International Financial Institutions and Population Programs: A Survey of Current Activity

International Financial Institutions and Population Programs: A Survey of Current Activity

98-303 F
CRS Report for Congress
Received through the CRS Web
International Financial Institutions and Population
Programs: A Survey of Current Activity
March 27, 1998
Jonathan E. Sanford
Analyst in International Political Economy
Foreign Affairs and National Defense Division
Congressional Research Service ˜ The Library of Congress

ABSTRACT
This report examines the population or family planning activities financed by the
international financial institutions (IFIs), based on a survey of their activities. Only the
World Bank and the Asian Development Bank currently fund family planning projects. The
regional multilateral development banks do not fund projects in this area. The International
Monetary Fund also does not finance projects. Brief reference is made to the international
framework for family planning activity approved by the International Conference on
Population and Development, held in Cairo in 1994. Tables are included listing all family
planning programs funded by the World Bank and ADB between 1993 and 1997. The report
will be updated if the IFIs should institute significant policy changes in this area.

International Financial Institutions and Population Programs
Summary
Congress has been considering legislation to approve U.S. participation in an
expansion of the financial resources of the International Monetary Fund (IMF) and
to appropriate annual funding for the multilateral development banks (MDBs). In
that context, Members of Congress have raised questions whether the international
financial institutions (that is, the IMF and MDBs) finance population or family
planning programs and whether their programs in this area finance abortion. This
paper describes the policies and the activities of the IMF and the multilateral banks
in this regard.
The International Monetary Fund does not finance projects in its borrower
countries. In particular, it does not finance projects aimed at helping countries
provide family planning services or other activities aimed at limiting the growth of
their population. The United Nations Conference on Population and Development,
held in Cairo in September 1994, identified a number of important issues and
highlighted roles that bilateral and multilateral agencies could play regarding this
issue. It did not specify any role for the IMF in this issue. The IMF Managing
Director, in his address to the Conference, emphasized that rapid economic growth
was a principal means for cutting the link between poverty and rapid population
growth and for creating the domestic environment in which countries could
“complete the transition to appropriate fertility levels.”
The World Bank and Asian Development Bank (ADB) regularly lend to help
countries undertake family planning and population programs. Between 1993 and
1997, the World Bank lent an estimated $870 million and the ADB allocated $65
million for family planning activities. This was approximately 1% of total World
Bank lending and two tenths of 1% of ADB total lending for this period. In recent
years, the World Bank and ADB have moved from funding free-standing family
planning programs towards programs that treat family planning as one element in a
more comprehensive health program. The ADB does not finance abortion and it
normally allows other foreign aid providers to fund the purchase of contraceptive
materials. The World Bank finances the purchase of contraceptives. In recent years,
the World Bank has begun to shift its focus in the health sector from one of
supporting specific autonomous projects to one of supporting comprehensive multi-
donor programs to strengthen national health care systems. In the process, in
countries where abortion is legal and abortion services are supplied by government
health providers, Bank loans may help support institutions that provide that service,
notwithstanding a general understanding that the Bank does not fund abortion
programs. One instance has been identified where the World Bank has financed the
purchase of suction equipment with the explicit understanding that it will be used for
the medical termination of pregnancy.
The Inter-American Development Bank, European Bank for Reconstruction and
Development, and African Development Bank do not finance family planning or
population projects.

Contents
International Monetary Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The World Bank . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
World Bank Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Current Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
World Bank Funding for
Family Planning Programs, 1993-1997 . . . . . . . . . . . . . . . . . . . . . . . . . 8
The Asian Development Bank . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
ADB Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Current Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ADB Funding for Family
Planning Programs, 1993-1997 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Other Multilateral Banks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
List of Tables
Table 1. World Bank Lending for Population and
Reproductive Health Activities (RHA), 1993-1997 . . . . . . . . . . . . . . . . . . 15
Table 2. Asian Development Bank Lending for
Population Programs, 1993-1996 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

International Financial Institutions and
Population Programs
In 1997 and 1998, Congress has been considering legislation to approve U.S.
participation in an expansion of the financial resources of the International Monetary
Fund (IMF) and to authorize annual funding for the multilateral development banks
(MDBs). In that context, some Members of Congress have raised questions about
whether the international financial institutions (IFIs) -- that is, the IMF and MDBs --
finance population or family planning programs and whether their programs in this
area finance abortion. This paper describes the policies and the activities of the IMF
and the MDBs in this regard. In particular, it analyzes several projects that the
multilateral banks have said are exemplars of their activity and their approach to
population or family planning issues.
Development is, by its very nature, a process entailing fundamental change.
Development agencies often act as catalysts, urging or pushing countries to consider
changes in their perceptions, policies, procedures, and priorities. Along this line, the
international financial institutions (IFIs) often make a significant effort to encourage
countries to consider new ideas and new ways of dealing with their problems.
Even so, the international financial institutions (IFIs) are hesitant about
imposing social or cultural values on countries. Governments may be unwilling to
accept the imposition of values that contradict their countries’ basic cultural norms,
and the backlash against pressure of this sort can have a far-reaching negative effect
on the an IFI’s relationship with that country.
Additionally, borrower countries have considerable influence within the IFIs
themselves. In the Asian Development Bank (ADB), Inter-American Development
Bank (IDB), and African Development Bank (AFDB), regional countries own a
majority of the voting stock and have substantial influence. In the European Bank
for Reconstruction and Development (EBRD), the borrower countries (or non-
regional countries that are borrowers from other MDBs) control only 12.7% of the
voting stock. However, Western European countries that share close cultural
similarities with the borrower countries in Eastern and Central Europe own an
additional 65% of EBRD voting stock. Industrial countries own a majority of the
voting stock in the IMF and all the loans windows of the World Bank. But
developing countries have a significant share of the vote -- 39% in the IMF, 43% in
the International Bank for Reconstruction and Development (IBRD), World Bank’s
market-rate loan window, and 38% in the International Development Association
(IDA), the World Bank’s concessional loan facility. This gives the borrower
countries considerable influence, as well as a sense of participation and ownership
that encourages cooperation and helps diminish potential donor-recipient tensions
within the multilateral bodies.

