Foreign Assistance: AID's Population Program

Published by the Government Accountability Office on 1990-05-01.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                    United   States   General   Accounting      Office
                    Report to the Chairman, Subcommittee
GAO                 on Foreign Operations, Committee on
                    Appropriations, U.S Senate

May 1990
                    AID’s Population

               RESTRICTED--       Not to be released outside     the
               General Accounting   Offke unless specifically
               approved by the Office of Congressional
National Security and
International Affairs Division


May 1,199O

The Honorable Patrick J. Leahy
Chairman, Subcommittee on Foreign Operations
Committee on Appropriations
United States Senate

Dear Mr. Chairman:

In response to your request we reviewed several issues relating to the Agency for
International Development’s (AID) Population Program. This report focuses on program
policy, goals, and strategy; program resources and management; and program
accomplishments. The report contains two recommendations for AID.

As arranged with your Office, unless you publicly announce its contents earlier, we plan no
further distribution of this report until your scheduled May 15, 1990, hearing on AID'S
population program. At that time, we will send copies to several congressional committees;
the Administrator of AID, and other interested parties, and make copies available to others
upon request.

This report was prepared under the direction of Harold J. Johnson, Director, Foreign
Economic Assistance Issues. He can be reached at (202) 275-5790, if you or your staff have
questions. Other major contributors are listed in appendix II.

Sincerely yours,

Frank C. Conahan
Assistant Comptroller General
                     or projects that attempt to examine the underlying reasons couples want
                     large families or to specifically motivate people to have smaller families.

                     Program management is decentralized. About 50 percent of AID'S popula-
                     tion funds are administered by the Office of Population, but the Office
                     does not control population funds administered by AID’S regional
                     bureaus and overseas missions. AID’S information systems do not provide
                     the comprehensive financial and management information needed to
                     make sound programming and budget decisions.

                     AID reports that its efforts have resulted in the improved safety, effec-
                     tiveness, and acceptability of contraceptive methods, and that over 200
                     million people are now using family planning services. AID also stated
                     that it has taken the lead in development of innovative service delivery
                     through operations research and private sector approaches.

Principal Findings

Changed AID Policy   Congress’ policies and objectives for U.S. population assistance include
                     the intention that the United States promote reductions in population
                     growth rates and motivation of people to have smaller-size families.
                     Until the early 198Os, AID promoted reductions in population growth
                     rates, both through its projects and by initiating policy discussions with
                     developing countries regarding the need to reduce population growth
                     rates to achieve economic and social development.

                     AID’S policy since the early 1980s suggests that if a developing country’s
                     economy cannot keep pace with its population growth rate, the country
                     has three alternatives, or a combination thereof, for development, eco-
                     nomic and social progress, and improved quality of life: (1) increase eco-
                     nomic productivity, (2) obtain higher levels of external, donor
                     assistance, and/or (3) reduce population growth rates. The distinction is,
                     however, that under the current policy, AID no longer initiates discus-
                     sions on these matters with developing countries that are not already
                     committed to population planning programs.

                     While population growth rates have declined in some regions and coun-
                     tries, they have exceeded economic growth rates in much of Africa and
                     Latin America, particularly during the 1980s. High population growth
                     rates add to the socioeconomic difficulties of many countries at a time

                     Page 3                                             GAO/NSLAD9@112PopuLstion
Executive Summan

and that this is the reason for its emphasis on delivering family planning

GAO does not dispute AID'S stated concern about the relationship between
population and economic growth, However, high-level AID officials
stated to GAO that AID does not, as a matter of policy, initiate discussions
of population growth rate reductions with foreign governments reluc-
tant to address the issue. Also, AID has no projects or programs to under-
stand or address the reasons couples desire large families, or directed
toward motivating people to have fewer children.

AID acknowledged that its management of the population program is
decentralized, but stated that this is the same management approach AID
has adopted for all its programs. AID emphasized that program success is
more likely when programs are controlled at the field level and tailored
to the needs for each country. GAO agrees with AID that programs must
be tailored to the needs of each country and managed at the field level
to be successful. However, GAO also believes that the success of decen-
tralized program implementation requires a centralized management
information system that allows decisionmakers at the highest levels to
have the financial and other information needed to appropriately allo-
cate resources and set priorities.

AID disagreed with GAO'S assessment of its program evaluation efforts,
and stated that GAO had not recognized the complexity of these efforts,
downplayed AID'S use of evaluation findings, and did not take note of
the evolution of AID'S evaluation process. GAO believes that it gave full
recognition to the evaluation efforts AID has made, and devoted an entire
chapter to a discussion of AID'S program accomplishments. However, GAO
found that AID'S evaluations generally address the question of whether
it is doing things well rather than whether it is doing the right things.
GAO believes that program impact evaluations would help answer the
latter question.

Page 6                                              GAO/NSIAD-W-112Population

          Appendix II: Major Contributors to This Report                       67

Tables    Table 1.1: Total Fertility Rates for Selected Regions and             10
          Table 3.1: Ranking of the Top Ten Countries Receiving                 22
              Bilateral Population Assistance, Fiscal Years 1979-88
          Table 3.2: AID Expenditures for Family Planning During                23
               Fiscal Year 1988 by Region and AID Funding Unit

Figures   Figure 3.1: Congressional Allocation of Funds for
               Population Activities During Fiscal Years 1968-88
          Figure 3.2: Flow of AID’s Population Assistance Funds


          AID        Agency for International Development
          GAO        General Accounting Office
          GDP        Gross domestic product
          IUD        Intrauterine Device

          Page7                                             GAO/NS-112   Population
Chapter 1

reduced standards of living, domestic budget constraints for social
expenditures, limited productivity and job creation, and almost unman-
ageable external debt and debt-servicing obligations. Many also continue
to face high population growth rates.

Because developing countries are responsible for the success or failure
of their population and family planning policies and programs, AID and
other donors can only assist in the countries’ development efforts.
Within this framework, AID’S family planning assistance has health and
individual choice objectives. To achieve these objectives, AID’s Office of
Population has a program emphasis that gives priority to research and
service delivery activities that assures access to, or availability of, a
wide range of acceptable voluntary family planning services. The under-
lying premise behind this strategy is that developing countries have an
unmet demand for services. Am-supported demographic surveys and
demonstration projects undertaken in countries where contraceptive use
is low have shown that there is a demand for family planning, that
many couples want to space and limit births, and that many couples
would use family planning methods if they had access to such services.

Since 1965, AID has provided about $3.5 billion in population and family
planning assistance to developing countries. The United States has been
the foremost source of international population assistance for family
planning activities. AID reports accomplishments in each of the compo-
nents of its family planning program: contraceptive development, data
collection, operations research, policy development, service delivery,
management support and training, communications, and commodity

AID reports that its program has improved maternal, infant and child
health by giving couples increased opportunity to choose the number
and spacing of their children. However, as shown in table 1.1, although
there has been some reduction in total fertility levels in selected African
countries (chosen for illustrative purposes), almost no change has
occurred in Sub-Saharan Africa as a whole between 1965 and the late
1980s. In Latin America, East Asia, and the Near East and South Asia,
there have been declines in fertility rates. However, population growth
rates have exceeded economic growth rates in both Africa and Latin

Page 9                                             GAO/NSIAIMO-112 Population
Chapter 1

In Washington, DC., we met with officials from AID, the Department of
State, the Population Institute, the Centre for Development and Popula-
tion Activities, the Population Crisis Committee, the Population Refer-
ence Bureau, Population Reports International, the American Enterprise
Institute, the Population Association of America, and with former AID
personnel associated with AID’S population program. In New York City,
we met with officials of the United Nations Population Fund, and repre-
sentatives of the Population Council, the Western Hemisphere Regional
Office of the International Planned Parenthood Federation, the Alan
Guttmacher Institute, and the Margaret Sanger Institute.

We reviewed legislation and numerous reports, studies and other publi-
cations by AID and other U.S. government agencies, international organi-
zations, nongovernmental entities, and specialists in demographic/
population/family planning matters. We did not perform work overseas.
Our review work was performed between June and December 1989 in
accordance with generally accepted government auditing standards.

Page 11                                          GAO/NSL4B9&112 Populstion
                          Chapter 2
                          Policy, Goals, and Strategy

                          In 1967, Congress expressed its sense that voluntary family planning
Legislative Objective     programs could make a substantial contribution to economic develop-
Is to Reduce              ment, among other things, and authorized the President to provide assis-
Population Growth         tance for programs relating to population growth in friendly foreign
                          countries and areas. In 1973, Congress authorized the President to fur-
Rates                     nish assistance for population planning and health “to increase the
                          opportunities and motivation for family planning [and] to reduce the
                          rate of population growth....” Then, in 1978, Congress recognized, as
                          part of its statement of development assistance policy, that controlling
                          population growth is an element of a country’s commitment to develop-
                          ment and progress in moving toward the objective and purposes of the
                           United States’ bilateral assistance (22 USC. 2151-1). Congress also
                           expressed policies and objectives for population and health programs as

                          “The Congress recognizes that poor health conditions and uncontrolled    population
                          growth can vitiate otherwise successful development efforts.

                          “Large families in developing countries are the result of complex social and eco-
                          nomic factors which change relatively slowly among the poor majority least
                          affected by economic progress, as well as the result of a lack of effective birth con-
                          trol. Therefore, effective family planning depends upon economic and social change
                          as well as the delivery of services...While every country has the right to determine
                          its own policies with respect to population growth, voluntary population planning
                          programs can make a substantial contribution to economic development, higher liv-
                          ing standards, and improved health and nutrition....” (22 U.S.C. 2151b.)

                          An intention in the congressional declarations of policy is that U.S. pop-
                          ulation assistance be directed toward limiting population growth rates.
                          The legislation is also aimed at motivating people to have smaller-size
                          families, while recognizing that each country can and should set its own
                          policies. The law also prohibits the use of U.S. assistance to (1) perform
                          abortions as a method of family planning or motivate/coerce people to
                          practice abortions; (2) perform involuntary sterilizations as a family
                          planning method or motivate/coerce people to undergo sterilization; and
                          (3) conduct biomedical research that relates to methods or performance
                          of abortion or involuntary sterilization as a means of family planning
                          (22 U.S.C. 2151b(f)).

                           In July 1969, President Nixon sent the first Presidential message on pop-
Changes in                 ulation growth to the Congress. The message emphasized a world popu-
Administration   policy    lation crisis caused by high rates of population growth in many

                           Page 13                                                   GAO/NSIAMJO-112Population
                       Chapter 2
                       Policy, Goals, and Strategy

                       growth is, of itself, a neutral phenomenon....More people do not necessa-
                       rily mean less growth....” The policy’s emphasis appeared to subordinate
                       the need for population and family planning programs to the need for
                       proper economic restructuring and free-market economics. The policy
                       was supported by certain groups in the United States who were promot-
                       ing the idea that developing country population growth rates were irrel-
                       evant, since technological innovation and economic adjustments can
                       accommodate high rates of population growth. It was also supported by
                       those who viewed population programs and family planning as undesir-
                       able or immoral.

                       In a study undertaken at AID'S request, the National Academy of Sci-
                       ences issued an assessment of the relationship between population
                       growth and economic development in developing countries3 in 1986.
                       Without coming to any definitive conclusions, the assessment neverthe-
                       less summarized that, “on balance, we reach the qualitative conclusion
                       that slower population growth would be beneficial to economic develop-
                       ment for most developing countries.”

                        Since the early 198Os, AID officials responsible for the population pro-
The Evolution of        gram have been in the difficult position of attempting to adhere to the
AID’s Population and    administration policy that population growth rates are neither good nor
Family Planning         bad but neutral, while continuing to meet the legislative objective of
                        motivating reductions in growth rates. AID has consequently adopted
Assistance              subtle policy changes in its approach to the linkage between positive
                        economic development and reductions in population growth rates. A
                        high-level AID official said that AID’S 1982 population policy was written
                        in broad terms to provide flexibility and thus revision was not necessary
                        to bring it in line with what was termed “White House statements”
                        made in Mexico City. AID officials stressed that AID’S population and
                        family planning projects and the implementation of its program have
                        not changed. Despite this, we found that AID’S policy no longer has a
                        population focus directed toward promoting reductions in population
                        growth rates. Instead, AID'S program is focused on promoting family
                        planning for reasons of health and individual rights without a direct link
                        to economic development.

                        3Wor!4ngGroup on Population Growth and EconomicDevelopment,Committeeon Population,Com-
                        missionon Behavioral and SocialSciencesand Education,National ResearchCouncil,PO ulation
                        Growth and EconomicDevelopment:Policy Questions,National AcademyPress,Washmgton,
                                                                                                      -E-7: D.

                        Page 16                                                    GAO/NSL4B90-112Population
             Chapter 2
             Policy, Goals, and Strategy

             reduced population growth rates with governments that are not commit-
             ted to such policies. However, AID officials said that the agency will not
             initiate discussions of population growth rate reductions.

             The policy paper did note that “continued high rates of population
             growth significantly increase the cost and difficulty of achieving basic
             development objectives by imposing burdens on economies presently
             unable to provide sufficient goods and services for the growing

             AID’S June 1985 Blueprint for Development, which is its “primary state-
             ment of purpose [and] objectives,” discussed “unmanageable population
             pressures” and outlined family planning goals for 2-and 5year periods
             (1986-87 and 1986-90), but no mention was made of reducing population
             growth rates or motivating families to have fewer numbers of children.

             In its fiscal years 1989 and 1990 congressional presentations, AID based
             its family planning rationale on (1) the right of a family to choose the
             number and spacing of children, (2) the fact that family planning con-
             tributes to maternal and child health, and (3) the belief that family plan-
             ning leads to reductions in abortions. However, there was no mention in
             the rationale of the need to reduce population growth rates or the need
             to bring population and economic growth rates into balance.

             According to a noted demographer who critiqued AID’S February 1989
             report entitled Development and the National Interest: U.S. Economic
             Assistance into the 21st Century, AID treated population growth as a
             non-issue and dismissed years of AID experience and effort in both the
             population and family planning fields. He wrote that “the inference that
             AID’S new thinking would rather forget about population growth as a
             development issue is...supported by an entirely inadequate, and in key
             instances plainly erroneous, presentation of the consequences of popula-
             tion growth and of demographic facts.”

             AID’s population   assistance program continues to be based on the princi-
Conclusion   ples of voluntarism and informed choice. Its policy objective of enhanc-
             ing the freedom of individuals in developing countries to choose
             voluntarily the number and spacing of their children has remained
             essentially intact over the life of the program, and the agency continues
             its principal activity of providing family planning services delivery.

