Reproductive Health: Lessons from Bangladesh

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.

Doy Santos aka The Cusp

Doy Santos is an international development consultant who shuttles between Australia and the Philippines. He maintains a blog called The Cusp: A discussion of new thinking, new schools of thought and fresh ideas on public policy (www.thecusponline.org) and tweets as @thecusponline. He holds a Master in Development Economics from the University of the Philippines and an MS in Public Policy from Carnegie Mellon University.

  • http://www.bworldonline.com/content.php?title=Tax%20reform:%20A%20must%20fight%20for%20P-Noy&id=26244

    It is all about the state not ceding its sovereign power to any sector domestic or foreign. That power is defined by the power to raise revenue to govern. That is what gives the state the power to create assets.

    The right to confiscate property and redistribute wealth to enable economic development.

  • J_ag

    http://www.bworldonline.com/content.php?title=Tax reform: A must fight for P-Noy&id=26244

    The first and most important problem that the country will have to address is the lack of the collective consciousness on the necessity of statehood.

    The entrenched elite in this country get richer because they grow rich and deliberately do not want the ideas of an effective state to prosper.

    The entire political system pivots around the small-entrenched elite.

    No program of the state will work under these conditions. Plus the policy framework based on the neo-liberal doctrines of market is a major hindrance.

    There is no effective center between the extreme left who want no market and all state and those at the extreme right who want no state and all market.

    The truth based on history is that policies that worked are something in the middle between center-left and center-right. When the center goes you will have major problems.

    While the country struggles technological evolution does not stop. It makes it even a more complex and difficult problem.

    Human life spans have doubled over the last century. Technology and science is primarily responsible.

    A country that lacks the resources for hard public goods and soft public goods has obviously not been pursuing a developmental policy.

    It speaks volumes about the necessity for effective statehood.

    That deep lack of the need for statehood is the biggest problem besetting the country. That makes the need for resources for the State the primordial challenge.

    That is a huge challenge for mindsets to be broken.

    To speed it up let the free market forces reign and that may force the contradiction to the surface. The failed state announcement of the ARRM could be signs of what is to come. To a lesser degree the dysfunctional state is prevalent all over the country.

    Left on its own it will fall. It will be bloody. The Ampatuan massacre and the suicide of Angelo Reyes may be portents of things to come.

    • This seems to be a recurring theme of yours, J_AG. I hesitate to respond given how off-tangent it seems, but I know for a fact that many have expressed agreement with your view that it is the elite that want to perpetuate the status quo to maintain cheap labor, etc. So I will for argument’s sake take your view on this.

      But first of all, allow me to correct something in your statement about the elite supporting liberal free market policies. If there is one thing that oligarchs hate, it is free markets. They would prefer limited competition, oligopoly if not outright monopoly.

      What is the antidote to oligarchy? Well it is in fact opening up of markets both economic and political.

      To steer the conversation back to the topic at hand, giving greater access to the poor for both information and products/services with respect to reproductive health will enable the masses to make better informed decisions about their future. It will break the stranglehold of several institutions over this market.

      The people need to pressure the political “elite” to grant them these rights however. I agree that it won’t happen if we simply rely on them to think in the nation’s interest given their short term frame of mind.

  • KG

    Jag says population is a non issue.
    After shooting down the thesis of the author he mentions other problems like land use, urban planning and economic concentration on metro manila.

    So let us go outside metro manila and open a can of worms.

    The lack of a legislated land use policy guidelines leaves the real estate developers to do what they want resulting to agricultural lands being turned into golf courses,subdivisions,malls and what not.

    What do we do with our agriculture, our department secretaries and under secretaries for the department are lawyers(or were lawyers like Art Yap). Where are the technocrats with agriculture degrees?Our farms have farmers with an average age of fifty.Give it ten years and we will have another crisis farmers will be sixty by then.

    There must be a way to entice children of farmers to become farmers if not many will just sell their farm lands to be the next mega mall or the next resort even with a land use law what will stop that from happening if people don’t want to be farmers?

    Now as to the remaining agricultural land available,we must realize that we have more coconut farms than rice farms.
    What do we do to develop the coconut industry that will benefit the farmers? The coconut farmer is the poorest among farmers.

    We have old farmers, we don’t have enough agriculture graduates in government (not only in government).We don’t have a land use law and even if we do, we suck at implementing laws.

    lumalayo na ako sa topic.
    yun lang po.

    • UP nn grad

      a policy seems to be quite slick.

      Do not allow Filipinos to own large-sized farms. It attracts controversy to allow Filipinos to own large-sized farms. (Abe Margallo…. cvj… where are you???? )

      BUT…. sell tens-of-thousands of hectares to China. I mean… lease, not sell. (Abe Margallo… cvj… where are you???)