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The IFIs do not implement projects or programs directly. Rather, they help
finance programs or projects implemented by their borrower country governments
or the governments’ subsidiaries or designees. The IFIs may have a substantial role
in the project design process. They may require, in connection with structural
adjustment loans, that borrower countries adopt economic policy reforms the latter
find painful. For project loans, the IFIs may require borrowers take financial,
technical, organizational, or legal steps deemed necessary for the success of
proposed project. These conditions are generally related to the goal of project
effectiveness and normally consistent with the principle set forth in their charters,1
that “only economic considerations shall be relevant to [IFI] decisions.”
In general, the international financial institutions are sensitive to the cultural
values and religious belief systems of their borrower countries. Considering the
influence that borrower countries have in the banks and the stipulation that only
economic considerations should be relevant, the IFIs tend to be circumspect about
issues likely to offend the cultural or moral sensitivities of their borrower countries.
This is particularly true as regards issues such as family planning. Developing
countries vary considerably in their attitudes and cultural norms. Activities and
policies that are deemed acceptable or appropriate in some developing countries are
not acceptable in others. It is in this context that the multilateral agencies finance
their social sector lending.
International Monetary Fund
The IMF does not make projects loans and, in particular, it does not make loans
to finance population or family planning programs. IMF loans are intended to help
the borrower countries stabilize their economic situation and cover (and ultimately
reverse) chronic deficits in their balance of payments. Generally, a country’s central
bank is the borrower and recipient of the IMF funds. It uses the proceeds to help
cover the country’s international payment obligations (debts, imports, etc.). To
receive an IMF loan, the borrower country must file a letter of intent with the IMF,
describing the steps it will take to rectify its economic situation. When the IMF
approves a loan, it opens up a line of credit for the borrower country and it disburses
money against that line of credit when the country shows that it has met the targets
and schedule specified in its letter of intent.

In April 1994, the joint IMF-World Bank ministerial committee on the transfer
of resources to developing countries (Development Committee) discussed issues
relating to the upcoming United Nations Conference on Population and
Development, held in Cairo that September. The participants on the Development
Committee are high ranking financial officials (Minister of Finance or equivalent) in
their home countries. The press communique issued following the Development
Committee meeting reported that the participants agreed that the world’s population
was likely to double in the next fifty years, if it continued growing at its present rate,
and they said the “massive economic, social, political, and environmental
1See, for example: Articles of Agreement of the International Bank for Reconstruction and
Development. Article IV, Section 10. TIAS 1503; TIAS 5929.

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consequences of these changes cannot be ignored.” The ministers agreed that people
should have the right to decide freely and responsibly on the number and spacing of
their children. They also said that “family planning is only one of the available
instruments and needs to be seen in the broader context of changing social patterns
and the increased awareness of women’s role.” The ministers agreed that more
emphasis should be given to improve the primary school enrollment rate, improve
access to family planning and related health services, and to reduce maternal and
child mortality in developing countries.2

No functions for the implementation of these goals were specified for the IMF.
The Ministers approved of the fact that the World Bank had increased its lending for
population, health, nutrition, and education programs and they welcomed the Bank’s
willingness to respond to further requests in those areas. They said they recognized
“that the Bank is not the principal organization concerned with population, but that
its policy dialog and wider operations give it a unique opportunity to promote
population policies.” They called on the Bank, donors, other multilaterals such as
UNFPA and borrower country governments “to collaborate fully in operations and
in mobilizing the institutional and financial resources needed....”3
The press communique issued following the Development Committee’s October
1994 meeting reports that the ministers “welcomed the outcome of the recent United
Nations Conference on Population and Development” and they “called on the World
Bank and conference participants to play an active role in implementing the Program
of Action approved by the Conference.4” No role was specified for the IMF. The
IMF annual reports for 1994 and 1995 reprinted the press communiques issued by the
Development Committee as well as copies of resolutions adopted by the IMF Interim
Committee and the IMF executive board during those years.
The IMF has made no official statements regarding family planning or
population policy. The closest thing to this may be the address 5 to the 1994
population conference in Cairo by IMF Managing Director Michel Camdessus, in
which he noted that rapid population growth in the context of poverty was the source
of many serious problems. The central concern, he said, is the need for more
economic growth. This will raise living standards and “create the domestic
environment needed to complete the transition to appropriate fertility levels....” To
achieve high-quality growth, he maintained, countries need sound macroeconomic
policies, appropriate structural policies, a trade and exchange regime open to
international trade and investment, good governance, and effective social policies
2Joint Ministerial Committee of the Boards of Governors of the Bank and the Fund on the
Transfer of Real Resources to Developing Countries (Development Committee). Press
Communique. Forty-eighth Meeting, Washington, April 26, 1994. Reprinted in the IMF
Annual Report, 1994, pp. 204-5.
3Ibid., p. 205.
4Development Committee. Press Communique. Forty-ninth Meeting, Madrid, October 3,
1994. Reprinted in the IMF Annual Report, 1995, p. 214.
5Address by Michel Camdessus to the UN International Conference on Population and
Development, Cairo, September 5, 1994. Photocopy supplied by IMF External Relations.