             Page 17                                            GAO/NSIABW-112 Population
    Chapter 2
    Policy, Go&, and Strategy

    achieve population growth rate reductions. While the legislation states
    that AID should motivate people to have smaller-size families, AID has no
    projects specifically directed toward motivating families to have fewer

    AID also commented that

l   a principal AID policy objective has been lowering population growth and
    fertility in developing countries and
l   through policy dialogue with leaders of developing countries, and
    through the provision of technical assistance and training, it raises the
    negative impact that high rates of population growth have on govern-
    ments’ economic aspirations, and recommends smaller families as one
    way to directly deflate these rates.

    Despite AID’S official comments on our draft report, AID officials, through-
    out our review, consistently stated that a reduction in population growth
    rates was not an AID objective. AID officials also informed us that AID, a.s a
    matter of policy, does not initiate discussions about reducing population
    growth rates with leaders of developing countries, and generally only
    discussed this issue when raised by leaders of the developing countries.

     Page 19                                            GAO/NSIAD9%11Z Population
                                              Funding and Management

Figure 3.1: Congressional Allocation of Funds for Population Activities During Fiscal Years 1966-66
300 Dollarsin MilliOM

136871 1972      1972   1974   1975    1976     1977     1976    1979     1960     1991     1932    1983     1964     1965      1966   1947       1966
Fiscal Years

                                              Fiscal years 1966-71 reflect cumulative congressional earmarking of development   funds Remaln!ng
                                              years reflect congressional approprlatlons for population actwtles

                                              In addition to specific congressional allocation, population and family
                                              planning assistance has also been supported by other AID programs such
                                              as Economic Support Funds and the Sahel development funds,’ and since
                                              1988, the Development Fund for Africa.2 During the last 10 years, about
                                              $2 15 million of Economic Support Funds and Sahel development funds
                                              were obligated for family planning activities. Development assistance
                                              funds for health and child survival have also supported the family plan-
                                              ning program.

                                              Historically, about half of all population funds has been allocated to
                                              support centrally administered projects of the Office of Population in
                                              the Bureau for Science and Technology. The other half has been allo-
                                              cated to support regionally administered projects or bilateral (govern-
                                              ment to government) projects, which are administered by AID’S overseas

                                              ‘AID developmentassistancefunds directedtoward human resourcedevelopment,fiiancial manage-
                                              ment, policy analysis,infant health and nutrition, family planning, and regionaleconomicintegration
                                              for countries in the Sahel.
                                              ‘A specialprogramfor SubSaharan Africa directedtoward renewingeconomicgrowth which is
                                              broad-based,market-orientedand sustainable.

                                              Page 21                                                               GAO/NSIADso-112 Popuhtion
                                         Chapter 3
                                         P,u,ding and Management

                                         Table 3.2 shows fiscal year 1988 expenditures by funding unit and
                                         regional area. It provides an indication of geographic distribution of cen-
                                         trally funded assistance, as well as the proportion of assistance pro-
                                         vided through central projects versus mission/region projects.

Table 3.2: AID Expenditures for Family
Planning During Fiscal Year 1966 by      Dollars   in thousands
Region and AID Funding Unit                                                                      Funding Unit
                                                                                                     . -                      Central               Total
                                         Africa                                                            $21,349            $31,220            $52,569
                                         Asia/Near    East                                                  80,748              20,050           100,798
                                         Latin America                                                      24,115              32,019            56,134
                                         WorldwIde                                                                   .          24,343            24,343
                                         Contraceptives                                                                  b      13,205             13,205
                                         Total                                                            $126,212           $120,637         9247,049
                                         %cludes funds from the populat~or account, Economic Support Fund, Sahel Development                Fund, and
                                         Development Fund for Afnca
                                         bNot shown IS $28 mIllIon in expenditures   for contraceptwes;    these expenditures    are included III regional
                                         categories above

                                         AID’S family planning program is highly decentralized. It is implemented
Family Planning                          by overseas missions, regional offices and bureaus, and by the Office of
Program Organization                     Population. In fiscal year 1988,43 AID organizational units administered
                                         family planning projects worldwide. Principal responsibility for plan-
                                         ning, formulating, and managing the program is divided among the three
                                         geographical bureaus and the overseas missions. The Office of Popula-
                                         tion, within the Bureau for Science and Technology, specializes in popu-
                                         lation and family planning. Although the Office does not have
                                         responsibility for planning and managing AID’S population programs, it
                                         administers a number of population projects designed to strengthen and
                                         complement mission programs.

                                         The Bureau for Program and Policy Coordination is responsible for over-
                                         all program and policy formulation, planning, coordination, resource
                                         allocation and evaluation activities. The Bureau develops economic
                                         assistance policies, provides guidance on program planning, economic
                                         analysis, sector assistance, and project analysis and design. However,
                                         the Office of Population and the geographic bureaus and overseas mis-
                                         sions are responsible for actual implementation of the population assis-
                                         tance program.

                                          Page 23                                                                        GAO/NSL4&90-112Population
                                                        Chapter 3
                                                        Funding and Management

Figure 3.2: Flow of AID’s Population Assistance Funds

                                                                      Regional Bureau                             Office of Population
                       Mission Projects             +                     Projects

                          Assiitance                                        Assiitance                                  Assistance
                         Agreements                                        Agreements                                  Agreements
                                 I                                                1                                           I
           Bilateral                                            Mission                                 Mission or
          ksistance                                             Buy-In -                              Region Buy-h *

                                 v                                              v                                            v                \

                                                                 U.S. Cooperating        Agencies

                 Sub-Assistance                                                                                     Sub-A&stance
                  Agreements                                                                                          Agreements




                            -                  Represents AID funds used to support local government contracts
                            --         -       Represents provisions of goods or services.

                                                         Note AssMance agreements         include contracts. grants, cooperative     and other types of assistance
                                                         agreement instruments

                                                         Page 26                                                                      GAO/NSIAB90-112 Population
                                chapter 3
                                Funding and Management

                                need for improved control over the shipment of commodities, strength-
                                ening and broadening existing quality assurance measures, proper dis-
                                posal of deteriorated contraceptives, and tightened control over sales
                                proceeds were also emphasized.

                                The Inspector General recommended that the Director of the Office of

                        . formulate a strategic plan with specific goals, objectives, and clearly
                          defined roles, responsibilities and performance criteria to clarify mana-
                          gerial control over the program and assign sufficient staff to effectively
                          implement the plan;
                        l take the lead role in developing effective procedures to control (1)
                          requirements estimates; (2) contraceptive procurement regarding sizes,
                          varieties, and colors; (3) sales proceeds; (4) domestic and international
                          transportation, warehousing, and distribution of commodities; (5) regis-
                          tration of products for use in other countries
                        . prepare an action memorandum for the AID Administrator, recom-
                          mending the development and implementation of an improved funding
                          mechanism for contraceptive commodities that is consistent with cen-
                          tralized procurement activity;
                        l develop and implement a quality control program that establishes per-
                           formance standards and criteria for storing, warehousing, shipping and
                           handling commodities, as well as testing contraceptives throughout the
                           distribution system;
                        l  establish and implement procedures for recording and reporting contra-
                           ceptive disposal and losses, as well as instructions for filing refund
                           claims; and
                           develop specific plans for transferring responsibility for estimating com-

                           modity requirements to recipient countries.

                                Office of Population officials said that AID is taking corrective actions
                                and that the recommendations should be resolved shortly.

                                Evaluation is a critical element of program management and oversight.
AID Has Placed Little           Evaluations serve as the mechanism for measuring accomplishments
Emphasis on Overall             and their impact, and for providing management with the information
Program Evaluation              needed to adjust or redirect program efforts. Missions, regions, and the
                                Office of Population perform numerous mid-term, final, and other man-
                                agement evaluations of their projects. In addition, AID has funded 78
                                external evaluations of its family planning projects, at a cost of about
                                $3.6 million since 1984. However, evaluations are not well coordinated,

                                 Page 27                                            GAO/‘NSIALX3@112
                        Funding and Management

                        Population recently issued guidelines for evaluations, but the guidelines
                        do not set the criteria to be used.

                        Most evaluations performed have been narrow in scope. Of the 78 exter-
                        nal evaluations performed between 1984 and 1988,69 focused on sub-
                        project activities, such as (1) a training program for Senegalese
                        midwives, (2) a social marketing program in Bangladesh, (3) advance
                        training for nurses in Zaire, and (4) general training in Latin America
                        and the Caribbean. Although the evaluations provided meaningful and
                        necessary information and recommendations, they were not coordinated
                        with other evaluation efforts and thus did not address the impact of
                        U.S. assistance on recipient countries.

                        AID has several automated information    systems which are intended to
AID Lacks Centralized   meet agencywide accounting and reporting needs. However, we found
Management              that these systems do not provide the comprehensive financial and man-
Information             agement information necessary for making sound programming and
                        budgeting decisions. Also, AID’S project and procurement data systems
                        operate independently of each other. According to AID officials, the data
                        required for management decisions exists, but is difficult to pull
                        together since several systems must be accessed.

                        AID’S project reporting systems, which provide data used in preparing
                        the agency’s annual budget presentation, have only limited information.
                        For example, these systems identify which countries receive assistance
                        through bilateral family planning projects, but do not identify the coun-
                        tries receiving assistance through central and regional projects. Such
                        projects accounted for over half of the $2.4 billion in funds obligated for
                        population assistance during fiscal years 1979 through 1988. However,
                        based on an analysis of fiscal year 1988 expenditures, we identified 70
                        percent, or about $83 million, of centrally funded projects with specific

                        Bilateral population projects provide assistance funds for multiple fam-
                        ily planning-related activities such as training and education, govern-
                        ment service delivery, private-sector activities, or provision of technical
                        assistance, contraceptives, or other commodities for local programs.
                        AID’S reporting systems do not contain information about the nature of
                        activities being funded. For example, the AID Administrator encouraged
                        the incorporation of private-sector entities into population project
                        design because he believed that private-sector institutions often oper-
                        ated more cost effectively than government entities and were often more

                        Page 29                                            GAO/NSIAlXW-112 Population
                          F-undii and Management

                          The Executive Director of the United Nations Population Fund told us
                          that AID cooperation and coordination, through discussions, meetings,
                          and exchange of data at both the international and individual country
                          level, has always been, and continues to be excellent. AID officials said
                          that program coordination among donors in host countries is conducted
                          by the AID missions. Budget restraints limit the participation of Office of
                          Population personnel in donor meetings abroad. While we noted that AID
                          participates in various coordination activities, we did not evaluate the
                          effectiveness of these efforts.

                          AID conducts a control assessment process annually to provide AID man-
Internal Controls for     agement with reasonable assurance that (1) program objectives were
Accountability and        achieved, (2) obligations and costs complied with applicable law, (3)
Control                   assets were safeguarded against waste, loss, unauthorized use and mis-
                          appropriation, and (4) programs were efficiently and effectively carried
                          out in accordance with applicable law and management policy. AID sub-
                          mits the results of the assessment to the Congress and the President.
                          Although the Office of Population conducted such assessments, its files
                          contained little documentation that its assessment process has consist-
                          ently complied with AID guidance.

AID’s Internal Controls   The Federal Managers’ Financial Integrity Act of 1982 (31 USC. 3512)
Process                   requires government agencies to establish and maintain adequate sys-
                          tems of internal controls, which are to be consistent with internal
                          accounting and administrative control standards prescribed by the
                          Comptroller General. AID established an Internal Control Oversight Com-
                          mittee in 1982, to coordinate implementation of the legislation and to
                          direct and monitor internal control policies. AID’S Science and Technol-
                          ogy Bureau, which includes the Office of Population, is one of the 38
                          component organizations that report on assessment results. The
                          Bureau’s internal control reporting is based on data collected from each
                          of the unit offices, including the Office of Population. These offices sub-
                          mit their assessments to the Bureau, where they are reviewed and incor-
                          porated into an overall bureau assessment certification.

Office of Population      The Office of Population’s assessment process requires each of its divi-
Internal Controls         sions to assess their projects using a standard AID risk assessment form.
                          Division responses are then consolidated into an Office report, which is
                          sent to the Science and Technology Bureau. However, the Office has lit-
                          tle documentation to show that the assessments were consistently and

                          Page 31                                            GAO/NsIAD9o112 PopoLation
                      Funding and Mam@xwnt

                      To improve program oversight, we recommend that the Administrator
Recommendations       of AID develop a centralized management information system to obtain
                      comprehensive financial and management information of all AID popula-
                      tion projects and activities, which will also enable the Administrator to
                      improve on making decisions about resource allocations and program

                      To improve program evaluation, we recommend that the Administrator
                      of AID direct that an overall program impact evaluation be performed,
                      along with country specific impact evaluations in those countries with
                      large programs.

                      In commenting on this report, AID said we were overly critical of its
Agency Comments and   decentralized method of operation. AID is a highly decentralized agency,
Our Evaluation        and our discussion of AID'S organizational structure and approach for
                      providing population assistance simply presents the framework in
                      which the program operates. Our discussion dealt with the shortcomings
                      in this decentralized structure, which lacks a mechanism for centralized
                      oversight, evaluation, and information. We do not dispute the need for
                      field involvement to tailor programs to the needs of each particular
                      country, nor the need for their involvement in monitoring, controlling,
                      and evaluating in-country activities. We do have reservations about a
                      system with no focal point responsible for ensuring that various decen-
                      tralized units are effectively and efficiently using program resources
                      and achieving program goals.

                      InitS comments on its management infOrXIIatiOn SySteIIIS,AID points Out
                      that it is developing new classification/special issues codes for its pro-
                      ject system. AID also said that its population project database system
                      includes information on mission and regional activities.

                      We reported that AID was developing a new coding system, which is
                      intended to provide management with a better profile of project activi-
                      ties However, as noted in the report, the system only captures about
                      half of AID'S population assistance activities. Additionally, the new cod-
                      ing system does not address our concerns with the project systems’
                      inability to attribute regional and centrally funded project assistance to
                      the recipient countries.

                      Our work indicated that the database reflects information collected from
                      reports submitted by cooperating agencies under contract with the
                      Office of Population. The Office of Population has asked these agencies

Chapter 4

Accomplishments in Family Planning

                  AID'S family planning assistance has been heavily focused on activities
                  related to (1) research and policy development, which have received
                  about 29 percent of AID'S Office of Population budget since 1965 and (2)
                  the delivery of family planning services, such as training, communica-
                  tions, and recurrent budget support for services and commodities, which
                  have accounted for about 71 percent of the budget since 1965. The
                  Office of Population reports accomplishments in contraceptive develop-
                  ment, data collection, policy development, service delivery, management
                  support and training, communications, and commodity support.

