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Friesen, John K.; Moore, Richard V.Country Profiles, Iran.Population Council, New York, N.Y.Oct 7220p.The Population Council, 245 Park Avenue, New York,New York 10017 (Free)

EDRS PRICE MF-$0.65 HC -$3.29DESCRIPTORS *Demography; *Developing Nations; *Family Planning;

National Programs; Population Distribution;Population Growth; *Population Trends; SocialSciences

IDENTIFIERS Iran

ABSTRACTA profile of Iran is sketched in this paper. Emphasis

is placed on the nature, scope, and accomplishments of populationactivities in the country. Topics and sub-topics include: locationand description of the country; population--size, number ofhouseholds, women of reproductive age, growth patterns, role ofwomen, urban/rural distribution, ethnic and religious composition,literacy, economic status, and contraceptive knowledge; populationgrowth and development - -national economics and social welfareexpenditures; history of population concerns; population policies;population programs--objectives, organization, operations,governmental role, education and communication efforts, and privateagencies in family planning; and foreign assistance for familyplanning activities. Summary statements indicate that program policyis to offer contraceptive information and services through thegrowing national network of family planning clinics, relying almostexclusively on, pills as the contraceptive technique. The strength andsense of urgency of the national commitment can be seen both in therapidly increasing channeling of talent and financial resources tothis effort and in the ambition of national goals for decreasing thecurrent high population growth rate. References and a country map aregiven. (BL)

Country Profiles

IRAN

U.S. DEPARTMENT OF HEALTH.EDUCATION & WELFAREOFFICE OF EDUCATION

THIS DOCUMENT HAS BEEH REPRO-DUCED EXACTLY AS RECEIVED FROMTHE PERSON OR ORGANIZATION ORIG-INATING IT. POINTS OF VIEW OR OPIN-IONS STATED DO NOT NECESSARILYREPRESENT OFFICIAL OFFICE OF EDUCATION POSITION OR POLICY.

by JOHN K. FRIESEN and RICHARD V. MOORE

The authors are, respectively, the resident advisor of the Population Councilin Iran and a University of Michigan fellow in Iran. They expresstheir appreciation to the Family Planning Division, Ministry of Health,for generous and valuable cooperation in providing information andsuggestions for this second edition of the Iran Country Profile.

Location and DescriptionIran is a large and unusually hetero-genous country from every point ofview. Topographically and climati-cally it includes high mountain ranges,vast deserts, tropical lowlands (alongthe Caspian littoral), and hot dryplains near the Persian Gulf. In gen-eral, water resources are a majorlimiting factor to growth, with onlyabout 13 percent of the country's 1.65million square kilometers (637,000square miles) cultivable. At present,approximately one-third of this landis under cultivetion. Much of Iran ismountain and plateau at an altitudein excess of 1,500 meters (4,900 feet).It borders on Turkey and Iraq to thewest, on the Persian Gulf and the Seaof Oman to the south, on Pakistanand Afghanistan to the east, and onthe USSR to the north.

Socially, the country is just as di-verse. A substantial portion of thepopulation is of Turkish, Arabic,Caucasian, or Central Asian origin.Although Farsi is the official lan-guage, Iran's rich ethnic mosaic sus-tains the use of many other languagesand dialects. Last year Iran cele-brated the 2,500th anniversary of themonarchy that began with Cyrus theGreat, making Iran the world's long-est-lived monarchy.

Historically Iran has been a basi-cally agricultural and rural countryonly intermittently tied together intoa discrete national entity. The world-wide modernizing forces of the last100 years, awelerated and promoted

-PERMISSIRIGHTEDBYel MC POPULATION COUNCIL. INC.. 1971

in Iran by the former and presentshahanshahs, are bringing about rapidand far-reaching changes throughoutthe society. One of the important re-forms of recent decades has been thecomprehensive land reform programinitiated by the monarch. This pro-gram, in which many thousands ofhectares of land have been redis-tributed, was declared completedduring 1971. Also undergoing rapidchange is mass communication. Al-though media are still concentratedin urban areas, a sophisticated na-tional telephone and telecommunica-tions network is nearing completion.For better transportation, Iran, incollaboration with Turkey, in 1971completed a rail link with westernEurope, and a Central Treaty Or-ganization (cErrro) road links Iran toboth its eastern and westerr neigh-bors. Other social institutions, espe-cially education, have received con-siderable improvement during recentdecades and are developing rapidly.

The major source for the financingof Iran's rapid modernization is thecountry's vast oil resources. Otherleading exports include fruits andnuts, carpets, minerals, wool andtextiles, some manufactured goods(for example, trucks and buses), andcaviar.

POLITICAL AND ADMINISTRATIVEORGANIZATION

Iran is a constitutional monarchywith executive, legislative, and judi-cial branches of government. The ex-

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A PUBLICATION OF

THEPOPULATIONCOUNCIL

October 1972

ecutive branch is divided into 19ministries, united at the top by theoffice of the prime minister and cabi-net. The nation itself is a centralized,unitary system divided into 13 prov-inces and nine governorates, the headof each of these 22 divisions being ap-pointed by the shah. Each provinceand governorate is further brokendown into counties (shahrestans) andabout 1,200 cities and townships.These latter entities are headed bymayors and city administrations thatare separate from the executive struc-ture at the local level, a structure thatresembles the central ministerial or-ganization.

PopulationAccording to the 1966 census, thepopulation was 25,078,923 (12,981,665males and 12,097,258 females). By1972 it has been estimated to be 31

(Saxena 1972).

HOUSEHOLDS

The number of households in 1966was 5,029,320, of which 3,068,619were in rural arid 1,960,701 in urbanareas. The average size of householdsin rural areas was 7.6 persons, andin urban, 5.8 persons. Ninety-fourpercent of household heads weremale, and nearly half of all house-holds included one or more literatepersons. The country has an esti-mated 3,898,719 housing units, ofwhich about 19 percent are occupiedby two or more households (1966census; Amani 1971).

WOMEN OF REPRODUCTIVE AGE

There were 5,212,803 women of re-productive age (15-44) in 1966. The1971 estimate is 5.51 million, of which4.54 million are married. Approxi-mately half of the women in the 15

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19 age group are married. The meanage of a man's first marriage is 25.5years, while a woman's is 18.6 years.The minimum legal age at marriageis 15 years. The UN "low" growthprojection forecasts almost 11 millionwomen in the 15-44 age group in1990, plus nearly 3 million more whowill have passed through this agerange during the preceding 20 years.Subtracting never-married and sub-fecund women from these estimatesleaves a target group for family plan-ning purposes of over 10 millionwomen within the next 20 years (UN1971, TAO/IRA/60, pp. 43, 44; Tay-lor and Berelson 1971, p. 27; 1966census).

GROWTH PATTERNS

Iran's rate of population increase wasestimated to be about 2.9 percent peryear during the 1956-1966 period.Current estimates place the 1971birthrate at about 48 per thousandper year, and the death rate at about16, which provide a current esti-mated rate of natural increase of 3.2percent per year, one of the world'shighest. The women of Iran averageabout seven live births. At the currentestimated growth rate the presentpopulation will double in 21 years.

Assuming constant fertility we canforecast a population size of 86.9million by the year 2000. Assuming a"low" growth rate, that is, assumingthat the growth rate will declinedramatically so as to reach 1 percentper year by 1992, provides a pro-jected population of 48.6 million per-sons by 2000 (Figure 1). In structuralterms, the country has a very youngpopulation, 46 percent being under 15years of age in 1966, up from 42 per-cent in 1956. The percent under 15years will remain about 45 percent ofthe total population if fertility doesnot increase very much and if infantmortality continues to decline. It isestimated that the dependency ratio(population 0-14 and over 65 dividedby population 15-64) was 101.0 in1966 as compared with 65.8 in theUnited States. The sex ratio haschanged from 104 males per 100females in 1956 to 107/100 in 1966.Demographers and census takers be-lieve that this figure is the result ofan undercounting of females. Lifeexpectancies at birth during the 1956-1966 period were 59 years for menand 50 years for women. The jointmale-female figure for 1971 is esti-mated at 55 years. Birth spacingand infant mortality, like most other

2

demographic variables, show a con-siderable urban -rural differential.Birth spacing averages 3.4 years inrural areas and 4.4 years in the capi-tal. By way of contrast, the averageperiod between births in France was8.4 years in 1964. Infant mortality isvariable too, being 80 per thousandlive births in urban areas versus 120in rurala national average of 104(Saxena 1972; Amani 1971; Nortman1972, Table 4; UN 1971, TAO/IRA/60, pp. 26-31; 1966 census). Figure 2compares recent and predicted birth-rates in Iran, the United States, andJapan.

ROLE OF WOMEN

Although attitudes regarding wom-en's status have been gradually im-proving in urban Iran, they remainmore traditional in rural areas; ruralareas have much lower rates of par-ticipation by females than do urbanareas in education, employment, andhealth services. Literacy, infant mor-tality, expectation of life at birth,and other social data all validate thisobservation (UN 1971, TAO/IRA/60, p. 104). One of the first explicitsteps to improve the status of womenwas taken by Reza Shah in 1935 withhis proclamation allowing women tohold government jobs, attend uni-versities, and join professions hithertoclosed to them. In 1963 the presentshah called for an amendment to theelection law to give wcmen the rightto vote and to be elected to Parlia-ment and other bodies. At the presenttime there are numerous women's or-ganizations, and these, led by the Na-tional Iran Women's Association, areconducting a review of the country'slaws to eliminate all vestiges of legaland actual discrimination againstwomen and to ensure just enforce-ment of the laws in this regard. TheFamily Protection Law of 1967, cur-rently being revised, is the principallegislation explicitly in support ofwomen's rights. As in many otheicountries, there is still much to bedone (Iran Almanac 1971, pp. 558-560).

RURAL-URBAN DISTRIBUTION

Although Iran is still predominantlya rural country, the rural-urban ratiois changing rapidly. In 1966, 61 per-cent of the population lived in ruralareas and 39 percent in urban, com-

FIGURE 1. POPULATION ESTIMATES for Iran under four fertility as-sumptions (constant fertility, 1 percent per year growth achieved in 1993, zerogrowth achieved in 2008 and 2023). Source: Saxena 1972.

1973 1988

pared with 69 per..:ent rural and 31percent urban in 1956 (1966 census).This distribution a2proximates quiteclosely the urban-rural ratio in mostother Middle Eastern countries.While the population of the entirecountry increased by 36 percent dur-ing 1956-1966, the population ofTehran increased by 80 percent, andseveral smaller cities increased byover 60 percent. The overall rate ofurbanization is nearly 7 percent peryear, which means a doubling time of11 years. By 1966 over one-fourth ofthe population of urban areas had

Ten Largest Cities

According to the 1971 Iran Almanac,populations (in thousands of persons)of the ten largest cities in Iran areas follows:

Tehran 3,400Isfahan 440Mashed 425Tabriz 420Abadan 280Shiraz 280Ahwaz 215Kermanshah 190Rasht 150Qom 140

2003 2018

been born in counties different fromthe ones they were living in; amongyounger adults the fraction was al-most one-half for males and two-fifthsfor females. The most common agespan for new u:laanites is 23-34.Tehran, with its surrounding CentralProvince, is in every sense the heart-land and magnet of the nation. It isestimated that Tehran, in addition tobeing both the capital and by farIran's largest city (about 3 millioninhabitants), contains: 41 percent ofall urban literate women, 53 percentof the nation's physicians, 46 percentof its engineers, and 35 percent of itscivil servants. In 1966 the CentralProvince contained over 35 percentof the entire urban population of thecountry. But like the country as awhole, water resources may prove tobe the absolute limiting factor, andTehran's maximum population capac-ity is thought to be 5.5 million(Amani 1971; UN 1971, TAO/IRA/60, :pp. 101-104; 1966 census). Interms of health services, the followingtable indicates current rural-urbandifferentials (Taylor and Berelson1971, p. 29).

