Background


Mid-ICPH 2018 Background

Over the past 60 years, population control has become an increasingly urgent issue worldwide as a growing population strains already limited resources. It has been predicted by the World Resource Institute that the population will increase by 34% by the year 2050. Of this, over 90% increase will occur in the developing world. The prediction of population growth began as early as 1798 by Thomas Robert Malthus, who in his “Essay on The Principle of Population” (1888), wrote that the world population would continue to grow until they were limited by resources mainly, famine and diseases (Komu and Ethelberg, 2015).

Population control has come to be regarded as a kind of “leading sector” in the development process. Population controls according to neo-Malthusian are programs and policies with deliberate intention to decrease population growth. It is usually related to neo-Malthusian view and development plans where rising population is nega­­­­tively associated as a hindrance to national economic growth. Reduction of the current high rates of population growth is considered to be a necessary condition for economic development in the less developed countries (Kaler, 2004; Heil et al., 2012; Komu and Ethelberg, 2015)).

Family planning program has become the goal of most population control policies and interventions. The family planning movement has been a major contri­­­­­­­­­bu­tor of fertility reduction programs, aside from other conditions such as improved health, lowered mortality, and altered opportunity structure which make these contributions possible (Heil et al., 2012). It is the practice of control­ling the number of children in a family and the intervals between their births. The World Health Organization refers to family planning as the possibility of allowing indi­­­­­vi­­duals and couples to anticipate and attain their desired number of children and the spacing and timing of their births (WHO, 2012).

Family planning may involve consideration of the number of children a woman wishes to have, including the choice to have no children, as well as the age at which she wishes to have them.  Con­­­­­­­tem­­­porary notions of family planning tend to place a woman and her child­bearing deci­­­­­sions at the center of the discussion, as notions of women’s empower­­­­­­­­ment and repro­­­­­­­­­­ductive autonomy have gained traction in many parts of the world (Heil et al., 2012).

Family planning has profound health, economic, and social benefits for fami­­­­­­­lies and communities. It protects the health of women by reducing high-risk preg­­­nan­cies, protects the health of children by allowing sufficient time between preg­­­­­­nan­cies, reduces abortions, supports women’s rights and opportunities for edu­­­­­­cation, employ­ment, and full participation in society, and protects the environ­­­­ment by stabi­­­lizing population growth. Contraception is typically the primary compo­­nent of family planning programs, but programs often include other medical, educational, and soci­­­­­al activities, such as sexuality edu­­­­cation, prevention and management of sexually transmitted infections, pre-concept­­ion counseling and management, and infertility management (Heil et al., 2012).

Family planning renders positive impacts on maternal and child health as it can significantly reduce the risk of maternal, newborn, infant, and child illness and death by preventing a high-risk pregnancy in women with certain health conditions or characteristics, or by preventing an unplanned pregnancy. Women typically wel­­­­­­come pregnancy and childbirth, especially when planned. However, many preg­­­­nan­­­­­cies are unintended or mistimed, and the risk of illness and death associated with these events can be very high. Access to family planning information and services pre­­­­­vents unnecessary maternal death or illness due to an unintended pregnancy (fphandbook, 2017).

Family planning benefits families and communities. When couples have only the number of children they want, there are fewer children needing educational and other community services. Healthy children are better able to learn, which puts less strain on teachers and schools. Researchers have shown that personal savings and invest­ments increase when working parents have fewer dependents to support. Family planning results in smaller, healthier families that are better able to care for themselves. The health, education, and public services of communities are less bur­­­­­­­dened. It is also one of the most cost-effective and powerful strategies to empo­wer women and improve their lives. Women who are empowered to make choices about childbearing are more likely to get better education and job experience, and are more likely to contribute to the economic health of their families and commu­­­­ni­ties (fphand­­­­­­­­­­book, 2017).

Family planning benefits nations by enabling increased public spending per person in all sectors. Governments around the world are focused on combating poverty and achieving a range of health and development goals. Family planning contributes to achieving nearly all of these goals. Reducing the number of unplanned births and having smaller families helps to reduce the level of need for public-sector spending in health, water, sanitation, education, and other social services. Preventing unplanned pregnancy among HIV infected women is the most cost-effective way of preventing maternal to child transmission of HIV. Family planning helps nations to reach social and economic goals, beginning at the community level. Family planning is an important and cost-effective investment for governments and contributes to multiple economic and health priorities, including reducing poverty (fphandbook, 2017).

The success of family planning, however, has not been consistent across countries or even within countries. In some countries, the level of contraceptive use has remained low or risen slowly over the years. Developing countries aiming to build strong family planning programs often look to Indonesia as a model — and with good reason. The Indonesian Family Planning Program has been recognized as one of the successful program in the world. During the administration of former President Suharto in the 1980s-1990s, Indonesia was recognized as an international leader in family planning and reproductive health (Randall, 2012; Putjuk, 2014).