                  AID reports that its contraceptive development program has supported
Contraceptive     over three thousand studies and projects to develop, assess, and intro-
Development       duce contraceptive technology and methods. AID has helped fund the
                  development of female sterilization techniques and the introduction of
                  the Copper-T-380A IUD. Third-phase clinical trials are underway to
                  demonstrate the effectiveness and safety of a 3-month injectable contra-
                  ceptive. In 1990, AID hopes to introduce a new contraceptive method-
                  Norplant, which is a subdermal implant. if U.S. Food and Drug Adminis-
                  tration approval is given.

                  Through funding projects related to the development, evaluation, and
                  introduction and promulgation of new and improved sterilization tech-
                  nologies, AID reports that its support for sterilization as a family plan-
                  ning method helped popularize the method over the last 20 years. AID
                  believes that the increase in voluntary sterilization may have had more
                  impact on reducing unwanted fertility in the developing world than any
                  other single factor. AID is also giving greater emphasis to traditional
                  family planning methods, such as breastfeeding and natural family

                  AID assistance has supported data collection efforts by funding censuses
Data Collection   and demographic surveys, which serve to identify population problems,
                  monitor population t,rends, and evaluate family planning programs. AID
                  stated that, since 1965, it has provided a wide range of technical assis-
                  tance and training activities for censuses in over 85 countries. AID also
                  supported some social science research on population issues in the
                  developing world, including implementation of one of the largest social
                  science surveys ever undertaken. According to AID, much of what is
                  known today about population dynamics in the developing world is the
                  result of AID-sponsored data collection efforts. AID has helped officials in
                  developing countries to recognize the importance of censuses and

                  page35                                             GAO/NSlAD-9M12Population
                   chapter 4
                   Accomplishments in Family Planning

                   Security Institute in Peru used the results of a study, which assessed the
                   effects of expanding family planning services, to increase its budget
                   expenditures for these services.

                   Policy development efforts have also focused on getting more public and
                   private resources committed to population and family planning pro-
                   grams. AID reports that the number of developing countries providing
                   direct support for family planning services has increased from 75 in
                   1976 to 102 in 1989. AID believes that its policy reform efforts have
                   encouraged private companies to invest their own resources in contra-
                   ceptive services, resulting in more diversified service delivery as well as
                   overall increased investment in family planning.

                   AID believes that its assistance has contributed to major changes in the
Service Delivery   availability and use of family planning services. When AID started pro-
                   viding population assistance in the mid-1960s, 15 million people were
                   using family planning services in the developing countries (excluding
                   China). Today, according to AID, over 200 million people are using these
                   services and AID expects this number to double within the next 20 years.
                   During the last two decades, the overall contraceptive prevalence rate
                   for developing countries has risen from 15 percent to about 40 percent.
                   A major factor accounting for this growth, according to AID and United
                   Nations Population Fund officials, has been the increasing availability of
                   family planning services due largely to AID’s expansion of these services.

                   AID has promoted public sector as well as nongovernmental organiza-
                   tions’ service-delivery efforts, It has initiated and expanded services in
                   countries and areas that may not have otherwise been reached. AID
                   reports that these organizations played an important role in launching
                   family planning services and demonstrating the safety and acceptability
                   of family planning. Some are major providers of family planning ser-
                   vices, while others support the expansion of public and private services
                   targeted at low income, special minority, and other critical groups.

                   AID’s Office of Population supports 318 family planning service delivery
                    subprojects in 49 countries. About 70 percent of the subprojects are
                    with the private sector, including 7 percent with profit-making busi-
                    nesses. The Office has eight service delivery project initiatives, of which
                    two are for-profit, private sector projects: (1) the contraceptive social
                    marketing project and (2) the Enterprise project.

                    Page 37                                            GAO/NSlABW-112 Population
                         Chapter 4
                         Accomplishments in Family Plmning

                         AID’S efforts focused on management are intended to provide popula-
Management Support       tion/family planning leaders and managers with a better understanding
and Training             of (1) specific management problems hindering effective service deliv-
                         ery, (2) steps that can be taken to overcome these problems, and (3)
                         procedures to plan and monitor human and material resources more
                         effectively. Adoption of effective management systems may be a key
                         determinant in the success or failure of family planning programs in
                         many countries. AIDsponsored efforts should, over time, strengthen the
                         ability of developing country organizations and institutions to plan and
                         manage more effective and self-sustainable programs.

                         AID reports that it has undertaken efforts to improve host country man-
                         agement, such as

                     . sponsoring the training of over 1,500 senior and mid-level program
                       administrators from more than 25 countries in basic management skills,
                       financial planning for sustainability, operational planning, management
                       information systems, organizational development, and supervision of
                       health personnel;
                     . providing technical assistance to managers in 34 public and private sec-
                       tor family planning organizations, and fellowships to 29 senior-level
                       managers attending U.S. graduate programs in public health and
                     . supporting nearly 100 other individuals to attend short-term health
                       management training at various U.S. and third country institutions; and
                     . helping nearly 200 program administrators attend study and observa-
                       tion tours of family planning programs in Asia, the Near East, Latin
                       America, and the United States.

                         AID reports that its educational programs have supported the training of
                         almost 200,000 health care professionals, including physicians, nurses,
                         general practitioners, anesthesiologists, and medical and nursing stu-
                         dents, from nearly 7,000 institutions in 122 countries. These programs
                         have included training in administration, general reproductive health,
                         voluntary surgical contraception, IUD insertion, infertility, and curricu-
                         lum development for reproductive health education. AID has also pro-
                         vided equipment for medical schools and clinics, and the technical
                         support for training in equipment repair and maintenance. It has
                         assisted in establishing regional training centers in Kenya, Morocco,
                         Nigeria, Thailand, Egypt, and the Philippines. Am-funded projects have
                         produced three major training and service procedure manuals that are
                         in use in many developing country organizations.

                          Page 39                                           GAO/NSIAEWO-112Population

                    broadcast companies in its host countries have donated millions of hours
                    in radio and television air time.

                    In the Philippines, market research on a youth-oriented communication
                    campaign which uses music video reports that 92 percent of the survey
                    respondents remembered the video. Further, 70 percent interpreted the
                    message of the video correctly, 51 percent stated that they were influ-
                    enced by the message, 44 percent said that they talked with parents and
                    friends about the message, and 25 percent stated that they subsequently
                    sought contraceptive information. AID has also sponsored interpersonal
                    communication activities, including counseling and client-staff

                    Commodity support is a major part of AID'S family planning program.
Commodity Support   AID reports that worldwide demand for contraceptives in AID-sponsored
                    programs is now growing at an annual rate of 10 percent. AID used ware-
                    house stocks to meet a large part of this growth during 1989, but main-
                    tains that increased demand in the future can only be satisfied by
                    increasing Am-financed contraceptive production and/or by major
                    growth of contraceptive support from other international donors.

                    Since 198 1, AID has used a consolidated procurement system that aggre-
                    gates worldwide requirements of selected contraceptive commodities.
                    The system aggregates AID central and bilateral funding for contracep-
                    tive purchases. Five production contracts offer oral contraceptives, IUDS,
                    condoms, and vaginal tablets, packaged under more than 20 different
                    product brands. From 1986 to 1989, obligations for contraceptive com-
                    modities have increased from about $30.4 million to about $58.6 million.
                    In 1988, AID sent contraceptive shipments valued at $39.8 million to
                    family planning programs in 70 countries and completed new procure-
                    ments for $41 million in future contraceptive production. AID maintains
                    that its commodities meet or exceed the U.S. Food and Drug Administra-
                    tion’s quality standards The 1988 contraceptive shipments included
                    over 530 million condoms, 60 million monthly cycles of oral contracep-
                    tives, 5.5 million RIDS, and 11 million vaginal tablets. In 1988, in terms of
                    dollars spent, over 90 percent of the commodities went to 20 countries
                    and almost 56 percent went to 5 countries.

                    page41                                             GAO,‘NSIAB90-112Population
                       International Development

                            Boreian        Assistance:            AID's      Pomlation   Promram

                        Beeponse      of    the   agency         for     Iatomational    Development
                                                         April         3, 1990

                 The following    constitutes   A.I.D. 's response to the draft report
                 from the General Accounting Office entitled:             "Foreign
                 Assistance:     AID's Population     Program".     On the whole, the GAO
                 has documented A.I.D.‘s      considerable     committment to and
                 progress in the field of population.           Yet, A.I.D.    is concerned
                 about several points made in the report,           and believes that in
                 certain   areas, A.I.D.'s    population    program is not fully
See pp.19-20.    The GAO states that A.I.D.        is not concerned    about the
                 relationship      between population    and economic growth and does
                 not advocate smaller families,         as mandated by Congress.         When
                 appropriate      during policy discussions      with developing    country
                 leadership,     A.I.D. does raise the negative       impact high rates of
                 population     growth have on governments'       economic aspirations       and
                 does recommend smaller families         as one way to directly       deflate
                 these rates.       A.I.D.  is also concerned about responding to the
                 demand for family planning,         not only in terms of creating        that
                 demand, but in meeting it.          For this reason, the emphasis of
                 A.I.D.'s     program is on delivering      family planning    services.
See pp. 32-33.   The GAO's report criticizes          A.I.D.    for not having a centralized
                 population     overseer,   believing      that this has created       some
                 management problems.         The population       program is managed in the
                 same manner as other A.I.D. programs.                In fact,
                 decentralization       is part of a conscious effort           to make programs
                 as effective      as possible.      Experience shows that success in
                 population     programs -- as well as other sectors -- is more
                 likely    when control    is vested at the field          level and programs
                 are tailored      to the needs of each particular            country.
See pp.32.33.    Lastly,  the GAO criticized    the program's evaluation     process.
                 Since the GAO team was unable to travel,        it was unable to take
                 a complete look at all evaluations       done by the Agency at the
                 country level.    In addition,    the report did not recognize the
                 strides  A.I.D. has made in evaluation,      the considerable    efforts
                 made in data collection     and monitoring   of programs, and the use
                 the program makes of this information.

                         page43                                                            GAO/NSIAMMJ-112
      CommentsFromthe Agencyfor
      International Development

The health consequences of population           assistance   and family
planning took on a more prominent role in the mid-1980s because
new research evidence documented several important
relationships      between patterns    of childbearing     and the health
of mothers and children.         The most important      of these is the
link between proper birth        spacing (intervals      of two or more
years) and reduced infant and child mortality.              Former A.I.D.
Administrator      M. Peter McPherson focused on the health
rationale     for population   assistance    in an address in 1985.
Child spacing also receives attention           as part of A.I.D.'s     child
survival     program begun in the late 1980s.
A.I.D.'s     population      assistance    is also concerned with enhancing
the freedom of individuals             in developing  countries    to choose
voluntarily      the number and spacing of their children.              This
human rights       objective     has appeared in all major international
declarations       on population       and family planning    and has
consistently       been an important policy objective           for A.I.D.   as
well.      Family planning       is a key enabling factor for improving
the status of women. Women who have access to information                    and
services and can control            their fertility   are better able to
take advantage of educational             and employment opportunities.
Other research relevant        to A.I.D.'s  policy basis for family
planning  assistance    include the effects       of rapid population
growth on the environment        and the effects    of voluntary   family
planning  in decreasing      the incidence   of abortion.
Chancies in Develooina      Countrv    Policies
Partly as a consequence of A.I.D.'s     assistance,    an
international    consensus has been formed on the importance of
reducing population     growth.  As the table below shows, 68
developing    countries  now support lower population     growth
compared to only nine when A.I.D. Is population       assistance was


        Page46                                                GAO/NSIALMO-112
         Gmment.9 From the Agency    for
         International Development

     o      Under the policy A.I.D.  does not provide funding for
            foreign non-governmental   organizations  that perform or
            promote abortion  as a method of family planning     in
            foreign countries  with funds from u     source.
     o      This policy does not apply to U.S. non-governmental
            organizations   or to foreign governments for
            constitutional    and sovereignty   reasons.    US.
            organizations   receiving   A.I.D.  grants, however, may not
            subgrant A.I.D.    funds to foriegn non-governmental
            organizations   that are ineligible     for direct  assistance
            from A.I.D.
A.I.D.'s      population    assistance     program emphasizes:
      o     the encouragement of population    growth rates that are
            environmentally  sound and consistent    with sustained
            economic development;
      o     the critical health benefits          of family   planning    for
            mothers and young children:          and
      o     the right of individuals   to choose voluntarily             the
            number and spacing of their children.



          proiected      Number of Familv      Plannina    Users bv Reaion
                      on         1985           2000         2010
             Africa                 15            40           81
             Latin America          35            57           71
             Asia                  106           210          308
              TOTAL                156           307          460
          Source:    United Nations, Levels and Trends of
          ContraceDtive    Use, 1989; New York.
          NOTE:       Estimates take into account a near doubling of
          women of reproductive       age over this period and assume an
          increase in the contraceptive        prevalence     rate from 35 to
          59 percent,     corresponding   to the U.N.rs medium-variant
          projection     series where the total     fertility     rate
          declines    from 4.8 to 3.1.
          Estimates      exclude China; totals         for Africa    include
          countries      of North Africa.

Service    ADDrOaCh Results
Experience with family planning assistance                over the past two
decades has shown that investments          in family planning services
and the corresponding       increase in availability           of services have
a dramatic impact on both contraceptive            use and family size,
i.e.,   it works!     Since 1965 the total      fertility        rate* in the
developing   countries     has declined from 6.0 to 3.85.5             A
recent authoritative,       macro-level    study6 estimated that in
the absence of donor assisted         family planning         programs, the
average number of births        would have been 5.4.           The declines
have been steepest in those regions of the world where family
planning   services have been made more widely available.                  For
     0     From 1960-65 to 1980-85 in East Asia (including   China)
           where contraceptive prevalence has risen from 13% to
           74%, the average number of births  has dropped from 6.1
           to 2.4.

*Total fertility  rate is defined as the average number of
children  a woman will have assuming that current  age-specific
birth rates will remain constant throughout   her childbearing


          page49                                                    GAO/NSIABsO-112Popalation
           comment From the Agency for
           International Development

Flexible       and Consistent     Amroach

While A.I.D. has maintained           a consistent    emphasis on the
provision      of quality   family planning      services,     the program has
remained flexible,        as specific    program elements vary
considerably       from place to place and time to time.               In the
central     Office of Population       program, A.I.D. built         in the "R
and D" for family planning programs -- the operations                    research
program -- which has the means to identify               alternative      delivery
possibilities,        that are then tried out in carefully             controlled
settings,      before being adopted on a large scale.
A.I.D.    has developed alternative        sources of services to
increase users' options,         most significantly,   through the
private    sector.     Community-based distribution,      social marketing
of contraceptives        and work-place    programs are noteworthy
innovative     approaches now widely adapted in country programs.
Finally    A.I.D.‘s    biomedical    research has increased the range of
available     contraceptive    choices,    such as copper-bearing  IUDs
and the mini-pill.