3

3

Marriedwomen(15-44) Populationper per nurse-obstetrician midwife

ieswithprofessionalsuper-vision (%)

Rural31,000 92,400 5

Urban7,100 26,450 30

RELIGIOUS AND ETHNICCOMPOSITION

Most of Iran's population is Muslim;90 percent of these are Shia Muslims,and 10 percent, Sunni Muslims. In ad-dition there are 19,000 Assyrians,190,000 Armenians, 24,600 otherChristians, 67,800 Jews, 21,000 Zoro-astrians, and about 100,000 personsof other faiths. Iran includes a num-ber of tribal groups of different ethnicorigins. The most important of theseare the Bakhtiaris and Lurs, Kurds,Turkamans, Baluchis, Qashqais, andthe Khamseh, each of which has itsown culture and language or dialectin addition to Farsi, the official lan-guage used in all educational andother institutions (Iran Almanac1971, pp. 527 and 575).

LITERACY

Iran's literacy is climbing rapidlyfrom its former low level. There arealso considerable male-female andurban-rural variations. As is to beexpected, literacy is highest amongurban males and lowest among ruralfemales. It is noteworthy that theeducational and other reforms of thepresent shahanshah have and arestimulating a rapid increase in liter-acy, assisted by a major UNESCO(United Nations Educational, Scien-tific and Cultural Organization) proj-ect in several regions. During 1956

FIGURE 2. BIRTHRATES, past andpredicted, for Iran (assuming constantfertility), the United States and Japan.Source: Bourgeois-Pichat 1966.

tawOWSISSISIN ME16211216 21211 MU ME

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1975 1985 1995

FIGURE 3. ECONOMICALLY AC-TIVE POPULATION according tothe 1966 census was distributed asshown among carious professional andcommercial activities.

3% Professional 3.7% Miscellany

1966 overall literacy (both sexes) in-creased from 15 to 30 percent. (In1966 male literacy was 41 percent,and female literacy was 18 percent.)Total literacy values for urban andrural areas in 1966 were 51 and 15percent, respectively (1966 census).In recent years, Iran has experiencedan exceptionally rapidincrease inschool enrollment at all levels, espe-cially the secondary. One imagina-tive approach to the literacy problemis the establishment of a LiteracyCorps made up of young peoplecalled up for national service whoask to become teachers in rural pri-mary schools. The number of childrenbeing reached .by the corps is sub-stantial and growing. Adult educationis also receiving attention through thenational campaign for the eradicationof illiteracy and through the LiteracyCorps and the Experimental WorkOriented Literacy Project. The latterproject has covered over a quarter ofa million adults up to the presenttime and, on an experimental basis,has been used to impart family plan-ning concepts to the students (UN1971, TAO/IRA/60, pp. 104-106).

ECONOMIC STATUS

According to the 1966 census, about46 percent of the total settled popu-lation aged 10 years and over (7.6million) were economically active. Ofthis group, 87 percent were male and13 percent female. These figures donot include female farming activity in

rural areas. Of the active populationin 1966, 45.8 percent were engaged inagriculture and related activities;29.6 percent in production and trans-portation; 17.9 percent in sales, clini-cal, and service fields; 3 percent in theprofession.) and technical areas; and3.7 percent in miscellaneous eco-nomic activities (Figure 3). The ma-jority of employed females (66 per-cent) live in rural areas and abouthalf work in textile manufacture, in-cluding carpetmaking. In general,women may be said to participateeconomically in a minor way com-pared to men (1966 census). Figure 4shows the male-female distribution byactivity. But the economic picture ischanging quite rapidly and this trendis expected to continue. Between1956 and 1966 the number of personsemployed in rural industries (agri-culture, animal husbandry, forestry,fishing and hunting) fell from 56 per-cent to 46 percent and may now beno higher than 40 percent. It is esti-mated that within 20 years three-fourths of the work force will be em-ployed in urban occupations. Duringthe past decade per capita incomeand expenditure have both risen con-siderably. Per capita income is now$420 per annum, up from $193 in1962 (Plan Organization of Iran1968).

CorrrRAcErnvz KAPThe primary sources of data used hereare a KAP (knowledge, attitudes,practice) study done in Tehran inmid-1971 (imEsco 1971) and surveystaken as part of the Isfahan MassCommunications Project. As will beobvious, one major goal of the Tehranstudy was to compare the knowledge,attitudes, and practices of literatewith illiterate women. Surprisingly,perhaps, most women (96 percent),whether literate or not, believe in thepossibility of birth control by fami-lies. The study indicated that face-to-face communications (especially withfamily and friends) play a major rolein awareness and learning about con-traception and family size concepts.Family size ideals in Tehran rangefrom 2.9 children for literate womento 3.2 for illiterate women. The fam-ily size ideal expressed here pro-vides a remarkable contrast with cur-rent fertility behavior, which aver-ages about seven live births per

44,

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FIGURE 4. MALE-FEMALE DIS-TRIBUTION among economically ac-tive and inactive parts of the populationover 10 years old according to the 1966census.

Males Females

woman nationally.The most suitablemarital age for women was thoughtto be 19.5 years and for men, 27 years.

In the UNESCO study, both cate-gories of respondents felt that birthcontrol was justified by the need toeducate children and for reasons offamily finance, in that order. Lessthan 1 percent felt that birth controlwas never justified. Most women feltthat the termination of childbearingor of pregnancy was a more compel-ling reason for using contraceptivesthan for child spacing (71.5 percentamong literates and 66.8 percentamong illiterates). More than two-thirds of all respondents reported aknowledge of some contraceptivemethod, although patterns of use ap-pear to vary a great deal. Coitus in-terruptus is by far the preferredmethod, at 46 percent, in Tehran.Pills were used by 32 percent ofthe Tehran respondents, and 57.7percent were using some form of con-traception (69.6 percent of literatesand 45.8 percent of illiterates).

The KAP findings in Isfahan aresimilar in several ways to the resultsobtained in the capital city. In Isfa-han, 23 percent of the villagers sam-pled (against 11 percent of those inurban areas) believe that having chil-dren is solely in the hands of God.Alai), most women have some aware-ness of Ministry of Health activitiesin family planning. As in the Tehranstudy, interpersonal communicationswere of major importance. Despitethis finding, only 21 percent of therespondents claimed to have dis-cussed family planning with their

1

spouses. Of these, 27 percent of thewives talked about wanting to stophaving children. The number is gen-erally consistent with the findingthat 35 percent of Isfahan couplessaid that they had not wanted theirlast pregnancy. Not surprisingly,ideal family size is higher in this morerurally influenced area than in Teh-ran (4.1 children among illiterate vil-lage women and 3 among urbanwomen). As in Tehran, over two-thirds reported a knowledge of somecontraceptive method with coitus in-terruptus again the preferred method,at 24.3 percent of rural contraceptors.In Isfahan only 1 percent reportedhaving an IUD, no one admitted to avasectomy, and fewer than 1 percentof the women had undergone a tuballigation. Thirty-five percent of cou-ples surveyed expected to use a con-traceptive method in the future.

It is not clear to what degree thesecontraceptive KAP and continuationrates are typical of those in Irangenerally, especially in rural areas.Clearly, a great deal more research isneeded. To help fill this informationgap, the Ministry of Health is plan-ning several KAP surveys of nationalscope.

Population Growth andDevelopment

NATIONAL ECONOMICS

The current average economic growthrate is over 10 percent per year, oneof the world's highest. Domestic sav-ings amount to approximately 21 per-cent of gross national product (BankMa rkazi 1970). Iran's share of thetotal value of its oil exports was in-creased substantially during 1971;meanwhile the annual exports ofcrude oil grow larger every year. Thisincrease in output and revenue (cur-rently more than $2 billion per an-num) is expected to continue. Non-oil exports have shown a steady rise aswell, increasing by 11 percent during1971. Unfortunately for balance oftrade, imports have increased almostas rapidly. Industrial production wasup 13 percent in 1971. Although agri-culture contributes the largest shareof GNP, it has shown slow growth (2.6percent per year during the ThirdPlan, 1963-1968) relative to otherparts of the economy and thus hasdeclined relatively as a source of na-tional output (Iran Almanac 1971,

1IOURE 5. SECTORS OF THEECONOMY and their changes from1960 to 1969 expressed in terms ofprices with 1959 values as the base.Source: Plan Organization 1971.

pp. 225-260). Agriculture contrib-uted 27 percent of GNP in 1965,when about 64 percent of the popu-lation were living in rural areas. It isestimated that by 1985 the agricul-ture share of GNP will be reduced toabout 12 percent, with approximately40 percent of the population still liv-ing in rural areas. Using past trendson yield per acre and amount of landunder cultivation, it is estimated thatthe supply of agricultural productswill increase 3.5 percent per year,reaching a value of 180 billion rials($2.37 billion) for 1985. Using antici-pated per capita inczne and moder-ate population estimates (a totalpopulation of 42 million) to calculatedemand for food in 1985, one deducesa food shortage equal to approxi-mately 170 billion rials ($2.24 billion)at 1965 retail prices (Ronaghy). Ingeneral, however, it may be said thatIran has a sound and growing econ-omy led by oil exports that are basedon long-term reserves. These oilrevenues can help to underwrite thecountry's major development costswhile rapid industrialization endeav-ors to provide jobs for the many job-seekers now and to come. Without asubstantial reduction in the present

5. 5

population growth rate, however, ad-ditional agricultural, housing, em-ployment, and social service needswill account for an ever-increasingshare of the country's resources justto maintain the current quality of life.In the ECAFE (Economic Commis-sion for Asia and the Far East) re-gion it is :estimated that a populationgrowth rate of 3 percent per year re-quires an investment of 9 percent ofthe national income to maintain thestandard of living. This assumes acapital output ratio of three (mean-ing that for each $3 of investmentthere would be a return of $1).Changes in the portions of the econ-omy assigned to different sectors canbe read from Figure 5, which showsthe relative changes in Iran's majoreconomic sectors during the 1960decade.

