Experts: “Unmet Need” is Bogus
At the same time governments pledged billions of dollars to push contraception in poor countries
based on the idea of an “unmet need” for family planning, an elite group of experts dismissed the term as a poor measure of development aid’s effectiveness.“The usual numbers bandied about for estimates of ‘unmet need’ do not correspond to any definition of ‘unmet need’ that any economist (or just common sense) could agree to. They are an advocacy construct that has been successfully used in the overall political agenda for promoting family planning,” noted Harvard economist Lant Pritchett.The remarks were part of an online discussion hosted by Berk Ozler,
senior economist at the World Bank. Ozler noted that recent research has validated academics who argue family planning programs have little effect on fertility rates. He cited a recent study from Zambia showing that couples in traditional societies don’t use contraception even when given vouchers because they are already planning their family by other means.“A need with no demand might make sense for political activism, but not for programs or policies,”
said University of California San Francisco epidemiologist Dominic Montagu. He supported Ozler’s idea of abandoning the concept of “unmet need” and replacing it with a scientifically-based indicator such as actual customer demand.Pritchett emphasized the fact that “unmet need” is “predominantly” made up of women who do not want to use contraception due to religious or health reasons, or because they are past childbearing age or are celibate. “The fact that the movement has consistently attributed ‘need’ for contraception to women who have articulated reasons why they don’t want it reveals the paternalistic approach inherent in demographically driven family planning programs–we population bomb advocates can override what you want with what you need,” he said.
Population Council’s vice president John Bongaarts countered Pritchett citing a 1977 study from Matlab, Bangladesh to argue that contraception-based family programs can reduce fertility in traditional societies. But one of the researchers who worked on the Matlab study, Shareen Joshi, said that he agreed with Pritchett that “unmet need” should not be used as a rationale for family planning programs since it does not correspond to what any economist would call demand.
David Bishai, professor of public health at Johns Hopkins University added that “John Bongaarts incorrectly attributes all of the treatment effects on household wealth to family planning–the Matlab treatment included a large array of child and maternal health services in addition to family planning.”
Bishai said using “unmet need” as an indicator for development investment is only “slightly better than randomly throwing money at reproductive health goals.” “One point of unmet need reduction is worth 0.02 points of TFR [total fertility rate] reduction, not controlling for any other variables that would confound the relationship,” a very small effect, he said. In his comments, Bishai argued that it makes no economic sense that USAID spent $649 million on family planning in 50 countries in 2010 but ignored the other factors that affect fertility such as the desires of spouses and children.
“Finite donor resources force the question of return on investment on family planning [as it does] everywhere else,” Bishai continued, “It should not be dodged by sanctimony or blind advocacy. There is an important stewardship role for all spending on behalf of the poor. …The research community can do better [than “unmet need”] to guide policy, but we haven’t done it yet.”