Report No. 724a-TH The National Family Planning Program A Sector Report Thailand HLE COtPY Public Disclosure Authorized November 3, 1975 Population Projects Department Not for Public Use U Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Document of the World Bank This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS Currency Unit = Baht (#) US$1.00 = % 20.00 US$1 million = g 20 million g 1.00 = US$0.05 i 1 million = US$50,000 INITIALS AND ACRONYMS ANM = Assistant Nurse Midwife ARD Accelerated Rural Development AV = Audio-Visual CBFPS = Community-Based Family Planning Services CBD = Community-Based Delivery CBR = Crude Birth Rate DEIDS = Development and Evaluation of Integrated Delivery Services DSCS = Development Support Communications Service (UNDP) H.C. = Health Center IEC = Information, Education, Communication IPPF = International Planned Parenthood Federation (London) MCH = Maternal and Child Health MCH/FP = Maternal and Child Health/Family Planning MOI = Ministry of Interior MOPH = Ministry of Public Health NESDB = National Economic and Social Development Board (formerly designated the NEDB) NFPP = National Family Planning Program NRR = Net Reproduction Rate PPAT = Planned Parenthood Federation of Thailand RTG = Royal Thai Government UNFPA = United Nations Fund for Population Activities USAID = United States Agency for International Development WHO = World Health Organization Thai Name Administrative Units Number English Equivalent Changwat Province 70 Amphoe District 516 Tambon Sub-District 4,600 approximately Muban Village 45,000 approximately Estimated GNP ner capita (1972): US$220 THE GROWTH OF THAILAND'S POPULATION, 1850 - 2000 Populat. in Millions 1102 A - 107.4 million 100 2 9o 7 a- 89.6 million 80_E _ _ A - If 1970 fertility continued B- if 50% decline in 70 - fertility by 2000 C- If fertility declines 65.7 million as fast as assumed 60 - by Thai targets for 1976 and 1981. 53 ** i 50 -5 40- 30- 20~ ~~ ~ ~ ~ ~ ~ ~~~~~~. 10 '850 1911 1919 1929 1937 1947 1960 1970 1980 1990 2000 YEAR ;1911 1970 sho~* census years) World Bank-9567(R) (I 91 1 - 1970 show census years) Definition of Demographic Terms Acceptors Persons accepting the practice of contraception. Average Family Size = Average number of persons in the family, i.e., surviving children and parents. Age-Specific Fertility Rates = Number of live births per year to 1,000 women in five-year age group during 15-49 years. Crude Birth Rate Number of live births per year per 1,000 of population. Crude Death Rate = Number of deaths per 1,000 of population. Dependency Ratio Number of persons of 14 years or under, plus 65 or over, divided by the population 'aged 15 to 64 years. A frequently used but not very satisfac- tory measure of the balance between non-producing and producing members of society. Expectation of Life at Birth Average number of years an infant, exposed to a given set of mortality rates, is expected to live. General Fertility Rate = Number of live births per year per 1,000 women aged 15-49 years. Gross Reproduction Rate = The average number of daughters a woman will bear if she experiences a given set of age-specific birth rates throughout the reproductive ages, with no allowance for mortality over this period. Infant Mortality Rate = Annual deaths of infants 0-12 months per 1,000 live births during t:he same year. Maternal Mortality Rate = Number of deaths as a result of complications of pregnancy, childbirth and the puerperium, per 1,000 live births. Net Reproduction Rate = Same as the gross reproduction rate but adjusted for mortality of women over their reproductive years. A net reproduction rate of 1.0 when reached, indicates that the country will be able to reach zero population growth rate after five to six de- cades. The population continues to increase after NRR has reached 1, because of the "above-replacement daughters already born after the NRR fell to 1.0. Rate of Population Growth = Rate of natural increase adjusted for (net) immi- gration or emigration. Rate of Natural Increase = Difference between crude birth and crude death rate --usually expressed as a percentage. Total Fertility Rate = The average number of children a woman will have if she experiences a given set of age-specific birth rates throughout her reproductive life. A good in- dex to measure fertility changes as it is indepen- dent of age and sex distribution. THAILAND THE NATIONAL FAMILY PLANNING PROGRAM: A SECTOR REPORT FOREWORD 1. This report brings together in one document a considerable amount of information about Thailand's demographic situation and the Government's National Family Planning Program. Although much is already known about these matters, an independent review of the program seemed timely in view of the approach of the Fourth Five-Year Development Plan (1976-81). Con- sequently, the Government invited the Bank to conduct a Sector Review which might assist it in preparing the Fourth Plan and which might also help external donors, including the Bank, to formulate their plans for financing population activities during the next Plan period. 