    • As I was mentioning to J_AG population policy is multi-faceted. So when we use terms like overcrowding we have to define what we mean by them.

      Australia for instance has a population of 22M spread over 7.6M sq kms. That’s a mere 3 per sq km. One would think there would be no “overcrowding” here, and yet as its population is projected to reach 35M by 2050 people are questioning whether the land can support it.

      That is because what we call the “carrying capacity” of the land is limited by the water available(most of Australia is arid and dry). One can argue that you can increase this with desalination plants but those things cost a lot to build and operate. That additional burden has to be borne by existing taxpayers.

      Finally we haven’t even talked about linking this with labor markets and expected needs of industry. As I argued previously in this space, the trend over the past decade or two has been for less and less workers to produce the same output whether in agriculture, services or industry due to the same technological improvements that J_AG seems to be harping on about.

      We also haven’t discussed the fact that as people get richer, their dietary habits change. They start to demand more meat, which requires more energy and land to produce. So drawing up a land use policy is not that simple either.

      It is really a complex web of policies and issues that you have to deal with here. But that was not even the main point.

      Again let me reiterate the main point behind an RH bill is to improve health outcomes for women and children as well as for men (by preventing HIV/AIDS infection, a position which the Pope now endorses) and to facilitate intelligent well-informed choice on the part of couples in deciding the size of their families. A decision that both the State and the Church may seek to influence but ultimately resides with the couple to make.

      • KG

        Yes Cusp there will always be a web of complex policies and issues in every problem.

        One thing leads to another.You solve a problem another one appears like plugging leaks in a dike.

        Btw sorry for going out of topic.
        About the RH bill, Congress supported it but GMA did not.

        Now, the majority leader of the senate said he will always be against the RH bill.

        But is it justifiable to kill a bill if a strong lobby group will be against even with just one or two bullet points of a bill?

        Maybe it is better to kill a bill rather than mess up a bill like some of most of our laws which are a products of wheeling and dealing resulting to its being watered down, being half baked or whatever.

  • Population density of Makati and its Barangays

    HK and Singapore have close to 7k per sq km.

    Dhaka in Bangladesh is at 44k per sq m.

    manhattan in NYC is at 25K per sq km.

    Please note the disparities in population density between Forbes park and some barangays in Makati that are even more densely populated than Dhaka.

    Also check out the population density in Manila and not metro manila. Nationally the population density is 300 per km. Metro Manila is at 18K per sq km

    Draw your own inferences.

    http://www.makati.gov.ph/portal/contents/about_makati/city_profile/geographical/demographics-population.htm

    • Why are some locations densely populated and those areas are usually populated by squatters?

      At the turn of the country due to foreign and domestic immigration and rapid population growth of immigrants that began arriving since the 1860’s Manhattan, NYC had a population density of 100k per sq km. After the Civil War the black came from the South and settled in Harlem. The largest pop growth rates was registered amongst the blacks. In all Northern cities it was the same until the 70’s and 80’s. The civil rights battles for equal education under Brown versus Board of Education and then under Johnson’s great Society and in 2008 you have a Black president and blacks have gone up the labor value added chain.

      Today the largest demographic as far as population density in the States are among the Latinos mostly Mexican immigrants. From the black areas to the ghettos to the barrios. A combination of economic development and schooling and education changed the population equation.

      Why is the economic center of the Philippines centered on Metro Manila which is less in land area than Singapore? Explain that. Singapore has a larger land area than Metro Manila.

      There is no overpopulation problem in the country. The insane over concentration of the economy on Metro Manila is the problem. Labor will always follow capital. Both public and private.

      Who is the idiot that put the only rapid transit train along three major arteries. That will draw more people around these rapid transit routes. Look at Edsa. That goes for all classes of people.

      Today the population of Manhattan expands and contracts on every working day due to the rapid transit systems that extend to other States. 5-6M people spread out over adjoining states and boroughs commute.

      Where is land use plan and zoning plan or even the master the Metropolis. Ayala, Henry Sy and the rest of the real estate developers cannot accomplish this.

      The State is the primary provider of public goods.

      Does anyone realize the importance of that? How can you plan and build and deliver public goods if this is not attached to the overall plan for the economy.

      For the love of God the Romans build the roads the bridges and water systems in their time. They exist till today. That is how they conquered most of the Western World.

      The U.S. organized West Point because they needed to build the canal system and they needed a national engineering brigade. Till today the U.S. Army Corps of Engineers are responsible for maintaining all U.S. waterways. The U.S. Industrial heartland was in the North East and the canal system between the great lakes served as the transportation routes.