           Page61                                               GAO/NSIABWllP        Population
          Appendix I
          CommentsFrom the Agency for
          Intmnetiond Development

     This decentralized      approach, which puts considerable      emphasis
     on the field     is considered to be one of A.I.D.'s     strengths   by
     the donor community.       For instance,    the United Nations
     Population    Fund is moving toward a country level,       service
     delivery   orientation,    which was ratified    in November 1989 in
     the Amsterdam Declaration       -- "A Better Life for Future


           page53                                           GAO/NSIAD9@112Population

     2) Recular aroiect        evaluations      of cen&,E&l Droiects      - such
        as social marketing,         training,     contraceptive      logistics,
        etc.    The Office of Population           established     the POPTECH
        project    specifically       to provide objective       information
        for project     assessment.         Project evaluations       are
        required    periodically        to meet mimimum Agency standards.
        However, the Office has exceeded minimal requirements                    by
        carrying    out evaluations         of program areas which are
        addressed by more than one project,               such as
        contraceptive       social marketing,       and by experimenting
        with alternative        methodologies      such as telephone
        interviews     and mailback guestionnnaires            to achieve
        maximum field       input.
Collectina      Basic Da-
A.1.D supports the collection        of data through the Demographic
and Health Surveys (DHS) and predecessor projects           which yield
nationally    representative    data on contraceptive    prevalence,
fertility,     infant and child mortality     and a rich variety     of
other data for policy and programmatic evaluation.            Since the
initiation    of the World Fertility     Survey (WFS) in 1972, some
134 national      level surveys have been completed in 61 different
countries.       At the end of the current round of DHS in 1994,
fifteen    additional   surveys will be completed in an additional
five countries.
We know of no other social science effort       that even approaches
the comprehensiveness   of A.I.D.'s    demographic surveys.    Most of
what we know about population      dynamics in the developing   world
is the direct   result of A.I.D.-sponsored     surveys.
What is not so widely known is that family planning          service
projects,    even at the subproject    level, quantify  their targets
and their achievements.        These data are generally   used for
routine   project  monitoring,    but may also be used for project
and program evaluation.
Utililization      of Findin-
Evaluations   & influence   program directions     and decisions.      In
the Office of Population,    for example, evaluations       are
typically   conducted just prior to the design (or plan) for a
follow-on   project.   An important   area of consideration      for the
evaluators   is not only an assessment of what has been done so
far, but what, if anything,     should be done next.      Recent
examples of evaluations    which influenced    program direction


         Page66                                                 GAO/NSLAMO-112Poptition
        International Development

   0     A.I.D.   recognized the need to systemize evaluation
         efforts    and to increase their   rigor. This led to the
         creation    of the internal  Office of Population  Evaluation
         Working Group in 1988 which examines methodological
         questions,    reviews scopes of work, and coordinates
         evaluation    plans.
    0    The Office of Population      and regional bureaus
         wholeheartedly     embraced the proposed population     impact
         evaluation    series by the Agency's Center for Development
         Information    and Evaluation   (CDIE), and worked with CDIE
         to identify    key issues, and appropriate    countries   and
         team members.
    0    The Office of Population   supported the creation    of a
         task force by its cooperating    agencies to establish
         performance standards which can be used across projects.
    0    On a regional   bureau and mission level,   there are
         several evaluation,   monitoring  and assessment processes
         --   Bureau policies     and strategies as well   as country
              specific  strategies    that are developed   and updated
              every few years:
          -- Sector   analyses that are undertaken     in many countries
             before   program are developed:
          -- Identifying priority countries      for population
             programs (as well as for other      sectors):   and
          -- A broad range of programmatic alternatives        for
             countries wishing to undertake population        activities.
The GAO's emphasis on evaluation     has provided further      impetus
to A.I.D.'s  evolving   efforts.   The Office of Population       has
proposed adding a formal evaluation     function     to one of its five
functional  divisions.     This change will   strengthen   A.I.D.*s
evaluation  capability.


        Page57                                             GAO/NSIAD-9@112Population
                          International Development

                 I.Df&.l .,                                         Issues   Codes
See pp. 32-33.   Last year A.I.D.      began developing    a new classification         system
                 to comprehensively      describe the types of A.I.D. programs and
                 projects,    called the Activity     Classification/Special         Interest
                 Codes (AC/X).       It relies   on reporting      by all A.I.D. project
                 managers to track both the primary objectives                and special
                 A.I.D.    concerns for all projects'using         a percentage format that
                 can be translated      into actual obligation        levels.
                 Activity   Classification    Codes (ACs) are comprehensive in that
                 the primary objective     of a project  and all its components are
                 completely   described using these codes (100% of the project
                 must be accounted for by one or more AC). There are presently
                 60 ACs. The following      three ACs are used to capture A.I.D.'s
                 work in family planning:
                      0    Family   Planning   Program Development
                      0    Family   Planning   Service   Delivery
                      0    Family   Planning   Contraceptives
                 Special Issues Codes (SIs) allow for further          description       and
                 classification    of A.I.D. activities      by addressing themes that
                 are of general concern to the Agency as a whole (e.g., policy
                 reform, training,     research, work with the private        sector,     and
                 development communication).         Using SIs, A.I.D. can determine
                 the percentage     (or obligation    amounts) of family planning work
                 that involve    such activities     as biomedical   research,     training
                 for the private     sector,    or working with local PVOs. At present
                 there are 80 Special Interest        codes.
                 Project level information      is collected  for all accounts (e.g.,
                 DA, DFA, and ESF). Project information         can be analyzed by
                 country or region:   however, centrally-funded       activities    are not
                 broken out by region or country in this system.             Formal updates
                 for the past, present and upcoming fiscal        years are made for
                 the Congressional   Presentation     and the Annual Budget Submission.
                 As  the system evolves and as project managers become more adept
                 at reporting,   the AC/S1 system is expected to become an
                 integral   part of the planning and budgeting process within


       Appendix I
       comments From the Agency for
       IntemationaI Development

In addition  to those major program accomplishments     featured in
the GAO report,   A.I.D. would like to highlight   its innovative
programs in population   communication,  surgical  contraception,
programs in the private   sector, and provision   of contraceptives.
&Igaunication        Proaram for Family         Pla&
A population      communication project        implemented by Johns Hopkins
University     capitalizes      on - and leverages - the commercial
private    sector to reach millions          of couples with strong family
planning messages for a fraction             of the cost of the actual mass
media time used.          The young people's music project          in Latin
America, for example, yielded $1 billion               worth of radio and TV
time for an investment          of $300,000.       In the Philippines    a
similar    project     yielded $1.2 million        in corporate
contributions.         A replicate    project    is now underway in Africa.
Other campaigns, such as a $320,000 effort                in Turkey which
yielded $1 million          in TV time, have been launched on all
yoluntarv       Suraical   Contraceotion
A.I.D.     is widely recognized         for     its leading role in greatly
furthering     the availability         of    voluntary    sterilization in
developing     countries.       Because       of its safety and intended
permanence, voluntary         sterilization          is the most popular form of
contraception      worldwide,      as it      is in the United States.
Two sterilization         procedures which minimize surgical
complications       -- no-scalpel      vasectomy and minilaparotomy           under
local anesthesia        -- have been supported by A.I.D. and widely
adopted in developing          countries.       These innovative
technological       advances have contributed           to the noteworthy        fact
that sterilization-related            mortality    rates in international
programs supported by the Association                for Voluntary      Surgical
Contraception        (AVSC) from 1973-1986 were essentially              the same
as those in the United States despite the more basic clinical
conditions      found in most developing          countries.       During this
period, AVSC performed over 2 million                sterilization      procedures.
In developing    countries   where A.I.D.     funds family planning
service delivery    programs, it has been estimated that over
1,000 pregnancy-related      maternal deaths are prevented for every
100,000 female sterilizations       provided.      Thus, A.I.D.'s  efforts
in this program alone have prevented 20,000 maternal deaths.


        Page 61                                                    GAO/NSLMMJ-112 Population
        rntematioti    Development

    Enterprise    has shown that private    sector family planning is
    sustainable;    that is, projects    can continue without donor
    support.     Over 80 percent of Enterprise      projects will
    continue with their own funds.

A.I.D. has been a major provider  of contraceptive    commodities.
Between 1967 and 1989, A.I.D. purchased and delivered     $567.7
million worth of contraceptives.   Specifically,   A.I.D. provided:
    0    6.9 billion       condoms;
    0    1.6 billion       cycles     of oral     contraceptives:
    o    49.7 million        IUDs; and
    0    16.5 million       vaginal     foaming tablets.
These contraceptives   provided 312 million couple                  years   of
protection,   and were distributed to 75 countries.



1.   A.I.D.   Policv     Paoer:     Pooulation   Assistance,   September 1982.
2.   McPherson, M. Peter, "International     Family Planning:   The
     Reasons for the Program,,, Presentation    to the American
     Enterprise  Institute, November 25, 1985.
3.   Demographic and Health           Surveys    (DHS); "Population   Reports,,,
     no. 8, 1985.
4.   World DemoaraDhic Estimates             and Proiections    1950-2025,   United
     Nations 1988, New York.
5.   Center   for   International        Research,   U.S. Bureau of the Census
6.   Bongaarts, John, Parker Mauldin, and James Phillips;  "The
     Demographic Impact of Family Planning Programs,', The
     Population  Council, February 1990.
7.   Sources for data on fertility       rates are: for 1965, UN
     Population  Division,    World Pooulation    Prosoects.  1988; for
     1989, Population    Reference Bureau, "1989 World Population
     Data Sheet" and recent DHS survey reports.          For contraceptive
     prevalence  rates:    World Fertility     Surveys, and DHS.
8.   Norris,    Jerry,   Sallie Craig Huber, and John Cleland,
     USAID/Dhaka Family Planning Assessment, February 1990,
     Debriefing     notes.
9.   Philipps,    James F., Ruth Simmons, Michael Koenig and J.
     Chakraborty;     "Determinants    of Reproductive Change in a
     Traditional    Society:    Evidence from Matlab, Bangladeshl, in
     Studies in Familv Planninq,       Vol. 19, No. 6., Nov/Dec 1988.
10. Estimates are derived from:
    - Gillespie,      Duff G., Harry E. Cross, John G. Crowley, and
        Scott R. Radloff,      'Financing    the Delivery    of
        Contraceptives:       The Challenae of the Next Twenty Years"
        in The Demoaraohic and Proarammatic Conseouences-of
        ContraceDtive     Innovation,     Sheldon Segal, Ami Tsui, and
        Susan Rogers, eds.; Plenum Publishing           Corp. New York, 1989.
      -   Also from calculations   used by John Stover of The Futures
          Group in "Moving into the Twenty-First     Century:
          Principles for the Nineties',,   draft strategy   paper, Family
          Planning Services Division,    Office of Population,    A.I.D.
          April 1989
 11. Population        Crisis Committee, "1990 Report on Progress            Toward
     Population        Stabilization,', Briefing Paper No. 23.

9ppendix II

Major Contributors to This Report

                        Thomas R. Brogan, Assistant Director, Foreign Economic Assistance
National Security and      Issues
[nternational Affairs   John D. De Forge, Evaluator-in-Charge
Division, Washington,   Maclelon B. Savaides, Deputy Evaluator-in-Charge
                        Bruce L. Kutnick, Economic Adviser
D.C.                    Juan F. Tapia-Videla, Evaluator
                        Frederick J. Barrett, Evaluator

(472188)                Page67                                         GAO/NSIADso-112
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12. See wrt         of the International   Forum on Pooulation    in the
    mentv-First       Cent=,     Amsterdam, The Netherlands,
    November      6-9, 1989.
13. Center     for   International   Research,   U.S. Bureau of the Census
14. Dr. Ronald Roskens, Response to Questions Submitted by the
    Senate Foreign Relat ions Committee, February 27, 1990.


A.I.D. has consistently         been by far the largest donor in
population.      Even now, while other donors have increased their
contributions,      A.I.D. accounts for almost half of all donor
assistance     in population.      Moreover, A.I.D. has been pivotal   in
developing     and diffusing     programmatic and technological
innovations.       Indeed, no family planning program in the
developing     world exists today that has not directly         or
indirectly     benefited    from A.I.D.'s    effort. A.I.D. more than
any other bilateral        donor has been the leader in the population
Because so much remains to be done, past accomplishments                are
too easily   forgotten.       The pace of recent fertility       decline has
been unprecedented      in history.      Since 1965, the fertility       of
the developing     world has dropped by 35 percent,        a remarkable
change in just 25 years.          This precipitous  drop would not have
happened so rapidly       without   couples having access to modern
family planning.       By comparison,     it took more than twice that
time for fertility      in the United States to drop to the same
level,  but of course, without modern family planning.13
A.I.D.    is proud of the role it     has played in this historical
drama. The recently       confirmed   Administrator stated in his
confirmation     hearing:
     I want to increase the impact of the [population]
     program.    The international    community has quite
     ambitious targets     for family planning,    and A.I.D.
     ought to remain an active leader in achieving
     that degree of impact . . . I would certainly      argue
     personally    for a robust voluntary    family planning
     program, and hope to have the resources to
     support it.'4
Congress has given A.I.D.' s population     program strong bipartisan
support over last 25 years.     Congressional    support has been well
placed and essential  for maintaining     a robust program.   A.I.D.
looks forward to a continuation     of this support in the future.