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that militate against poverty, provide education for girls and women, and enable
people “to exercise freely and responsibly their rights of parenthood, including the
number and spacing of their children.” The principal focus of his remarks addressed
the need for improved economic policies in developing countries and international
cooperation to create a more open world economic system.
Except for the above references to action by the Development Committee, the
IMF does not mention population or family planning in its recent annual reports. No
action by the executive board on this subject is mentioned and no publications or
studies on this topic are listed in the back of its annual reports.
The World Bank
World Bank Policy
The World Bank regularly lends to help countries undertake family planning
programs. It has made loans for this purpose from its market-rate loan window, the
International Bank for Reconstruction and Development (IBRD), and from its
concessional loan facility, the International Development Association (IDA). The
International Finance Corporation (IFC) and Multilateral Investment Guarantee
Agency (MIGA), the Bank’s affiliates oriented towards private sector activity, have
not been active in this area.
The World Bank published a book in 1994,6 in connection with the population
conference in Cairo, outlining its position regarding population programs. It makes
five basic points: (1) slowing population growth is still a high priority in the poorest
countries; (2) population policy should be integrated with social policies that address
a range of poverty reduction and human development objectives; (3) population
programs should provide the poor with access to high-quality, user-oriented services
that offer a range of choices for fertility regulation and other reproductive health
needs; (4) country specific strategies are required; and (5) other demographic issues
such as urbanization, migration and aging must also be addressed. The book says
there is a growing consensus “that population policy objectives should be integrated
with broader social development goals and that population program strategies should
build on the linkages between demographic behavior and social and economic
progress.” In particular, it says, “interventions which are responsive to individual
needs and aspirations are not only better from a humanitarian and social development
perspective but also more effective in lowering fertility than are programs driven by
top-down demographic targets.”
For the most part, the book treats the prevalence of resort to abortion as an issue
of concern, especially the use of abortion as a means of fertility control in some
countries (Ukraine, for example) with moderate rates of population growth. It also
notes that women in poor countries may resort to abortion when the inadequacies in
available methods leads to contraceptive failure. The book argues that the level of
6World Bank. Population and Development: Implications for the World Bank. Washington,
D.C., August 1994.

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contraceptive use will go up, the health of women will be improved, and rates of
abortion will go down if women and girls are educated, if family planning becomes
an aspect of basic health programs and if patients are able to select (from a range of
modern methods) the birth control methods most appropriate for themselves. The
book notes, in box 1-1, that the idea of offering project staff or prospective recipients
financial inducements in order to achieve numerical targets for the use of specific
birth control techniques is controversial and dubious. It says that targets, if needed,
“should be stated in terms of the proportion of individuals who are provided with
quality services” rather than specific reductions in the fertility rate or adoption of
particular methods. The book also argues, in box 6-2, that services for the
management of unwanted pregnancy, including “medical termination of pregnancy
(where permitted)” is part of the “essential women’s health package” it recommends.
It says in the text that the “components of the package will vary on a country-by-
country basis, depending on local needs and institutional and financial capacity.”
In his introduction to the volume, Armeane Choki, then-vice president for
human resource development and operations policy at the Bank, emphasized the need
for action to reduce maternal and child mortality in developing countries, to increase
women’s education, and to raise their economic and social status. “Such investments
are beneficial in their own right,’ he said, “and will also help slow rapid population
growth.” Likewise, he said, sustainable economic growth is a “prerequisite for
human development and for completion of the demographic transition.”
Current Practice
In its 1997 annual report, the World Bank indicated that it is trying “to more
closely link population policies with reproductive health policies, thus integrating
them into poverty reduction effort and the overall development agenda.” It said that
two projects approved that year, a $100 million loan to Argentina and a $248 million
loan to India, illustrate this approach.
The Argentine loan helps fund the second phase of the country’s maternal health
and child welfare program. All provinces that elect to participate in the Argentina
government program must provide the same package of services. The program aims
to reduce the rates of childhood and maternal mortality in Argentina through
immunization, improved nutrition, and better prenatal, neonatal, and post-partum
maternal care. It also provides family planning services. The World Bank estimates
that approximately 31% of the money from the loan will be used to fund reproductive
health activities. It has no separate figure for family planning alone. Spokesmen for
the potential beneficiaries and for relevant non-governmental organization (NGOs)
are supposed to participate in the design and implementation of the program. There
is no indication in the project documents7 whether particular birth control methods
will be emphasized or whether project staff will receive incentives to encourage
increased utilization of this aspect of the program. The documents seem to suggest,
however, that women’s participation in the family planning aspect of the program
7World Bank. Project Appraisal Document for a Proposed Loan in the Amount of US$100.0
million to the Argentine Republic for a Second Maternal and Child Health and Nutrition
Project. April 24, 1997. Report 16419-AR.

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will be voluntary. The private sector provides most of the medical care in Argentina.
Government programs are basically supplemental and directed at specific needs.
Abortion is not legal in Argentina.
The loan to India helps finance an expansion of the government’s Family
Welfare Program in 19 rural or tribal areas and 7 urban slums. The combined
population of the areas to be served is about 36 million persons. According to the
World Bank project appraisal document,8 the project aims at “reducing maternal and
infant mortality and morbidity, and unwanted fertility, thereby eventually
contributing to stabilization of population growth.” It focuses on helping women and
children below five years of age by improving health during reproductive years and
early childhood and by enabling couples to space or limit births.
The total cost of expanding the Family Welfare Program through this project is
about $309 million over five years, of which $284 million will be provided by IDA.
The World Bank says the Family Welfare Program is a component of the Indian
government health care system. When all other costs are included and allowance is
made for the input by the national and state governments and other donors, the World
Bank estimates that it is financing about 15% of the cost of the health care system.
The Indian project will reportedly use a “participatory management approach”
to family planning. The project appraisal document says this model, previously
called the “target free” approach, “removes management incentives that have placed
excessive focus on achieving annual method-specific contraceptive acceptor targets.”
The removal of all such targets or incentives by the Government of India is a
specified condition the World Bank required for execution of the loan. The World
Bank document says that different types of contraception will be available, depending
on the preference of the user, to meet the needs of people at different stages of their
life cycle. “It is the central hypothesis of the project that a more client-oriented
service which offers greater contraceptive choice and the ability to give attention to
reproductive health needs will, together with reductions in infant and child mortality,
increase the utilization of family planning services.” In effect, it says, this means a
shift away from permanent methods (sterilization) to temporary methods, which
allow control over the spacing of births.
The India loan document provides a comprehensive description of the Family
Welfare Program’s “package of essential RCH [reproductive and child health]
services” that will be provided by the project. In the section outlining procedures for
the prevention and management of unwanted pregnancy (p. 105), it mentions oral
contraceptives, condoms, tubal ligations and vasectomies, IUDs (with required
screening for contraindications), and counseling and medical termination of
pregnancy within first trimester or referral to a district health center for termination
of pregnancy in the second trimester.9 NGO and private sector services will be
involved in the delivery of services, though the public sector will continue to play the
8World Bank. Project Appraisal Document, India Reproductive and Child Health Project.
April 29, 1997. Report 16393-IN.
9 Among the items to purchased in conjunction with the project are “suction apparatus
(equipment) for the medical termination of pregnancy” (p. 36).

