Thailand’s success story – Family planning with creativity and humor

Thailand implemented a unique voluntary family planning program starting in the 1960’s, accelerating the reduction of population growth from greater than 3% to below 1% in just 20 years. The rapid spread of family planning services and information and consequential decline in fertility rates (from above 6 to below 2 TFR) was in large part due to a spirit of innovation and pragmatism within the Ministry of Public Health, coupled with the openness of Thai culture and religion. The program’s uniqueness lay in the creative, playful approach that a genial key figure, Mechai Viravaidya, and his organization developed and used. Promoting contraceptives in fun ways achieved tremendous success towards breaking taboos and clarifying misconceptions. Together with creative community development programs, family planning programs increased the wellbeing of all Thais.

By Patrícia Dérer

The next installment in TOP’s population policy and family planning case studies series deals with Thailand, the peaceful military led monarchy. The third happiest country in Asia (according to the 2019 World Happiness Report) has a low, below replacement fertility rate similar to Japan’s. The fertility rate dropped from above 6 in the 60’s to below 2 in only two decades (Figure 1). This remarkable transition was in large part a result of the voluntary national family planning (FP) program started in the late 1960’s, as in some other Asian countries such as South Korea and Indonesia. The fertility drop led to a large demographic dividend and concurrent socioeconomic development. The largest Thai NGO, the Population and Community Development Association (PDA), played a key role in this development, especially in initiatives focused on poverty reduction and community development through FP.

TFR and Popgrowth
Figure 1 Total fertility rate and population growth rate in Thailand. Dashed line is replacement fertility, 2.1 children/women.

How did Thailand’s success story start?

In the late 60’s, Thailand was a predominantly rural society where women had more than 6 children on average. Consequently, the population growth was unprecedentedly rapid – 3% per year. Aside from a postpartum program in the capital, Bangkok, the government did not offer FP services and maintained an essentially pro-natalist position.1 Despite a World Bank warning that Thailand’s population growth rate was excessively high and would adversely affect economic development, the government did not believe there was a population problem.

Yet, thanks to the interest of some key Thai academics and health officials, a series of national population seminars were held, discussing the adverse effects of high population growth.2 As a result, the Ministry of Public Health organized a research project (Potharam Project) that showed that rural couples were interested in limiting their childbearing and would make use of FP services if they were available. According to the results, in the 1960’s, three quarters of women in the rural community wanted no more children than they already had; yet, less than three percent of couples used any kind of contraception.

Thanks to the proven need and interest among the people, the Ministry of Public Health started experimenting and implementing innovative approaches to deliver FP services without any formal governmental support. First, FP became integrated into the ministry’s health and hospital services, using no new and expensive infrastructure. Between 1968-1970 the so-called „Family Health Project”, the precursor of the National Family Planning program, trained personnel to be able to provide quality FP information and services, preparing for a change in the government’s formal population stance. Thousands of auxiliary midwives and nurses were trained who were – uniquely in the world – later allowed to prescribe pills even in the most remote rural areas.2 The Family Health Project operated very quietly: since there was still no public communication allowed, the information spread person-to-person only, but the FP services were very well received by the population from the very beginning. Even though the program was effective without loud campaigns and contraceptive prevalence started to grow (Fig.2), the ministry believed that educational campaigns were also necessary to reach even larger circles of women.

Contraceptive prevalence
Figure 2. Prevalence of contraceptive use in Thailand 1969-1996

A new chapter of the FP program opened with a change in the government’s official standpoint. It manifested in the first official population policy in 1970, that called for lowering the population growth rate from 3% to 2.5% in only 5 years3. It turned the silent and unsupported Family Health Project into the well-funded and communicated National Family Planning Program with a slogan “The more children, the poorer3. The program had many innovative approaches contributing to its success, such as the invention and use of minilaparotomy (a simplified, minimally invasive form of female sterilization) and the usage of new injectable contraceptives. Perhaps the most important innovation was community-based contraceptive distribution, centered around incentives and a humorous approach.

The iconic figure of the FP communication and community distribution was, and still is, Mechai Viravaidya. Convinced that people’s attitudes needed to be changed regarding the number of children they should have, the secretary-general of the Family Planning Association established a contraceptive and information delivery system in rural villages. His conviction originated from his knowledge of studies that showed the inability of families to provide enough resources and care to their large families, keeping them in a poverty trap; and from personal experiences in rural Thailand. He said:

Everywhere I went, there were so many children; I could see that population growth was just eating away at whatever progress we made in terms of our development (…) a change would contribute to some long-term good, or at least get us out of the deep hole being dug by massive population growth4

mechai
Mechai Viravaidya (whose name means victory) showing V for victory, in this case meaning “Stop at two children”.