Back in the 1960s, Indonesian women routinely had six children, at least two of whom would die before reaching school age. Realizing that preventing rapid popu­­­­lation growth was important to both Indonesia’s future and to its family’s wellbeing, President Suharto signed the World Leaders’ Declaration on Population in 1967 and set up a family planning program. With the support of Muslim leaders, the country doubled its contraceptive prevalence rate to nearly 60 percent between 1976 and 2002, and halved its fertility rate from 5.6 to 2.6 children per woman. This undoubt­­­­­edly helped lay the ground­­­­­­work for Indo­­­­­ne­sia’s rapid and impressive annual eco­no­mic growth of at least 5 percent since 1980. President Suharto’s central role in the formation of the family planning program in the 1970s and 1980s, and his unswerv­­­­ing support for its imple­­­­­­mentation was internationally recognized in 1989, when the United Nations gave him its Population Award (Randall, 2012; Putjuk, 2014).

There are four reasons that contribute to the success of Indonesia’s family plan­ning and population program (Randall, 2012). First, there existed strong nati­­­onal leadership and high-level poliical will. Suharto apparently got right when he envisioned that any possibility of development would be choked by unrestrained population growth.

Second, the population program became a mass movement. It began as a top-down movement, but it soon became a bottom-up movement. During the Suharto regime, the family planning policy was practically forced, with program counselors knocking on doors to ask people, mostly women, to use contraceptives. Innovative organizing at the village level sustained the momentum of the program, and central to this process was a charismatic figure named Haryono Suyono. Signs proclaiming, ―Two Children are enough‖ were planted everywhere, and blue chromatic circles were imprinted on houses whose residents were practicing contraception.

Third, the program was integrated into income-support programs. One of the major reasons for successful expansion of village family planning groups in Indo­­ne­sia was the ability of National Family Coordinating Board (BKKBN) to come up with innovations to make these groups more attractive to village women that served as incentives for women to limit births. Making micro-credit available was one such initiative.

The fourth reason was an active government effort to recruit religious leaders to support the process. The role of the ulamas or Muslim leaders trained in Islamic doctrine and laws was critical in convincing Indonesia’s majority Muslim population, so the BKKBN initiated a sustained dialogue with them.

However, since 2006 there have been phenomena of flat trend in several indi­­ca­tors of the achievements on the Indonesian family planning program. Indo­ne­­­sia’s remarkable progress has recently stagnated. In the past decade, the country’s fertility rate has remained the same. Its CPR has risen a meager 1.5 percent, and its maternal mortality ratio remains high at 190 deaths per 100,000 live births. This is largely due to a complex decentralization and devolution process that shifted power over family planning programs from the national to the district level, leading to confusion around roles and responsibilities — and, at times, inaction (Hull and Mosley, 2009; Putjuk, 2014).

To address this stagnation, revitalization of family planning program in Indo­­­­­­­­ne­sia has been recommended. This recommendation is based on assessment on the past, present, and projection of family planning, reproductive health, and demo­­­gra­phic situation in Indonesia in asso­­ciation with change of the governmental system from centralization to decen­­tralization. This transformation of governmental system has also implicated on the policies and strategies on the implementation of family planning program. As such, there is an urgency to reformulate the family planning program in response to current dyna­­­­mic situation in this country. In line with the decen­­­tralization system, important role of local government to meet the needs of their community and better management on the family planning services has been emphasized (Hull and Mosley, 2009).

Since the 2012 London Summit on Family Planning, the Indonesian govern­­­­­­­ment has announced efforts to revitalize the country’s national family planning program. Among other things, the government is committed to (Putjuk, 2014):

  1. Strengthen the program at the provincial and district levels, to bolster local access to family planning.
  2. Provide family planning services and supplies free of charge as part of the country’s universal health coverage program that was launched in January 2014.
  3. Boost health worker training efforts, particularly around long-acting reversible methods.
  4. Improve 23,500 family planning clinics by the end of the year.
  5. Achieve a fertility rate of 2.1 children per woman by 2025.

These efforts are supported by a much stronger budget. In fact, the country’s allocation for family planning quadrupled from $65.9 million in 2006 to $263.7 million in 2014, and the government is committed to maintaining this investment (Putjuk, 2014).

Reference:

fphandbook (2017).  Promoting family planning. https://www.fphandbook.­org/­sites/default/files/chapter1_1.pdf. Accessed December 2017.

Heil SH, Gaalema DE, Herrmann ES (2012). Incentives to promote family planning. Prev Med. 55(Suppl): S106–S11.

Hull TH, Mosley WH (2009) Revitalization of family planning in Indonesia. The Government of Indonesia and United Nations Population Fund.

Kaler A. (2004). The moral lens of population control: condoms and controversies in Southern Malawi. Studies in Family Planning, 35(2), 105-115. doi: 10.1111/­j.1728-­4465.2004.00012.x

Komu EA, Ethelberg SN (2015). Family planning and population control in deve­­lo­­­­p­ing countries: Ethical and sociocultural dilemmas. Online Journal of Health Ethics, 11(1). http://dx.doi.org/10.18785/ojhe.1101.06

Putjuk HF (2014). Indonesia’s family planning program: From stagnation to revi­­­­­­ta­li­zation. https://www.devex.com/news/indonesia-s-family-planning-program-­from-stagnation-to-revitalization-84387. Accessed December 2017.

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