2. As readers will quickly learn, the Sector Review mission formed a high opinion of the National Family Planning Program. The Program has in fact achieved a rate of family planning acceptance whic:h is exceeded by only four or five developing countries. A number of reasons appear to explain why the Program is working so well. One major reason is the flex- ible, pragmatic way in which the Ministry of Public Health has dealt with questions of technical and administrative policy involved in the adminis- tration of specific family planning services -- an area of great importance to the availability and accessibility of services. Another reason is t'he existence of a health network that is relatively well-developed, despite the fact that many people still live beyond its present reach. A third major reason for Program success is the high quality of foreign technical assistance, and the large amounts of grant assistance which external donors have provided to help get the Program started. Finally, Thai culture seems unusually receptive to family planning; Chapter III of the full report tries to describe why this is so. 3. The family planning Program in Thailand, unlike that in many countries, is characterized as supply-constrained rather than demand-constrained. This means that for the next few years more new acceptors can be recruited by extending and improving the system for delivering family planning services than by trying to educate and motivate people who are already within range of services but who for one reason or another do not choose to use them. The report does not dismiss information, education, and communication activ- ities as unimportant; far from it. But for the next few years, continuing attention to the extension of services seems more important than worrying about a limiting lack of demand. The report pays considerable attention to the various channels available for the delivery of contraceptives and other family planning services. It urges that the National Family Planning Program adopt the broadest possible definition of the Program so that strategic plan- ning will not overlook networks, private as well as public, which can serve as resources for attaining national population objectives. - ii - 4. The service network of the Ministry of Public Health is likely to remain the dominant delivery network in the total system, accounting for well over half of all active users of family planning services. Neverthe- less, major contributions to national objectives can be made by the private commercial sector, by Government health-delivery networks outside the Ministry of Public Health (notably the University hospitals, the Ministry of Interior, and the Bangkok Municipality) and by the promising but still unproven Community-Based Distribution experiments which have recently started. The primary role played by the Ministry of Public Health means that the expansion of its network will be of great importance to the spread of family planning, although the report emphasizes that expansion decisions should be based primarily on broader considerations of health services delivery. One major extension of the health-delivery system that may be of great importance for family planning is the Ministry's plan to appoint a large number of village health volunteers. This new class of part-time health auxiliaries would be authorized, after suitable training, to distrib- ute pills and other contraceptives. 5. The report sees no need for any major organizational changes in the Program. Some minor changes, plus some increase in permanent staffing, are considered necessary. As the Program will expand in size by about 75 percent by 1981, more money will be needed. The present National Family Planning Program (even when broadly defined) is not now an expensive activity (about Bt.100 million per year = US$5 million) and is unlikely to become so. Asubstantial share of total costs can be, and are being, paid for by clients, just as for most health services in Thailand. Nevertheless, the Government budget faces sharply higher allocations for family planning during the Fourth Plan, partly to meet the costs of program expansion and partly because the Government is expected to take over from external donors a much higher proportion of total program costs, now carried 80-90 percent by foreign grant assistance. Even if the family planning appropriation expands by 400 percent during the Fourth Plan, it will still account for only about 7-8 percent of the Ministry of Public Health's 1981 budget. This is an insignificant fraction of the overall Government budget, especially for a program of such importance to the long-run future of the country.