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central role. NGOs and beneficiaries will be involved in monitoring implementation
of the program. The World Bank estimates that half the proceeds from the $248
million loan will be used for reproductive health activities. No separate figure for
family planning is available. Because of the high levels of poverty, government-run
programs account for a substantial share of the medical care available in India.
Abortion is legal in India and is regularly available through the health care system
administered by the national government or by individual Indian states.
The Indian loan underscores what seems to be an emerging trend in foreign aid
funding in the health sector -- consolidated multi-donor funding for general health
care systems rather than targeted single-donor funding for specific activities.
According to the World Bank, foreign aid donors often have focused in the past on
particular diseases or on specific issues, such as immunization, family planning,
nutrition, maternal and child health, or family planning. Separate administrative
structures needed to be created to administer each program, in order to assure that
project funds were used for only the designated purposes and to guarantee that the
policy or procedural requirements for each donor were met. The result could be a
hodgepodge of fiefdoms, where programs addressing the same problem could have
different requirements, depending on the source of funding, and the recipient
country’s ability to fund its overall health care system could be limited by the
requirement that it provide local currency counterpart funds to match the foreign aid
money provided for the special programs. Because the overall composition of the
health care system was often beyond the scope of their individual projects, foreign
aid donors sometimes lacked opportunities to address general issues of priority and
emphasis. Countries could use their own money to finance high-tech medical
treatment facilities for elites, for example, while expecting foreign aid agencies to
help cover the cost of basic care for the general public.
The move towards consolidated funding is reportedly an effort to remedy this
situation. The recipient country government includes the issues of special concern
in its national health care system and the donor agencies each agree to underwrite a
specific share of the system’s cost. As long as items are on the approved list of
goods and services that will be financed and they meet the procedural requirements
for procurement (international competitive bidding), for example, the World Bank
will disburse funds to support its agreed percentage share of a particular aspect of
the Indian care system.
From an operational or administrative perspective, the many development
specialists view this new approach as an improvement. It is more efficient, it
involves less micro-management, and it gives the World Bank and other foreign aid
providers opportunities to influence the overall composition of the countries’ health
care systems. From a policy perspective, however, the new approach limits a foreign
aid donor’s scope of policy choice. In the past, there was a general understanding
that the World Bank did not finance abortion in its family planning or population
programs. If a developing country wanted to include abortion on its menu of possible
services, it could seek bilateral funding from countries that offered such assistance.
Under the new approach, however, the World Bank and other donors all finance a
share of all the medical services provided by the national health regime. If abortion
is one of the medical services the system offers, then in effect the foreign aid donors
will finance a share of that service along with the other system costs.

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In the case of the India loan, the World Bank seems to have accepted the idea
that the Indian government should make the basic policy decisions in this area, even
though it will be paying roughly 90% of the costs for the particular functions covered
by the loan, and it stated in the project document that the suction equipment financed
by the loan (equipment that can have non-abortion related medical uses) would be
provided for the purpose of medical termination of pregnancy. World Bank staff
argue that they do not advocate abortion or believe that it is an appropriate birth
control technique. They say the Bank-funded family planning programs such as the
one in India are likely to reduce the incidence of abortion because they assure women
access to adequate contraception. They also say that other Bank programs, such as
education for girls, have an intended effect over time in reducing the incidence of
abortion. They say the Bank will not allow its funds to be used for sex-selection
activities or to fund population programs in countries where such practices are likely
to be supported.
World Bank Funding for
Family Planning Programs, 1993-1997

The World Bank reports that, between 1993 and 1997, all but 14 of its 106
loans in the Population, Health and Nutrition Sector and 2 of the loans in its Social
Sector involved reproductive health. (Population and family planning activities are
included in the total for reproductive health activities. Since 1995, the World Bank
has not regularly reported figures for population programs alone.) Table 1 (at the end
of this report) shows all the loans since 1993 that reportedly help fund reproductive
health activities. The total amount for the 94 loans was $7.08 billion; the Bank says
that $1.96 billion of this funded reproductive health activities.
Analysis of the data suggests, however, that the World Bank’s emphasis on
family planning and reproductive health is probably less than these figures would
suggest. Four of the projects on Table 1 dealt only with the prevention and treatment
of sexually-transmitted disease (AIDS, etc.), clearly an important issue but a different
one from the subject addressed in this report. Several other projects (some of them
very large) had no reported outlays for reproductive health. These are shown as NA
(“not available”) on the table. It is not evident why the World Bank included them
on its list. Furthermore, of the 70 projects designed to finance the delivery of health
services, only 33 allocated a third or more of their resources for reproductive health.
Many devoted only a small fraction for this purpose.
In 1993 and 1994, the World Bank channeled into population or family planning
programs some 75% of the $446 million it lent to fund reproductive health activities
other than those targeting sexually transmitted disease. If this trend continued during
the period 1995 through 1997,10 then one can estimate that $870 million of the $1.18
billion the World Bank lent for reproductive health programs other than the
suppression of sexually transmitted disease during those years went to fund family
planning. For the period 1993 through 1997, the total would be about $1.21 billion.
10This assumption may not be sound, however, as the model used for family planning after
1994 involved a considerably larger outlay for medical care than did the model used before
that date.