SOCIAL WELFARE EXPENDITURES

Education and HousingThe socioeconomic consequences ofpopulation growth can be illustratedby showing the effects of two rates ofdemographic growth. If we start withan assumed primary school age popu-lation of 4.847 million in 1971, rapidpopulation growth leads to a pri-maiy school age population of 8.773million by 1986; moderate growthprovides a projected size of 7.527million by 1986. Thus the differ-ence between these two increases willbe 1.246 million children of pri-mary school age in 1986. Convertingthis to the number of primary schoolclasses required (at about 30 studentsper class) indicates 292,400 and251,000 classes and proportional num-bers of teachers. The difference of41,400 classes has obvious implica-tions in terms of educational invest-ment and manpower development(Figure 6). Estimating the housingneeded can be accomplished by pro-jecting the annual number of mar-riages. Assuming a constant mar-riage rate, it wilt be necessary tobuild 378,000 to 408,000 housingunits in 1986, just to house newlymarried couples, not counting hous-ing replacements due to deterioration(Amani 1971).

HealthIran's health budget is 5 percent ofthe national budget, an annual percapita health investment of $4.83.

FIGURE 6. PRIMARY SCHOOLCHILDREN according to two growthhypotheses. Source: Amani 1971.

1971 1976 1981 1986

This is one of the highest per capitahealth expenditures in the developingworld. Within the present fourth five-year plan (1968-1973), Iran plans toexpand rural health services from acoverage of about 50 percent to 65-70 percent, including the establish-ment of 500 new rural health clinics.There are plans for a massive increaseof hospital beds, addition of five newnursing schools and ten new schoolsfor Yu 2rsing assistants, and increasedtraining facilities for midwives. Thenumber of rural Health Corps unitsis to be increased to 450. Althoughthe health funds for the fourth five-year plan have been reduced, the al-location for family planning has con-tinued to increase.

The budgetary features of the fam-ily planning program are as follows:In terms of health infrastructure Iranhas: 0.3 maternal-and-child-healthclinics per 1,000 births (comparedwith 1.0 for Turkey and 0.2 for Pun-jab, India); 0.3 family planning clin-ics per 1,000 married women aged 15-44 (0.1 for Turkey; 0.3 for Punjab);3.0 maternity beds per 1,000 births(2.7 for Turkey; 2.0 for Punjab); apopulation per physician of 4,100(2,800 for Turkey; 3,400 for Punjab);a 15 percent professional supervisionof deliveries (48 percent for Turkey;40 percent for Punjab) (Taylor andBerelson 1971, pp. 39, 40).

Population ConcernsTraditional methods of contraception,including coitus interruptus and folk

drugs and devices, have been knownand practiced in Iran from earliesttimes. Current research and clinicalexperience suggest the extensive useof coitus interruptus. The condom ap-pears to be the second most commonnonclinical method. Oral and IUDcontraceptives were introduced in theearly 1960s, I although the IUD hasnever gained the popularity of pills.The ratio of new pill to IUD accep-tors is about 20/1. The possible rea-sons for this large difference mayinclude: the limited experience ofmost doctors and midwives in the in-sertion of IUDs; the greater ease andshorter time for prescribing pills overinserting IUDs; the greater use-effec-tiveness of pills; the fairly widespreadopinion that an IUD is not suitablefor many women; the reluctance ofrural women to accept a pelvic exami-nation by a male physician; and theconcern over the more obvious sideeffects of the IUD. Condoms, chem-ical methods, and diaphragms havenever been strongly promoted, pre-sumably because of their low use-effectiveness (UN 1971, TAO/IRA/60, pp. 59, 60 and 64, 65).

As in many countries, induced abor-tion has been practiced in Iran sinceancient times. Abortion is currentlyillegal in Iran, however, except whenthe mother's life is in danger. Never-theless, there is some evidence thatthe actual rate of induced abortion isbetween 15 and 25 percent of the totalnumber of pregnancies. A survey ofIUD acceptors in Abadan revealedthat 23 percent of the women ad-mitted to one or more induced abor-tions, and the actual figure may behigher. Prosecution for illegal abor-tion is extremely uncommon. Iranauthorities are giving their close at-tention to future policy in this im-portant matter. The Iranian medicalprofession appears to favor a relaxa-tion of the current abortion law (UN1971, TAO/IRA/60, pp. 66, 67).

Sterilization is not the subject oflaw in Iran but remains a matter be-tween doctor and patient. The viewson sterilization as a family planningmethod differ widely as do the for-malities preceding the operation.Some form of written consent bywife and husband, with other under-takcings designated to protect theoperating physician, is usually drawnup. Most sterilization have been

6

tuba 1 iigations rather than vasec-tomies, although the total numbersof both operations are insignificantfrom the demographic point of view(UN 1971, TAO/IRA/60, p. 68).

Population PoliciesThe first public instruction in contra-ception was given by maternal-and-child-health clinics set up in 1953,but these did not supply contracep-tive materials. In 1957 the Interna-tional Planned Parenthood Federa-tion started to encourage familyplanning activities in Iran and sup-plied a number of Iranian volunteerswith contraceptives, such as foamtablets, jellies, and diaphragms. In1961 the importation of oral contra-ceptives was allowed.

The first official government inter-est in family planning dates from1960. At this time his imperial maj-esty the shahanshah and the govern-ment began to be concerned aboutthe rate of population increase follow-ing demographic studies based on the1956 census that showed a rapid in-crease. The report of a populationcommittee was included in studiespreceding the third five-year develop-ment plan in 1963. In 1966 a Popula-tion Council mission was invited towrite a report on the population prob-lem, and several Ministry of Healthofficials were sent to study popula-tion problems in Egypt and Pakistan.Subsequently the government ap-pointed an undersecretary for familyplanning in the Ministry of Health,and a few months later a specific planwith budgetary estimates was sub-mitted to the government. This pro-gram, which aimed to use the maxi-mal feasible fraction of Iran's phy-sicians for part-time family planningservices, got underway in April 1967.

The objective of the family plan-ning program in Iran, as expressed inthe fourth plan, is to promote "thephysical, mental, social and economicwelfare of families and in consequencethat of society." In view of the seri-ous influence of current rapid popula-tion growth on overall developmentof the country, the governmentadopted a more aggressive popula-tion policy in May 1970. The ultimategoal was to reduce annual populationincrease to 1 percent within 20 years.The Ministry of Health was called onto design a new national program en-

suring the coordinated involvementof all relevant government, nongov-ermnent, and voluntary agencies. Thenational tradition of numerous agen-cies providing medical and relatedsocial services including family plan-ning makes this coordination func-tion both important and difficult. Theprogram is to emphasize flexibilityand experimentation. The Ministryof Health is responsible for planning,organizing, and carrying out the fain.ily planning program. The major serv-ice aspects of the program are closelylinked to the health and medical serv-ice systemespecially maternal-and-child-health servicesof the country.Basically MCH clinics are used asservice points for contraceptive meth-ods and the staffs are being trained.in the management of clinical contra-ception. The overall objective is tohave the Ministry of Health, otherministries, and nongovernment andprivate organizations provide contra-ceptive services wherever clinical fa-cilities exist. These family planningservices are also being introduced intohospitals providing maternity careand are being provided by variousother government and nongovern-ment agencies.

The natality implications of cur-rent social-insurance, workers'-bene-fits, and income-tax policies have notbeen systematically examined, al-though the question is recognized asimportant by government officialsand others. At the request of thegovernment, an International LaborOffice expert conducted a study of theSocial Insurance Organization in 1971(UN 1971, ILO/FPA/Iran/R.25).The study provides much needed in-formation on this important question.In addition, the government is plan-ning a project for.the comprehensivestudk of Iranian law and population.

SUPPORT AND OPPOSITION

Strong and constant support for thefamily planning program has comefrom his imperial majesty the shahan-shah. In 1967 he joined 29 otherleaders in signing a Declaration onPopulation, which was presented toformer United Nations SecretaryGeneral U Thant (World Leaders1967). Since that time, the shah hasspoken out several times about theneed for limiting Iran's rapid popula-tion growth. There has also been gen-

eral support of the need fo, birthlimitation among other high Iranianauthorities and opinion leaders.

In terms of acceptance of familyplanning by the majority of the popu-lation, there is good reason to believethat motivation and demand are al-ready present to a considerable de-gree, especially in the more de-veloped areas (UN 1971, TAO/IRA/60, pp. 92, 93, 191). Indeed, it isclear from clinic cards that only about10 percent of contraceptive acceptorswant any more children at all (UN1971, TAO/IRA/60, pp. 5, 45). Butthe foregoing does not mean that edu-cation and motivation are unimpor-tant. The education and motivationof low parity women, of those im-mersed in traditional attitudes, andof males remain a large and difficultundertaking.

Opposition to family limitation hasbeen negligible, coming mainly fromthose who still believe that Iran hasample room for population expansionand those unaware of the rapidly fall-ing infant mortality. But family plan-ning has never been a controversialissue. Since 1966, when the nationalcensus confirmed the rapid popula-tion growth and demographers andeconomists pointed out the conse-quences for the society of uncheckedgrovith, there has been a growingawareness of the need for family plan-ning. In general, acceptance and prac-tice of family planning probably arenot so much a problem of oppositionor support as of widespread lack of in-formation and concern (compoundedby misinformation) on the part of theelite and literate groups and of ignor-ance, fatalism, and apathy on the partof the rural and illiterate. That thestatus and literacy of women are lowis not incidental to the problem. Tothe degree that the foregoing is true,it points up the critical function of theeducation and motivation job to bedone (UN 1971, TAO/IRA/60, pp.103, 104).

RELIGIOUS ATTITUDES

A Tehran study in 1971 indicated thatthe majority of married women inter-viewed (63 percent) felt that birthcontrol and family planning were ac-ceptable practices within the Islamicfaith; 67 percent of literate and 59percent of illiterate women expressedthis view (tmEsco 1971). As noted

7

above, apathy, fatalism, ignorance,and status of women are probablymore important than religion, as such.

Religious leaders in Iran generallyaccept family planning and use of con-traceptives. On the other hand, state-ments by authoritative Iranian reli-gious leaders have specifically op-posed sterilization and any form ofcontraceptive that would result inabortion even from the very beginningof conception. Statements from reli-gious leaders in other Islamic coun-tries also prohibit abortion but onlyafter the "quickening" of the em-bryo. It is not known whether theattitudes of religious leaders arechanging on these points or what theinfluence of such attitudes is uponpeople's practices regarding contra-ception and abortion.

Population Program ActivityOBJECTIVES

The program is striving to achieve thepsychological, social, economic, andphysiological welfare of familiesthrough advising and assisting thepublic to control family size, that is,to help couples strike a balance be-tween the number of children in afamily and its socioeconomic circum-stances. Within this general objective,the program seeks to achieve the fol-lowing aims: reducing induced abor-tions, especially those without pro-fessional supervision; correlating therate of population increase with percapita income; balancing the agestructure of the population; increas-ing the economically active popula-tion of the country; and facilitating areduction in the present populationgrowth rate to levels commensuratewith natural resources and socio-economic goals. To accomplish theseobjectives, the Ministry of Health is:providing training to both medicaland opinion leaders' groups; inform-ing the general public; establishingfamily planning services in clinicsthroughout the country; conducting,supervising, and encouraging researchin demographic, medical, and socialsciences; extending contraceptive in-formation and services to rural areas;providing supplies and technical ad-vice; and arranging for internationalassistance wherever required (Iran,MOH 1971).