      From Michigan to Chicago, Indiana, Ohio Pennsylvania to New Jersey. Then the railroad West.

      That facilitated the internal migration.

      The cause of the problem is uneven economic development not overpopulation.

      Engineering the difference. That is what defines the industrialization process.

      You guys do not even know what technology means. it is the engineering/scientific process behind the machine or electronic gadget.

      Pinoys are not taught how to think.. they are taught how to memorize. There are no jobs here for engineers and scientists. They are not valued.

      Parts of the City of Rome still stand today. Apart from the rice terraces there is no engineering project that exists in the Philippines built and conceptualized by the Indios.

  • When a technorat makes a simplistic quantitative comparison between the Philippines and Bangladesh He will always fail to make a qualitative distinction.

    The population density in the Philippines spread over the lowlands, semi highlands and highlands.

    http://www.nscb.gov.ph/factsheet/pdf08/FS-200806-SS1-01.asp

    Now please compare it to Bangladesh with the geography of the country which is situated on a delta. Old Manila is similar to Dhaka -at or below sea level. Most of Roxas Blvd was formerly ocean.

    Compare the population of Dhaka with Metro Manila. Look at the gap in density in MM and even Makati. Just go to the Makati City Hall and check on the population densities of the rich enclaves of Makati.

    The transportation, water, electric grids are centered on MMetro Manila. Naturally it becomes a draw for rural migration.

    • “When a technorat makes a simplistic quantitative comparison between the Philippines and Bangladesh He will always fail to make a qualitative distinction.”

      I think you are falling into the same trap that you mention here by quoting your own stats. Population policy is a multi-dimensional thing, which is the point I was making.

    • GabbyD

      jag,

      what is your point? what is the connection between density and how a population program works (or not?)

      what is the QUALITATIVE DISTINCTION you want to make exactly?

  • Like so many Philippine superstitions, arguments against responsible birth education are puffs of imagination that become real because people think they are.

    What is real is that Philippine resources cannot feed all the mouths created by unrestrained birthing, nor can the economy create jobs to employ them. Church doctrine insists that the Philippines remain a “nation of servants”, shipping its excess bodies to other countries to find work, too often servile or abusive work.

    Common sense is in order here, not faith or superstition.

    • It’s not Philippine superstition per se that is at fault here. The religious right in America opposes this as well on religious grounds (unless you are referring to all religious beliefs as being grounded on superstition, in which case, it is not a Philippine phenomenon alone).

      I think however we are in agreement that we have to be sensible about our approach here. Bangladesh in a way had no choice. Theirs is one of the most densely populated countries if not the most. And climate change will badly affect them.

      One can argue as the CBCP does that the overcrowding in our country is a myth. Well, in comparison to Bangladesh probably. But if you consider the water requirements, power, employment, you might come to a different conclusion.

      Ultimately it is about the rights of couples to decide on the size of their family whether large or small. The manner by which the state ensures that those who want smaller families get to follow their choice, should not impinge on those who want large families.

      • Wow the Philippines is overcrowded. Once again spreading ignorance.

        Kindly check the population density of Singapore, HK, New Jersey and Manhattan against the density per sq. km in Manila, the Philippines.

        The world are urbanizing. Technology being applied to food production is throwing people off the farms.

        To narrow down the problems of this country to people having too much babies is an oversimplification at best.

        States whose government have been up to the job of inclusive development are doing it with minimal problems. However those with entrenched elite’s and weak governments are seeing the resource base of the country savaged.

        The environmental damage this country has suffered over the last 100 years of extractive policies is telling. Just look at Metro Manila.

        Human resources are the more critical parts of the ecology and is at the top of the ecological pyramid.

        The State has still to realize this.

        Schooling and training is one thing. Educating is another. Our entrenched elite’s and their agent technocrats have stopped educating themselves a long time ago.

        • “One can argue as the CBCP does that the overcrowding in our country is a myth. Well, in comparison to Bangladesh probably. But if you consider the water requirements, power, employment, you might come to a different conclusion.”

          Please don’t get your knickers all twisted over this statement that I made J_AG. All I meant to say was that there are probably many ways to define “overcrowding” and urban density of population is merely one of them. Your conclusions depend on your definition.

    • When one sees a hanging fast balls based on ignorance it is a sure home run.

      The WB did a study that the system of land ownership and economic policies contributed to the degradation of the resource base of the country.

      80% of the forrest cover is gone. Both illegal logging and the practice of clearing land for planting since land ownership was skewed to only a few.

      That in turn has devastated the supply of arable land in this country. The degradation continues.

