Family planning by the numbers: Quotas haven’t gone away, they have merely changed their name

Although officials with the US Agency for International Development deny the practice, current documents and training programs indicate that the Agency still uses quotas to evaluate so called “family planning programs.”

When Mark Schneider, USAID’s Assistant Administrator for Latin America and the Caribbean, testified before Congress about USAID’s potential involvement in Peru’s sterilization campaign, he wanted to make sure legislators understood that USAID “in no way” approved of the use of quotas in family planning programs like Peru’s, testifying:

As soon as USAID became aware of the government of Peru’s more toward quantitative targets for sterilization and campaign strategy. US officials communicated strong concerns about the potential for distortions to the government.

As well they ought. Quotas, targets and other ways of measuring the success of family planning programs by the numbers of women using so-called “modern” contraceptive methods have been officially out of favor since 1994, when the Program of Action from the International Conference on Population and Development (ICPD) officially condemned the practice. “Governmental goals for family planning should be defined in terms of unmet needs for information and services. Demographic goals, while legitimately the subject of government development strategies, should not be imposed on family-planning providers in the form of targets or quotas for the recruitment of clients,” the ICPD document said.1 But condemnation on paper does not always mean a change in behavior and recent evidence indicates that, when it comes to evaluating family planning programs, USAID still measures success by the numbers.

Standard Operating Procedure

A philosophy of quotas may persist in USAID’s Family planning because similar means are used to evaluate other, non-population related, Agency programs. Writing in Harper’s Magazine, Matthew Bivens, a former employee of a USAID contractor, described how important USAID viewed “deliverables” in evaluating its overseas aid and other programs. A “deliverable” Bivens defined as being “any physical proof of our work.” Examples of deliverables, Bivens said, include “’written agendas and programs, local media coverage, and carefully composed photographs…All of it — photographs, agendas, news clippings — goes into a box delivered to USAID in Washington, DC.”2 The directive from a budget-sensitive Congress is clear, US taxpayers money spent overseas has to “do something,” and that something has to be tangible.

The way this thinking finds its way into family planning programs can be seen in the regular budget requests that USAID makes each year to the US Congress. Here, in clear text, is proof that USAID evaluates the success of its family planning programs not simply in terms of information distributed or diminishing “unmet needs,” but instead by actual numbers of women choosing to use a contraceptive method that meets with the Agency’s approval. For example, when discussing some of the background to the $6.1 million USAID wanted to spend on preventing Kenyan births in 1998, the Agency noted:

Between 1984 and 1995, USAID was the lead donor to the Kenya national family planning program. Its financial and technical assistance has contributed to an increase in modern method contraceptive prevalence among women of reproductive age, from 9% in 1984 to 30% in 1995…3

And lest anyone imagine that such a statistic merely reflected past attitudes, the Agency goes on to make clear that it will consider the family planning program in Kenya a success if modern contraceptive prevalence” rises from 28% in 1996 to 31% in the year 2000.4

And Kenya is only one example. Guinea will have a population program which pleases USAID if its contraceptive prevalence rate moves from two percent in 1992 to five percent in 2001, according to the Agency.5 Even Uganda, many of whose women may reasonably want more children to replace those lost during recent conflict, is expected to see “contraceptive prevalence” rise from 12.5% in 1995 to 15% by 1998, if its program is to be called a success.6

The numbers come home

But do such numbers presented to the US Congress translate into similar attitudes at the local level? Is there any indication that USAID encourages local family planning programs to evaluate success by their numbers? Yes, without question.

One of the programs USAID funds is called the Family Planning Management Development (FMPD) project, which is administered by an organization called Management Sciences for Health (MSH). USAID paid MSH over $7.5 million through late September 1997 to create FPMD.7 FPMD is meant to help “national and local family planning programs and organizations develop their capability to successfully plan and manage sustainable family planning programs.8 “FPMD tries to do this mostly by introducing management concepts and practices which have become familiar to private enterprise in the developed world.

In practice this means training family planning staffs around the world and publishing a detailed journal, The Family Planning Manager, four times a year. Each issue of Family Planning Manager provides articles addressing some aspect of family planning management and a subsequent case study to illustrate that article’s lesson. Given that these articles and case studies are meant to represent the cutting edge of advice to managers on how to run family planning programs, they represent a valuable window onto the mentality that still animates at least some of the family planning programs in the developing world.

In an article entitled “Using National and Local Data to Guide Reproductive Health Programs,” for example, the Manager frankly instructs readers on how to set up “indicator panels” to “monitor the effectiveness of your reproductive health program.”9 An accompanying graphic clearly uses the indicators of national and local “modern contraceptive acceptors” as recommended measures while a later section of the article is even more explicit. Under the heading ‘“recommended local reproductive health indicators” are listed: percentage of new contraceptive acceptors; percentage of continuing contraceptive users; contraceptive method mix; number of referrals for long-lasting or permanent contraceptive methods.” The article’s accompanying case study. “Tracking the Progress of Reproductive Health Services in the Highland District” is similarly explicit. In the ease study, a team of family planning managers puts together a plan for advancing family planning services in their district. The plan explicitly places the number of “new contraceptive acceptors” for the example months January-March at 212 and states the “year end objective” at 650. Later charts provide slots for measuring “progress during first quarter.”10

Other articles from back issues of The Family Planning Manager are similarly instructive. “Using Service Data: the Tools for Taking Action,”11 an article from the journal’s first year, advises:

You can assess your clinic’s performance by checking to see whether there has been a steady flow of new acceptors and continuing clients to your clinic each month, whether clients are choosing effective contraceptive methods, and how they are learning of your services.

While “Using Information on Discontinuation to Improve Services,”12 frankly admits:

If family planning clinics paid as much attention to keeping existing clients as to trying to enroll new ones, they could achieve a greater impact on contraceptive prevalence with less effort and at lower cost. Yet, clinic managers are continually pressured to increase numbers of new acceptors. [Emphasis added.]

Why all this matters

This entire issue can seem like mere numbers on a page until a situation like that of Peru appears. Then it becomes clear what USAID’s continuing reliance on quotas has wrought. Hundreds of thousands of women in Peru and elsewhere have had to confront workers from government and other organizations who view them not as human beings but rather as numbers to be entered into a report or a means of filling a quota. Such attitudes, for example, are responsible for menopausal Peruvian women undergoing sterilization operations and led to other women being badly pressured into “accepting” the sterilization. Mark Schnieder was correct to decry even the possibility of quotas in Peru’s family planning program, but given the Agency’s continued reliance on similar numbers, the denunciation rings hollow.

Endnotes