The UN "low" population projec-tion for Iran estimates a population

FIGURE 7. FAMILY PLANNING DIVISION in the Ministry of Health is organized in flue major units. Theundersecretary at the head is responsible for planning, coordinating, organizing, and implementing the program.

in 2000 somewhat greater than the48.6 million accepted by the govern-ment, a population growth rate of 1percent by 2010, and a stable popula-tion in the 100-125 million range. Toachieve these figures will requireaverting 250,000 births a year by1975, half-a-million annually by 1980,and 750,000 by 1985. These numberswork out to be about 50,000 extrabirths averted each year or a newgain of about 150,000 effective con-traceptors each year. To meet thetarget of 1 percent growth rate by1990 would require rates of acceptors,effective practice, and births avertednearly twice those required by theUN "low" projection (UN 1971,TAO/IRA/60, pp. 32-37).

OPERATIONAL POLICY

That the program is being imple-mented through existing health andclinical facilities means that introduc-tion of family planning functions callsfor employment of existing technicalstaff on a part-time basis and of addi-tional staff for motivation, homevisits, supervision, and record keep-ing. Follow-up of new acceptors,regular home visits, and more con-venient access to supplies and serv-

ices are gradually being added to theprogram and are expected to improveacceptance and continuation rates.Preventive health care, includingfamily planning, is provided free ofcharge, although a small registrationfee (about $0.20) is usually requestedfrom clients who can afford it. On thequestion of incentives, the currentpolicy I of self-motivated and volun-tary aiceptance of family planning isexpected to continue. Thus incentivesto field staff and local functionariesfor referrals and contraceptive dis-tribution, and subsidies to privatephysicians for IUD insertions, are notcurrently awarded except on an ex-perimental basis.

One important function of the Min-istry of Health is to set standards andsecure an even national distributionof resources and services. The rapiddevelopment and complexity of thenational effort. make it imperative toachieve common basic patterns as tocategories and numbers of staff,equipment and drugs, managementof contraceptive services, follow-up,records' management, field workerproductivity, etc.

The ministry has delegated to anonprofit company the purchase and

supply to government health centersof condoms and drugs including oralcontraceptives. Iranian governmentaland private organizations that havetheir own supply distribution systemand some that do notare alsoprovided with pills through this chan-nel. Intrauterine devices (Lippesloops) are being provided to the min-istry by the Population Council anddistributed to clinics free of cost.Some condom supplies have beenprovided by the Swedish Interna-tional Development Authority. Threedifferent brands of oral contracep-tives are used in the program: EUGY-NON, VOLIDAN, and LYNDIOL (2.5), thelatter tw" being manufactured lo-cally. Other common brands areavailable on the open market. Brandsof oral contraceptives that includeplacebo tablets to assist women inmaintaining an unbroken contracep-tive regime are also available com-mercially.

FAMILY PLANNING ORGANIZATION

As noted above, the government hasgiven to the Ministry of Health theresponsibility to plan, coordinate, or-ganize, and implement the familyplanning program. These functions

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have been delegated to a special divi-sion in the ministry headed by anundersecretary of state for health andfamily planning. This position is heldby his excellency, Dr. Amir MansourSardari, formerly director-general ofmedical services in the Ministry ofRoads and Communications and asenior professor on the faculty ofmedicine at the University of Tehran.The division is organized into themajor units shown in Figure 7.

The Family Planning Divisionworks closely with other parts of theMinistry of Health to ensure coordi-nation and obtain technical assistancein such activities as health education.One result of this coordinated ap-proach has been the strengthening ofdivision capacity through the trans-fer to it of the ministry's maternal-and-child-health unit and the entireWomen's Health Corps.

The central ministries are repre-sented at the provincial level bydirectors-general. The Family Plan-ning Division is represented in theprovincial health departments. Thegovernment policy of decentraliza-tion provides for coordinating thework of the different ministries underthe governor-general of the provinceand for reducing with all deliberatespeed their current vertical responsi-bilities to the central ministries inTehran. Many nongovernmental andprivate agencies also have branchesin the provinces that report to theirheadquarters in Tehran. In the pro-vision of health and family planningservices, the director-general of eachprovincial health department has akey position, assisted by a directorfor family plliming. The director-gen-eral is the head of the public healthservice of the province and the execu-tive officer of its health councils, acommittee of appointed and publiclyelected members concerned with com-munity health services. He is also thehead of the provincial branch of theImperial Organization for Social Serv-ices and a member of the provincialcouncil of the Red Lion and Sun So-ciety. On the basis of personal inter-est and commitment the director-gen-eral for health serves as coordinatorfor all family planning services insome provinces. The personnel of theFamily Planning Division maintain aliaison and working relationship withthis important official. The provincial

FIGURE 8. PROVINCIAL HEALTH ORGANIZATION FOR FAMILYPLANNING is headed by the governor-general of the province. The director-general for health is assisted by a director for family planning.

director for family planning is ap-pointed by the director-general forhealth. Decision making on most mat-ters of substance is done by familyplanning officials at the center, oftenby the undersecretary himself. Suchdecisions are based in varying degreeson information provided by provin-cial staff. The structure of the Pro-vincial Health Organization for Fam-ily Planning is shown in Figure 8.

ROLE OF OTHER ORGANIZATIONS

Revolutionary CorpsOne of the principal innovations ofthe shahanshah's White Revolutionof 1962 was the use of two-year con-scripts in the military service to im-plement social reform and develop-ment activities. After a period of basicmilitary training, conscripts are as-signed to various corps such as theLiteracy Corps, the Health Corps,and the Extension and DevelopmentCorps. Corps members are sentthroughout the country to teach;build roads, bridges, and schools; im-prove sanitation; and generally to aidin the development of better stand-ards of life in the rural areas. Thepromotion of family planning hasnow been added to their duties. fol-lowing 8 to 12 hours of instructionon family planning. Although theLiteracy Corps family planning ac-tivities are limited to disseminating

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general information, corps membersplayed a crucial role in the Experi-mental Work Oriented Literacy Proj-ect, which introduced adults to fam-ily planning concepts. The HealthCorps plays a more direct role, mainlythrough its distribution of oral con-traceptives and condoms by its mo-bile units operating in rural areas.Also, as noted above, the entireWomen's Health Corps has been as-signed to the Family Planning Divi-sion and plays a direct role in theHealth Ministry efforts to deliverfamily planning information and serv-ices. Research is required to find outhow consistently and enthusiasticallyRevolutionary Corps members actu-ally promote family planning andhow many contraceptive acceptorsmay be attributed to their efforts.

Other MinistriesThe Ministry of Education, in coop-eration with the Ministry of Heahb.has introduced population educationmaterial into the junior high andhigh school biology and social studiescurricula. Material prepared for pri-mary schools also deals with the ele-ments of reproduction and the fam-ily. At the university level the non-medical faculties now include in theirsyllabuses a wide range of social sci-ence and biomedical subjects directlyrelated to reproduction and family

planning. The ministrie.. of Labor,Housing and Development, Agricul-ture, and Land Reform also includeshort courses on family planning ingeneral training programs, and theyencourage their staffs in the field todisseminate information on familyplanning. The Ministry of Labor,through the Workers' InsuranceScheme, is charged with providinghealth and medical services to wageearners, usually industrial workers,and their dependents.

Other components of the govern-ment provide health and medical carefor discrete groups. These include thearmed forces, the gendarmerie, andthe police forces, which providehealth services for their personnel andfamilies. The National Iranian OilCompany and its associate subsidi-aries have an extensive program andnetwork of health and medical carefacilities for employees and theirfamilies.

COORDINATING BODIES

The principal coordinating body atthe center for the major organizationsengaged in family planning-relatedactivities is the High Council for Co-ordination of Family Planning. Thecouncil meets under the chairman-ship of the undersecretary of state forhealth and family planning. The fol-lowing government and nongovern-ment agencies are represented on thecouncil: Armed Forces Health Serv-ices, Gendarmerie Health Services,Police Force Health Services, 'RedLion and Sun Society, NationalIranian Oil Company Health Serv-ices, Imperial Organization for SocialServices, Institute for the Protectionof Mothers and Children, FamilyPlanning Association of Iran, Minis-try of Labor Insurance Organization,Ministry of Land Reform, Rural In-surance Organization, and the Na-tional Women's Organization. Sincethe council has met only infrequently,it is premature to speculate on howeffective it may be in its coordinatingrole.

At the provincial level there are, inaddition to the coordination providedby the director-general for health,two principal coordinating bodies:local health councils and the county(shahrestan) level executive boardsfor family planning Membership ofthe health councils is made up of

elected and appointed officials andprominent citizens. These councilsperform an information and advisoryfunction regarding community healthcare but principally act as aggregatorsand disbursers of health and familyplanning funds received by that body.Health councils, untrammeled by thenormal exigencies of civil service andin close touch with local needs, pro-vide an extremely important source ofprogram flexibility. Executive boardsfor family planning are currentlybeing established in counties through-out the country. The purpose of theseboards is to maximize the flow of in-formation among important officialsand family planning-related agenciesin each county. The provincial direc-tor for family planning attends eachof these meetings.

PROGRAM OPERATIONS-DELIVERY OF SERVICES

The major problem of family planningin Iran is to reach not only the coun-try's urban population but also its50,000 villages, many of which are inremote areas. To meet the demand1,529 clinics were operating by mid-1971, 79 of which were opened in thefirst three months of that year. A va-riety of government and private or-ganizations operate these clinics. TheMinistry of Health itself operates 678clinics. The other 851 are dividedamong the following organizations:Health Corps (mobile units) 397; Im-perial Organization 249. (both aremajor operators of rural clinics); edu-cational institutions 22; Social Insur-ance Organization 43; Imperial ArmedForces 82; National Iranian Oil Com-pany 9; Women's Organization 23;Red Lion and Sun Society 16; chari-table organizations 6; others 4. Mostof these clinics are in urban areas andvery few are primarily devoted to thedelivery of contraceptive services. Toexpand clinical services in ruralareas, 37 mobile family planning clin-ics were made operational in 1971.These mobile teams, together withHealth Corps units, operate as exten-sions of the stationary clinics forhealth and family planning (Iran,MOH 1971). IMplementing the pro-gram through these existing facili-ties has given itfor the time beingat leasta clinic versus a field de-livery orientation. This orientationmeans that most clients have to go to

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clinics for services, for checkups, andfor new supplies and contraceptives,usually one cycle of pills at a time.Acceptors of oral contraception areexpected to return for reappraisal andsupplies each month. Routine visitsfollowing IUD insertions involve thre?initial revisits during the first twomonths and then a revisit every threeto six months (UN 1971, TAO/IRA/60, p. 59). Some large health ,2entershave a special loca,lon to which theclients are referred for mon, compre-hensive advice and f.s contraceptives,after receiving irlfounation 'aboutfamily planning by the regular ma-ternal- and - child- heath staff at theclinic. Agencies are being encouragedto offer extra clinic hours in the eve-nings exclusively for family planningto reach clients who are unable toattend the clinics during normal work-ing hours, that is, mornings andsometimes early afternoons.

