NATIONAL SECURITY STUDY MEMORANDUM 200 (NSSM 200)
IV. Provision and Development of Family Planning Services, Information and Technology
In addition to creating the climate for fertility decline, as described in a previous section, it is essential to provide safe and effective techniques for controlling fertility.
There are two main elements in this task: (a) improving the effectiveness of the existing means of fertility control and developing new ones; and (b) developing low-cost systems for the delivery of family planning technologies, information and related services to the 85% of LDC populations not now reached.
Legislation and policies affecting what the U.S. Government does relative to abortion in the above areas is discussed at the end of this section.
The effort to reduce population growth requires a variety of birth control methods which are safe, effective, inexpensive and attractive to both men and women. The developing countries in particular need methods which do not require physicians and which are suitable for use in primitive, remote rural areas or urban slums by people with relatively low motivation. Experiences in family planning have clearly demonstrated the crucial impact of improved technology on fertility control.
None of the currently available methods of fertility control is completely effective and free of adverse reactions and objectionable characteristics. The ideal of a contraceptive, perfect in all these respects, may never be realized. A great deal of effort and money will be necessary to improve fertility control methods. The research to achieve this aim can be divided into two categories:
1. Short-term approaches: These include applied and developmental work which is required to perfect further and evaluate the safety and role of methods demonstrated to be effective in family planning programs in the developing countries.
Other work is directed toward new methods based on well established knowledge about the physiology of reproduction. Although short term pay-offs are possible, successful development of some methods may take 5 years and up to $15 million for a single method.
2. Long-term approaches: The limited state of fundamental knowledge of many reproductive processes requires that a strong research effort of a more basic nature be maintained to elucidate these processes and provide leads for contraceptive development research. For example, new knowledge of male reproductive processes is needed before research to develop a male "pill" can come to fruition. Costs and duration of the required research are high and difficult to quantify.
With expenditures of about $30 million annually, a broad program of basic and applied bio-medical research on human reproduction and contraceptive development is carried out by the Center for Population Research of the National Institute of Child Health and Human Development. The Agency for International Development annually funds about $5 million of principally applied research on new means of fertility control suitable for use in developing countries.
Smaller sums are spent by other agencies of the U.S. Government. Coordination of the federal research effort is facilitated by the activities of the Interagency Committee on Population Research. This committee prepares an annual listing and analyses of all government supported population research programs. The listing is published in the Inventory of Federal Population Research.
A variety of studies have been undertaken by non-governmental experts including the U.S. Commission on Population Growth and the American Future. Most of these studies indicate that the United States effort in population research is insufficient. Opinions differ on how much more can be spent wisely and effectively but an additional $25-50 million annually for bio-medical research constitutes a conservative estimate.
A stepwise increase over the next 3 years to a total of about $100 million annually for fertility and contraceptive research is recommended. This is an increase of $60 million over the current $40 million expended annually by the major Federal Agencies for bio-medical research. Of this increase $40 million would be spent on short-term, goal directed research. The current expenditure of $20 million in long-term approaches consisting largely of basic bio-medical research would be doubled. This increased effort would require significantly increased staffing of the federal agencies which support this work. Areas recommended for further research are:
1. Short-term approaches: These approaches include improvement and field testing of existing technology and development of new technology. It is expected that some of these approaches would be ready for use within five years. Specific short term approaches worthy of increased effort are as follows:
a. Oral contraceptives have become popular and widely used; yet the optimal steroid hormone combinations and doses for LDC populations need further definition. Field studies in several settings are required.
Approx. Increased Cost: $3 million annually.
b. Intra-uterine devices of differing size, shape, and bioactivity should be developed and tested to determine the optimum levels of effectiveness, safety, and acceptability.
Approx. Increased Cost: $3 million annually.
c. Improved methods for ovulation prediction will be important to those couples who wish to practice rhythm with more assurance of effectiveness than they now have.