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This is 17% of the total the World Bank lent (committed) in the Population, Health
and Nutrition Sector and 1% of the total it lent for all purposes during this period.
The Asian Development Bank
ADB Policy
The Asian Development also lends to help support population or family
planning programs in borrower countries. Most of its loans for this purpose have
been funded by its concessional loan window, the Asian Development Fund (ADF),
though projects in the more economically advanced regional countries such as
Indonesia have funded by the ADB’s regular market-rate loan program.
The ADB’s policy in this area is set forth in a policy paper11 published in 1994,
in preparation for the Cairo population conference that year. The study said that
“Integration of family planning with health and community development efforts as
fully as possible is the preferred route to sustaining fertility decline in the context of
general improvement in human welfare.” This replaced an earlier strategy, described
in a 1991 ADB publication, which said that population and health issues could be
dealt with separately.12 The 1994 study said that particular emphasis should be given
to programs that reduce maternal and child mortality, improve prenatal, neonatal,
reproductive health and child welfare, and expand female education. The approach
stresses the availability of service, wide choice of methods, and reliable follow-up
activity to monitor results. The sector study said “The crucial variable is the educated
and healthy Asian woman able to manage her productive and reproductive life in the
best interest of family and society.” The report also specified that “future health
projects should consider integrating population components unless there is a
prohibitive reason for not doing so.”
The policy statement said there should be a clear distinction between public
polices that encourage couples to have fewer children and policies that coerce
couples in this respect. “Protection of this most intimate right (planning one’s
family) is the sine qua non of humane population policy,” it concluded. It also said
that evidence regarding effectiveness does not provide “a convincing rationale for
fertility policies involving client-targeted financial incentives or various forms of
coercion.” The document does not address the issue of abortion. It indicated,
though, that provision of a wider and more appropriate choice of birth control
methods appropriate to prospective users should encourage use of contraception and
lessen the incidence of unwanted pregnancy.
The ADB study found that there are four types of developing countries in the
region: those with little or no concern, some concern, moderate concern, or high
11Asian Development Bank. Population Policy: Framework for Assistance in the
Population Sector. Manila, 1994. Approved by the ADB Board of Directors July 12, 1994.
12Asian Development Bank. Health, Population and Development in Asia and the Pacific.
Manila, 1991. Approved by the President of the ADB April 11, 1991.

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concern about population planning and population issues. The approach that the Bank
takes for each type of country will vary. In countries with little or only some
concern, the report said the Bank should gather information, consult with officials,
and provide technical assistance. Population activities might be a component of
ADB education or health loans in these countries. On the other hand, in countries
where there is greater concern about population issues, the report said the ADB
should undertake detailed studies, it should help the country strengthen the relevant
institutions and policies and it should finance integrated population and family
planning projects or even stand-alone population projects when appropriate.
The study said that “resources for population activities need to be concentrated
in DMCs [developing member countries] that face acute population-resource
problems and have not been able to bring down population growth rates sufficiently
in the past.” It identified Afghanistan, Bangladesh, Bhutan, Cambodia, India, Laos,
Nepal, Pakistan, Philippines, and Vietnam as being of particular concern.
Current Practice
The ADB said, in its 1996 annual report (the most recent report available) that
its “main objective for the health and population subsector is to improve the quality
of services, increase efficiency, and widen access, particularly for women and
children, to primary health care and family planning services.” The annual report
emphasized in particular health projects the ADB had agreed to fund in Cambodia,
Indonesia, and Vietnam. The ADB also approved another project involving family
planning that year, not mentioned in the health section of the annual report, in
Pakistan. The ADB has also made public its country economic reviews for
Cambodia, Vietnam, and Pakistan. Consequently, it is possible to see how the
population projects approved in 1996 fit into the ADB’s analysis and policy
framework for those countries.
Funded jointly by the ADB, the World Bank/IDA, and the German export
finance agency, the ADB’s $43 million loan to Vietnam in 1996 for a population and
family health project emphasizes safe motherhood and family health in order to
improve population services in 15 provinces having a population of 20 million
persons. The ADB estimates that about $8.6 million of the total will be used
specifically to fund family planning activities. IDA is financing the purchase of all
contraceptive supplies and the family planning health delivery services in 5
provinces. The ADB will fund the delivery of these services in 10 other provinces.
The project will involve the private sector and NGOs in the provision of services.
It will offer a broader variety of modern contraceptive methods; the ADB believes
this will help reduce reliance on IUDs and sterilization, with their attendant problems
of infection, overuse, and non-use by younger women. It also believes this will also
reduce the number of abortions. Abortion is legal in Vietnam. The project
emphasizes health care for mothers and children and education on family health.
There is no indication in the project proposal13 how Vietnam's current policies
13Asian Development Bank. Report and Recommendation of the President to the Board of
Directors on a Proposed Loan to the Socialist Republic of Viet Nam for the Population and
(continued...)