Although information and educe-libta campaigns are used periodicallythroughout much of the country,mainly focused on urban areas, it isfair to say that client recruitment, assuch, has only rarely been attempted.However, the maternal-and-chilci-health clinics are heavily utilized bythe public, thus coming into contactwith family planning information andservices in a positive, health-orientedcontest (UN 1971, TAO/IRA/60, p.72). The expanding education, mo-tivation, and extension services oi theprogram are expected to result in in-creasing numbers of health and fam-ily planning clients in the rural areas.

PersonnelThe great majority of family planningworkers do not have to be recruitedand paid for by the Family PlanningDivision. The principal relationshipbetween the division and the manymedical and paramedical personnelwho man the clinics is that of trainer,advisor, standard setter, motivator,contraceptive supplier, planner, andcoordinator. In addition to the morethan 700 Health Corps girls workingin clinics and as field personnel, socialworkers and field workers with spe-cial training in family planning in-formation and motivation are em-ployed to work directly with the cli-ents in health centers and for follow-up visits. Also employed in the clinicsare nurses' assistants (behyars). The

1

MS

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program employs four categories ofmotivators: Women's Health Corps,ex-corpswomen now employed, youngwomen employed as community work-ers, and locally hired personnel. Aspecial category of field worker is be-ing developed of married women 25-40 years of age with at least six yearsof schooling recruited from the eeriewhere they will work. By mid-1971,455 workers of this kind had beentrained and posted. Assuming that asingle field worker can visit 100-200acceptors every month, the programcurrently requires at least 1,500 suchpersonnel. By the end of the next five-year period (1977), a total of 5,000will be needed (Iran, MOH 1971;UN 1971, TAO/IRA/60, pp. 62, 63).The Health Corps units are staffed bymale physicians and assistants. Thestaff for each of the 30-40 mobilefamily planning units consists of aphysician or midwife, a nurse assis-tant, two motivators (usually HealthCorps girls), and a driver (UN 1971,TAO/IRA/60, p. 58). The typicalcity clinic consists of a doctor, mid-wife or nurse, one nurse's aide, threemembers of the Women's HealthCorps, and a servant.

The government plans to increasethe number of paramedical villageand clinical personnelparticularly

'midwivesand to encourage the dele-gation of less complex and demandingtasks to the lowest possible staff level.Also to be substantially increased arethe numbers of home visitors and mo-tivation personnel: Health Corpsgirls, "mature" field workers, socialworkers, and supervisors. The gov-ernment is also concerned with deter-mining and establishing optimal ate-fmg patterns and delivery systemsfor all types of outlets throughout thecountry. As noted above, local func-tionaries (village heads, traditionalmidwives, and others) are being con-sidered as sources of referrals and asdistributors of contraceptives. Con-doms are available at the Ministry ofHealth clinics and commercially butare not regularly available at clinicsbelonging to other organizations. Toincrease the availability of condomsthe Family Planning Division is work-ing on new techniques for increcteingthe delivery of condoms throug,, :utthe country. The use of chemicalmethods and diaphragms is insig-nificant.

POSTPAR7 UM PROGRAM

Tile, Farah Maternity Hospital inTelnoxt, one of the world's largest, isa participant in the InternationalPostpartum Program sponsored bythe Population Council. This inter-national program now includes about250 hospitals. About 40,000 deliveryand 6,000 abortion cases were ad-mitted to the Farah Hospital during1970. At discharge, 60 percent of thepatients show a positive interest inadopting some contraceptive method,although only 15-20 percent of thesewomen return tp receive services. Inaddition, a number of nonpostpartumwomen hear of the contraceptive serv-ices and come to the hospital forthem. The hospital has approximately120 deliveries per day and has a dailyattendance at its family planningclinics of 60 new acceptors, of which40 are nonpostpartum. It is expectedthat the number of new and continu-ing acceptors will increase if thoseinitially interested in contraceptionare subject to regular hong visits andthe continuance of maternat-and-child-health services. It is interestingto note that there has been a drop offive years in the average age of ac-ceptors since the program began in1966. The Farah Hospital is run bythe Institute for Protection of Moth-ers and Children, a nongovernmentalorganization financed primarily by aspecial gasoline tax (UN 1971, TAO/IRA/60, pp. 70-74). The recognizedvalue of a postpartum program andthe success of the Farah postpartumeffort has encouraged the FamilyPlanning Division to offer regularpostpartum and MCH-related con-traceptive services at a number ofadditional hospitals. The division,with international assistance, is nowimplementing a plan to introduceorganized maternity-centered familyplanning services initially in five hos-pitals and eight MCH clinics in dif-ferent parts of the country. Thesecomprehensive services will be ex-panded gradually to include all ma-ternity hospitals and services by 1975.A national coordinating and advisorycommittee, formed by representa-tives of all agencies and organizationsproviding maternity care services, isto be established to plan, direct, andoversee the implementation of thiseffort. The undersecretary of state for

11 "

health and family plsnrsing will pre-side over the committee,

TRAINING

It is manifest that basic to the imple-mentation of the national familyplanning effort is an adequate, con-tinuing supply of trained personne%medical (doctors and nurses); ad-ministrative and supervisory; func-tional specialists (information, moti-vation, education, and technical);paramedicals (nurses' assistants, as-sistant midwives, and rural mid-wives); and field staff (home visitors,motivators, and public educators)..

At this writing the Family PlanningDivision operates a number of train-ing centers in different parts of thecountry to supply these people. Theoldest and largest of these is theFirouzgar Center in Tehran. In addi-tion to short orientation cour.es isthe provinces, the '-irouzgar Centeroffers various intensiv% family plan-ning training courses for many of themedical, paramedical, and field per-sonnel who will be performing fam-ily planning functions within thegovernmental or nongovernmentalcontext. By mid-1971 this and otherTehran centers had trained the fol-lowing personnel in relevant familyplanning coursr.. for up te threeweeks per etude it

Physicians, nurses, and mid-wives (three-week course) 1,350

Physicians of the ImperialOrganization 254

MPH graduates specializingin family planning 36

Health CorpsMale doctors and aids 4,500Women 1,780

"Mature" field workers(women) 455

In addition, large numbers of person-nel from other governmental andnongovernmental agencies, plus alimited number of private practi-tioners, have received training in, orat least exposure to, family planningsubjects.

A partial list of this trainingfollows:

Literacy Corps. Over 40,000 malorecruits have received nine hours oftraining in family planning arrangedby the Ministry of Education in co-operation with the Ministry of Health.

Extension and Development Corps.Both men and women members ofthis corps receive nine hours of fam-ily planning instruction as part oftheir general training. More than5,000 workers had received this train-ing by mid-1971.

Home Economic Agents. Five hun-dred married women employed by theMinistry of Housing and Develop-ment to teach village women havereceived 12 hours of family planninginstruction during their training.

Cooperative Society Supervisors.Agents employed by the Ministry ofLand Reform to supervise the estab-lishment of cooperative societies inrural areas ha-re received six hoursof instruction in family planning. Ap-proximately 1,000 had been so in-structed by mid-1971.

Women's Association. Over 500 ofthe association's volunteer workers inhealth, education, and welfare areashave taken three-day courses on fam-ily planning. Many others have at-tended family planning briefings atthe provincial level (Iran, MOH1971).

The Family Planning Associationof Iran, a pioneer in the nation's fam-ily planning effort, has for some yearsconducted training for volunteers,and has operated a few clinics in thelow-income areas of Iran.

By mid-1971 there were seventraining centers for rural midwives,with eight additional ones to be estab-lished during 1971-1972. Each centerhas a capacity of ten students at atime. Five additional technical train-ing centers are to be established dur-ing 1971-1972, beginning with oneadditional center in Tehran and onein Isfahan. General training will con-tinue to be conducted at the provin-cial level (UN 1971, TAO /IRA /60,PP. 77, 78).

In addition to the above, many ofthe professional staff in the overallfamily planning effortgovernmen-tal and nongovernmentalhave at-tended domestic and internationaluniversity courses, conferences, andworkshops, and have taken a numberof fact-finding trips to countries withactive family planning programs. Thegovernment is also beginning to re-spond to the need for increased staffskills in system analysis, action pro-

grams, and implementation tech-niquea, that L, in management.

New training initiatives include:training more resource personsteachers and staffto expand train-ing capacity; a training program forprivate physicians in concepts, pro-cedures, and techniques of familyplanning; a new training program fortraditional birth attendants to facili-tate their participation in the pro-gram; and more practical training inmaternal and child health and familyplanning for medical students, stu-dent nurses, and midwives in hos-pitals and maternity homes.

COMMUNICATIONS AND EDUCATION

The two major tasks of the nationalfamily planning program are to de-liver information and services toIran's population. For information,the Family Planning Division estab-lislmad a unit for motivation and com-munication two years ago as part ofits technical affairs section. At presentthe communication activities of thedivision consist mainly of productionof public displays such as graphs andcalendars, preparation and showing offamily planning films, production anddistribution of leaflets and pamphlets,and publication of family planningbulletins in both Farsi (monthly) andEnglish (quarterly) with a total cir-culation of over 50,000. Radio andtelevision are the newest and poten-tially most useful media in the pro-gramwhich still basically relies onface-to-face methods of contact andcommunicationand the division isbeginning to make greater use ofthese. Several filnis and film stripshave been produced for televisionand cinema. The division is setting upits own printing facility to producelarge quantities of leaflets and postersfor different audiences and purposes.

The division is also developing itsown staff of education and communi-cations officers to work in the field. Anetwork of mobile education andcommunications units, each mannedby a health or family planning educa-tion officer, an assistant, and adriver, is being developed to operateout of smaller cities. These units willNerve these small urban areas and,where possible, reach out into ruralareas. Their task is to promote, ar-range, and coordinate communica-tions for adult education and social

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welfare through all existing channels.The division hopes to have about 80such units in operation during 1972and to increase the number to 150.In addition, the division plans to putat least 27 mobile audiovisual unitsinto the field, seven of them by theend of 1972. They will support train-ing and communications at differentlevels. They will be equipped to pro-ject films, film slides, and strips andto broadcast sound recordings in localdialects. Each unit will be manned byone education and communicationsofficer and one driver-projectionist(Iran, MOH 1971; UN 1971, IRA/TAO/60, p. 82; UNFPA 1971, Annex7). In June 1970, with the help ofthe Population Council and the FordFoundation, the division cospon-sored, with the University of NorthCarolina, an international workshopin Tehran on communications andfamily planning. The workshop wasattended by participants from 18countries and a number of interna-tional organizations. Participants un-dertook to prepare for their respec-tive countries detailed schedules ofproduction materials in family plan-ning education and communication(Blake 1971).