Approx. Increased Cost: $3 million annually.
d. Sterilization of men and women has received wide-spread acceptance in several areas when a simple, quick, and safe procedure is readily available. Female sterilization has been improved by technical advances with laparoscopes, culdoscopes, and greatly simplifies abdominal surgical techniques. Further improvements by the use of tubal clips, trans-cervical approaches, and simpler techniques can be developed. For men several current techniques hold promise but require more refinement and evaluation.
Approx. Increased Cost $6 million annually.
e. Injectable contraceptives for women which are effective for three months or more and are administered by para-professionals undoubtedly will be a significant improvement. Currently available methods of this type are limited by their side effects and potential hazards. There are reasons to believe that these problems can be overcome with additional research.
Approx. Increased Cost: $5 million annually.
f. Leuteolytic and anti-progesterone approaches to fertility control including use of prostaglandins are theoretically attractive but considerable work remains to be done.
Approx. Increased Cost: $7 million annually.
g. Non-Clinical Methods. Additional research on non-clinical methods including foams, creams, and condoms is needed. These methods can be used without medical supervision.
Approx. Increased Cost; $5 million annually.
h. Field studies. Clinical trials of new methods in use settings are essential to test their worth in developing countries and to select the best of several possible methods in a given setting.
Approx. Increased Cost: $8 million annually.
2. Long-term approaches: Increased research toward better understanding of human reproductive physiology will lead to better methods of fertility control for use in five to fifteen years. A great deal has yet to be learned about basic aspects of male and female fertility and how regulation can be effected. For example, an effective and safe male contraceptive is needed, in particular an injection which will be effective for specified periods of time. Fundamental research must be done but there are reasons to believe that the development of an injectable male contraceptive is feasible. Another method which should be developed is an injection which will assure a woman of regular periods. The drug would be given by para-professionals once a month or as needed to regularize the menstrual cycle. Recent scientific advances indicate that this method can be developed.
Approx. Increased Cost: $20 million annually.
Exclusive of China, only 10-15% of LDC populations are currently effectively reached by family planning activities. If efforts to reduce rapid population growth are to be successful it is essential that the neglected 85-90% of LDC populations have access to convenient, reliable family planning services. Moreover, these people -- largely in rural but also in urban areas -- not only tend to have the highest fertility, they simultaneously suffer the poorest health, the worst nutritional levels, and the highest infant mortality rates.
Family planning services in LDCs are currently provided by the following means:
1. Government-run clinics or centers which offer family planning services alone;
2. Government-run clinics or centers which offer family planning as part of a broader based health service;
3. Government-run programs that emphasize door to door contact by family planning workers who deliver contraceptives to those desiring them and/or make referrals to clinics;
4. Clinics or centers run by private organizations (e.g., family planning associations);
5. Commercial channels which in many countries sell condoms, oral contraceptives, and sometimes spermicidal foam over the counter;
6. Private physicians.
Two of these means in particular hold promise for allowing significant expansion of services to the neglected poor:
1. Integrated Delivery Systems. This approach involves the provision of family planning in conjunction with health and/or nutrition services, primarily through government-run programs. There are simple logistical reasons which argue for providing these services on an integrated basis. Very few of the LDCs have the resources, both in financial and manpower terms, to enable them to deploy individual types of services to the neglected 85% of their populations. By combining a variety of services in one delivery mechanism they can attain maximum impact with the scarce resources available.
In addition, the provision of family planning in the context of broader health services can help make family planning more acceptable to LDC leaders and individuals who, for a variety of reasons (some ideological, some simply humanitarian) object to family planning. Family planning in the health context shows a concern for the well-being of the family as a whole and not just for a couple's reproductive function.
