Factors Influencing retention of Health Workers in Primary Health Care Facilities: A Case of the Kakamega County

LECTURE NINE LEVEL II MBChBPROF. E.K. MUCHUNGASchool of Public HealthUniversity of NairobiPopulation Policies

GOAL To learn about population policies relating to fertility, mortality and migration with specific reference to developing countries of Asia, Africa and Latin America.To define population policy and outline how government policies influence demographic behaviour.To focus on Chinas one child per family pop policy and determine the consequences of such a policy.

2According to Kenneth Godwin, policy is something that a government chooses to do or not to do. The policy or policies may be pronatalist, antinatalist or neutral. These policies may be either stated (documented) or not stated in public document.Hope T. Eldridge defines population policies as legislative measures, administrative programmes, and other governmental action intended to alter or modify existing population trends in the interest of national survival and welfare.However, there is clearly lack of consensus with respect to the exact definition of population policy.

Definition of Population PoliciesAreas of Disagreement on Pop Policy Three areas are discussed:Should there be an explicit statement or document by the government that a population policy exists?Using United States as an example, no official population policy exists. Yet the Federal government finances and supports programmes designed to eliminate unwanted childbearing and avail contraceptives to target populations (especially the disadvantaged or the poor). These programmes have a demonstrable demographic effect of lowering fertility despite the absence of an official pop policy.

Should there be a planned course of action or (programme)?Absence of specific measures to influence the population is interpreted as a form of population policy i.e. where total fertility rate is below 2 children per woman and no measures to raise the birth rate, then it is argued that refusal to intervene in this context is a population policy in favour of low fertility. Others dont agree with this standpoint.Should the goals be demographic or could they be social and economic? Additionally, should the demographic effects be intended and direct, or they could be indirect and unintentional?China, attempted to increase the status of women for ideological reasons, but these measures had a demographic effect. Does China have a pop policy in this context?In Latin America, governments had attempted to lower the prevalence of induced abortion by providing women with contraceptives. Do these governments have a population policy favouring low fertility?These three fundamentals areas are discussed to show that there are no correct answers in matters relating to population policy. It is very difficult to determine whether a country has a pop policy or not.Attempts to Influence Fertility LevelsPronatalist and Antinatalist MeasuresPronatalist policies were prevalent before the twentieth century, and were geared towards high fertility and population growth. They assumed the following characteristics.Pronatalist propagandaMeasures related to the family i.e family allowance programmes, tax systems and rewards to mothers with large families.Restrictions on the distribution and use of contraceptives and abortion.In developing countries, there was a perception that a larger population was necessary for economic growth, or for settling sparsely populated areas.Marxist and leftist Latin America leaders also believed that problems in their countries were social and economic rather than demographic. To their view, population growth is a prerequisite the revolution necessary to achieve social, economic and political change. They opposed the idea of limiting population growth terming it a reactionary plot by the West in order to exploit the resources of Latin America.Developed countries such as Japan, Germany and Italy adopted population policies to encourage high fertility between World War I and World War II.Intensive pronatalist propaganda, cash payments to families with children the restriction of access to contraceptives, the regulation of emigration all reflected the attempts by these governments to raise fertility.

France and Romania adopted a pronatalist population policy while having an antinatalist policy as well. Marriage loans, premiums on the birth of a first child, and other forms of aid for parents were provided in France.Romanian government was even more forthright.Stopped official importation of oral contraceptives and IUDs.Taxes on unmarried and married couples with no children aged 25 years and above were raised by 10 and 20 percent.Taxes on families with three or more children were reduced by 30 percent.Mothers of large families were promised early retirement from their jobs.Divorces were made extremely difficult to obtain, and the required fees were raised to prohibitive levels.Mother Heroine awards established to reward mothers of large families. They were given wide publicity by the media.The result for Romania were apparent.

The birth rate tripled from 12.8 per 1000 in 1966 to 39.9 in 1967 (9 months).Thereafter, it declined fairly steadily, reaching 20 per1000 in 1980.Reliance on one method of contraceptives to prevent births can result in high fertility if there is restriction to that method in the short run.In conclusion, it does not appear as if pronatalist measures in developed countries have been effective. In France, Belgium, Bulgaria and Germany, crude birth rates were below 15 per 1000 despite the existence of pronatalist policies.Romanian Graph: 1966-1970

The Romanian example shows that traditional Romanian preference for a small family was not affected by the shift in legislation. In the absence of a fundamental change in motivation for limiting family size and engage in family planning, legal restrictions on abortion, coupled with generous pronatalist welfare provisions, are likely to result in more than a short term increase in the birth rate.Antinatalist PoliciesThese aim at reducing fertility. The two basic approaches are government-sponsored family planning approaches and non-family planning approaches.National Family Planning Programmes.Aim is to reduce fertility by providing contraceptive supplies, services, and information to couples who want to space or stop their family size.The rationale of F/P Programme is that if you inform people about the methods and give them good service, then a significant number will accept.Antinalist Policies (Cont)It is voluntary in nature, with the emphasis on the right of parents to decide the number and spacing their births.Avoidance of unwanted births is stressed.However, changes in attitudes, values and desired family size are not underscored.In Kenya, the Government published a policy paper entitled African Socialism and Its Application to Planning in Kenya, Sessional Paper No. 10, in which the main theme was how to utilize resources of the country (1965).Antinalist Policies (Cont)The basic tenets were:Recognition of high population growth rate and the consequences in terms of a large dependent population, the reduction of money available for development, and increased pressure on the social services.Unemployment problem was cited as a major concern, and saving for development would be reduced by high population growth rate.Steps to be towards family planning education were recommended by the paper.

