsibly the number and spacing of their children and to have the information and means to do so and to ensure informed choices…the principle of informed free choice is essential to the long-term success of family-planning programmes…Governmental goals for family planning should be defined in terms of unmet needs for information and services.

The distinction between “supply-side” and “demand-side” population interventions is important in the context of a rights-based approach to health. The design of population programs must be based on careful attention to the needs and rights of vulnerable groups, rather than the ease of implementation. While “supply-side” programs might focus on expanding access to existing technologies, “demand-side” approaches might seek to address gender gaps in education or racial disparities in access to family planning services.

Going forward, the Bank should be explicit about its population strategy. Interventions aiming to expand access to contraception should target populations with significant unmet need. But reducing total fertility rates below 5 will also require expanding the opportunities and resources available to women and couples.

As Pritchett concluded in his 1994 working paper, “reducing the demand for children – for instance by giving girls more education – is vastly more important to reducing fertility than providing more contraceptives or family planning services.”