Finally, providing integrated family planning and health services on a broad basis would help the U.S. contend with the ideological charge that the U.S. is more interested in curbing the numbers of LDC people than it is in their future and well-being. While it can be argued, and argued effectively, that limitation of numbers may well be one of the most critical factors in enhancing development potential and improving the chances for well-being, we should recognize that those who argue along ideological lines have made a great deal of the fact that the U.S. contribution to development programs and health programs has steadily shrunk, whereas funding for population programs has steadily increased. While many explanations may be brought forward to explain these trends, the fact is that they have been an ideological liability to the U.S. in its crucial developing relationships with the LDCs. A.I.D. currently spends about $35 million annually in bilateral programs on the provision of family planning services through integrated delivery systems. Any action to expand such systems must aim at the deployment of truly low-cost services. Health-related services which involve costly physical structures, high skill requirements, and expensive supply methods will not produce the desired deployment in any reasonable time. The basic test of low-cost methods will be whether the LDC governments concerned can assume responsibility for the financial, administrative, manpower and other elements of these service extensions. Utilizing existing indigenous structures and personnel (including traditional medical practitioners who in some countries have shown a strong interest in family planning) and service methods that involve simply-trained personnel, can help keep costs within LDC resource capabilities.
2. Commercial Channels. In an increasing number of LDCs, contraceptives (such as condoms, foam and the Pill) are being made available without prescription requirements through commercial channels such as drugstores.  The commercial approach offers a practical, low-cost means of providing family planning services, since it utilizes an existing distribution system and does not involve financing the further expansion of public clinical delivery facilities. Both A.I.D. and private organizations like the IPPF are currently testing commercial distribution schemes in various LDCs to obtain further information on the feasibility, costs, and degree of family planning acceptance achieved through this approach. A.I.D. is currently spending about $2 million annually in this area.
In order to stimulate LDC provision of adequate family planning services, whether alone or in conjunction with health services, A.I.D. has subsidized contraceptive purchases for a number of years. In FY 1973 requests from A.I.D. bilateral and grantee programs for contraceptive supplies -- in particular for oral contraceptives and condoms -- increased markedly, and have continued to accelerate in FY 1974. Additional rapid expansion in demand is expected over the next several years as the accumulated population/family planning efforts of the past decade gain momentum.
While it is useful to subsidize provision of contraceptives in the short term in order to expand and stimulate LDC family planning programs, in the long term it will not be possible to fully fund demands for commodities, as well as other necessary family planning actions, within A.I.D. and other donor budgets. These costs must ultimately be borne by LDC governments and/or individual consumers. Therefore, A.I.D. will increasingly focus on developing contraceptive production and procurement capacities by the LDCs themselves. A.I.D. must, however, be prepared to continue supplying large quantities of contraceptives over the next several years to avoid a detrimental hiatus in program supply lines while efforts are made to expand LDC production and procurement actions. A.I.D. should also encourage other donors and multilateral organizations to assume a greater share of the effort, in regard both to the short-term actions to subsidize contraceptive supplies and the longer-term actions to develop LDC capacities for commodity production and procurement.
1. A.I.D. should aim its population assistance program to help achieve adequate coverage of couples having the highest fertility who do not now have access to family planning services.
2. The service delivery approaches which seem to hold greatest promise of reaching these people should be vigorously pursued. For example:
a. The U.S. should indicate its willingness to join with other donors and organizations to encourage further action by LDC governments and other institutions to provide low-cost family planning and health services to groups in their populations who are not now reached by such services. In accordance with Title X of the AID Legislation and current policy, A.I.D. should be prepared to provide substantial assistance in this area in response to sound requests.
b. The services provided must take account of the capacities of the LDC governments or institutions to absorb full responsibility, over reasonable timeframes, for financing and managing the level of services involved.
c. A.I.D. and other donor assistance efforts should utilize to the extent possible indigenous structures and personnel in delivering services, and should aim at the rapid development of local (community) action and sustaining capabilities.
d. A.I.D. should continue to support experimentation with commercial distribution of contraceptives and application of useful findings in order to further explore the feasibility and replicability of this approach. Efforts in this area by other donors and organizations should be encouraged. Approx. U.S. Cost: $5-10 million annually.
3. In conjunction with other donors and organizations, A.I.D. should actively encourage the development of LDC capabilities for production and procurement of needed family planning contraceptives.