        Page64                                             GAO/NSIADsO-112Population
       Intzmatioml Development

                       Delivery   throuah     the Private   for   Profit   a

A.I.D.     is unique among donor agencies in its ability            to work
with the private       and commercial sectors.        A.1.D has pioneered
the development of innovative           approaches to the commercial
distribution       of contraceptives      through contraceptive     social
marketing;      the application      of business principles      to the
management of family planning           service delivery     programs; and
the involvement       of commercial     enterprises   in the support or
delivery      of family planning      services to their employees.
     mtraceotive        Social Marketinq:         Contraceptive     Social
     marketing    (CSH) uses the marketing process and the existing
     commercial infrastructure           to increase the availability,
     knowledge and correct          use of contraceptives         among couples
     in the middle and lower socio-economic               strata.      CSM
     programs are designed to complement other family planning
     service delivery       aproaches, such as clinics            and
     community-based systems.            A.I.D.'S    support for India's
     pioneering     social marketing effort          in 1968 was the first
     A.I.D.-sponsored       intiative      to take advantage of commercial
     marketing techniques.            Since its inception,        other sector5
     such as Agriculture         and Nutrition      have designed initiatives
     which market nutritious           weaning foods and agricultural
     inputs along the CSM model.
     In any consideration       of the CSM Program's accomplishments
     it should be noted that the current project          has contributed
     737,315 couple year5 of protection         since 1985.
     Additionally,     evidence from consumer intercepts         in four
     early programs indicates        that low income groups are being
     reached.      (In Indonesia 88%, in Mexico 95%, in the
     Dominican Republic 84% and in Barbados 67% of CSM product
     users were from lower income groups.)           The project    has also
     successfully     attracted    new users.   As of 1988 in Indonesia,
     30% of Dualima condom users had never before used
     contraception.        In Mexico, that percentage was 32% of
     PROTEKTORusers, and in Barbados it was 47% of Panther
     me Enterorise    Proaram: The Enterprise    Program, designed to
     work with the private    sector in LDCs, has demonstrated to
     employer5 that family planning programs can cut company
     costs on such benefits    as maternal health and child care,
     reduce absenteeism and improve labor and community
     Enterprise  has helped shift    financial     responsibility       for
     family planning    from the public to the private          sector.     In
     Mexico, 24 percent of acceptors in the IUSA project               are
     transfers  from the public sector:        in Zimbabwe, 60 percent
     of private   sector acceptors formerly used public services.

       Page62                                                 GAO/'NSIAD90.112
          Comments Ram the Agency   for
           Intemationd Development

    Ponulation    Proiects   Database
    The Office of Population           uses a management information        system
    to track expenditures         by centrally-funded      projects    in each
    country which they are active.             As subprojects     are approved,
    both descriptive        information    and funding data are provided by
    each project.       The system also includes         data gathered from the
    Congressional      Presentation      on mission and regional       country
    activities    in Population.         It is therefore     possible to develop
    a complete and comprehensive overview of all A.I.D.-funded
    population    activities      for each A.I.D.-assisted        country.


           Page60                                                GAO/NSIADSO-112Population

As projections of population  growth and demand for family
planning demonstrate,  the amount of money needed for family
planning will continue to grow.
It is estimated that in 1985 $2.3 billion       was required    in the
public sector alone to support population       programs.    Estimates
are that this figure will rise to between $4.3 and $5.8 billion
by the year 2000, and between $5.8 and 8.4 billion         by the year
2010.'0    Other estimates I1 indicate     that as much as $10.5
billion   will be required by the public and private       sectors to
stabilize    world population at 9.3 billion    by the year 2000.
Recognizing these overwhelming needs, the participants                of the
November 1989 International          Forum on Population      in the
Twenty-First     CenturylZ    called on all governmental!
inter-governmental        and non-governmental     organizations     and the
private    sector to increase their financial          commitments to meet
escalating     population    assistance     needs and the burgeoning
demand for family planning          services.
Facing the realities      of budget constraints    both now and in the
near future,  A.I.D.    is placing increased emphasis on private
sector support for population       programs.    New approaches are
being explored to attract       and leverage private    sector funding
in developing   countries    for population    and family planning


       Page68                                              GAO/NSIAIMO-112Poptition
         Appendix I
         CommentsFrom the Agency for
         International Development

    o       Evaluation      of the Family Planning Enterprise                 and the
            Technical     Information     of Population        for the Private
            Sector (TIPPS) projects         recommended a radical
            restructuring       of Office of Population           initiatives
            involving     the for-profit      sector.       As a result,         a new
            project     is being developed to concentrate                 in three
            areas: innovative        investments      (including       debt swaps and
            diversion     of blocked funds for population                activities),
            utilization      of commercial channels for expanding access
            to family planning products and services,                     and
            employer-provided        family planning        services.
    o       The social marketing approach has been the object of
            intense evaluation.          Two recent evaluations     of
            contraceptive       social marketing    (CSM) efforts    in
            bilateral     programs in Ghana and Ecuador yielded
            important     lessons on the need for training        pharmacists
            and the pricing       structure    for CSM products.     These
            lessons have been taken into consideration            in the design
            of several new centrally-funded          CSM programs.      These two
            evaluations      also served to reinforce      the important
            lessons identified         in a major program evaluation      of
            contraceptive       social marketing which the Office of
            Population      commissioned in October 1987.
     0      In Kenya, where a 1979 WFS revealed an unprecedented
            rate of population    growth of four percent annually
             (which would lead to doubling of the population          every 18
            years),   the government reformulated     its population
            program placing increased emphasis on changing family
            size desires and on expanding the provision         of
            contraceptives.     In 1988, a follow-up     DHS measured the
            impact of these reforms in Kenya. Fertility           dropped to
            its lowest point ever:      6.7, fully   1.6 children     less
            than the fertility    rate observed in 1979.
Evolution        of Evaluation      Effort
In carrying   out its population   program, A.I.D. has recognized
the need to move beyond the project      level and to examine the
overall   impact of its population   program.   To do this,  A.I.D.
has taken several steps, listed     below, which were already been
underway prior to the GAO study.
     o       A.I.D.    recognized that it is not enough to ask "Are we
             doing well?*', but "Are we doing the right thing?"       This
             evolution     is reflected in mission country strategies
             (e.g.,    in Egypt and Zaire).
        0    A.I.D. addressed common program elements across projects
             in the private  sector, in the example described above
             and as planned for population  communications   efforts
             which span several projects.

            Page66                                                  GAO/NSIAIMU%l12Population
                        International Development


Seepp. 32-33   The GAO study faults A.I.D.    for not putting            enough emphasis on
               evaluation  of its overall  program impact.              However, the study:
                   o      fails to recognize        the complexity   of A.I.D's        evaluation
                   0      overlooks the       population  program's emphasis on
                          collecting    the    basic raw data to indicate     project   and
                          country level       performance -- b.,    fertility     rates and
                          contraceptive       prevalence:
                    o     downplays     the utilization     of evaluation        findings:   and

                    0     makes no note of the significant           evolution       of A.I.D's
                          evaluation effort.
                                                      The simplest and most critical
               stage of evaluation    is to determine if A.I.D.‘s     projects,   at
               the central  or country-level,      are achieving  what they are
               designed to achieve.      Evaluations   take place on two levels:
                    1) Periodic    countrv orocram evaluations         - most of which are
                       carried out by A.I.D.         country missions.     These
                       evaluations      address questions concerning       the design of
                       A.I.D.'s    bilateral     projects,   the method of
                       implementation        as well as an assessment of the overall
                       effectiveness       and impact of the project      under review in
                       the context of the country.           Good evaluations    take into
                       account A.I.D. 's role and that of other donors, and
                       attempt to address the question of what A.I.D. should be
                       doing, as well as what it is doing.
                           In addition,    most A.I.D.   missions review projects
                           semi-annually,    and strategize    annually in the Action
                           Plan process.     These result    in any needed adjustments              in
                           project   implementation.
                           The number of external         evaluations  cited in the GAO
                           report greatly      understates     country level evaluations
                           since the statistics        presented in the report reflect
                           only those conducted through the Office of Population's
                           central    evaluation    project    (POPTECH). The POPTECH
                           project    in turn reflects      only a small fraction    of those
                           evaluations     carried out by missions and regional         bureaus.


                           International Development

                A.I.D,'s       OrcaniZatiOnal          ADDrOaCh
See pp. 32-33   A.I.D.#S population     program is organized basically       along the
                same lines as A.I.D.      itself.    It has a strong field presence
                with a cadre of development professionals         based overseas.     They
                have the responsibility        for developing country programs within
                broad policy guidelines        from A.I.D. Washington headquarters.
                This structure     is roughly modeled on the regional       breakdown of
                the State Department.        Recent tendencies have been to emphasize
                the importance of the field missions by further          delegating
                program authority.
                A.I.D. has a proven track record of field accomplishments.                 The
                seeming lack of programmatic uniformity          noted in the GAO report
                is not due to a lack of managerial direction,             but rather,
                represents   a conscious response to the differing            needs of the
                countries  A.I.D. works in, and a flexible          structure    that is
                designed to work closely      with each host country on an
                individual   basis.    To succeed, family planning programs, like
                other development efforts,       must be tailored      to the cultural
                dictates,  economic realities,      and specific     desires of the
                people who use the services.        These circumstances        vary widely
                among countries     and regions.

                The population     program, like other sectors and programs in
                A.I.D.,    works from two organizational          approaches designed to
                complement each other.          The Office of Population       provides a
                strong central     focus for overall       program and technical       issues,
                while regional     bureaus and missions concentrate          on implementing
                field programs.       Efforts     are coordinated    through a number of
                mechanisms, including         regular meetings of the Population           Sector
                Council and coordination          groups for each region:      formal
                regional    bureau and mission clearance for each family planning
                subproject     and each traveller;       and mutual participation        in
                program design, strategy,          and evaluation.
                Through its twin approach of field       focus complemented by a
                central  office, A.I.D. has been responsive to the needs of
                family planning  users while directing        a coherent,   innovative
                and comprehensive population    program.       In fact, while the locus
                for the program is on a field    level!     the central    office   does
                exercise a great deal of technical       influence     over the program,
                and, in effect,  manages almost two-thirds         of the population
                account when mission and regional       buy-ins are considered along
                with the Office of Population's     allocation      of the population
                account, which in 1990 is approximately          52%.


                            Page 62                                            GAO/NSIAD-AM-112Population
         IntematioMl Development

    o     In Latin America for the same period,      where private
          agencies have assumed primary responsibility       for family
          planning  service delivery,  contraceptive    prevalence has
          risen from 14% to 56%, and the average number of births
          has dropped from 5.9 to 4.1.
          at the National      Level
Data from surveys'     have shown a similar    increase in
contraceptive   prevalence    and decline   in fertility       at the
country level.     The following   examples illustrate         these trends
in countries   that have received considerable           A.I.D. population
     o    Mexico has moved from a prevalence  rate of about 13% in
          1973 to over 53% in 1987, and the total  fertility rate
          has dropped from 6.7 in 1965 to 3.8 in 1989.
     0     Zimbabwe has moved from a contraceptive  prevalence rate
           of about 10% in the late 1970s to 43% in 1988, and from
           a fertility rate of 6.6 in 1965 to 5.7 in 1989.
     0     Indonesia moved from a prevalence  rate         of under 20% in
           the late 1970s to about 50% and fertility          dropped from
           5.5 in 1965 to 3.4 in 1989.
Repeatedly,    strong family planning programs have demonstrated
that delivery     of safe,     acceptable    services results     in fertility
declines    even in areas and countries          where economic development
is limited.     A recent      reviewa of the Bangladesh population
program demonstrates        the impact of population       assistance      in a
conservative,     poor country where other socio-economic            gains
have been limited.         Approximately     half of all U.S. assistance
to Bangladesh is for population,           and A.I.D. has been the lead
donor in that sector.           With such assistance     and a strong
government commitment to family planning,             the average number of
births   in Bangladesh has declined          from 7.2 to about 5 in 1989
and contraceptive      prevalence      has risen from 7.2% in 1972 when
A.I.D.   began assistance,         to 32.8% in 1989.
          Area   Studies
Several controlled,           small area studies provide more detail          on
the relationship          between fertility       and family planning.      A
multi-year         health and family planning         study carried   out in the
Matlab    region of Bangladesh confirmed that a strong family
planning      component associated          with a few basic maternal and
child health services            can result     in an increase in
contraceptive          use -- in this case from 7 percent to 45 percent
between 1978 and 1985.9 Over this same time period,                    the
total    fertility       rate in the project       area dropped to 26 percent
below   the rate observed in the control                area.  Infant and
maternal mortality           rates also declined.

                               -- -.-   -8-

         Page60                                               GAO/NSlAD88l12Popslation
               Comments lhm    the Agency for
               International Developmrnt

    A.I.D.'s   basic approach has always focused on the delivery             of
    family planning     services.     An important      assumption for A.I.D.'s
    population    program has been that if high quality,           voluntary
    services   are made available,        people will use them. In fact,
    the services themselves help create demand for family
    planning.     Whatever the rationale        for population    programs, and
    whatever the specifics        of a country program, A.I.D. recognizes
    that couples cannot contracept           to control   and lower their
    fertility   if family planning        information    and services are not
    available.     A.1.D has thus concentrated          on this necessary
    condition   for fertility      decline.
    Evidence      of Demand
    Surveys and        other research3 indicate   that there is
    considerable        existing  demand for family planning services.             The
    table below        shows percentages of women who have indicated            that
    they wish to        delay or limit  having more children.
                              pprcentaae of Women Wishina    to:
                               Delay Next   Limit Total                   % Using
       ' n                        Birth      of Births       Total      Contr aceotion
    Africa                             36.4           24.6    53.8              11.1
    Asia/Near East                     19.7           47.5    60.5               --
       Mid East/SA                     19.4           43.9    55.1              28.4
       SE Asia/Oceania                 24.7           56.6    76.1              42.8
       Near East                       11.3           51.8    62.7              32.9
    Latin America                      15.0           65.0    80.0              56.0

          Source:  Johns Hopkins University  "Fertility          and Family
          Planning Surveys:  An Update", Population           Reports, no. 8,
          1985; Demographic and Health Surveys.
    While degrees of demand vary across    and within regions,  there                  is
    a consistent   pattern  of more women wanting to space or limit
    births   than are already doing so.
    Increasina        Demand
    Over the next two decades the demand for family planning                in LDCs
    will      increase even more and will surpass the ability         of A.I.D.
    and other donors to meet it.           This increase is inevitable
    because the absolute number of potential             users (women of
    reproductive        age) will  increase by about 45% from 1985 to 2000
    and by another 23% by 2010.4 If one assumes only conservative
    increases        in rates of contraceptive     prevalence,   then the numbers
    of people who must be provided with the means to regulate
    fertility        is truly staggering.      This is represented   below:


                                                                     GAO/NSIAlMO-112 Population
      Comments From the &ency     for
      International Development

                     Developing Countries Favoring
                    Lower Population  Growth, by Year
                                  1965             1975               1988
     Asia/Near East                 8               18                 20
     Latin America                  0                9                 18
     Africa                         1                4                 30
      Total                         9                31                68
    Updated 3/90
    Source:       1965, 1975 - Nortman,        D., ponulation     and Fe
    ed., The Population      Council, New York,           1985; 1988 - W&la
    Population   Monitoring:    1989, Population           Division, United
    Nations,   New York, 1989.

