DEMOGRAPHIC TRANSITION: Lessons from Bangladesh’s Success Story © 2020 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Design: Silvia López Chavez, Junya Yuan DEMOGRAPHIC TRANSITION: Lessons from Bangladesh’s Success Story INTRODUCTION Between 1960 and 2017, the global total fertility rate (TFR) of women declined from about 5 births per woman to 2.4. However, this clear progress has been uneven across the world. At one extreme, SSA countries reduced TFR by as little as 2 births per woman, on average, between 1970 and 2016 (World Bank, 2019), with Niger, Chad and Democratic Republic of Congo having similar levels of TFR in 2017 as BANGLADESH they did in the 1960s. On the other hand, Bangladesh has REDUCED TFR FROM been a star performer on fertility reduction, reducing its 6.7 IN 1960 TO 2.1 IN TFR from 6.7 in 1960 to 2.1 in 2017 (i.e. the replacement 2017 level of fertility) (Figure 1)1. Most countries at the pre- dividend stage of the demographic transition, especially BETWEEN those in Africa, could learn from Bangladesh’s experience. 1970 AND 2018 THE COUNTRY’S GDP Bangladesh’s progress on fertility reduction has been PER CAPITA the most rapid even among the South Asian countries, INCREASED FROM most of which have succeeded over time in achieving a US$411 TO US$1203 convergence of their TFRs at or just above the replacement rate (Figure 2). In particular, Bangladesh’s fertility declines between 1975 and 1990 (Figure 3), when it was still grappling with serious economic and social issues, were remarkable, and hold important lessons for other countries striving for similar success in optimizing their population growth. How did Bangladesh achieve such a rapid fertility decline despite economic constraints? This short note attempts to answer this question following a theoretical framework outlined in the following section. 1 Replacement level fertility is the average number of children born per woman that allows a population exactly to replace itself from one generation to the next, without migration. 4 Demographic Transition: Lessons from Bangladesh’s Success Story Figure 1. Uneven progress in fertility reduction across countries Figure 2: Bangladesh has the fastest total fertility rate reduction among South Asian countries (1960-2017) Figure 3: Bangladesh’s period of fastest fertility decline was during a period of volatile growth 10 10 0 0 GDP Per Capita Growth (annual %) 5 -1 0 -2 -2 -5 -5 -3 -3 -10 -10 -4 -15 -4 -15 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 YEAR TFR growth (annual %) GDP Per Capita Growth (annual %) Source: Authors using data from World Development Indicators (various years) 5 THE THEORETICAL DRIVERS OF OF FERTILITY TRANSITION Fertility reduction can be driven by different factors, such as female education and labor participation, reductions in child mortality, economic development and urbanization (Kabeer, 2001; Mohanty et al., 2016). These drivers of fertility are themselves interrelated. Female education and employment reduce the desired level of fertility by increasing the opportunity costs of having children. Female education is also associated with reduced child mortality, which has been found to be associated with reduced fertility (van Soest and Saha, 2018). In areas where child mortality is common, parents give birth to a higher number of children than their desired level of fertility to replace deceased children. Improved health conditions reduce this ‘replacement motive’. It also reduces the ‘insurance motive’, which is the idea that parents have an ideal ‘final’ number of children they want, and that they adjust according to the perceived mortality risk. Economic development and urbanization raise the opportunity costs of child bearing, as they are usually associated with more employment and educational opportunities for women. Economic development also raises the returns to investing on children’s human capital, which given the costs of these investments per child could incentivize parents to reduce fertility. In the absence of extended family members, parents that migrate to urban areas also face increased cost of child care, raising the incentive to lower child bearing. Economic development also contributes to the reduction of child mortality, hence decreasing the demand for children. At the same time, family planning programs - which entail increasing the supply of contraceptives and reducing barriers to contraception - among other measures, have been cited as an independent enabler of fertility reduction, even when the economic context may not necessarily be favorable. 6 Demographic Transition: Lessons Bangladesh’s fromSuccess Bangladesh’s Story Success Story 3. HOW DID BANGLADESH MANAGE A RAPID AND SUSTAINED REDUCTION IN FERTILITY? 