CRS-11
limiting family size will be related to the program or if program staff will have
incentives to encourage public participation in the program. The project document
says population growth is a major problem in Vietnam.
The ADB country economic review for Vietnam14 mentions the population issue
only in passing. It focuses instead on the flow of people from rural to urban areas
that are unprepared to receive so many new residents. One sentences says a reduction
in the population growth rate would lessen the pressure in that regard.
The ADB's $200 million loan to Pakistan for its Social Action Program Project
in 1996 funds part of the $1.5 billion foreign exchange cost of the $7 billion program.
Bilateral foreign aid agencies and the World Bank will fund the other foreign
exchange costs and the Government of Pakistan will pay the remaining $5.5 billion
cost. The project has four components: primary health, primary education,
population welfare, and rural water supply and sanitation. The ADB estimates that,
of the $200 million provided by the loan, $32.6 million will be used to fund health
programs, including $7.3 million for family planning or population activities.
In the population area, the Pakistan loan aims to expand coverage by family
planning outlets from 40% to 85% of the population by the year 2000. Operations
will be integrated with the health, education, and water and sewerage components of
the program and decentralized. Beneficiaries and NGOs will be involved in its
preparation and implementation. There is no discussion in the project document15
whether project staff will have targets, quotas or incentives to encourage public
participation or what types of family planning methods will be available to patients.
Abortion is not legal in Pakistan.
The Bank's country economic review for Pakistan notes that high population
growth and low rates of economic growth are major barriers to the elimination of
poverty. It attributes the country's high levels of unemployment and
underemployment to these problems. The primary focus of the country economic
review16 centers on ways for promoting economic growth. It stresses, in particular,
the need for sound economic policy, more investment and saving, more foreign
investment, and judicial and legal reform to facilitate private sector growth.
Discussion of population issues is limited to a few early sentences in the study.
The ADB's $20 million loan to Cambodia in 1996 funds all the foreign
exchange costs and 80% of the total costs for the country's new basic health services
13(...continued)
Family Health Project. August 1996. Doc. RRP:VIE 26378
14Asian Development Bank. Country Economic Review, Socialist Republic of Viet Nam.
October 1997. Doc. CER:VIE 97021.
15Asian Development Bank. Report and Recommendation of the President to the Board of
Directors on a Proposed Loan to the Islamic Republic of Pakistan for the Social Action
Program (Sector) Project II. November 1996. Doc. RRP:PAK 28330.
16Asian Development Bank. Country Economic Review: Islamic Republic of Pakistan.
September 1997. Doc. CER:PAK 97013.

CRS-12
project. The objective is to reduce preventable mortality and morbidity, particularly
for poor women and children in rural communities, in five provinces that previously
lacked basic health care service. There is no separate emphasis on family planning.
The ADB reported, when queried, that none of the funds for the project will be used
for family planning activities. However, depo-provera and progesterone are listed
among the medications to be purchased and one of the 18 objectively verifiable
indicators is the goal that at least half the married women aged 15 to 45 will know
at least three modern methods of birth spacing and a source of supply for each. The
ADB country economic review17 lists health and education as areas of major concern
but does not mention population growth as a factor inhibiting Cambodian
development. Improvements in economic policy and performance are the main focus
of the review.
The ADB's fourth action in 1996 to help fund family planning was a $45 million
market-rate loan to Indonesia for a family health and nutrition project. It will provide
basic health services to poor villages in five provinces. It aims to help families
identify their health needs and make informed decisions to address them via public
health facilities. Some 122,000 families are potential beneficiaries. According to the
project document18 each family's health needs will be identified and listed on a family
health card and families will be responsible for updating the card and taking
appropriate action, after consulting with health workers. "Capacity building...and
empowerment of the beneficiaries to become responsible for their health are key
objectives of the Project," the document reports. The ADB reported, when queried,
that no funds from the loan are being be used to finance family planning activity.
The design summary for the project (p. 41) indicates, however, that “family
partnership for health, nutrition and family planning” is one of the project
components and a 20% increase in the contraceptive prevalence rate and a 20%
increase in new family planning users are specified output indicators. The project
seeks to strengthen the capacity of village-level health centers and provide needed
resources. It will provide resources to community organizations to better support
their health initiatives and help them serve as a village health committee. Each
village committee will analyze each family's priorities and actions and maintain a
village health map. The project will also support mini-campaigns at the local level.
There is no indication in the project document how the family planning aspects of the
project will be implemented or what methods will be available to potential users,
how the privacy of patients will be maintained, how patients will be protected from
pressure for services they do not desire, and whether community mobilizers or
project staff will be given incentives or targets to encourage participation. No
country economic review for Indonesia is currently available.
ADB staff report that the Bank usually looks to the World Health Organization
(WHO) or the U.N. Population Program (UNFPA) regarding the contraceptives and
procedures that may be supported through ADB projects. The ADB only finances
17Asian Development Bank. Country Economic Review: Cambodia. October 1996. Doc.
CER:CAM 96022.
18Asian Development Bank. Report and Recommendation of the President to the Board of
Directors on a Proposed Loan to the Republic of Indonesia for the Family Health and
Nutrition Project. September 1996. Doc. RRP:INO 28074.

CRS-13
the purchase of contraceptive supplies when other funding sources are unavailable.
The U.N. agencies are the preferred source of supply. ADB staff say a few ADB
projects have provided supplies of condoms, birth control pills, IUDs, and injectable
forms of contraception when a funding gap existed. None directly financed the
provision of vasectomy or tubal ligation. ADB staff emphasize that the Bank does
not provide funding for abortion. It is unclear whether other international or bilateral
aid providers are financing surgical forms of contraception or abortion in connection
with national programs the ADB is also supporting with its projects.
The ADB stressed, when asked, that its policy specifically prohibits any use of
coercion or inappropriate incentives to influence clients to participate in population
programs against their personal wishes or best interests. ADB staff report that “A
careful review of the projects approved since 1993 reveals that all comply with the
letter and the spirit of the Bank’s policy.” In particular, as regards the four projects
discussed above, ADB staff state emphatically that “there are no cases where
coercion or inappropriate incentives have been sanctioned or tolerated in these
Projects.” ADB staff did not indicate, however, if specific directives to this effect
have been issued to project staff in the four countries or if disciplinary procedures
have been specified or used to assure compliance with the policy.
ADB Funding for Family
Planning Programs, 1993-1997
Between 1993 and 1997, the ADB made 18 loans to finance health programs.
The two projects approved in 1995 and the six projects approved in 1997 seem not
to have had a population component. The other health projects approved during
these years had some family planning components, though the cost of those
components in some cases (the Cambodian and Indonesian loans discussed above,
for instance) may have been small. The combined total for these 10 loans was $494
million. The ADB says that, of this amount, about $65 million was to be used to
support family planning activities. This was approximately 11% of total ADB
lending in the health sector and about two tenths of 1% of total ADB lending for the
1993 to 1997 period.
Other Multilateral Banks

