The first time a coherent population policy framework linked to family planning was adopted in the Philippines was during martial law. In 1968, contraception adoption in the Philippines (measured by the ratio of married women aged 15-49 who practice or whose sexual partner practices any form of contraception) was 15%*. By 1986, that ratio went up to 44%. The average number of births per woman during this 18 year period declined from 6.45 to 4.66.
The Aquino administration upon assuming office in 1986 and heavily influenced by the Catholic bishops of the Philippines abolished the population commission set up by Marcos. Over two years, the prevalence of contraception went down to 36%. Since then it has steadily risen to just over 50% where it stood in 2008. The number of births per woman went down to 3.08 (forty years for it to halve!).
During this time, something remarkable happened in Bangladesh. With the adoption of some sensible population and health policies, they have been able to increase contraceptive prevalence from 27% in 1986 (when records were first kept) to 53% in 2008. Similarly, the number of births per woman went down from 5.4 to 2.3 in that same period. It took them just over two decades to halve their fertility rate to roughly equal the replacement rate (meaning that over the coming years their population will remain stable).
This is remarkable given that the per capita GDP (adjusted for purchasing power) in Bangladesh was in 2008 only about a third of the Philippines ($1,350 v $3,690). For those that argue that a change in fertility is affected by income, this might seem puzzling. Of course in general higher income levels lead to smaller families as demonstrated by the fact that fertility rates for both countries have been declining as incomes have risen. But policies aimed at providing options to families also play a determining role.
Continuity and stability of policy framework
Consider the different policies adopted by these two countries. I have already mentioned the almost stop-and-go nature of population planning and policy in the Philippines. In Bangladesh, they have sustained their policy framework close to forty years and have already graduated into second generation policies.
The first phase of their population policy lasted just over twenty years, from 1973 to 1996. This phase focused on implementing programs aimed at reducing the population growth rate. These programs were centered on providing maternal and child health care services through home visitations, expanding the availability of contraceptives, multi-sectoral collaboration and encouraging the adoption of family planning services.
It took Bangladesh half the time it took the Philippines to halve its fertility rate. This is despite the fact that Bangladeshis are poorer on average than their Filipino counterparts.
The second phase began in 1997 and continues until the present. It has been more focused on integrating family planning services into a broader set of health programs affecting a wider target group. From just focusing on reproductive and infant health it became concerned with the control of HIV/AIDS and other sexually transmitted diseases. From being home-based, the services concentrated on clinics to deliver a broad range of services.
The results speak for themselves. One area in which such programs have been effective has been in reducing adolescent fertility. In Bangladesh, the number of adolescents giving birth has gone down from 114 (per one thousand women) to just 70.5 in a span of just ten years (from 1998 to 2008). In contrast the figure for the Philippines has hardly moved in that time moving from 47 down to 44.
This reduction in adolescent fertility might have helped Bangladesh increase the participation of women in school. In 1990, the ratio of girls to boys in primary and secondary education for Bangladesh was at 75%. By 2006, this rose to 105%. It went from 99% to 102% for the Philippines.
As a result of their integration of maternal and child health services, Bangladesh saw a reduction in the cases of infant mortality and a rise in immunization rates of infants. In 1986, infant mortality in Bangladesh was at 111 (per 1,000 live births), more than twice that of the Philippines which was at 50. By 2008, it was down to 43 for the former, while for the latter it had declined to 27. In 1986 immunization of children (between 12 and 23 months) was at a mere 3% in Bangladesh compared to 51% for the Philippines. By 2008, it rose to 89% for the former compared to 92% for the latter.
Lessons and assignments
As Father Joaquin Bernas, SJ wrote in his column for today’s Inquirer, the merits of the current RH bill must be debated on the basis of whether or not the use of state power to influence the behavior of the populace serves the public good and whether it is exercised in a reasonable manner, not coercive or oppressive.
These statistics demonstrate that the adoption of some kind of reproductive health service is defensible from a public benefit point of view. Whether the use of the public purse in providing “safe, effective and legal methods, whether the natural, or artificial that are registered with the Food and Drug Administration (FDA) of the Department of Health (DoH)” (notice how the wording avoids the use of prescriptive terms such as pill, intra-uterine device (IUD), injectables, condoms, ligation, vasectomy) is reasonable depends on the specific measures in the bill.
One of these provisions has to do with the way employers include such services as part of their worker’s entitlements. For Father Bernas, the specifics of the policy are worth debating, but not the policy aims. For him, you don’t “burn down an entire house to make lechon.” In other words, if there are certain objectionable parts to the Reproductive Health Bill, then these provisions should be revised, but that should not alter the need to have this all important bill passed.
The case of Bangladesh clearly demonstrates how a sustained implementation of an integrated health, family planning and population policy has had a massive positive impact on the welfare of its citizens within a generation. It should serve as a reminder to our politicians that a far-sighted policy outlook is needed in dealing with this issue.
For too long, the country has gone without a legal framework for determining its reproductive health policies. It is about time that our leaders and the public at large take a look at the proposals embodied in the reproductive health bill. Above the shrill cries of those who seem to be stuck over worries that this will lead to population control (a hangover from the 1970s’ debate) on the one hand, and on the other hand those who see in the bill a path towards the legalization of abortion, our leaders need to chart a sensible path based on reason and common sense.
* This and all other statistics cited in this article come from the World Development Indicators taken from the World Bank and available on Google’s public data explorer.