Population EducationIran recognized the need for develop-ing a population education programat an early point in its own populationeffort when the ministries of Healthand Education initiated an ambitiousprogram of public school curriculumand textbook revision for populationeducation. Today most textbooks inIran's junior and senior high schoolscontain material on population edu-cation. The Family Planning Divi-sion followed up the initiation of cur-riculum and textbook change with aprogram designed to introduce andexplain population to the country'spublic school teachers. During thesummer and fall of 1971 the divisionheld many seminars throughout thecountry to bring this new educationaleffort to the teachers who would im-plement it. Over 20,000 teachers at-tended these one-day seminars. Thethird major initiative of the FamilyPlanning Division, an extensive andcarefully structured seminar on popu-lation education, was held in thespring of 1972. In preparation forthese sessions, the division organized

ta series of study groups that metweekly from October 1971 to January1972 to determine necessary revisionsin the entire public school curriculum,look into functional literacy, developa plan of effective teacher training,and grade material on family life edu-cation (with an emphasis on sex edu-cation) into different educational

-levels. Work groups on each of thesesubjects included senior representa-tives from ministries (Health andEducation), teachers' colleges, theUniversity of Tehran (faculties ofEducation, Social Sciences, and Pub-lic Health), and religious leaders.The reports completed by these workgroups formed the basis for discus-sions at the seminar.

In addition to the above majoractivities, the Family Planning Divi-sion is laying plans to establish acomprehensive Population EducationBureau. Because of the multifacetednature of the subject matter, thisbureau will require the maximumfeasible cooperation from all relevantagencies. Accordingly, the planningdiscussions are being conducted inclose cooperation with the Ministryof Education.

Isfahan ProjectTo gather information about the ef-fect of communications on people'sknowledge, attitudes, and practicesof family planning, a large-scale masscommunications project was initi-*ated in December 1970 in Isfahanprovince with the assistance of thePopulation Council (Iran, MOH,Isfahan report 1972).

The objectives of the project wereto:

conduct a before-and-after baselinesurvey of knowledge and practice offamily planning

measure rates of acceptances atclinics before and after the experi-mental treatments.

pretest and produce radio pro-gramming, newspapers, magazine ad-vertisements, cinema film strips, post-ers, mailings, leaflets, exhibits, andtapes for sound trucks

conduct a campaign using radiofor three months and then combineradio with all other mass media forthree months

determine the potential use offunctionaries such as Revolutionary

Corpsmen, teachers, religious leaders,village heads, private physicians, andothers

conduct a maximum contact effortin one urban and several rural settingsusing full-time workers and function-aries conducting home visits andgroup meetings.

The Mass Communications Projectwas conducted from December 1970to March 1971. Before the campaignthree months of radio programminghad raised acceptance rates 34 per-cent. The mass campaign increasedacceptance an additional 30 percent,for a net increase of 64 percent. Thenumber of patients returning to theclinics for additional supplies in-creased 101 percent during the sixmonths. During the latter part of thecampaign a survey showed that 87percent of those interviewed recog-nized the project slogan, "Two orthree children is better; the loop andpill are safe." In the two districtswhere functionaries were employed,acceptances increased 115 percent.Also, in the urban and rural intensiveproject areas, every household in thispopulation of 20,000 was visitedthree times by family planning work-ers. Although not necessarily relatedto contraceptive practice or fertility,there was a decline in ideal familysize from 3.9 to 3.0 in one rural areaand a decline of from 3.5 to 2.3 in theurban areas. In cooperation with theIran-tnrksco Literacy Project, theIsfahan Program also included fam-ily planning content in the literacytexts for villagers (Fattahipour 1972).The postsurvey, media expansion,functionary, and intensive projectfeatures of the Isfahan project areexpected to continue in 1973.

Budget and Program CostsThe amount originally allocated tofamily planning by the Plan Organi-zation was 500 million rials (US$6.7million) for the fourth five-year de-velopment plan (1968-1973). A re-view of the dimensions of Iran's po-tential population problem led to areview of the population policy bythe High Plan Council in 1970 andto a more aggressive programmaticeffort. The budget allocation for thefourth plan was quadrupled to 1.5billion rials, the additional amount tobe spent over the three final years ofthe plan. Thus, for 1970-1971, the

13 13

program was allocated 3.5 times theamount for the previous year and amuch expanded program for 1971-1972 is underway. Family planningfunds from the Plan Organization,which derive from oil revenues, aresupplemented by salary and otheroverhead monies received from theparent Ministry of Health. WithHealth Corps and cooperating agen-cies, both public and private, con-tributing substantially from theirown funds, and with increasingamounts of foreign grants, familyplanning enjoys considerably highersupport than the above plan figuresindicate. Historically, the Plan Or-ganization budget has increased fromUS$600,000 in 1968-1969 to about$5.4 million for 1971-1972. It islikely that at least a comparableamount is being expended by otheragencies through other budget com-mitmentsa total of at least $10-12million. The government budget pro-vides for grants-in-aid to about 150health councils to increase familyplanning activity at the local level.Nongovernmental organizations suchas the Imperial Organization, the RedLion and Sun, the Women's Organi-zation, the Institute for the Protec-tion of Mothers and Children, andthe National Organization for FamilyWelfare are also given grants-in-aid.Contraceptives are provided fromMinistry of Health funds as are train-ing and operational aids (Iran, MOH,FPD 1971; Namazi 1970; UN, FPA1971). Figure 9 shows the 1971-1972

FMURE 9. EXPENDITURES by theMinistry of Health Family PlanningDivision in 1971-1972 were distributedlike this. Source: Iran, MOH 1971.

Equipment 5%

distribution of expenditures by theFamily Planning Division of theMinistry of Health.

PROGRAM EVALUATION

An evaluation unit headed by an ex-perienced public health physician wasformally established in the FamilyPlanning Division late in 1970. Aftera request to the UN, an expert ondemography was assigned to the unitto help improve the service statistics,KAP survey, and evaluation systemof the program. When new patientsare enrolled at a clinic (Ministry,other governmental agency, volun-tary, and most private clinics) an ac-ceptor card is completed and a dupli-cate sent to Tehran. Complete recordsof women who fail to return to theclinic are reviewed, thus allowing acomparison of dropout cases withnew cases. New acceptor cards anddropout records are analyzed at peri-odic intervals by the central evalua-tion unit. In addition, KAP surveysand other family planning-relatedstudies, done either by the ministryor other personnel, are reviewed fortheir relevance to the program. Oneproblem that has emerged is thegreat difficulty in locating acceptorsfor follow-up purposes from the ad-dresses provided on the clinic cards.For this and other reasons, a newclinic card is currently being de-veloped. To improve the evaluationsystem further, a one-month ECAFE-sponsored evaluation workshop washeld in Tehran during November-December 1971 for 30 field staff.With the conclusion of the workshopthe staff members returned to theirprovinces to form the basis of a muchmore rigorous and efficient nationalfamily planning evaluation system.Keypunch and tabulating equipmentprovided by the Population Councilpermit ready computerization andanalysis of national service statistics.The Population Council also pro-vided, during 1971, the short-termservices of an evaluatic: expert towork with local staff on the design ofthe augmented statistics and evalua-tion system.

RESEARCH

BiomedicalSome biomedical research is beingcarried out, mainly in the country'suniversities, and the government in-

tends to develop or strengthen re-search on the biomedical, clinical, andepidemiological aspects of humanreproduction. With this in mind thegovernment is considering a central,multidisciplinary institute for re-search in human reproduction andpopulation dynamics and for post-graduate research training. It is anti-cipated that such an institute willhelp guide the planning and imple-mentation of the family planningprogram. The government is alsoconsidering ways to develop and en-courage research in the nation's uni-versities and other educational insti-tutions through a grant allocationsystem.

DemographicAlthough the country has developedsome capacity for research, censuses,and statistical evaluation, there ismuch to be done to strengthen andexpand these efforts. This will be donethrough a more carefully designedand more frequent census, a stream-lined annual demographic survey,improved registration, and specialstudies.

Knowledge, attitude, and practiceA surprising number of KAP studieshave been conducted in Iran, begin-ning in 1965. The latest was spon-sored by urtzsco in August 1971(mesa) 1971). A special KAP studyof Iran's private physicians was com-pleted by the Family Planning Divi-sion and released early in 1972. It isexpected to provide a wealth of inter-esting data. A large-scale, nationalKAP study is currently being plannedby the division staff. Other specialKAP-type studies are planned, forexample, of teachers, paramedicalpersonnel, and industrial workers.

Family planning deliveryOne of the most critical but leastresearched areas in family planning inevery country, Iran included, is de-livery of family planning services. Asof late 1971, the Family PlanningDivision was developing three studiesto provide insights into techniques inthis area. Two are comparative, one toevaluate the relative performance ofclinics in Tehran with those in otherurban areas, and the second to evalu-ate the relative performance of theMinistry of Health clinics with those

14

14

of other hen lth agencies. The thirdstudy, being developed by a UN ex-pert in demography and a populationintern from the University of Michi-gan, in collaboration with Iraniancounterparts, is a cost-effectivenessanalysis of clinic performance in termsof the characteristics of the setting.In another contemplated study, com-plementary to the three just men-tioned, the division will try to assessthe performance of various categoriesof field workers in a variety of geo-graphical and organizational situa-tions together with the effect of train-ing on performance.

PROGRAM EFFECT

The table shows the record of contra-ceptive acceptors and distributed sup-plies between 1967 and mid-1971.Fri,m the number of pill cycles dis-tributed, usually a cycle at a time,the Caradon mission (UN 1971,TAO/IRA/60) calculated that about37 percent of the new clients in thepreceding 25 months were continuing.Similarly the continuation rate be-comes 34.5 percent over the entire31-month reporting period enumer-ated in the table if it is assumed that80 percent of all new clients duringthe final six months were also pre-scribed pills. In addition, many of theestimated 90,000 pill cycles soldmonthly through commercial chan-nels (an 18-fold increase since initia-tion of the program) undoubtedlywent to sometime acceptors at a re-porting clinic.

It is nearly impossible at this stageto calculate continuation rates forIUD and condom users. AlthoughIUD expulsions and removals re-ported by clinics amount to 25 per-cent of all insertions, these are prob-ably only a small fraction of thedropouts.

A follow-up survey of Farah Ma-ternity Hospital family planning ac-ceptors indicated adjusted 12- and24-month continuation rates of 33 and23 percent, respectively, for the pill,38.5 and 27.5 for the IUD, and 34and 23 for all methods. The 12- and24-month figures for all acceptorsstill practicing some contraceptionare 46 and 34 percent, respectively.These figures are for Tehran. Outsidethe capital probably fewer womenwho discontinue the contraceptive

Iran family planning results for 1967-1971 In six -month intervals

Fixedclinics-reportingand total Month

Patientsseen

Condoms IUDs cycles New pilldistributedb insertede distributedd patientS

160 April 1968 15,361 797 8,588 -235 Oct. 1968 39,653 848 27,691 784400/444 April 1969 84,399 845 72,501 17,260469/554 Oct. 1969 120,710 1,175 105,520 19,110574/683 April 1970 151,807 4,411 1.320 134,405 22,226775/981 Oct. 1970 183,322 4,983 941 169,509 24,907917/1,068 April 1971 231,798 8,168 1,220 212,957 31,6061,056/1,200 Oct. 1971 268,538 9,703 1,001 251,628 34,293

Health Corps Units are included in this table.b in dozens. Earlier figures not cited because of inaccuracy.4 Up to March 1988 approximately 18,000 IUDs were inserted. Total insertions since January 1987, 81,557,expulsions, removals, and reinsertion. excluded.d In addition, commercial sales have increased from about 50,000 in March 1988 to about 100,000 in

July 1971.Figures prior to September 1988 not available.

pill resort to another reasonablyeffective method.