      The normal evolutionary migration of rural to urban has resulted in the ever growing number of slums. Slums are growing constantly. The serious lack of jobs in a industrial sector that never took off is responsible. No industrialization – no climbing up the ladder of better value added jobs for the labor force the formation of domestic demand is stymied.

      The result is catering to the external demand for labor. What is clear that labor migration also changed with the demand for higher skills evolving.

      From field workers to professionals today. That is what is keeping the economy afloat. The road to middle income status was through this labor export policy.

      Population growth rate is slowing and the fertility rate is dropping as more people are getting to learn to mange their own families.

      However to try to compare the level of country consciousness between Bangladesh and the Philippines is wrong. Before World War II this country did not exist. It was born after numerous armed conflicts.

      A large part of the country lies at sea level and below sea level. naturally the resource base of the country is severely limited. Their government did pursue effective interventions in maternal health etc.

      Their crisis of resource lack is real. In a way the politics of the region created the problem. In our case it was self inflicted by our semi-colonial and feudal state of consciousness that still does not see that the resources of the country should be for the economic development of the country.

      That has proved disastrous in our own development of human capital.

      We still stupidly export crude industrial metals to other countries that will be transformed into finished goods that we import.

      Unfortunately the technocracy of this country see the problem as one of mechanisms who see humans as part of the machinery. Not of the ones who create the mechanisms themselves.

      Ergo is there is widespread poverty it must be because there is a surplus of labor because those who choose not to work volunteer not to do so are simply making babies.

      • You seem to be offended by my mere suggestion that we could learn something from the humble Bangladeshis. True, no two countries will ever be identical.

        That does not mean that their experience in policy development cannot be instructive to us as we grapple with it ourselves.

        By the way, are you suggesting that because things are not so dire here as it is over there, that we can afford not to have an RH policy? Will we wait until our situation becomes truly desperate before we finally act? I think that would be the most short-sighted thing to do.
        Maňana, maňana. Isn’t that what the Spanish taught us?

  • GabbyD

    cusp,

    the opponents NEVER said it wont work. they claim/said, it would cause other problems.

    • Yes, I agree GabbyD. In fact the critics are afraid that it might work all too well.
      The policy aim of the RH bill should not be misconstrued to be population control. If couples want to have large families, then they have the right to do so.
      The conservatives are afraid it would encourage promiscuity among the young. Again, if they are worried about that then they should as Fr Bernas argues ensure the legislation includes the rights of parents to determine what kind of sex education their kids get exposed to in school.
      What grown up consenting adults do, however, is another matter. No one can legislate for or against that, I am afraid.

      • UP nn grad

        actually, the CBCP has managed to legislate what grown-up consenting adults do (from the CBCP “we have to protect the youth” from books and magazines that mention fornication and with pictures of nipples and breastfeeding mothers). Pinoys-in-Pinas can’t seem to figure out how to break the CBCP’s hold on the adults of Congress.

        Failing to break CBCP’s hold on pictures of naked men and women, Pilipinas Congress totally unable to modernize Pilipinas libel laws. I still can’t believe a Pinas newsman got jailed for several months for a story on some mayor (or was it a congressman) caught in a hotel.

  • UP nn grad

    Pilipinas will have to get the Reproductive Health Bill into law without NoynoyAquino. NoynoyAquino may have used RH as part of his “..I am am modern leader, I will listen to the plaints of the Filipina”, but in the end, it was just a slogan.

    PresiNoynoy does not have a family. More importantly, the 50-year old bachelor has been too insulated from family health issues faced by Filipinas across all demographics. Depending on PresiNoynoy leads to little progress. Pilipinas will have to get the Reproductive Health Bill into law without NoynoyAquino.

    • Bert

      You mean, UP n, that you’re waiting for Villar or Gibo to become president, or you’re waiting for Gloria to be Prime Minister for the Philippines to have the Reproductive Health Bill into law?

      Those dudes who are your manoks are against the RH Bill, do you still remember? And Charter Change, your pet project, is not gonna happen, so, are you saying you’re going to wait forever?

      • UP nn grad

        Bert: a few Pinoys have escaped your viewpoint and way of thinking. A number of Pinoys-in-Pinas can ignore the color of the shirts they wore during elections-2010 because they share common beliefs. A few who are solid-rah-rah-Pro-Noynoy now discard-Yellow and belief in Noynoy leadership when it comes to putting priority to getting RH into law. A few who didn’t vote Noynoy-President (e.g. Beth Angsioco) were acknowledging noynoy-as-president-and-leader and had thought Noynoy was going to prioritize RH. Now they are wading thru the obfuscations from Malacanang and solid in realization Noynoy has to be bypassed.

        Oh, yeah… GMA Talsik Diyan!!!

        Marcos believers, too (some of them) are joining others who want RH as priority bill.