Special Footnote: While the agencies participating in this study have no specific recommendations to propose on abortion the following issues are believed important and should be considered in the context of a global population strategy.
1. Worldwide Abortion Practices
Certain facts about abortion need to be appreciated:
No country has reduced its population growth without resorting to abortion.
Thirty million pregnancies are estimated to be terminated annually by abortion throughout the world. The figure is a guess. More precise data indicate about 7 percent of the world's population live in countries where abortion is prohibited without exception and 12 percent in countries where abortion is permitted only to save the life of the pregnant woman. About 15 percent live under statutes authorizing abortion on broader medical grounds, that is, to avert a threat to the woman's health, rather than to her life, and sometimes on eugenic and/or juridical grounds (rape, etc.) as well. Countries where social factors may be taken into consideration to justify termination of pregnancy account for 22 percent of the world's population and those allowing for elective abortion for at least some categories of women, for 36 percent. No information is available for the remaining 8 percent; it would appear, however, that most of these people live in areas with restrictive abortion laws.
The abortion statutes of many countries are not strictly enforced and some abortions on medical grounds are probably tolerated in most places. It is well known that in some countries with very restrictive laws, abortions can be obtained from physicians openly and without interference from the authorities. Conversely, legal authorization of elective abortion does not guarantee that abortion on request is actually available to all women who may want their pregnancies terminated. Lack of medical personnel and facilities or conservative attitudes among physicians and hospital administrators may effectively curtail access to abortion, especially for economically or socially deprived women.
2. U.S. Legislation and Policies Relative to Abortion
Although the Supreme Court of the United States invalidated the abortion laws of most states in January 1973, the subject still remains politically sensitive. U.S. Government actions relative to abortion are restricted as indicated by the following Federal legislation and the resultant policy decisions of the concerned departments and agencies.
a. A.I.D. Program
The predominant part of A.I.D.'s population assistance program has concentrated on contraceptive or foresight methods. A.I.D. recognized, however, that under developing country conditions foresight methods not only are frequently unavailable but often fail because of ignorance, lack of preparation, misuse and non-use. Because of these latter conditions, increasing numbers of women in the developing world have been resorting to abortion, usually under unsafe and often lethal conditions. Indeed, abortion, legal and illegal, now has become the most widespread fertility control method in use in the world today. Since, in the developing world, the increasingly widespread practice of abortion is conducted often under unsafe conditions, A.I.D. sought through research to reduce the health risks and other complexities which arise from the illegal and unsafe forms of abortion. One result has been the development of the Menstrual Regulation Kit, a simple, inexpensive, safe and effective means of fertility control which is easy to use under LDC conditions.
Section 114 of the Foreign Assistance Act of 1961 (P.L. 93-189), as amended in 1974, adds for the first time restrictions on the use of A.I.D. funds relative to abortion. The provision states that "None of the funds made available to carry out this part (Part I of the Act) shall be used to pay for the performance of abortions as a method of family planning or to motivate or coerce any person to practice abortions."
In order to comply with Section 114, A.I.D. has determined that foreign assistance funds will not be used to:
(i) procure or distribute equipment provided for the purpose of inducing abortions as a method of family planning.
(ii) directly support abortion activities in LDCs. However, A.I.D. may provide population program support to LDCs and institutions as long as A.I.D. funds are wholly attributable to the permissible aspects of such programs.
(iii) information, education, training, or communication programs that promote abortion as a method of family planning. However, A.I.D. will continue to finance training of LDC doctors in the latest techniques used in obstetrics-gynecology practice, and will not disqualify such training programs if they include pregnancy termination within the overall curriculum. Such training is provided only at the election of the participants.
(iv) pay women in the LDCs to have abortions as a method of family planning or to pay persons to perform abortions or to solicit persons to undergo abortions.
A.I.D. funds may continue to be used for research relative to abortion since the Congress specifically chose not to include research among the prohibited activities.