The foregoing figures mean that,given present dropout rates, if everywoman in the country were contactedby the program, the birth rate wouldnot fall below the range of 36-40births per 1,000 per year and com-pleted fertility would not fall below5.4-5.9 live births per woman. Irancannot reach its target of a 1 percentannual growth rate unless the birth-rate is reduced to 20 and completedfertility to 3 (assuming continuedmortality decline). That is, givenpresent continuation rates, the pro-gram will have only 37 to 24 percentof the effect required to reduce com-pleted fertility to 3, even if all womenpractice contraception perfectly, anunrealistic assumption (UN 1971,TAO/IRA/60, pp. 38-45). It is clearthat a combination of continuing con-tact, education, and remotivation on amassive scale, together with adoptionof all available methods of contracep-tion and birth limitation, will be re-quired to meet the national target.Clinic figures for a one-month periodin the fall of 1970 showed that theMinistry of Health clinics accountfor 75 percent of all family planningclients (141,000 out of the 188,000total); 71.5 percent of all new clients(20,800 of the 29,000 total); 13 per-cent of all pill cycles; 58.6 percent ofall IUDs inserted; and 84.2 percentof all condoms. Closest to the minis-try in terms of total clients is theFarah Maternity Hospital at 4.7 per-cent. Closest in terms of new clientsis the Health Corps at 4.6 percent(UN 1971, TAO/IRA/60, pp. 128,129).

Private AgenciesThe Government of Iran seeks to in-crease the provision of family plan-ning information and services to cou-ples and thus ultimately to producebetter family health and higher livingstandards for millions of families(LINFPA 1971). The goal of an ap-preciable reduction from the presenthigh fertility has been emphasized,of course, throughout the govern-ment's program. In the managementand operation of the population pro-grams presently underway in thecountry and those that are shortly tobe implemented, the government re-lies in part on the expertise and or-ganizational structure of a number ofprivate and nongovernment agencies.Through their headquarters andbranch units, these agencies reachmillions of clients and serve a funda-mental role in the health and popu-lation information activities so nec-essary for successful family planningprograms. The government has beenturning to these organizations fortheir operational skills in managingthe nation's hospitals. During 1971-1972 virtually all government hos-pitals in the country are being oper-ated by the Red Lion and Sun So-ciety and other nongovernment or-ganizations. These organizations ob-tain funding from government andnongovernment sources, and betweenMarch 1971 and March 1972 some$260,000 in grants was distributedfrom the family planning budget ofthe Ministry of Health. The mostactive of the nongovernment organi-zations currently engaged in familyplanning activities are the following:

Imperial Organization for Social

1515

Services, a large nationwide socialservice facility that operates underfunding and administrative controlof the Imperial Court. One of its par-ticular activities involves operationof 249 rural clinics that serve a largeportion of the rural population of thecountry.

Red Lion and Sun Society. Like theRed Cross in some other countries,this is a charitable agency that servessociety in time of emergency. It is en-gaged in family planning through itsmany clinics, and family planning isa regular subject in all nursing schoolsof the society.

The Women's Organization of Iran,which functions under the presidencyof Her Royal Highness PrincessAahraf Pahlavi and seeks to increasethe participation of Iranian womenin the development and growth ofmodern Iran. By the end of 1972 some50 "Women's Institutes" are expectedto be completed. They will includehealth and family planning centers.

Institute for the Protection of Mothersand Children. As noted above, thisinstitute operates Farah MaternityHospital in Tehran with over 40,000obstetrical cases per year. The organi-zation also has 11 maternity hos-pitals to serve rural communities in anumber of provinces.

The Community Welfare Center ofIran, which operates under the aus-pices of Her Imperial Majesty Em-press Farah with a board of trusteesof government and selected nongov-ernment persona. The following serv-ices are offered: day-care services forchildren; health classes for mothers;family planning; handicraft trainingclasses; literacy classes; an in-servicetraining program for day-care in-structors; and a youth program.

The seven Iranian universities-Tehran, National, Isfahan, Pahlavi(Shiraz), Jundi Shahpour (Ahwaz),Mashed, and Tabriz-all of whichhave medical schools with clinics andhospitals attached. They engage inresearch, evaluation, and the provi-sion of clinical services on familyplanning. They are beginning to in-volve other disciplines such as thesocial sciences and professional areas.

COMMERCIAL AcrivrmsAnother critical source of manpower,expertise, and services lies with thenation's private and commercial ac-

tivities: private physicians, hospitals,clinics, public relations and advertis-ing agencies, and the commercial dis-tribution system. The Family Plan-ning Division began to contact Iran'sphysicians in 1971 to put them intouch with family planning activities.Iran was included in a three-countrystudy of commercial contraceptivedistribution commissioned by thePopulation Council from Arthur D.Little, Inc. (Little 1972). The policyimplications of this study will receivecareful attention. Several additionalproposals to study the present andpotential rate of private and com-mercial distribution are being con-sidered. A national organization ofphysicians is currently emerging andis expected to facilitate the exchangeof information and contacts with theMinistry of Health.

Foreign AssistanceCOORDINATION

In mid-1970 the government of Iranrequested the United Nations De-velopment Program office in Tehranto initiate a procedure whereby allexternal inputs into the national fam-ily planning effort would be coordi-nated by the office of the UN residentrepresentative. The purpose is tomaximize the effect of outside supportby reducing duplication among donoractivities. The procedure is also ex-pected to reveal areas that need sup-port in the evolution of the compre-hensive program. An initial donors'meeting was held in New York in1970 and was followed by meetings inTehran. A more comprehensive meet-ing was held in November 1971 tobrief donors and prospective donorson the current status and plans of thegovernment programs and to identifyportions requiring additional support.

UNITED NATIONS

In 1969 the United Nations Develop-ment Program appointed a popula-tion program officer, resident in Teh-ran, to serve the Turkey- Iran -Af-ghanistan region. The present UNSenior Population Advisor servesIran only. In early 1971 after theinitial donors' conference describedabove, the UN carried out a compre-hensive review of the Iranian programthrough a ing-wHo-uNzaco teamchaired by Lord Caradon. After thisteam had submitted its interagency

report in mid-1971, the governmentprepared a series of project requeststhat were directed to the UN Fundfor Population Activities (uNFeA) andother donor groups. UNFPA indicatedits intention to support a number ofthese projects, and the details of theirimplementation were worked out inlate 1971. The projects to be sup-ported by war% are:

a pilot project on maternity-cen-tered family planning to introduceand develop maternity-centered fam-ily planning (postpartum) activitiesinitially in five maternity hospitalsand eight maternal-and-child-healthclinics

a pilot project to develop a com-prehensive family planning programin a model province and to employand evaluate different approaches de-signed to increase the acceptanceand continuous use of contraception

a pilot project to develop a com-prehensive maternal-and-child-healthand family planning program (includ-ing postpartum) in a model county

assistance to family planning train-ing activities in terms of both currenttraining needs and long-term plan-ning

support to research related to thefamily planning program for expandedand coordinated research by the Min-istry of Health and other organi-zations

assistance to nongovernmental or-ganizations to finance new or addi-tional population and family planningproject activities

assistance to develop the communi-cations activities of the Family Plan-ning Division

assistance to a central manage-ment and implementation unit ofthe Family Planning Division tostrengthen its implementation, moni-toring, and reporting procedures

a project to be carried out by theUniversity of Tehran to improve agereporting through development of acalendar of well-known events

provision of 109 vehicles, some topilot projects and some for improvedeffectiveness of field workers and theirsupervisors.

Cooperating with UNFPA for theimplementation of this large grantagreement are mum (the UN Chil-dren's Emergency Fund), umsco,WHO, and others. To carry out these

16

projects; UNFPA is providing a grantof $1.61; million to be used during the17-month period between completionof the agreement and the beginningof the fifth five-year developmentplan in 1973 (UNFPA 1971).

In addition to projects mentionedabove, the UN has provided or hasagreed to provide:

two long-term demography con-sultants

fellowships and study grants forvisits to US-sponsored workshops

a short-term consultant on the de-velopment of a documentation center

one consultant each to the Insti-tute of Labor and Social Security andthe Social Insurance Organization

44 utility and specially equippedvehicles (UNICEF).

As already noted, ECAFE in Bang-kok sponsored and helped organize aone-month training program on pro-gram evaluation in the fall of 197i.

During November 1971 the Inter-national Bank for Reconstruction andDevelopment sponsored a thoroughinventory of all Iranian organizationscurrently active or interested in fam-ily planning. The study is intended to:assist the government to gain anoverview of current activities and or-ganizational resources, guide the na-ture and scope of UN population ac-tivities in Iran, and perform the nor-mal preinvestment functions of thebank as it prepares to consider a loanto Iran for family planning purposes.The study is being carried out by agovernment task force with the as-sistance of a UN consultant and incooperation with the World Bank. Adetailed report will be issued.

In addition, UNICEF formerly pro-vided teaching stipends and per diemfor training classes at the FirouzgarFamily Planning Training Center. Ithas also supplied vehicles and medi-cal equipment for a number of ma-ternal-and-child-health and familyplanning clinics. Before providing itstwo demographic experts, the UNprovided the services of a demogra-pher (subsequently supported by thePopulation Council) who assistedwith the first basic studies in familyplanning. WHO sponsored an inter-national seminar on "Advances inbasic, clinical, and public health as-pects of human reproduction" inTehran in 1969 and sponsored two

--)

training seminars abroad in thatsame year.

o.

POPULATION COUNCIL

In 1966 the government of Iran in-vited the Population Council to senda mission to undertake an initial sur-vey of the population problem. Sincethen the Population Council has pro-vided consultants, assisted the Minis-try of Health and Tehran Universitywith research grants, donated IUDsupplies, and supported trainingabroad. The Council since 1968 hashad a resident consultant to the pro-gram, and, since 1970, a second con-sultant on the Isfahan project. Since1968 the major areas of Council assis-tance to the Iranian program havebeen the following:

trainingsubsidizing the work ofthe Firouzgar Training Center; assis-ting with seminars and workshops;grants to help set up training centersin Tehran and Isfahan; short- andlong-term out-of-country training

postpartum programat Farah Ma-ternity Hospital for a four-year periodfrom 1971

consultantsnumerous short-termconsultants in various aspects offamily planning

researchacceptor studies, newcontraceptive trials, family planningin Muslim culture, the Taylor-Berel-son study on maternal and childhealth and family planning, attitudesto family planning, and the commer-cial distribution of contraceptives(Little 1972)

evaluationa study grant to theunit director and supply of a short-term consultant on organizing andoperating the unit

communicationssupport for themajor Isfahan project; communica-tions equipment, films, graphics, andan audiovisual vehicle; books andsubscriptions of council publications,journals, and other documents in thelibraries of the minister of health andseveral universities.

data-processing equipmentfor usein compiling service statist; -s and indoing research

contraceptivesall IUDs and in-sertors distributed by the Ministry ofHealth since 1967 and Copper-TIUDs for clinical trials.

Since its inception, Council grantsto the program total nearly $800,000.