1. The Primary Driver – The Bangladesh Family Planning Program (FPP) The overarching conclusion, based RECOGNIZING THE PROBLEM, on the available evidence, is that the SETTING A CLEAR VISION rapid declines in fertility observed in AND PROVIDING SUSTAINED LEADERSHIP Bangladesh – particularly between 1975 and 1990 – were driven significantly by At its independence in 1971, Bangladesh the national population program (Hasan was a country that was impoverished and and Reich, 2012), although economic devasted by the war of independence. growth, the expansion of the ready- Faced with rampant poverty and high made garment industry and related population growth, the government came contextual factors did buttress the impact to the Malthusian conclusion that if the of the program at subsequent stages of population continues to increase at the Bangladesh’s development trajectory same pace it would outpace available (Caldwell and Barkat-e-Khuda, 2000; resources. This conclusion was reinforced Caldwell et al., 1999; Kabeer, 2001). This by the deadly famine of 1974. Public finding in Bangladesh is in contrast to the debates, involving technical experts and experience in other countries in South policymakers, were organized to raise Asia (such as in India), where the fertility awareness and forge a broad consensus declines – although also impressive – on the population issue. The government have been more gradual and have been used clear indicators on the socio- shaped by the broader socioeconomic demographic situation of the country context. to highlight the growing concern on population issues: 76 million inhabitants, high population growth (3%) and density (500 people per square kilometer in 1970), low food production, generalized poverty (73% in 1973) and food price inflation 7 (Hasan and Reich, 2012; Levine and sub-national levels to coordinate action The What Works Working Group, 2004; across sectors under the broad ambit of a World Bank, 2019). Thus, managing the National Population Council, led by the population growth became a priority in Prime Minister. the policy agenda of the country and was included in the First Five-Year Plan (1973- Subsequent Five-Year Plans maintained 1978) by the Planning Commission. The the concerted focus on fertility control Planning Commission was constituted by with a national goal of reaching a policymakers from different ministries, Replacement Level of Fertility (i.e. under the Chairmanship of Bangladesh’s TFR of 2.1) by 1985, again with the first Prime Minister, Sheikh Mujibur express support of the highest levels Rahman, who was a passionate proponent of political leadership, most notably of population policies. led by Ziaur Rahman in 1976 and Hussain Mohammed Ershad in 1982. It The Plan document identified specific was only with the Fifth Five-Year Plan population activities for six other (1997-2002) that the population goals ministries, besides the Ministry of Health were embedded within broader health and Family Welfare, essentially reflecting goals for the provision of primary care a Whole-of-Government Approach to this services (Mabud and Akhter, 2000), critical issue. For example, the Ministry essentially converting the multisectoral of Rural Development was tasked with approach to population into a sectoral promoting women’s employment, as well approach within the health sector. Thus, as functional and family planning literacy, in addition to consistent support from through rural cooperatives. The Ministry the political leaders, cohesion within the of Agriculture introduced population and broader policy community was a major nutrition education in their extension factor in population’s high priority on programs. The Ministry of Education, the agenda in Bangladesh (Hasan and incorporated population education in Reich, 2012). academic curricula and also created a Department of Population Sciences at Dhaka University, while the Ministry of Information disseminated information promoting fertility regulation through various mass media channels. These ministries developed projects to implement activities supporting family planning, and Population Control Committees were formed at national and 8 Demographic Transition: Lessons from Bangladesh’s Success Story CREATING AN ENVIRONMENT however, which was borne by both the FOR PLURALISTIC REFORM government and donors (Hasan and AND MOBILIZING KEY Reich, 2012). STAKEHOLDERS The government, supported by the Religious leaders, who play an international donor community, fostered important leadership role at the pluralism in the implementation of village level in Bangladesh, were the population policies. It mobilized central to changing norms regarding all the relevant stakeholders in the family size at the community level public and private sectors, including and in increasing the acceptability of bureaucrats/technocrats and government FPP. The political leadership and the workers, religious leaders, academia/ bureaucracy were particular about researchers, NGOs and the private involving the religious establishment sector, and international organizations, in the population policy discussion, in this effort. Within the public sector, as well as in the implementation of Bangladesh’s FPP relied heavily on a the program. In addition to training massive deployment of married, salaried provided to the religious leaders by the female outreach workers (Family Welfare Islamic Foundation, the government Assistants (FWA)) recruited from the supported, with financial assistance from communities that they served. Since international organizations, exchange FWA’s belonged to the communities, visits of Bangladeshi religious leaders they enjoyed the trust of rural women, to countries like Egypt and Indonesia, and their jobs gave the FWAs an identity where they were exposed to the and authority, in addition to empowering progressive thinking of Islamic scholars them financially. At the peak of the on population issues. These leaders program, 28,000 FWAs were working subsequently started using religious texts throughout the country (Hasan and Reich, to explain to the population that Islam 2012). These women went door to door in does not prohibit family planning (Hasan their villages and delivered information and Reich, 2012). Overall, the political to improve knowledge about family engagement, training and international planning and shift fertility preference to visits