The Inter-American Development Bank (IDB) has a policy on population but
it makes no loans for population programs. The European Bank for Reconstruction
and Development (EBRD) and the African Development Bank (AFDB) have no
policies on population and they make no loans in that area.
The IDB indicates, in its population policy statement,19 that it wants “to avoid
an oversimplification of the population problem which would lead to the conclusion
that a reduction in the rate of population growth will in itself bring about social and
19Inter-American Development Bank. OP [Operations Policy]-741 Population. IDB home
page: http://www.iadb,org/poli/OP-741E.htm.

CRS-14
economic development.” The IDB says it will focus on development and it will
continue to emphasize the need for investment in the social fields as a concomitant
to economic growth. The IDB may do demographic analyses as appropriate. It will
also finance health projects to address maternal-child health concerns through
improvements in modern health institutions and more integrated health systems
aimed at meeting the needs of campesinos and marginal urban groups. The IDB’s
policy statement regarding public health20 reiterates these concerns but makes no
mention of any support for family planning activities.
The EBRD has made no loans in the health sector. The Inter-American
Development Bank approved nine projects between 1993 and 1996 (the last year for
which complete information is available) that address health services in a direct way.
Several (in Brazil, Guatemala, Panama, Peru, and Venezuela) focused on health
sector policy reform, though they also planned to provide increased services in low-
income areas. Loans to strengthen the social investment funds in El Salvador,
Guatemala, and Honduras aimed at improving facilities for local health care in poor
villages, among other things (such as schools, water and sewerage, etc.) Improved
health care for low-income people was also a goal of the social impact amelioration
loan to Guyana. Maternal health and child welfare were sometimes mentioned as
issues of special concern for all these projects but there was no indication in the IDB
annual reports that family planning or population issues would be addressed. The
combined total for the nine loans that dealt with health care issues was $788 million,
about 3% of the IDB’s total lending during this four year period.
The African Development Bank made two loans in 1994 through its regular
market rate loan window to strengthen health care services in Gabon and Mauritius.
It also made a private sector loan in 1995 to help investors build a state-of-the-art
diagnostic health center in Nigeria. The combined total for these loans was $67
million, a little over 1% of the AFDB’s market-rate lending for the 1993-1996
period. The AFDB’s concessional loan affiliate, the African Development Fund
(AFDF) made several additional loans in 1993 and 1996 for health projects. (The
AFDF suspended operations in 1994 and 1995 due to disagreements between the
Bank and donor countries.) Loans to Benin, Chad, Niger, and Uganda in 1993 sought
to improve basic health care service in rural areas and strengthen the countries’ health
policies and their national health institutions. The four loans totaled $39 million,
about 4% of AFDF lending that year. In 1996, the AFDF approved loans to
Mozambique and Rwanda to reestablish basic health service in areas damaged by
conflict and experiencing heavy inflows of returnees. The two loans totaled $18
million, about 3% of AFDF lending in 1996. There was no mention of family
planning or population issues in any of the loans approved by the AFDB and AFDF.
A 1993 loan to Senegal funded a demographic study of population movements and
residency patterns in that country, in order to help improve development and
economic policy. Though titled a “population” study, it was not a family planning
project.
20Inter-American Development Bank. OP [Operations Policy]-742 Public Health. IDB
home page: http://www/iadb.org/poli/OP-742E.htm.

CRS-15
Table 1. World Bank Lending for Population and
Reproductive Health Activities (RHA), 1993-1997
(millions of U.S. dollars)
Year
Country
Project Name
Loan
Amount
Amount
Total
for Pop
for Pop
& RHA
1993
Angola
First Health
19.9
-.-
1.20
Burundi
Social Action
10.4
.50
.50
Guinea-
Social Action
8.8
.90
.90
Bissau
Zimbabwe
STD Prevent/Care
64.5
-.-
64.50
Philippines
Urban Health & Nutrition
70.0
17.50
35.00
Honduras
Nutrition & Health
25.0
.01
1.00
Yemen
Family Health
26.6
10.70
13.30
India
Integrated Child Dev Services
194.0
-.-
19.40
India
Social Safety Net
500.0
40.00
40.00
Pakistan
Second Family Health
48.0
12.00
18.20
Indonesia
Third Com Health & Nutrition
93.5
9.40
37.40
Papua New
Population & Family Planning
6.9
5.90
6.90
Guinea
Chile
Health Sector Reform
90.0
-.-
.80
Colombia
Municipal Health
50.0
5.00
10.00
Ecuador
Second Social Development
70.0
15.40
23.10
Guatemala
Social Investment
20.0
.60
.60
Iran
Health & Family Planning
141.4
59.50
59.50
Jordan
Health Management
20.0
2.00
6.60
1994
Burkina Faso
Health & Nutrition
29.2
7.50
7.50
Burkina Faso
Population/AIDS Control
26.3
14.10
26.30
Chad
Health & Safe Motherhood
18.5
4.60
6.10
Comoros
Pop & Human Resources
13.0
2.80
4.30
Guinea
Health/Nutrition Sector
24.6
2.50
2.50
Uganda
Sexually Transmitted
50.0
-.-
50.00
China
Rural Health Manpower Dev
110.0
8.90
8.90
Nicaragua
Health Sector
15.0
.60
.60
India
Ninth Population
88.6
70.90
70.90