AGENCY FOR INTERNATIONALDEVELOPMENT

usian, the world's largest provider offunding for population activities, con-tributes indirectly to the Iranianprogram. Through a number of co-operating agencies USAID is providingassistance to the postpartum program(Farah Hospital), a World Educa-tion, Inc., project, and communica-tions projects, and offering fellow-shipv, which include provision ofthree overseas population internsfrom the United States currentlyworking in Iran.

SWEDISH INTERNATIONALDEVELOPMENT AUTHORITY

SIDA has supplied Iran with part ofits condom needs and has agreed toprovide equipment needed to set upa printing facility for family planningmaterials.

OTHERS

Other organizations that are assistingor cooperating in some way with theIranian population effort include theRegional Cooperation for Develop-ment (RCD) (a three-country organi-zation of Turkey, Iran, and Pakistan),the Central Treaty Organization(cPiero), the universities of NorthCarolina and Chicago, the Inter-national Planned Parenthood Federa-tion, the Pathfinder Fund, the FordFoundation, and the UK Ministry ofOversees Development.

Plans for the FutureThe overall goal of the family plan-ning program over the next six years(that is, to the end of the fifth five-year plan in 1978) is to reduce thepresent 3.2 percent per year rate ofnatural increase to 2.4. The corre-sponding crude birth rates are 48 and38 births per 1,000 population peryear. To accomplish this reduction theprogram will have to provide contra-ceptive services to 3.6 million womenand avert approximately one millionbirths. An assumption that eachwoman will visit a maternal-and-cluld-heakh end family planningclinic nine times per year translatesto 32.5 million visits during the peri-od. To meet this demand, the Fam-

17

ily Planning Division plans tostrengthen and expand program com-ponents as follows:

trainingto continue to expandtraining of medical and paramedicalpersonnel. Twenty-three additionalprovincial training centers will beneeded to meet the target of 400,000trainees during the fifth plan

information and educationto stepup these media-based and educationalactivities with the ultimate goal ofmaking the entire population awareof population and family planning

clinic servicesto establish a net-work of clinics to serve a rural popu-lation of 18 million with a target ratioof one clinic per 10,000 population(1,800 clinics). For the urban popula-tion of 13 million, 650 clinics will beneeded to meet the target ratio of oneper 20,000 population. As there arealready more than 1,600 clinics inoperation, it will be necessary to openan additional 850 clinics during thefifth plan to meet these targets. In ad-dition to these numbers, part-timeclinics will begin to operate on a full-time basic.

Other areas to be strengthened orexpanded include:

research and program evaluationstudy of population affairsto es-

tablish a socioeconomic basis forpolicy decision making

Women's Health Corpsto increaseoutput of trained personnel to 1,000per year.

SummaryLooking at Iran's family planningeffort from the perspective of its firstfive years, we can summarize the cur-rent situation as follows: programpolicy is to offer contraceptive infor-mation and services through thegrowing national network of familyplanning clinics, relying almost ex-clusively on pills as the contraceptivetechnique. The strength and sense ofurgency of the national commitmentcan be seen both in the rapidly in-creasing channeling of talent andfinancial resources to this effort andin the ambition of national goals for zdecreasing the current high popula-tion growth rate. It is fortunate thatthis strength of resolve exists, for itis matched by the problems thatstand between the program and its

17

goals. But these problems are wellknown to the nation's leaders, andmany of these legacies of the past areundergoing rapid improvement. Wemust conclude that if great effort,effective national leadership, and ade-quate resources-against a backdropof burgeoning socioeconomic develop-ment-can lead to success in familyplanning, the prognosis for Iran isfavorable.

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Problems of Children and Youthin Iran. A Pilot Study in Shiraz.Tehran: The Institute for SocialStudies and Research, University ofTehran, 1972.

et al. Problems of Children andYouth in the Iranian Family: A PilotStudy in the Villages of the KashanDesert Region. Tehran: The Institutefor Social Studies and Research, Uni-versity of Tehran, 1971.

Sardari, A. M. The Health Aspects ofFamily Planning and Population Dy-namics. Address delivered at theWHO Workshop for Health Statis-ticians, Tehran, March 1972. Tehran:Ministry of Health, Family PlanningDivision, 1972.

, and R. Keyhan. "The prospectsfor family planning in Iran." Demogra-phy 5, no. 2 (1968): 780-784.

Saxena, G. B. Future Estimates of Popu-lation in Iran: Second Report. Tehran:Ministry of Health, Family PlanningDivision, 1972 (mimeo).

Sivin, Irving. "Fertility decline andcontraceptive use in the internationalpostpartum family planning program."Studies in Family Planning 2, no. 12(December 1971): 248-256.

Taylor, H. C., and B. Berelson. "Com-prehensive family planning based onmaternal/child health services: Afeasibility study for a world program."Studies in Family Planning 2, no. 2(February 1971): 21-54.

Tehran, The University of, Institute forSocial Studies and Research, Demo-graphic Division. Series of published

and unpublished papers on the popu-lation of Iran, n.d.

UNESCO. Preliminary Report on the Studyof Impact of Education on Fertility andFamily Planning (Iran). Tehran: In-stitute for Social Studies and Re-search, University of Tehran, August1971 (mimeo). .

United Nations. Family Planning, In-ternal Migration, and Urbanization inECAFE CountriesA Bibliography ofAvailable Materials. Asian PopulationStudies Series, no. 2. Bangkok: ECAFE,1968.

. Population and Family Planningin Iran. Prepared for the Governmentof Iran by a UN Interagency Mission.TAO/IRA/60. New York: UnitedNations, April 7,1971.

Report to the Government of Iranon the Incorporation of Family Plan-

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ning Care within the Medical Servicesof the Social Insurance Organization.ILO/FPA/Imn/R. 28. Geneva: Inter-national Labor Office and the UNFund for Population Activities, 1971.

Report to the Government of Iranon Workers' Education and PopulationQuestions. ILO/FPA/Iran/R. 25. Ge-neva: International Labor Office andthe UN Fund for Population Activi-ties, 1971.

United Nations Fund for PopulationActivities. Project Agreement on FamilyPlanning between the Government ofIran and the UNFPA. Tehran: UnitedNations Development Program, No-vember 1971.

United States Bureau of the Census,Population Division. Population Pro-jections for Iran. Washington, D. C.:Government Printing Office, n.d.

THE POPULATION COUNCIL246 Park Avenue, New York, New York 10017

The Population Council is an organiza-tion established in 1952 for scientific train-ing end study in the field of population. Itendeavors to advance knowledge in thebroad field of population by fostering re-search, training, and technical consulta-tion and assistance in the social andbiomedical sciences.

BOARD OF Taugrzza

John D. Rockefeller 3rd, ChairmanNab York City

Bernard Bare leonPresident, The Population Council

Simile BakCambridge, Massachusetts

Dailey W. BrookPresident Emeritus, Rockefeller University

John C. BullittShearman & Sterling

Mary I. BuntingAssistant to the President, Princeton University

Robert H. Ebert, M.D.Dean, Harvard Medical School

Roswell L. GilpetricCravath, Swain, & Moon

Caryl P. Hasid=Washington, D. C.

A. Leon H*ginbotham, Jr.J udge, U. S. District Court for theEastern District of Pennsylvania

W. David HopperPresident, International Development ResearchCentre, Ottawa

Cordslia S. MayPittsburgh, Pennsylvania

Donald H. McLean, Jr.. President, Lahey Mink Inc.John T. Noonan, Jr.

Professor of LawUniversity of California, Berkeley

Frank W. NotesteinPresident Emeritus, The Population Council

Theodore W. SchultzProfessor of Economics, University of Chicago

U ThantFormer Secretary - General, United Nations

Gilbert F. WhiteDirector, institute of BehavioralScience,University of Colorado

Salvador Zublien, M.D.Director, Institute Nacional de laNutrition, Mexico

Country Profiles: occasional monographson selected countries, describing the soma!,economic, and demographic characteristicsof each country and the nature, scope, andaccomplishments of population activities.Available in English and French; selectedissues available in Spanish.

Country Profiles published to date in-dude:

Chile, October 1970.France, May 1972.Ghana, October 1970.Hong Kong, November 1969.Indonesia, April 1971.Iran, October 1972.Israel, February 1972.Jamaica, April 1971.Japan, March 1971.Kenya, May 1971.Korea, Republic of, April 1970.Malaysia, July 1970.Mauritius, September 1970.Nepal, April 1972.Pakistan, March 1970.The Philippines, June 1970.Sierra Leone, September 1969.Sweden, July 1972.Taiwan, February 1970.Thailand, March 1972.Trinidad and Tobago, August 1971.Turkey, January 1970.United Arab Republic, August 1969.

Other publications issued by the Popu-lation Council art:

Studies in Family Planning: a monthlypublication containing articles on a widerange of topics related to population andfamily planning. Available in English,French, and Spanish.

Reports on Population/Family Planning:series of occasional monographs, each ofwhich presents in depth current informa-tion and evidence on a central topic re-lated to the field. Available in English,French, and Spanish.

Current Publications in Population/Fam-ily Planning: a bimonthly bibliographyproviding abstracts of selected articles andbooks of particular interest to administra-tors and scholars. Available in Englishonly.

Persons wishing to receive any or all ofthese publications should address their re-quests to: Information Office, The Popu-lation Council. Bulk orders are availablefor educational purposes.

The Population Council also publishesbooks and occasional papers on selectedtopics related to population and familyplanning. The following publications willbe sent free of charge to libraries of uni-versities, research institutions, and relatedorganizations in the developing countriesof Asia, Africa, and Latin America wherestudy inpopulation and family planning isunder way or planned. Each requestshould be sent to the Information Officewith a letter describing the institution'straining and research programs. Purchaseorders from individuals and from institu-tions in areas other than those mentionedabove should be directed to Key BookService, Inc., 425 Asylum Street, Bridge-port, Connecticut 06610, USA.

BooksKim, Taek II, John A. Ross, and George

C. Worth. 77ee Korean National FamilyPlanning Program: Population Controland Fertility Decline. 1972. 240 pages.$4.50.

Newman, Sidney H., Mildred B. Beck,and Sarah Lewit (eds.). Abortion, Ob-tained and Denied: Research Approaches.1971. 200 pages. $4.50.

Population Council. A Manual for Surveysof Fertility and Family Planning:Knowledge, Attitudes, and Practice. 1970.427 pages. $4.50.

Schieffelin, Olivia (ed.). Muslim Attitudestoward Family Planning. 1967. 156pages. No charge.

Occasional PapersBean, tee L., Richmond K. Anderson, and

Howard J. Tatum. Population and Fam-ily Planning: Manpower and Training.1971. 136 pages. $3.95.

Callahan, Daniel. Ethics and PopulationLimitation. 1971. 49 pages. $3.95.

Fawcett, James T. Psychology and Popula-tion: Behavioral Research Issues in Fer-tility and Family Planning. 1970. 166pages. $3.95.

Friedman, David. Laissez-Faire in Popu-lation: The Least Bad Solution. 1972. 64pages. No charge.

Jones, Gavin. The Economic Effect of De-clining Fertility in Less Developed Coun-tries. 1969. 36 pages. No charge.

Simmons, George B. The Indian Invest-ment in Family Planning. 1971. 232pages. $4.50.

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