A major effect of the amendment and policy determination is that A.I.D. will not be involved in further development or promotion of the Menstrual Regulation Kit. However, other donors or organizations may become interested in promoting with their own funds dissemination of this promising fertility control method.
b. DHEW Programs
Section 1008 of the Family Planning Services and Population Research Act of 1970 (P.L. 91-572) states that "None of the funds appropriated under this title shall be used in programs where abortion is a method of family planning." DHEW has adhered strictly to the intent of Congress and does not support abortion research. Studies of the causes and consequences of abortion are permitted, however.
The Public Health Service Act Extension of 1973 (P.L. 93-45) contains the Church Amendment which establishes the right of health providers (both individuals and institutions) to refuse to perform an abortion if it conflicts with moral or religious principles.
c. Proposed Legislation on Abortion Research
There are numerous proposed Congressional amendments and bills which are more restrictive on abortion research than any of the pieces of legislation cited above.
It would be unwise to restrict abortion research for the following reasons:
1. The persistent and ubiquitous nature of abortion.
2. Widespread lack of safe abortion technique.
3. Restriction of research on abortifacient drugs and devices would:
a. Possibly eliminate further development of the IUD.
b. Prevent development of drugs which might have other beneficial uses. An example is methotrexate (R) which is now used to cure a hitherto fatal tumor of the uterus -- choriocarcinoma. This drug was first used as an abortifacient.
1. Utilization of Mass Media for Dissemination of Family Planning Services and Information
The potential of education and its various media is primarily a function of (a) target populations where socio-economic conditions would permit reasonable people to change their behavior with the receipt of information about family planning and (b) the adequate development of the substantive motivating context of the message. While dramatic limitations in the availability of any family planning related message are most severe in rural areas of developing countries, even more serious gaps exist in the understanding of the implicit incentives in the system for large families and the potential of the informational message to alter those conditions.
Nevertheless, progress in the technology for mass media communications has led to the suggestion that the priority need might lie in the utilization of this technology, particularly with large and illiterate rural populations. While there are on-going efforts they have not yet reached their full potential. Nor have the principal U.S. agencies concerned yet integrated or given sufficient priority to family planning information and population programs generally.
Yet A.I.D.'s work suggests that radio, posters, printed material, and various types of personal contacts by health/family planning workers tend to be more cost-effective than television except in those areas (generally urban) where a TV system is already in place which reaches more than just the middle and upper classes. There is great scope for use of mass media, particularly in the initial stages of making people aware of the benefits of family planning and of services available; in this way mass media can effectively complement necessary interpersonal communications.
In almost every country of the world there are channels of communication (media) available, such, as print media, radio, posters, and personal contacts, which already reach the vast majority of the population. For example, studies in India - with only 30% literacy, show that most of the population is aware of the government's family planning program. If response is low it is not because of lack of media to transmit information.
A.I.D. believes that the best bet in media strategy is to encourage intensive use of media already available, or available at relatively low cost. For example, radio is a medium which in some countries already reaches a sizeable percentage of the rural population; a recent A.I.D. financed study by Stanford indicates that radio is as effective as television, costs one-fifth as much, and offers more opportunities for programming for local needs and for local feedback.
1. USAID and USIA should encourage other population donors and organizations to develop comprehensive information and educational programs dealing with population and family planning consistent with the geographic and functional population emphasis discussed in other sections. Such programs should make use of the results of AID's extensive experience in this field and should include consideration of social, cultural and economic factors in population control as well as strictly technical and educational ones.
2. Use of U.S. broadcast satellites for dissemination of family planning and health information to key LDC countries
One key factor in the effective use of existing contraceptive techniques has been the problem of education. In particular, this problem is most severe in rural areas of the developing countries. There is need to develop a cost-effective communications system designed for rural areas which, together with local direct governmental efforts, can provide comprehensive health information and in particular, family planning guidance. One new supporting technology which has been under development is the broadcast satellite. NASA and Fairchild have now developed an ATS (Applied Technology Satellite), now in orbit, which has the capability of beaming educational television programs to isolated areas via small inexpensive community receivers.