The implementation         of A.I.D. assistance    for population
activities        is governed bv lesislative    requirements    as well       as
A.I.D.     policies.      Most notabiy:
        med         Choice:      Annual appropriation      acts provide that
        A.I.D.'s    family planning program will offer or provide
        information    about the availability         of a broad range of
        methods and services.          In 1981 the FAA was amended to
        ensure that information          and services   relating   to natural
        family planning        (NFP) methods be included among the
        population    activities     supported by A.I.D.
         Voluntarv   Sterilization:      Foreign assistance    legislation
         prohibits   the use of U.S. funds "to pay for the
         performance of involuntary       sterilizations    as a method of
         family planning      or to coerce or provide a financial
         incentive   to any person to undergo sterilization."
         [Section   104(f) of FAA enacted in 19781
         Km:                 The Kemp-Kasten amendment enacted
         originally     in 1985 prohibits       the U.S. from supporting
         any organization       or program which supports or
         participates      in the management of a program of coercive
         abortion     or involuntary    sterilization.
         Abortion/Mexico         Citv Policy:        A.I.D.    has not funded
         abortion      related    activities      since the Helms amendment,
         now section        104(f) of the FAA, was passed in 1973. In
         August 1984, the U.S. Delegation                 to the International
         Conference on Population             announced a new U.S. policy on
         international        population      assistance.       This policy,   known
         as the Mexico        City Policy,      is now implemented in A.I.D.
         population       assistance      program.

      Page46                                                    GAO/NSL4D9&112Popnlation
      Interna~iond Development

Support for voluntary        family planning has remained a consistent
element of A.I.D.'s       population     policy   since the United States
first   provided population       assistance    in 1965. Economic, health
and human rights       concerns form the basis for A.I.D.'s
population     program.     New information,      host country policy
environment,      and congressional      and administration    concerns also
influence     A.I.D.'s   program policy.
A.I.D.'~   population    policy was first     formalized     in a statement
published    in 1982. Its introductory        paragraph characterizes
the rationales      for the population    assistance     program:
     Continued high rates of population      growth significantly
     increase the cost and difficulty      of achieving   basic
     development objectives     by imposing burdens on economies
     presently  unable to provide sufficient      goods and services
     for the growing population.      Family planning assistance
     materially  advances social and economic development:
     enhances individual    freedom to choose voluntarily       the
     number and spacing of children:      and, provides critically
     important  health benefits    for mothers and young children.'
procrram Basis
Unprecedented population      growth rates have been considered a
serious impediment to sustainable         economic development.         Since
1965, lowering population      growth and fertility       in developing
countries    has been a principal    policy objective       of A.I.D.'s
population    program.  This objective       also recognizes that each
developing    country defines the nature and extent of its
population    problem -- not as an isolated        phenomenon -- but
within    the context of its overall      productive   capacity.
As a practical   matter, A.I.D. has found it more effective         to
discuss population     growth within the host country context
rather than prescribing      a universal  cure.    Custom tailored,
micro-computer   based demonstrations     and projections     using real
data and the country's      own development aspirations     are often
more compelling    than a predetermined    scenario.
Over the years, A.I.D.'s      population  program has emphatically
addressed this economic linkage in policy dialogue with LDC
leaders in countries     around the globe.     Considerable technical
assistance  and training     have been provided to LDC officials
with regard to the impact of population        growth on development
and the positive    effects   of smaller family size.

       page44                                               GAO,'NSIAMJ8-112Population
Comments From the Agency for
International Development

                              AGENCY      FOR    INTERNATIONAL       DEVELOPMENT
                                                WASHINGTON 0 c 20123

                                                                                   IJ   3 APR1990
           Frank C. Conahan
           Assistant    Comptroller       General
           National    Security     and International
              Affairs   Division
           General Accounting        Office
           441 G St.,    N.W.
           Washington,     D.C.     20548
           Dear Mr. Conahan:
           We are attaching       a     copy of A.I.D. 's comments on your draft          report
           entitled:      Foreign       Assistance:       A.I.D. 's Population   Program.     We
           greatly    appreciated         the opportunity       to meet with Messrs.    De Forge
           and Brogan of your           staff    last week.       If you have any questions
           about this     report,       please contact       Dr. Sarah Clark in A.I.D's
           Office    of Population          (875-4608).

                                                              %d‘!k       j,r$jd
                                                               Acting  Assistant dministrator
                                                               for Science and T chnology
           CC:    GC/CP,       S.Tisa
                  LEG/GL,      K. Latta
                  IG/PPO,      R. Parrish

                    Page 42                                                              GAO/NSL4D!W112 Population
                 Chapter 4
                 Accomplishments in Family Planning

                 AID has also developed management training materials that target typi-
                 cal problems faced by family planning managers in developing countries
                 and has distributed English, French, and Spanish versions of basic refer-
                 ence books on family planning to organizations in 24 countries. AID also
                 created a computerized bibliography of data relevant to family planning
                 management, general management, and training.

                 In Indonesia, AID assisted the government in making its population pro-
                 gram self-sustainable by involving the private sector. Elsewhere in Asia,
                 AID believes its assistance to improve management has contributed to
                 the decentralization of programs from central bureaus to regional and
                 local areas, thus improving the delivery of family planning services to
                 rural populations, which had frequently been neglected in the past. In
                 Latin American countries such as Ecuador and Brazil, AID has begun
                 assisting private family planning organizations in improving income
                 generation and better managing cash flows.

                 AID’S efforts in communication have focused on the development of new
Communications   strategies and techniques for application to family planning programs.
                 Evaluations undertaken in Africa, Asia, and Latin America report that
                 communication and informational efforts are highly effective in creating
                 awareness of the concept of family planning, changing knowledge and
                 attitudes towards family planning, and fostering behavioral change in
                 target audiences.

                 Since the mid-1970s AID has supported the publication, in five lan-
                 guages, of Population Reports, which is a family planning journal with a
                 reported circulation of about 150,000 readers per issue. AID also spon-
                 sored Popline, the world’s largest computerized population and family
                 planning database. Over 150 communications subprojects are reported
                 to have focused on delivering family planning messages in Africa, Latin
                 America, and Asia and the Near East. AID has also funded the produc-
                 tion of print materials, including leaflets, booklets, posters, newsletters,
                 and brochures. It has sponsored the development of other materials,
                 such as family planning logos, billboards, T-shirts, calendars, and key
                 chains, to inform and motivate the public acceptance of family planning.

                 AID sponsored the production   of professional entertainment music
                 videos in Nigeria, Mexico, and the Philippines to promote messages of
                 sexual responsibility and informed choice. According to AID, the videos
                 became commercial hits and also encouraged increased support for fam-
                 ily planning from the corporate commercial sectors. AID reports that

                  Page 40                                           GAO/NSIAlXh%112Population
Accomplishments in Family Planning

The worldwide contraceptive social marketing project is designed to use
existing commercial networks and methods to sell contraceptives to low-
income consumers, thus recovering some project costs while increasing
contraceptive prevalence. Targeting both urban and rural populations,
the project’s advertising has ranged from the use of standard mass
media to spreading messages on riverboat sails, in popular songs, or at
sporting events. Products offered include condoms, pills, IUDB,and
injectables, purchased through AID and directly from commercial manu-
facturers. Product distribution is being made by both commercial sales
outlets and village medical practitioners and doctors. AID has funded
contraceptive social marketing since 1972. Currently, AID funds commer-
cial sales programs in 22 countries. AID maintains that the project has
brought profit-making businesses into contraceptive product promotion
and distribution. Program cost-recovery has not been achieved, but AID
states that two subprojects are commercially independent.

The commercial market for contraceptive pills has grown by 66 percent
in the Dominican Republic since the project began there in 1986. The
organization implementing the project has reportedly generated an esti-
mated $100,000 in sales revenue, which is helping to finance its rural
community based distribution efforts. AID states that its efforts in Indo-
nesia have contributed to an increase of 55 percent in contraceptive
sales. The Indonesian private sector is supplying all products at no cost
to AID.

The Enterprise project is designed to work with the private sectors in
developing countries and to integrate family planning services into
existing profit-making commercial channels and employee benefit plans.
The project design attempts to develop new ways to use the profit-mak-
ing sector for service provision and make private voluntary organiza-
tions efficient and businesslike, while increasing contraceptive
prevalence. However, an AID evaluation shows that the overall impact of
the project is not likely to be significant, major increases in contracep
tive use will probably not be achieved, and the project has worked in
only a narrow part of the private sector, such as large companies in the
mining and plantation sectors. The project has no overall strategic plan
at either the global or country level but it has made gains in specific
subsectors: the workplace, nongovernmental organizations, and the for-
profit health care marketplace.

Page 38                                            GAO/NSIABBO-112Popuhtion
                     Accomplishments in Family Planning

                     surveys to development efforts; some of the poorest countries now com-
                     mit government resources to support censuses and surveys.

                     The results of Am-sponsored surveys currently provide the basis to cal-
                     culate total fertility rates and levels of unmet demand for contracep-
                     tives in developing countries. AID believes that the demographic surveys
                     it supported have also provided the information that encouraged some
                     governments, previously reluctant to undertake population programs, to
                     adopt population/family planning policy reforms. For example, survey
                     results in the Dominican Republic revealed that there was widespread
                     acceptance of female sterilization. According to AID, this led the Domini-
                     can government to add voluntary sterilization to its existing family
                     planning services. This is now the overwhelming method of choice
                     among Dominican couples and is used by one-third of all married women
                     of reproductive age. The total fertility rate in the Dominican Republic
                     has declined from 7.2 children in 1965 to 3.8 children in 1989.

                     AID assistance in population policy development emphasizes providing
Policy Development   important and up-to-date information on population and family plan-
                     ning to high-level officials in developing countries. For example, AID
                     reports that it has sponsored microcomputer-based presentations in 55
                     countries, including 28 countries in Sub-Saharan Africa, that outline the
                     implications of different rates of population growth under varying cir-
                     cumstances. While AID will not initiate policy recommendations unless
                     requested to do so by the host government, AID believes that these brief-
                     ings, which have been presented to cabinet and ministerial level officials
                     and 15 heads of state, have influenced some governments to begin
                     addressing population problems and family planning needs. In 1975,
                     only 31 developing countries had policies directed toward reducing pop-
                     ulation growth rates; by 1988, 66 countries had such policies. In Africa,
                     until the mid-1980s, only Mauritius, Ghana, and Kenya had adopted
                     population policies favoring lower population growth rates. By 1988,
                     Liberia, Nigeria, Senegal, and Zambia had also adopted such policies.

                     AID believes that policy dialogue efforts, including analytic studies, con-
                     ference support, and study tours, have resulted in the implementation
                     by a few countries of policies that improve access to family planning
                     services. AID has supported cost-benefit analyses for governments in five
                     countries and for three national social security institutes. For example,
                     the Indonesian government used the findings of an analysis of public-
                     sector expenditures to justify maintenance of spending for family plan-
                     ning in the face of a declining national budget. The National Social

                     Page 36                                            GAO/NSlAWW112 Population
Funding and Management

to include similar information for its activities performed under contract
with other AID units such as regional bureaus and overseas missions, but
we are unaware of any requirement that they do so. Also, missions and
regions provide assistance to local government and nongovernment
organizations, and to agencies which may not be under contract with the
Office of Population-information     from these entities is not reflected in
the population database.

In its comments on our discussion of AID’S evaluations, AID said that we
overlooked the population program’s emphasis on collecting basic raw
data to indicate project and country level performance, downplayed
AID’S use of evaluation findings, and ignored the evolution of AID’s evalu-
ation effort.

We highlight AID data collection efforts as an AID accomplishment in the
following chapter. However, since this information has not been used to
systematically assess and monitor population program activities, does
not involve analyses, and cannot be directly correlated to AID’S program
efforts, we did not include it in our discussion of AID’S evaluation efforts.
We discussed AID’S evaluation efforts, and noted that project evaluations
(e.g., whether a project designed to train health workers in contracep-
tive methods accomplished its purpose) were undertaken by AID. Our
concern was directed towards AID’S failure to perform program impact
evaluations that would provide an understanding of the overall impact
of U.S. assistance at the country level. We also noted that many of the
problems affecting program evaluations may have been due to the
absence of guidelines that specify common criteria or standards of eval-
uation. We noted that AID has recently started to improve its evaluation
efforts and is planning to undertake impact evaluations.

Lastly, AID said that, since we did not visit its overseas missions, we
were unable to take a complete look at all evaluations done by AID at the
country level. We did review evaluations performed by AID’S overseas
missions, which were available in Washington. While our review dis-
closed some problems with inconsistent criteria used in particular evalu-
ations, our primary concern was that AID has performed very few
country impact evaluations and no overall program impact evaluation.

 Page 34                                             GAO/NSIAIWO-112Popnlation
              Chapter 3
              Funding and Mamqement

              accurately performed, and discussions with division heads revealed that
              they had little knowledge of either the process or required

              The Office’s internal control files contained good documentation for
              1985, and the 1986 report contained a one-paragraph certification of
              general compliance in accordance with AID requirements, but without
              back-up documentation. There was no documentation for 1987. The
              1988 and 1989 reports were divided into five internal control categories:
              (1) organization and management, (2) project design, (3) project imple-
              mentation and monitoring, (4) project evaluation, and (5) contract moni-
              toring. Although several controls were reported to have been tested or
              verified, there were no supporting records or documentation in Office
              files. After we brought these deficiencies to the attention of AID officials
              during our review, the Office took action to improve its documentation
              for the October 1989 report. The 1989 report noted five unsatisfactory
              controls, including inadequate staffing and equipment, and unsatisfac-
              tory supervision of project sites, inadequate guidance provided to over-
              seas missions, and inadequate documentation. Office officials attributed
              unsatisfactory supervision of project sites to a lack of travel funds, and
              said that the unsatisfactory ratings for supervision, guidance, and docu-
              mentation were a result of unresolved Inspector General findings in the
              contraceptive procurement program.

              We believe that, despite the significant funding allocated for population
Conclusions   assistance, AID’S management has not exercised strong program over-
              sight and evaluation. Currently, at least 43 units in AID provide varying
              levels of assistance to 94 developing countries, but no one unit is held
              accountable for program efficiency and effectiveness. AID’S information
              systems do not provide the comprehensive financial and management
              information necessary for making sound programming and budgeting
              decisions. No single office has the authority for setting program priority
              and coordinating project activities and evaluations.

              Evaluations have been uncoordinated and provide information of only
              limited use. AID has not established criteria or set standards for evalua-
              tion units to measure program accomplishments. The Office of Popula-
              tion has issued an evaluation guideline that lacks established criteria.
              Little has been done to evaluate program impact or country specific

              Page 32                                             GAO/NSL4D9O-112Population
                       Funding end Management

                       acceptable to family planning users. However, AID'S system does not per-
                       mit AID management to readily identify and monitor the level of
                       resources the implementing units are devoting to private-sector initia-
                       tives. AID is developing a new “special issues” coding structure for
                       projects, which is intended to provide management with a better profile
                       of project activities.

