• Editors' Summary
• Credits

1. Why Informed Choice Matters
2. Making Family Planing Decisions
3. Policies for Informed Choice
• International Consensus for Informed Choice
• National Support for Informed Choice
• Policies That Promote Access
• Eliminating Targets, Incentives, and Disincentives
• Social and Economic Policies
• Donor Agencies
4. Communication for Choice
5. Improving Access
6. Managing for Informed Choice
7. Client-Provider Communication

• Figures
• Table
• Side-bars
• Bibliography

• What can be done?
• Women know what they want
• Why communities matter
• Eliminating targets
• More methods, more choices
• "Your health is in your hands"
• Do clients have choices?
• Please Ask!
• How much guidance?
• Active clients, better choices
• Counseling continuing clients

• POPLINE
• Media/Materials Clearinghouse
• Other Reports
• To Order
• CCP Home Page

Published by the Population Information Porgram, Center for Communication Programs, The Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA.

Policies that establish demographic targets, incentives, and disincentives in family planning policies and programs are undesirable because they focus on achieving numerical goals instead of meeting people's health needs. Explicit policies that constrain people's family planning choices are less common now than in the past. They continue to arise occasionally, however, and remain a concern (324, 443).

Targets. Such statistics as the number of clients served, couple-years of protection, continuation rates, and fertility rates can be valuable for management, planning, and projecting program needs (350). If they serve as programmatic or performance targets or goals, however, they jeopardize the principle of informed choice and threaten the rights of clients (1, 70, 255, 446, 449, 450).

Programmatic targets originated in the 1960s and 1970s, when some countries started national family planning programs out of concern that rapid population growth threatened national well-being and that people immediately needed to start having fewer children. Today most countries have abandoned such policies in response to objections from advocates for good-quality care and women's rights, and from others (207, 331).

Governments increasingly recognize that concerns about rapid population growth can be met best not by establishing demographic targets but rather by investing in better quality family planning programs that help people meet their own reproductive goals (388). For example, in March 1998 Peru reformed its family planning policies to remove programmatic targets that in 1997 had set the goal of performing 130,000 sterilization procedures for the year (71). This target had put pressure on local health centers to perform sterilizations even among women who did not consent. China's national family planning program, which pursued a “one-child” policy until the mid-1990s, has begun to offer more client-oriented services, and government regulations now prohibit family planning workers from imposing contraception on clients. Nevertheless, the central government has yet to fully implement the new policies, and many local practices have changed little (67, 333, 385).

Incentives and disincentives. Offering clients incentives and creating disincentives to influence people's choice of family planning methods can interfere with informed choice (207, 364), as can paying self-employed agents for recruiting clients (81). Most countries have never offered incentives or disincentives, while others have discarded them. Some programs, however, still reward clients who accept a contraceptive method (36, 261, 385). Family planning programs have offered clients money, goods, clothes, increased food rations, preference in housing, and similar inducements (261, 456, 476).

By far the most extreme population policy was in India between 1975 and 1977, when the government called a state of emergency, suspending civil rights (398). The government initiated a mass sterilization program, offering incentives such as road paving jobs for men and in some areas coerced thousands to undergo sterilization (456). These policies created a public backlash and led to a national fear of family planning. They also contributed to electoral defeat for the party in power in 1977 (207, 398).

There is debate about what constitutes an actual incentive. Some have said that payments to clients are justified when they help overcome fear and inertia to try reversible contraceptive methods (81, 406). Others have argued that payments are acceptable when they reimburse clients for their out-of-pocket costs of obtaining contraception, including travel or meals, because such payments are considered too small to influence the client's family planning behavior (338, 404). In Bangladesh, where family planning programs provide clean garments, subsidized food at the hospital, and the equivalent of US$3 to people who choose sterilization (226), the payment is intended to cover costs and compensate for lost work time. Whether these payments influence people's family planning decisions is unknown (225).

Disincentives usually have been designed to take effect after a couple has a specified number of children. Disincentives may include loss of maternity leave, restrictions on access to public housing, limits on schooling choices, and increased taxes (142, 340, 385). Iran's national assembly approved a law that went into effect in 1994 banning public benefits—such as paid maternity leave and social welfare subsidies to low- income women—for the birth of any child after the third (8).

Since disincentives in effect reduce a family's income, the poor feel their impact most (456). Some disincentives even focus on the “excess” children, penalizing children for the behavior of their parents (207). For example, the Indian state of Maharastra withholds subsidized food grains for the third child in an otherwise eligible family (381).

In Europe, where in a number of countries fertility has fallen below the replacement level of about two children per woman, governments have tried to encourage people to have more children by offering various incentives and disincentives (142, 251, 264, 452). In Romania from 1966 to 1989 the government imposed a tax on childless couples and limited access to contraception as pronatalist measures (97). Over the long term, however, policies that promote childbearing have had little effect (96, 314, 472).