A Case study of ChinaHas a population estimated at 1.341 billion by 2010. Ten years earlier, Chinas population was 1.295 billion as per census results.Chinas one child per family population policy has averted 400 million births since its inception in 1980.In 1997, 85% of married women practiced some form of Contraception with majority preferring IUDs after the birth of the first child. Abortion is also prevalent.

Incentives for 1 child family include:Bonuses for their family, lower taxes.Free health carePriorities in housing, school and employment.Those with no children at all are rewarded when they retire.This rigid population policy is enforced by the government using these social and economic benefits, peer pressure, while each commune determines the number of children to be born.All women are required to attend lecturers on family planning.Women who become pregnant for the third time are urged to get an abortion. It is considered unpatriotic to be pregnant for a third time.More recently, Family Planning Programme has undergone reforms which is more flexible following the 1994 World Population Conference in Cairo, Egypt.Emphasis on client needs, informed choice of contraceptives are becoming prevalent.Non-family Planning ApproachesAttempt to influence fertility by motivating people to desire and have fewer children.There is recognition from this approach that family size could be a response to the way a person perceives the socio cultural world.Emphasizes in the importance of altering the desired family size through changes in the institutional alignment and socio cultural environment of the population.The most reliable non-family method of reducing family size is societal modernization. As modernization occurs better health conditions that follow ensure that a woman will conceive and retain the foetus to term. Lower mortality raises the proportion of survivors to the age of reproduction, and reduces the probability of widowhood.Many countries have recommended for family planning and modernization to be accomplished together.

Another Non-Family Method Include:Increased female labour force participation.Research has established that women who participate in the formal sector have fewer children than women who do not participate in the labour force. This is consistent to Millennium Development Goal number 3 that emphasizes promotion of gender equality and empowerment of women.Attempts to Influence MortalityGovernments in industrialization countries subsidize health care and often provide free care to the public. The overall effect of such measure is to increase life expectancy.Other measures include development of new drugs and new techniques focused on organ transplants, heart and kidney etc.Government policies aimed at reducing the incidence of specific communicable, non-communicable diseases and reproductive health ailments are part of this strategy.Government regulations that focus on safety measures on driving (speed limits, safety belts) save thousand of lives.Other measures include immunization nutrition related information for mothers during ANC and Postnatal care services, smoking, drinking, drug abuse, and occupational health regulations for workers.

Measures to increase mortalityMeasures that endanger health, though unintentionally, include, international welfare; During World War II alone, 50 million people were killed. Other undeclared ethnic and internal conflicts of various types contribute to an increase in mortality.Genocide, as practiced in Nazi Germany resulted in the death of over six million Jews. Rwandas example is also a case in point.Measures to increase mortality (Cont)Government policies to allow tobacco growing (cigarette factories are major industries) plus establishment of breweries to produce beers, spirits, wines are examples of policies that indirectly contribute to a rise in mortality. Governments benefit from taxation, employment and development.

Policies on MigrationSome nations encourage immigration in order to increase the rate of population growth. This was the case in United States during the nineteenth century. Canada and Australia have also allowed immigrants.Israel is a country that explicitly seeks more immigrants.Countries that are characterized by high population pressure view emigration as a safety valve to relieve pop. pressure. Some Caribbean countries are examples.Policies on Migration (Cont)Barriers to immigration are numerous. Immigration policies are subject to change in response to national, demographic economic, and political factors.Levels of education, acquired in employment, financial stability are some of the considerations used in screening potential migrants.Indeed the term brain-drain is used to connote that the most educated, well trained persons stand the best chance of emigrating to other countries to work. In return, these emigrants remit money back home to their families, relatives and nation building.ConclusionDemographic DividendIndia has benefitted immensely from a demographic dividend due to global competitive advantage brought about by the people.What is required for a demographic dividend to commence is for a sudden preferably natural fall in the fertility rate of a country. The large number of young people who mature and start working will have fewer children, and fewer dependents.The economy will have an opportunity a time when a lot of young people highly motivated, with a smaller dependent population to look after.This opportunity could result in rapid economic growth that might lead to economic takeoff.Consequently, a more affluent society always finds its total fertility rate of about 2-3 children per woman. In India, the people were transformed into human capital.New arrivals are systematically given education, marketable skills to make them productive and consumptive. Lower mortality, leads eventually to a lower fertility, and as such, savings for development will rise.The pool of skilled labour create a source Indigenous Investment capital. (Infrastructure, education, and demand for goods & services.

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