cemented the ownership of smaller number of children. They also religious leadership of the population provided a range of contraceptive supplies issue, enhanced their social standing, and at home. In addition, clinics where FWAs helped to legitimize the program from a could refer their clients for long-term or religious perspective. permanent contraceptive methods were established. This program did involve a The financial and technical assistance high financial cost ($120 million in 1995), provided by international organizations 9 was vital for the success of the population to deliver reproductive and other health program, with organizations like USAID, services were tested. The experimental Ford Foundation, Population Council program relied on community health and UNFPA taking the lead. Local NGOs, workers (married and educated women such as the Bangladesh Association for who were also using family planning Voluntary Sterilization and the Family methods and coming from influential Planning Association of Bangladesh, families in the village) to make home while they were not major players in the visit about every two weeks and propose policy discussions, also contributed to family planning methods to married Bangladesh’s FPP by providing family women.2 Several studies showed the planning information and services success of this program (Phillips et al. (Chowdhury et al., 2013). 1988; Fauveau et al. 1991, Schultz and Joshi 2007). For example, an evaluation of the program covering 149 villages USING EVIDENCE (with 180,000 inhabitants), of which FOR POLICY MAKING seventy were program villages showed AND PROGRAM that, by 1982, fertility declined by about IMPLEMENTATION/ 15 percent in the program villages MONITORING compared to the control villages and that birth spacing between the second Bangladesh also invested significantly and third birth increased significantly in population research, which was key (Schultz and Joshi 2007). Results of such for program design, enhancement, research conducted in Matlab village monitoring and evaluation. Academic improved and helped frame the design institutions and NGOs collaborated with of the Bangladesh FPP. the government to scale-up innovative solutions and were highly involved in the research (Levine and The What Works Working Group, 2004). For example, the International Centre for Diarrheal Disease Research, Bangladesh (ICDDR, B), launched in 1977 an experimental family planning and maternal and child health (FPMCH) program in the Matlab village- a religiously conservative village in Bangladesh where various methods 2 The program slowly expanded to include other services such as the provision of measles immunizations to all children from the age of nine months to five years, training of traditional birth attendants, oral rehydration therapy for diarrhea, and antenatal care. The evaluation showed that women age 30 to 35 in program villages reported a greater likelihood (11 percentage point) of having some prenatal care in each of their pregnancies. 10 Demographic Transition: Lessons from Bangladesh’s Success Story 2. Secondary Drivers – Year Plan of the country. The government supported reforms that helped expand Women’s Empowerment, basic education and improved quality and standards through increased public Economic Development expenditure. For instance, there was and Reductions in Child an increased government expenditure on education from 0.9% of the GDP in Mortality the early 1980s to 2% of GDP in the late 1990 (World Bank, 2019). The Female While not part of a grand plan to reduce Secondary School Stipend Program was fertility per se, women’s empowerment, launched in 1982 and scaled up in 1994. economic development, and It provided free tuition and stipends improvements in child health outcomes to eligible girls from grade 6 to 10, all contributed to accelerated fertility conditional on their school attendance reduction, particularly from the mid- and test score achievement. This led 1980s onwards. to an increase in female secondary enrolment (from 1.1 to 3.9 million PROMOTING girls between 1991 and 2005). This WOMEN’S secondary school enrolment appears to EMPOWERMENT be negatively associated with TFR, as shown in figure 4. In fact, some studies While population policy dominated in the have established a causal relationship (see 1970s and early-1980s, female education Kadir et al. (2003)). and microcredit programs gained priority in the 1980s and 1990s (Hasan and Reich, Certain economic and development 2012). Bangladesh’s Second Five Year Plan programs improved women (1980-1985) focused on reducing poverty, empowerment. First, the recruitment illiteracy and unemployment. In the 1990s of women as FWAs for the FPP made and 2000s, it achieved a notable success the mobility and work of women more in ensuring access to school for girls and socially acceptable. This was partly poor children. This successful campaign facilitated by BRAC and other NGOs was based on an acknowledgement by involving local religious leaders in government of the importance of mass discussions of contraception and the role education for national development, as of women outside the household. Second, evidenced by the Fourth and Fifth Five- the microfinance movement (Ahmed 11 et al., 2013) increased their bargaining THE ROLE OF ECONOMIC power for resources and the use of AND INFRASTRUCTURE family planning (Chowdhury et al., DEVELOPMENT 2013). The majority of the beneficiaries of these microfinance programs (such as The country also witnessed an increase the Grameen Bank) were women, who in the