CRS-16
Year
Country
Project Name
Loan
Amount
Amount
Total
for Pop
for Pop
& RHA
Nepal
Population & Health
26.7
21.40
21.40
Malaysia
Health
50.0
.50
.50
Argentina
Maternal/Child Health/Nutri
100.0
12.00
12.00
Brazil
AIDS Control
160.0
-.-
160.00
Peru
Basic Health/Nutrition
34.0
10.50
10.50
1995
Benin
Population & Health
27.8
NA
13.80
Burundi
Health/Population
21.3
NA
6.00
Cameroon
Health/Fertility/Nutrition
43.0
NA
21.50
Chad
Population/AIDS Control
20.4
NA
20.40
Kenya
Sexually Transmitted
40.0
NA
40.00
Senegal
Community Nutrition
18.2
NA
1.82
Uganda
District Health
45.0
NA
11.35
Zambia
Health Sector
56.0
NA
26.00
Zambia
Second Social Recovery
30.0
NA
0.90
China
Iodine Deficiency Disorder
27.0
NA
2.70
China
Maternal & Child Health
80.0
NA
45.00
Indonesia
Basic Health on Five Islands
88.0
NA
22.00
Laos
Health Services
19.2
NA
4.80
Philippines
Women’s Health/Safe Mother
18.0
NA
18.00
Lebanon
Health
35.7
NA
8.99
Panama
Rural Health
25.0
NA
4.00
Croatia
Health
40.0
NA
1.60
Estonia
Health
18.0
NA
0.18
Turkey
Second Health
150.0
NA
37.50
Bangladesh
Nutrition
59.8
NA
14.95
India
AP District Health Service
133.0
NA
28.60
Pakistan
Population Welfare Program
65.1
NA
65.10
Cambodia
Social Development Fund
20.0
NA
1.00
Mexico
Essential Social Services
500.0
NA
50.00
1996
Vietnam
Population & Family Health
50.0
50.00
50.00
Pakistan
Northern Health Program Proj
26.7
NA
26.70

CRS-17
Year
Country
Project Name
Loan
Amount
Amount
Total
for Pop
for Pop
& RHA
Cote d’Ivoire
Integrated Health Services
40.0
NA
13.50
Vietnam
National Health Support Proj
101.2
7.50
89.60
Georgia
Health Project
14.0
.22
8.12
Bulgaria
Health Sector Restructuring
26.0
NA
9.50
India
State Health System Dev Proj
350.0
NA
56.00
China
Disease Prevention Project
100.0
NA
NA
Mozambique
Health Sector Recovery
98.7
6.00
35.90
Indonesia
HIV/AIDS/STD Prevention
24.8
NA
24.80
Sierra Leone
Integrated Health Sector
20.0
NA
1.30
Argentina
Provincial Health Dev Project
101.4
NA
NA
Mexico
Second Basic Health
310.0
NA
111.80
Egypt
Population
17.2
NA
17.20
Argentina
Health Insurance Reform
350.0
NA
NA
Kyrgyz Rep
Health
18.5
NA
4.20
Morocco
Improved Primary Health
68.0
NA
20.30
Russia
Medical Equipment
270.0
NA
90.00
Indonesia
Social Sector Reform
20.0
NA
NA
Brazil
Health Sector Reform
300.0
NA
NA
Macedonia
Health Sector Transition
16.9
NA
NA
Argentina
Health Insurance TA
25.0
NA
NA
Bosnia
War Victims Rehabilitation
5.0
NA
NA
1997
Niger
Second Health
40.0
NA
1.70
Senegal
Endemic Diseases
14.9
NA
NA
Cambodia
Disease Control & Health
30.4
NA
8.10
Indonesia
Iodine Deficiency Control
28.5
NA
1.90
Bosnia
Essential Hospital Services
15.0
NA
2.00
Russia
Health Reform Pilot Project
66.0
NA
19.70
Turkey
Primary Health Care Service
14.5
NA
4.40
Argentina
AIDS Prevention/STD
15.0
NA
15.00
Argentina
Maternal & Child Health
100.0
NA
31.30
Paraguay
Rural Health
21.8
1.96
16.25

CRS-18
Year
Country
Project Name
Loan
Amount
Amount
Total
for Pop
for Pop
& RHA
India
Malaria Control
164.8
NA
NA
India
Reproductive Health
248.3
NA
124.15
India
Rural Women’s Development
19.5
NA
NA
India
Tuberculosis Control
142.4
NA
NA
Sri Lanka
Health Services Development
18.8
NA
7.64
Source: World Bank
Table 2. Asian Development Bank Lending for
Population Programs, 1993-1996
(millions of US dollars)
Year
Country
Program Name
Loan
Family
Amount
Planning
1993
Pakistan
Population
25.0
25.0
Papua New
Population & Family Planning
7.1
7.1
Guinea
1994
Indonesia
Rural Health and Population
40.0
5.0
Marshall Is
Health and Population
5.7
.3
Pakistan
Social Action Program (health only)
38.5
12.0
Philippines
Women’s Health & Safe Motherhood
54.0
* 0.0
1995
No family planning projects
1996
Indonesia
Family Health
45.0
0.0
Vietnam
Population & Family Health
43.0
8.6
Pakistan
Social Action Program (health only)
32.6
7.3
Cambodia
Basic Health Services Project
20.0
0.0
1997
No family planning projects
Source: ADB
* ADB says USAID funded the family planning components of this project.