Introduction: The family planning
programme (FPP) in Bangladesh and its role in reducing the fertility
rate in the country has been at the centre of much scholarly debate. The
current contraceptive prevalence rate (CPR) is 61%- double the rate
observed in Pakistan, while the total fertility rate is 2.3 children per
woman. This paper highlights both the supply-and demand-side factors
explaining trends in contraceptive use over the last four decades. It
identifies the challenges plaguing the programme today that range from
funding and staffing deficiencies to bottlenecks in procurement
processes.
Methodology: The paper uses secondary data sources such as
Bangladesh Demographic and Health Survey (BDHS) 2004 and 2011 to show
Family Planning trends in Bangladesh and uses the Spectrum software to
forecast trends for the year 2015.
Results: The central message is that the current contraceptive
method mix, which is heavily biased towards temporary methods, cannot
support a sustained decline in fertility. The authors\' projected
estimates reveal that in order to achieve replacement-level fertility by
2016, users of long-acting and permanent methods would need to be
increased by 8-9 million. Drawing on global experiences, the paper
outlines greater flexibility in the use of funds and a
regionally-targeted approach, among other options, that could be adopted
to ensure that national population targets are met.
Keywords: Family planning program, Bangladesh, Contraceptive
method mix, Long-acting and permanent methods, Contraceptive
procurement, Population, Fertility.
Rationale and Methods
Although there is no dearth of literature on
the demand-side aspects of family planning (FP) and fertility decline in
Bangladesh, relatively little is known about the actual programme
itself or the reasons behind the plateauing in the uptake of
contraception during the 1990s. This paper starts off by providing the
backdrop for the adoption of a national family planning programme (FPP)
and explains the erratic nature of fertility decline since the1980s. The
focus of the paper, however, is on the contraceptive methodmix in
Bangladesh and supply-side aspects of the programme like staffing,
procurement processes, and funding. We project (using SPECTRUM) the
ideal method mix that is needed in order to achieve replacement-level
fertility by 2016. The main section describing the national FPP is
largely a desk review of published and unpublished literature spanning
the programme\'s lifetime.
Background on Population and Family Planning
The latest 2011 census of Bangladesh estimates a population of 149
million for the country implying an increase of 19 million since the
census of 2001. In 1901,the area that is now Bangladesh supported a
population of roughly 25 million and population growth was negligible.
By the late 20th century, due to a steep post-WWII mortality decline,
population growth exploded, and by the beginning of the present century,
at least a 100 million had been added.
1
Historically, Bangladeshi families had about seven children of whom less
than 40%survived to adulthood to become parents themselves. This meant
that only one son inherited the family land which, thus, was not
divided. Following WWII, the crude death rate (CDR) fell by 50%in 15
years (40-20 deaths per 1,000 population), then again by 50% (20-10
deaths per 1,000 population) by the mid-1970s. The consequence was that
child survival improved significantly such that five children per family
reached adulthood, which had major implications for land inheritance
and a rapid fragmentation of family landholdings.
The national FPP was initiated as a response to this rapid population
growth, and fertility has been falling rapidly since the early
1980s.This fall has not been steady or even. The 1980s saw a steep
decline in total fertility rate (TFR) from 6.5 to 3.3 by the early
1990s. This was followed by a decade-long plateau which was the
consequence of a \'tempo effect.
2 The adoption of FP by
Bangladeshi couples has always been after the first birth. The age at
marriage did not change and there was no delay in age at first birth,
and as such, no tempo effect was operating on first births. The 2004
Bangladesh Demographic and Health Survey (BDHS) showed the first nine
percent reduction in fertility (TFR of 3.3 to 3.0) for a decade. The
2011 BDHS confirmed a further decline in TFR to 2.3 children per woman.
Now, however, fertility levels are quite uneven - remarkably low in the
west of the country (below replacement, on average) and worryingly high
in the east (up to 1.5 children above replacement).
In order to attain any of the reasonable population estimates projected for mid-century (which range from 194 to 222 million)
3
a substantial increase in the contraceptive prevalence rate (CPR) will
be required in the next five years, and a CPR level in the order of 75%
(mostly modern methods) by 2020. This target could theoretically be
achieved if all current unmet need for FP (12% in 2011) were to be met.
Future population growth
There are a number of factors which influence
future population growth. Bangladesh has considerable built-in
population momentum because of high fertility in the past, and even with
reduced fertility, many young women will pass through reproductive ages
over the coming decades. For example, during the first decade of the
20th century, the number of women of reproductive age increased from
around 32 million to 41 million as the children born in the higher
fertility 1970s and early 1980s entered their childbearing years,
according to UN estimates. This trend will continue for several decades.
There needs to be a demand for fertility limitation in order to reduce
fertility in a non-coercive environment. The perceived value of children
has long been recognized as being a determinant of desired family size.
4
Historical demographic experience suggests that as recent investments
in female primary and secondary education in Bangladesh manifest
themselves in improved opportunities for formal sector employment for
young women, parents will tend to favour smaller families, investing
more per child in education-quality versus quantity. This trend will
also be influenced by the saturation of the rural labour force and the
fragmentation of agricultural land holdings such that there will be
deceasing employment opportunities for unskilled workers.
Current status of the family planning programme
Bangladesh is unique in terms of having a large non-government
organization (NGO) sector presence. While various donor partners have
supported the national FPP since its inception, the country has also
benefitted from the research and technical support of local NGOs. The
International Centre for Diarrhoeal Diseases Research, Bangladesh
(ICDDR,B) works closely with the government and has been instrumental in
shaping the health programme over the years. A number of interventions,
including FP integration with mother and child health (MCH), were tried
and tested by ICDDR, before being incorporated in the national
programme. Other NGOs, notably BRAC, Bangladesh, have provided extensive
reproductive health services in urban Bangladesh where public health
infrastructure is limited. One of the largest non-government FP-MCH
service delivery projects is the United States Agency for International
Development (USAID)-funded NGO Service Delivery Programme which serves a
catchment population of 20 million. These NGOs work in partnership with
the government in the provision of FP-MCH services.
Under the Directorate of Family Planning, the success of the Bangladesh
FPP has been based since the 1970s primarily on a nationwide rural
network of female fieldworkers called family welfare assistants (FWAs)
who have been providing outreach services to couples, particularly
married women with limited mobility outside the home or compound (bari).
These FWAs were usually all married women, only moderately educated,
and had a work schedule where they visited each of the houses in their
coverage units every two months.
The outreach approach largely explains the contraceptive method mix;
oral pills have always been the predominant method, currently accounting
for almost half of all users. Condom use remains low, though serving a
useful purpose, sometimes complementing other methods. The provision of
clinical services like intrauterine contraceptive devices (IUCDs),
injectables, or permanent methods require referral to higher-level
staff, such as family welfare visitors (FWVs), and for some methods,
clinical staff of the Directorate of Health.
The CPR has increased eightfold over the last four decades to 61.2%, in 2011.
5
This is equal to about 25 million of 41 million eligible couples. The
trend line for CPR suggests a plateau in 2004 when the level of
injectables users fell by three percent in the BDHS 2007 due to a
nationwide stock-out. The downturn in CPR recovered in 2007 when
supplies became available again in 2008.
6
There is wide recognition that to achieve replacement fertility or
below, a much greater proportion of eligible couples will need to be
using long-term and permanent methods. With the average age at marriage
for women (apparently7) still well below the legal minimum age of 18
years, many women have completed their childbearing by their mid- to
late 20s. This leaves them with 20 years or so of reproductive life to
protect themselves from unwanted pregnancies.