                       The Office of Population has developed a management information sys-
                       tem intended to fill the gap where the agency’s systems fall short. This
                       system attributes central office expenditures by country, and catego-
                       rizes central office expenditures, such as those made for policy develop-
                       ment, service delivery, or research. However, the system’s data is self-
                       reported by contractors and grantees and is not tied to AID'S project and
                       financial management systems, or reconciled to those systems. Because
                       this system does not contain bilateral and regional project information,
                       it provides management information for only about half of AID'S popula-
                       tions assistance activities.

                       AID participates  in a variety of activities that in some way involve coor-
Program Coordination   dinating its population program with those of other donors. For exam-
With Other Donors      ple, the Office of Population holds an annual meeting in Washington
                       principally for cooperating agencies, but also attended by other inter-
                       ested participants. The April 1989 meeting was attended by representa-
                       tives of 43 cooperating agencies (including agency subgroups), such as
                       the Columbia University Center for Population and Family Health, U.S.
                       Bureau of the Census, East-West Population Institute, Pathfinder Fund,
                       Population Council, and Population Reference Bureau. Other partici-
                       pants included representatives of the Alan Guttmacher Institute, Com-
                       mission of the European Communities, Japan International Cooperating
                       Agency, Overseas Development Administration (United Kingdom), Per-
                       manent Mission of Sweden to the United Nations, United Nations Popu-
                       lation Fund, and World Bank.

                       We attended the meeting and found it to be well-organized and highly
                       instructive, and an excellent forum for coordination and an exchange of
                       information. The 3-day session included general presentations on AID'S
                       program and the perspectives and programs of other donors and experts
                       in population/family planning. There were also sessions for technical
                       working groups on research, contraceptive development, demographic
                       and health developments, country-specific strategies, and other relevant

                       Page30                                             GAO/NMAIHM!-1lPPopuLstion
Chapter 3
Pundhq and Mmuxgement

limited in scope, and evaluate success primarily by individual project
objectives (e.g., the delivery of services or commodities). AID has not
placed enough emphasis on evaluating program outputs, such as the
overall impact of its family planning program or the impact of project
activities within recipient countries. As a result, AID does not know
whether population resources are effectively and efficiently achieving
program goals.

AID has delegated authority  for program implementation to 43 geograph-
ical bureaus, overseas missions, and the Office of Population. Although
AID’S Bureau for Program and Policy Coordination has responsibility for
agencywide program oversight, there is no single program office or
officer with overall program oversight authority. This system of man-
agement has left a void in responsibility for program implementation,
evaluation, and oversight.

We found few countrywide reviews or impact evaluations. AID’s Center
for Development Information and Evaluation in the Bureau for Program
and Policy Coordination has not conducted any impact evaluations. Fur-
thermore, only 9 of 78 external evaluations performed between fiscal
years 1984 and 1988 focused on country-specific programs. During our
review, the Center renewed its efforts in the area of impact evaluations,
and is designing a 2-year evaluation that will assess the impact popula-
tion assistance has had on six countries.

In September 1988, officials from the Office of Population formed a
working group to discuss AID evaluations of centrally funded and bilat-
eral population projects. The group found that AID’S approach had been
unsystematic, and as a result, “the quality of AID evaluations had been
uneven, and despite the considerable costs...have had relatively little
influence on project design and management.”

We believe some of these problems may result from AID’S decentralized
evaluation system, where no common criteria or standards have been
established. For example, although AID’S family planning assistance is
intended to provide access to family planning, and decrease infant and
maternal mortality, there is no requirement to include these elements as
measurement criteria in AID evaluations. Also, although a number of
standards, such as ( 1) couple years of protection, (2) number of
acceptors, and (3) contraceptive prevalence rates, provide information
necessary to adjust and redirect the assistance to better achieve pro-
gram goals, they are not consistently used in evaluations. The Office of

 Page 28                                          GAO/NS~AD~KI-~~~
                      Chapter 3
                      Funding and Management

                      In fiscal year 1988, centrally administered funds of the Office of Popula-
                      tion provided family planning assistance to developing country organl-
                      zations through 47 contracts, grants, and cooperative agreement@ with
                      28 cooperating agencies. Including buy-ins6 from missions and regions,
                      these agencies provided 94 developing countries with $30.5 million in
                      technical assistance, $13.2 million in contraceptives, and $50.5 in other
                      direct and indirect assistance. In addition, about $43.8 million was used
                      to fund the activities of local organizations.

                      Local government and nongovernmental organizations play an lmpor-
                      tant role in program implementation. AID believes that family planning
                      programs operated through private-sector institutions are often more
                      cost-effective than host-government operated programs, and may be
                      more acceptable to family planning users. In fiscal year 1984, almost
                      half of the population assistance funds supported the work of nongov-
                      ernmental organizations. AID does not have more recent agencywide data
                      on allocations. Of the $43.8 million central office funds used to support
                      local population activities, roughly 26 percent supported government
                      institutions and 74 percent supported nongovernmental organizations.

                      In September 1989, AID’S Inspector General issued an audit report on AID
Inspector General’s   contraceptive procurement that emphasized the need to strengthen and
Audit of AID          correct problems in AID’S management of this area. AID obligated almost
Contraceptive         $350 million for contraceptives during fiscal years 1979 through 1988,
                      and $58.6 million for fiscal year 1989.
                      The audit called attention to the absence of key management elements
                      such as (1) clear policy guidelines defining appropriate levels of finan-
                      cial assistance, the number of countries AID can and should assist, and
                      the diversity of products AID should provide; (2) an operational imple-
                      mentation plan to direct and control day-to-day implementation tasks
                      and to integrate and coordinate central procurement activities with
                      those of overseas missions and host countries; and (3) a comprehensive
                      statement of long-term and interim objectives that all players under-
                      stand and are committed to. The audit cited cases where technical assis-
                      tance was not designed to create self-sufficient in-country expertise. The

                      “An assistanceinstrument usedby AID to support or stimulate the recipient’sown programor project
                      and which involves AID on a partnership basis.
                      “A transfer of funds wlthin the Agency(e.g.,from an overseasmissionor anotheroffice to the Office
                      of Population) for a centrally frmdedproject.

                      Page 26                                                          GAO/NSIAIWO-112Population
Chapter 3
Funding and Management

Mission-administered projects are implemented under bilateral agree-
ments that identify the type of activities AID will fund and the level of
population funding it will provide to a particular country. Regional and
centrally administered projects are activity oriented. Centrally funded
projects are designed to complement mission projects as well as provide
assistance to countries without bilateral agreements. The funds flow
from these units to support the population activities of host-government
and nongovernmental organizations. Funds also flow to a number of
cooperating agencies,l which, in turn, provide developing countries with
services and contraceptives or other commodities such as sterilization
kits and technical assistance. Figure 3.2 shows the flow of AID’S popula-
tion funds.

‘%is generalterm refers to institutions such as universities, hospitals,and private profit and non-
profit enterprises,and U.S.governmentagencies.

Page 24                                                             GAO/NSIAD9@112Population
                                           Chapter 3
                                           Funding and Management

                                           missions. During fiscal years 1979 through 1988, about $1.3 billion was
                                           used to support Office of Population projects3 and $1.1 billion was used
                                           to support mission and regionally administered projects.

                                           Countries for which the Bureau for Asia and the Near East is responsi-
                                           ble have received the highest level of family planning assistance during
                                           the last 10 years. Of the $1.1 billion obligated for mission and regional
                                           projects from 1979 through 1988, about $808.4 million was for assis-
                                           tance to countries in Asia and the Near East. Latin American and the
                                           Caribbean countries received $166.8 million and African countries
                                           received $177.7 million. The high level of Asia/Near East funding is
                                           attributable, in part, to the use of about $194 million in Economic Sup-
                                           port Funds for family planning activities in the Near East. AID officials
                                           said that regional differences may also stem, in part, from host-govern-
                                           ment receptivity. Asian governments have been the most committed to
                                           population and family planning programs. Except for Costa Rica and
                                           Colombia, most Latin American governments have not been strong sup-
                                           porters of population and family planning activities, and many African
                                           governments    were reluctant to undertake such programs.

                                           Table 3.1 shows a ranking of the top ten countries receiving bilateral
                                           population assistance between fiscal years 1979 and 1988; eight of these
                                           countries are in Asia/Near East, with one in Latin America and one in

Table 3.1: Ranking of the Top Ten
Countries Receiving Bilateral Population   Dollars in thousands
Assistance, Fiscal Years 197949            Countrv                                                                       IO-vear obliaations
                                           Bangladesh                                                                               $528,808
                                           Eowt                                                                                      131.400
                                           Indonesia       __~         ~~ --__.                                                      110,640
                                           Pakistan                                                                                   91.550
                                           lndla                                                                                      76,100
                                           Philippines                                                                                47,051
                                           Kenya                                                                                      32,513
                                           Morocco                                                                                    31,525
                                           Thalland                                                                                   25.248
                                           El Salvador                                                                                 24 121-l

                                           Note. Bilateral assistance does not mclude central or reglonal funds

                                           31ncludesabout $239million in assistanceto the United NationsPopulationFund. AID hasnot pro
                                           vided assistanceto the Fund since 1985.

                                           Page 22                                                                GAO/NSlAWO-112 Population
Chapter 3

Funding and Management

                 AID has provided population and family planning assistance to develop-
                 ing countries for 25 years (1965-89), during which time Congress allo-
                 cated about $3.5 billion for this purpose. AID has delegated significant
                 authority to its geographic bureaus and missions to implement foreign
                 assistance programs, including the population program. Forty-three AID
                 units are implementing family planning projects, yet there is no central
                 point of control and accountability. Although half of population funds
                 are administered centrally by the Office of Population, the program’s
                 priority essentially rests with the country missions. Decentralized opera-
                 tions have resulted in fragmented implementation and evaluation. Little
                 agencywide data about the program is readily available for management
                 in its deliberations on resource allocations.

                 AID’S assistance for population and family planning activities began in
Funding Levels   1965, and obligations totaled $10.5 million for fiscal years 1965 through
                 1967. For fiscal year 1968, Congress first earmarked development funds
                 for population assistance; specific appropriations for population assis-
                 tance began for fiscal year 1972. For fiscal years 1968 through 1988,
                 Congress allocated about $3.5 billion for population activities, as shown
                 in figure 3.1.

                 Page 20                                           GAO/NSIAD90-112 Population
                      Policy, Goals, and Strategy

                      Congress has recognized, as part of its statement of development assis-
                      tance policy, that controlling population growth is an element of a coun-
                      try’s commitment to development and progress in moving toward the
                      objective and purposes of the United States’ bilateral assistance. Con-
                      gress also expressed policies and objectives for population and health
                      programs. A fundamental goal implicit in the congressional declarations
                      of policy is that U.S. population assistance helps developing countries
                      limit their population growth rates to levels that will facilitate economic
                      development. For most developing countries, this means reduced fertil-
                      ity and population growth rates. The legislation states that AID should
                      motivate people to have smaller-size families, while recognizing that
                      each country can and should set its own proprieties.

                      AID has no projects specifically directed toward motivating people to
                      have fewer children. Until the 1980s AID promoted demographic change
                      through reductions in fertility rates and linked economic and social pro-
                      gress with reductions in population growth rates. However, this objec-
                      tive was changed to a policy of “encouraging population growth
                      consistent with the growth of economic resources and productivity.”
                      While this new policy statement could be interpreted to continue to call
                      for linkages between population growth and economic development, the
                      implementation of the policy has been such that AID no longer takes the
                      initiative with developing countries in pressing for bringing population
                      and economic growth rates into balance.

                      In commenting on this report, AID said that we had stated that it was not
Agency Comments and   concerned about the relationship between population and economic
Our Evaluation        growth and does not advocate smaller families, as mandated by the Con-
                      gress. AID disagreed, and said that it is concerned about population
                      growth and does, when appropriate, advocate smaller families.

                      We have clarified our discussion about the change in AID policy that
                      occurred in the 1980s. We did not mean to imply that AID is unconcerned
                      about the relationship between population growth and economic devel-
                      opment Instead, we pointed out that an intention in Congress’ declara-
                      tion of policy is that 1J.S.population assistance be directed toward
                      limiting population growth rates and that, until the early 198Os, AID’s
                      policy objective promoted reductions in population growth rates and
                      linked economic and social progress to reductions in population growth
                      rates. AID’S policy change has resulted in a program which emphasizes
                      the delivery of family planning services, but without any specific
                      linkage with the economic and social changes which may be necessary to

                      Page18                                             GAO/NSL4D-9O-112Population
                            Chapter 2
                            Policy, Goals, and Strategy

AID’s Policy From 1967 to   AID issued its Policy Determination:
                                                            Population and Family Planning
                            Programs in November 1967. The policy stated:
                            “Rapid population growth seriously hampers man’s efforts to improve the quality
                            of life....Many governments lack a full appreciation of the enormous impact of fast-
                            growing populations on the life of their people, on their food supply, and on their
                            entire development effort.”

                            “Family planning seeks to influence human behavior. Motivation is therefore an
                            important part of any approach to the population problem. This requires under-
                            standing of cultural, social, psychological and economic forces....To accomplish
                            behavioral changes and provide contraceptive methods, a substantial, effective and
                            well-organized family planning program is necessary....”

                            In a 1973 circular to its overseas missions, AID emphasized that
                            increased attention was being focused on “desired family size,” since
                            there was “...growing concern in both developed and developing coun-
                            tries that even when unwanted pregnancies are largely eliminated
                            [through family planning practices], residual ‘desired family size’ may
                            still be too large to permit reaching low birth rate targets.”

                            In 1980, AID outlined its program objectives as (1) reducing population
                            growth rates that seriously impede economic and social development
                            and (2) providing families with effective options in choosing the number
                            and spacing of their children. AID issued its Rationale for AID Support of
                            Population Programs in January 1982, which stated that “[rapid popula-
                            tion growth] will impact on the quality of life in all nations for genera-
                            tions to come. Failure to act now to slow population growth will make
                            the task in the future more difficult.”

AID’s Policy From 1982 to   In September 1982, AID began to modify its long-standing objective when
the Present                 it issued its Population Assistance Policy Paper. AID dropped its objec-
                            tive to reduce population growth rates in favor of one which
                            “encourag[es] population growth consistent with the growth of economic
                            resources and productivity.” While the meaning of the new policy has
                            not been clearly defined, the policy suggests that if a developing coun-
                            try’s economy cannot keep pace with its population growth rate, the
                            country has three alternatives, or a combination thereof, for develop-
                            ment, economic and social progress, and improved quality of life: (1)
                            increase economic productivity, (2) obtain higher levels of external,
                            donor assistance, and/or (3) reduce population growth rates. The policy
                            statement as written would seem to allow AID to initiate discussions of

                            Page 16                                                   GAO/NSIAB96-112 Population
chapter 2
Policy, Goals, and Strategy

developing countries. President Ford’s message to the first World Popu-
lation Conference, held in August 1974 in Bucharest, Romania, also
noted that rapid population growth was one of the greatest challenges
man would face for the remainder of the century.