Viravaidya, or „Mr. Condom” as he later became known, founded the organization Community-Based Family Planning Service (later Population and Community Development Association (PDA)) in 1974. It complemented the government’s top-down approach, which lacked impact in rural areas, where it was needed most.4 Realizing that family planning was a sensitive, undiscussed subject, he used his extraordinary communication skills to push the topic into the open with humor. He organized condom blowing competitions in schools, free male vasectomy festivals on the King’s birthday, and started the condom themed restaurant and resort chain „Cabbages and Condoms”.

img_6486
At the Cabbages and Condoms restaurant. Birth control should be as accessible and as easy to buy as cabbage in the market. https://www.weekendnotes.com/cabbages-and-condoms-restaurant-bangkok/

Making contraceptives readily available even in the smallest roadside stands taught people that there was no reason to be shy about talking about sexual health and actually using contraceptives.

In order to achieve Mr. Condom’s real goal to improve people’s lives, PDA used a more comprehensive rural development strategy from the late 70’s onward. In addition to promoting contraceptives, the organization improved village water supplies, and promoted appropriate technologies at the village level by emphasizing renewable energy and reduction of energy waste. They provided loans linked to FP participation, a strong incentive. The key in all these projects was the grassroots, people-centered approach achieving very high participation rates from locals who did not feel that they were being managed by some far-away government.4

As a result, per capita income in Thailand has nearly doubled, and the total fertility rate and population growth fell rapidly and voluntarily since the announcement of the official population policy in 1970 (see Figure 1)5. These successes would have not been possible without the receptiveness and openness of Thai society. Thai people are famous for their attraction to „sanuk”, having fun. Compared to other developing countries of the time, relationships between men and women in Thailand were more egalitarian, and they remain so today. They make decisions together regarding children, family life, and contraception, and both genders share the tasks of childcare.5 This is related in part to particular aspects of Theravada Buddhism, the dominant Thai religion (95%). The religion emphasizes personal responsibility for behavior and individual autonomy and decision-making, thus avoiding religious fatalism. It teaches the right to plan for the size of the family as long as methods used do not destroy any life6. Mechai Viravaidya took the opportunity and reached out to the religious community via monks by highlighting the Buddhist scripture, “many children make you poor” .

Photo by Peter Charlesworth LightRocket via Getty Images
Thai health worker young women learn the use of condoms to prevent the spread of HIV/AIDS and unwanted kids. The teaching is taking place in a Buddhist temple. (Photo by Peter Charlesworth/LightRocket via Getty Images)

Thailand, like South Korea, represents a strong example of aligning population policy and family planning services with human capital development policies to accelerate economic growth.7 The decline in fertility led to a large proportion of the population being of working-age, achieving the so-called demographic dividend. Thailand was able to grow economically during its demographic window of opportunity, and reap the full benefit through policies and investments that targeted infrastructure, population, rural development, and industrialization.8 Today, the below replacement fertility rate has persisted for almost three decades, and naturally leads to societal aging, and to population stabilization in the next decade if this trend continues. Such population stabilization should be celebrated as a common success of Thai society, its benefits should be acknowledged and possible difficulties prepared for. In contrast, aging and the approaching population decline gets considerable negative publicity in Thailand, as elsewhere, and fertility-promoting population policies are coming into force to fix the issue of “too few babies”.3

We often hear that FP programs are forcing women to control their fertility. Thailand provides another example showing that people typically use FP voluntarily, happily and with relief when they have the opportunity. Perhaps with its focus on humor and family empowerment, the Thai example could provide strategies for countries still struggling with high fertility rates, such as many Sub Saharan African countries. Thailand demonstrates that if a society is receptive, then the right communication, large numbers of trained personnel, and the integration of FP into general health care and socioeconomic projects can have a lasting, rapid impact on fertility, and contribute to societal success.

Bibliography

  1. Rosenfield, Allan G.; Min CJ. The Emergence of Thailand’s National Family Planning Program. In: The Global Family Planning Revolution. Washington DC: The World Bank; 2009:221-233.
  2. Rosenfield, Allan; Bennett, Anthony;Varakamin, Somsak; Lauro D. Thailand’s Family Planning Program: An Asian Success Story. Int Fam Plan Perspect. 1982;8(2):43-51.
  3. Evolution of Thailand’s Population Policies.; 2012.
  4. Viravaidya M. The population and community development association in Thailand. J Polit Gov. 2016;6(special issue):1-14.
  5. Frazer E. Thailand : A Family Planning Success Story. Birth, Sex Death. 2017:1-3. https://www.context.org/iclib/ic31/frazer/. Accessed February 19, 2018.
  6. Suwanbubbha P. Sacred rights: The case for contraception and abortion in world religions. In: Maguire DC, ed. Sacred Rights: The Case for Contraception and Abortion in World Religions. ; 2011:1-304. doi:10.1093/acprof:oso/9780195160017.001.0001
  7. Jones G. Bearing the consequences of population policy in Thailand. East Asia Forum. 2011. https://www.eastasiaforum.org/2011/12/29/bearing-the-consequences-of-population-policy-in-thailand/. Accessed November 19, 2019.
  8. Starkey M. Demographic Dividend – The economic boost that follows a switch to low fertility. Popul Connect. 2015. https://www.populationconnection.org/demographic-dividend-the-economic-boost-that-follows-a-switch-to-low-fertility/. Accessed November 20, 2019.

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