NASA's sixth Applications Technology Satellite was launched into geosynchronous orbit over the Galapagos Islands on May 30, 1974. It will be utilized for a year in that position to deliver health and educational services to millions of Americans in remote regions of the Rocky Mountain States, Alaska and Appalachia. During this period it will be made available for a short time to Brazil in order to demonstrate how such a broadcast satellite may be used to provide signals to 500 schools in their existing educational television network 1400 miles northeast of Rio de Janeiro in Rio Grande do Norte.
In mid-1975, ATS-6 will be moved to a point over the Indian Ocean to begin beaming educational television to India. India is now developing its broadcast program materials. Signals picked up from one of two Indian ground transmitters will be rebroadcast to individual stations in 2500 villages and to ground relay installations serving networks comprising 3000 more. This operation over India will last one year, after which time India hopes to have its own broadcast satellite in preparation.
Eventually it will be possible to broadcast directly to individual TV sets in remote rural areas. Such a "direct broadcast satellite," which is still under development, could one day go directly into individual TV receivers. At present, broadcast satellite signals go to ground receiving stations and are relayed to individual television sets on a local or regional basis. The latter can be used in towns, villages and schools.
The hope is that these new technologies will provide a substantial input in family planning programs, where the primary constraint lies in informational services. The fact, however, is that information and education does not appear to be the primary constraint in the development of effective family planning programs. AID itself has learned from costly intensive inputs that a supply oriented approach to family planning is not and cannot be fully effective until the demand side - incentives and motivations - are both understood and accounted for.
Leaving this vast problem aside, AID has much relevant experience in the numerous problems encountered in the use of modern communications media for mass rural education. First, there is widespread LDC sensitivity to satellite broadcast, expressed most vigorously in the Outer Space Committee of the UN. Many countries don't want broadcasts of neighboring countries over their own territory and fear unwanted propaganda and subversion by hostile broadcasters. NASA experience suggests that the U.S. #notemust tread very softly when discussing assistance in program content. International restrictions may be placed on the types of proposed broadcasts and it remains technically difficult to restrict broadcast area coverage to national boundaries. To the extent programs are developed jointly and are appreciated and wanted by receiving countries, some relaxation in their position might occur.
Agreement is nearly universal among practitioners of educational technology that the technology is years ahead of software or content development. Thus cost per person reached tend to be very high. In addition, given the current technology, audiences are limited to those who are willing to walk to the village TV set and listen to public service messages and studies show declining audiences over time with large audiences primarily for popular entertainment. In addition, keeping village receivers in repair is a difficult problem. The high cost of program development remains a serious constraint, particularly since there is so little experience in validifying program content for wide general audiences.
With these factors it is clear that one needs to proceed slowly in utilization of this technology for the LDCs in the population field.
1. The work of existing networks on population, education, ITV, and broadcast satellites should be brought together to better consolidate relative priorities for research, experimentation and programming in family planning. Wider distribution of the broad AID experience in these areas would probably be justified. This is particularly true since specific studies have already been done on the experimental ATS-6 programs in the U.S., Brazil, and India and each clearly documents the very experimental character and high costs of the effort. Thus at this point it is clearly inconsistent with U.S. or LDC population goals to allocate large additional sums for a technology which is experimental.
2. Limited donor and recipient family planning funds available for education/motivation must be allocated on a cost-effectiveness basis. Satellite TV may have opportunities for cost-effectiveness primarily where the decision has already been taken -- on other than family planning grounds -- to undertake very large-scale rural TV systems. Where applicable in such countries satellite technology should be used when cost-effective. Research should give special attention to costs and efficiency relative to alternative media.
3. Where the need for education is established and an effective format has been developed, we recommend more effective exploitation of existing and conventional media: radio, printed material, posters, etc., as discussed under part I above.
1. For obvious reasons, the initiative to distribute prescription drugs through commercial channels should be taken by local government and not by the US Government.