The 1974 National Security Council’s National Security Study Memoran-
dum 2002 cautioned that rapid population growth rates could negatively
affect the environment and world food availability and production, and
endorsed a policy to combat rapid population growth. It stated that
“rapid population growth creates a severe drag on rates of economic
development [and] seriously affects a vast range of other aspects of the
quality of life important to social and economic progress in [developing
countries].” The memorandum noted that “the universal objective of
increasing the world’s standard of living dictates that economic growth
outpace population growth” and that “[the United States should
encourage] an all-out effort to lower growth rates.” The memorandum
served as administration policy on population through the Ford and
Carter Administrations. In 1980, under the Carter Administration, the
National Security Council reported that “current demographic projec-
tions convey a clear message that the future consequences of compla-
cency and delay in reaching replacement fertility levels will be billions
of individuals added to an overpopulated and overstrained future

The 1974 international conference on population, held in Bucharest, was
the scene of debate between the United States and the industrialized
countries on the one hand, and developing countries on the other. The
industrialized countries maintained that overpopulation was a principal
cause of developing countries’ poverty and that reductions in population
growth rates were a prerequisite for development. The developing coun-
tries generally maintained that unequal distribution of wealth was the
cause of their poverty, overpopulation was a symptom of this poverty,
and development would come with a North-South redistribution of

In 1984, a second conference was held in Mexico City. Developing coun-
tries had, by this time, come to recognize that slower population growth
rates would benefit their development. Consequently, the U.S. delega-
tion to the Mexico conference was surrounded by controversy when it
announced a revised IJ.S. population policy and held that, “...population

 ‘NSSM200,Implications of Worldwide PopulationGrowth for U.S.Security and OverseasInterests,
 Dec.10, 1974,declassifiedon July 3, 1989.

 Page 14                                                       GAO/NSIAB9@112Population
Chapter 2

Policy, Goals, and Strategy

                AID’S population  assistance program is based on the principles of volun-
                tarism and informed choice. AID'S stated policy objective is to “( 1)
                enhance the freedom of individuals in [developing countries] to choose
                voluntarily the number and spacing of their children, and (2) encourage
                population growth consistent with the growth of economic resources
                and productivity.” Its program goal is to ensure that 80 percent of
                couples in developing countries have access to family planning services
                through a strategy of providing widespread availability of acceptable
                voluntary family planning services.

                We reported’ in 1976 that AID'S overall economic development strategy
                was based on the premises that (1) population growth is outpacing the
                economic and governmental capabilities of developing countries and (2)
                fertility can and must be reduced. AID maintained that slowing popula-
                tion growth was critical to improving the quality of life in developing
                countries, and that efforts to contain population growth were part of
                AID'S legislative mandate.

                During the 198Os, as population and family planning assistance became
                increasingly controversial and politicized, AID'S program objectives
                underwent subtle changes. In the early years of the program, AID empha-
                sized family planning and motivation for smaller-size families as an
                urgent development need, based on the premise that population growth
                rates must be reduced in order for developing countries to achieve eco-
                nomic and social progress. During the Reagan Administration, the
                linkage between reduced population growth rates and economic and
                social progress was obscured. Administration officials deemed popula-
                tion growth rates to be a “neutral phenomenon” (neither good nor bad)
                and linked economic and social progress to market-oriented economic
                reforms by developing countries. AID stopped actively promoting popula-
                tion growth rate reductions and, according to AID officials, it no longer
                initiates discussions of population growth rate reductions, except in
                those countries whose governments themselves promote population
                growth rate reductions. However, AID'S policy change had little impact
                on its principal program activity-delivering    family planning services-
                which have been consistently provided since inception of the program.

                ‘Chalk e of World PopulationExplosion:To Slow Growth RatesWhile Improving Quality of Life
                (~AO,I?h33), Nov. 9, 1976.

                page12                                                        GAO/NSIAIMO-112Popuhtion
                                            Chapter 1

Table 1.1: Total Fertility Rates0 ior
Selected Regions and Countries              Country                                                             1965       1977          Late 1960s
                                            Kenya                                                                  8.0       7.0                8.1b
                                            Nigena                                                                 6.9       6.9                6.6
                                            Zimbabwe                                                               8.0       6.6                6.5b
                                               Sub-Saharan Afnca                                                   6.6       6.6                6.6
                                            Brazil                                                                 5.7       4.9                3.4
                                            Costa Rica                                                             6.4       3.6                3.5
                                            Mexico                                                                 6.7       5.7                3.0
                                               Latin Amenca                                                        5.8       4.9                3 6b
                                            lndonesla                                                              55        4.9                3.5
                                            Philippines                                                            6.8       5.0                4.6
                                            Thailand                                                               6.3       4.5                2.7
                                               East AsiaC                                                          58        4.6                3.5
                                            Egypt                                                                  6.8       4.8                5.3
                                            Jordan                                                                 80        7.0                6.2
                                            Pakistan                                                               7.0       6.7                6.5
                                               Near East and South Asia                                            6.4       5.5                4.9
                                            UnIted Statesd                                                         29         1.8               1.9
                                            ‘See p 9 for the deflnltlon of fertlllty rates
                                            bAID reports that recent demographic and health surveys lndlcate that fertility rates for Kenya,
                                            Zimbabwe, and Latm America should be 6 7, 5 7, and 3 7. respectwely

                                            ‘Excludes   China
                                            *FertMy rates for the Unlted States are mcluded for comparatw      purposes.
                                            Source. World Bank and Population Reference Bureau statlstlcs

                                            At the request of the Chairman of the Senate Appropriations Subcom-
Objectives, Scope, and                      mittee on Foreign Operations, we reviewed AID’S population program.
Methodology                                 Specifically, we focused on the following questions:

                                        l What are AID’S current population policy, goals and strategy, and how
                                          have these changed over the past 10 years?
                                        l Is AID organized effectively to manage the program and allocate
                                          resources appropriately, and how does it coordinate with other donors?
                                        0 What are AID’S accomplishments in population and family planning

                                             We also examined the extent to which AID’S Office of Population com-
                                             plied with requirements of the Federal Managers’ Financial Integrity
                                             Act’s internal control assessment process.

                                             Page 10                                                                GAO/NSIABW-112 Population
Chapter 1


               According to AID, the fundamental challenge of population growth rates,
               which outstrip developing countries’ abilities to support these growth
               rates, has not changed since AID began population and family planning
               assistance in 1965. However, over time, AID has moved away from a pop-
               ulation program focus, which emphasizes reductions in fertility rates’
               and subsequent reductions in population growth rates, to a family plan-
               ning program focus, which emphasizes the provision of contraceptives
               and services to help couples meet their personal objectives. Despite the
               increase in the use of family planning services, great disparities in popu-
               lation growth rates remain among the developing regions of the world.
               In East Asia, contraceptives are used by over 65 percent of married
               women of reproductive age. By contrast, contraceptive use in Africa is
               under 10 percent, and the annual rate of population increase is 3.1 per-
               cent. At this rate, the population of Africa will double in about 24 years.

               The consequences of rapid population growth are now more widely
               understood than even a decade ago. The damaging effect of rapid popu-
               lation growth on the health of mothers and children is particularly
               clear-maternal    and infant mortality rise measurably with large num-
               bers of births and with births too closely spaced, or when children are
               born at a too early or late age of the mother. Also, rapid population
               growth exacerbates economic and environmental problems, thereby
               making more difficult the challenge of reducing hunger in the develop-
               ing world, providing basic services, expanding productive employment,
               increasing incomes, and managing the natural resource base.

               In the 198Os, as economic conditions deteriorated in most developing
               countries, International Monetary Fund programs, World Bank struc-
               tural adjustment lending,z and U.S. assistance under AID’S Economic Sup-
               port Fund3 program were provided to assist developing countries in
               their efforts to stabilize and restructure their economies. However,
               many developing countries continue to experience severe problems of

               ‘The total fertility rate 1sthe averagenumberof children that will be born to a womanthroughout
               her childbearingyears (approximately from age 16to age49), given her society’schild-bearingcul-
               tural pattern and desiredfamily size.Dependingupon mortality levels, a fertility rate of 2.1 to 2.5 is
               considered“replacementlevel” or the rate at which population growth willstabiliie.
               %3ructural adjustmentlending is directedtoward reducingthe current accountdeficit to a sustaina-
               ble level, and maintaining or restoringgrowth through improvementsin trade policy, mobilization of
               domesticand foreign resources,efficiency in the use of domesticresources,and institutional reform.
               “The EconomicSupport Fund ISeconomicaid to promoteeconomicor political stability in areas
               where the United Stateshasspecialsecurity or other interests.It may be provided in projectform
               aimedat specific activities or as cashtransfers which provide untied dollars (i.e., for balance-of-
               paymentssupport), or under Ccnmcdity Import Programswhich finance a portion of specificcom-
               moditiesand equipment.

               Page 8                                                               GAO/NSIADSOM-112

Executive Summary                                                                               2

Chapter 1                                                                                       8
Introduction              Objectives, Scope, and Methodology                                   10

Chapter 2                                                                                      12
Policy, Goals, and        Legislative Objective Is to Reduce Population Growth                 13
Strategy                  Changes in Administration Policy                                     13
                          The Evolution of AID’s Population and Family Planning                15
                          Conclusion                                                           17
                          Agency Comments and Our Evaluation                                   18

Chapter 3                                                                                      20
Funding and               Funding Levels                                                       20
                          Family Planning Program Organization                                 23
Management                Inspector General’s Audit of AID Contraceptive                       26
                          AID Has Placed Little Emphasis on Overall Program                    27
                          AID Lacks Centralized Management Information                         29
                          Program Coordination With Other Donors                               30
                          Internal Controls for Accountability and Control                     31
                          Conclusions                                                          32
                          Recommendations                                                      33
                          Agency Comments and Our Evaluation                                   33

Chapter 4                                                                                      35
Ac&mplishments       in   Contraceptive Development                                            35
                          Data Collection                                                      35
Family Planning           Policy Development                                                   36
                          Service Delivery                                                     37
                          Management Support and Training                                      39
                          Communications                                                       40
                          Commodity Support                                                    41

Appendixes                Appendix I: Comments From the Agency for International               42

                          Page 6                                         GAO/NSL4IMO-112Population
                          when they face severe economic problems. Despite this, AID has no
                          projects directed toward motivating couples to have fewer children, thus
                          leading to reduced population growth rates.

Diffused Program          The program is implemented by 43 units within AID, and there is no sin-
Management                gle program office or officer with overall program management and
                          oversight authority and responsibility. Because AID does not have a sys-
                          tem to provide overall program management information above the pro-
                          ject level, GAO found that AID management does not have sufficient
                           information to make sound, fundamental decisions about resource allo-
                           cations and program priorities. GAO found that the actual impact of AID
                           population assistance, in meeting legislative objectives or the priority
                           development needs of recipient countries, is not adequately evaluated.
                           Furthermore, AID'S evaluations have been unsystematic, uncoordinated,
                           of uneven quality, and have had relatively little influence on project
                           design and management.

Program Accomplishments   According to AID, its efforts have improved the safety, effectiveness,
                          and acceptability of several contraceptive methods. AID reports that,
                          through its efforts, some previously reluctant governments have
                          adopted policy reforms and undertaken family planning programs. AID
                          has provided training and technical assistance to thousands of program
                          administrators and others, and equipment and technical support to med-
                          ical schools and clinics.

                          GAO recommends that AID develop a management information       system to
Recommendations           obtain comprehensive financial and management information of all its
                          population projects and activities, and conduct an overall program
                          impact evaluation, along with country-specific impact evaluations in
                          countries with large programs.

                          AID provided extensive comments on GAO'S report, much of which elabo-
Agency Comments           rated on its approach toward delivering, managing, and evaluating fam-
                          ily planning services (see app. I). AID stated that it is concerned about
                          the relationship between population and economic growth, and when
                          appropriate, during policy discussions with developing countries, it does
                          raise a concern about the negative impact high population growth rates
                          have on governments’ economic aspirations. AID stated that it does rec-
                          ommend smaller families as one way to reduce population growth rates,

                          page4                                             GAO/NSIABSO-11ZPoptition
Executive Summq

                   Developing countries continue to face burgeoning population growth
Purpose            rates that threaten to outstrip and set back economic growth and devel-
                   opment. To help countries around the world deal with this issue, the
                   Agency for International Development (AID) has, over the past 25 years
                   (1965~89), provided about $3.5 billion in assistance focused specifically
                   on population and family planning concerns. The Chairman, Subcommit-
                   tee on Foreign Operations, Senate Committee on Appropriations,
                   requested that GAO review AID’S population program. Specifically, GAO’S
                   objectives were to assess and provide information on (1) policy, goals,
                   and strategy; (2) management and resource allocations; and (3) program

                   Congress has expressed a policy of providing population and family
Background         planning assistance to developing countries to (1) reduce population
                   growth rates, (2) improve health and nutrition, (3) motivate people to
                   desire smaller-size families, and (4) contribute to economic development
                   and higher living standards, all of which will satisfy the objectives and
                   purposes of U.S. development assistance. To accomplish these goals, AID
                   funds contraceptives and other family planning services, training in
                   family planning and population matters, policy dialogue, information
                   and education assistance, biomedical research on contraceptives, and
                   demographic and operations research.

                         family planning program is based on the principles of voluntarism
Results in Brief   AID’s
                   and informed choice with regard to the number and spacing of children.
                   Congressional declaration of policy intends that U.S. population assis-
                   tance (1) be directed toward reducing population growth rates and (2)
                   motivate people to have smaller-size families. Until the 1980s AID’Spro-
                   gram policy paralleled these Congressional goals, and AID was active in
                   urging developing countries to reduce population growth rates. In the
                    198Os, AID continued many of the same population projects but no longer
                   actively promoted smaller families and lower growth rates. Instead,
                   AID’s stated policy calls for a linkage between population growth and
                   economic development. Even so, AID officials stated that in countries not
                   already committed to managing population growth, AID no longer takes
                   the initiative in urging such countries to bring population and economic
                   growth rates into balance.

                   AID family planning projects may induce some couples to practice con-
                   traception and reduce their family size. However, AID has no programs

                   Page 2                                            GAO/NSIABSO-112   Popuhtion