percentage share of electricity had no prior access to credit. Third, the and road spending in total public Multi-Fiber Trade Agreement enabled expenditures on agricultural and rural the establishment of large export- development from 16% in 1989–90 to oriented garment factories which 56% by 2000–01 fiscal year (World Bank, employed mostly women, as sewing 2003). In addition to improved overall was traditionally reserved to women in economic development, increased Bangladesh (Das, 2008). The rise of the infrastructure spending strengthened ready-made garment manufacturing access to information, social interaction sector over the period 1985-2015 has and access to health and education been empirically shown to explain the services. Figure 5 shows that higher access sustained fertility decline, the rise in to electricity was negatively associated age at first marriage and rapid increase with TFR in Bangladesh. A study by Fujii in girl’s education attainment both in and Shonchoy has demonstrated a causal absolute and relative terms. This is effect of rural electrification on fertility because the garment industry rewarded reduction in Bangladesh (Fujii and cognitive skills and increased the returns Shonchoy, 2015). to education (Heath and Mobarak, 2015). Altogether, the improved economic position of women and social acceptance of female mobility and employment CHILD MORTALITY laid the groundwork for changing REDUCTION fertility preferences. These demand side developments sustained the effects of the One of the goals of the Bangladesh Third supply side effects seen in earlier periods. Five-Year Plan (1980-1985) was to reduce maternal and infant mortality. The government allowed various NGOs to operate in this domain, with support from external aid agencies (World Bank Country Study, 2007) . For instance, there was a reduction by two-thirds in the under-5 12 Demographic Transition: Lessons from Bangladesh’s Success Story mortality rate in the 1970s and 1980s, Figure 4. Fertility decreased with the which was attributed to reductions in female secondary school enrollment in Bangladesh (1960-2017) diarrhea and the six vaccine preventable diseases. The NGO Bangladesh Rural 8 Advancement Committee (BRAC) 7 contributed to this achievement by 6 scaling up the Oral Therapy Extension 5 Program (OTEP), which taught mothers 4 how to make homemade oral rehydration solutions (Chowdhury, 1996) and helped 3 increase child survival. Gains made in 2 immunizing children contributed to 1 increased child survival, which in turn 0 has been established to contribute to 0 20 40 60 80 fertility decline in Bangladesh (Adams et al., 2013; van Soest and Saha, 2018). For example, a study of two-way causal relationship between infant mortality Figure 5. Fertility decreased with access rate and fertility rate by van Soest and to electricity in Bangladesh (1960-2017) Saha (2018, p. 1) shows a replacement 8 effect of infant mortality on total fertility 7 of about 0.54 children for each infant death. 6 5 4 3 2 1 0 0 20 40 60 80 Source: Authors using data from World Development Indicators (various years) 13 CONCLUSION Bangladesh’s success in its fertility transition is an outcome of a clear political will and policy direction, coupled with a commitment to an evidence-based and well-designed comprehensive strategy to reduce fertility even in the face of economic difficulties. This is evident, among other things, by the massive deployment of Family Welfare Assistants (FWA) and the actions taken to improve women education, empowerment and maternal and child health services. The involvement of key stakeholders such as religious and political leaders and NGOs were also critical in shifting social norms. Other countries that are struggling to accelerate fertility reduction, including those in the lowest economic bracket, can learn from Bangladesh’s success. This is, of course, not to say that Bangladesh’s FPP had no weaknesses. Of note are the creation of a parallel ministry to the existing health ministry (i.e. Ministry of FP) which brought about fragmentation and weakened the health system. In concluding, it is worth noting, as shown above, that the reduction of fertility in Bangladesh was followed by significant economic growth. In the 24 years between 1973 (the beginning of the First Five-Year Plan) and 1997 (the beginning of the Fifth Five-Year Plan when Bangladesh’s strategy shifted from multisectoral approach to population into a sectoral approach within the health sector), the country’s GDP per capita (in constant 2010 US$) only increased from US$328 to US$481. However, in the subsequent 21 years (from 1997 to 2018), it increased from US$481 to US$1203 (World Development Indicators (WDI), various years). Although no causal claim can be made from this observation itself, this pattern is consistent with the theory that declining fertility levels, combined with appropriate education and labor policies, can stimulate economic growth via the demographic dividend (Bloom et al., 2007; Bloom and Canning, 2008). This fact should, again, foster optimism among LMICs, including countries in Sub-Saharan Africa. 14 Bangladesh’s Lessons fromSuccess Demographic Transition: Bangladesh’s Story Success Story REFERENCES Adams, A.M., Rabbani, A., Ahmed, S., Mahmood, S.S., Al-Sabir, A., Rashid, S.F., Evans, T.G., 2013. Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development. The Lancet 382, 2027–2037. https://doi.org/10.1016/S0140-6736(13)62060-7 Ahmed, S.M., Evans, T.G., Standing, H., Mahmud, S., 2013. 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