Papua New Guinea has one of the highest fertility rates in the Asia-Pacific region (Figure 1), and the highest of any Pacific Island country in its most recent Demographic and Health Survey (DHS), conducted in 2016-18. Every year, the country adds about 230,000 people to its population, the net result of births minus deaths. The population has now exceeded 10 million. But schools, hospitals, policing and the formal labour market have expanded far more slowly. The results are visible in crowded classrooms, stretched health facilities, law and order problems and a growing number of young people competing for too few formal jobs.
Population pressure, however, is only part of the case. The more immediate issue is that many women are having more children than they say they want. PNG’s total fertility rate declined from 4.4 births per woman in 2006 to 4.2 in 2016-18, while wanted fertility is about three children.
A family planning policy should begin with this gap between what women say they want and what happens. Its purpose should be to support free and informed decisions, not to impose a preferred family size. I set out this argument in my recent report for the PNG Reset@50 project, “Big Bet 3: Enable universal access to voluntary family planning services”.
The report argued that family planning in PNG has a conversion problem: knowledge is widespread, but use is not. In the 2016-18 DHS, 88% of currently married women and 92% of currently married men knew at least one contraceptive method. On average, both women and men knew about six methods. Yet only 37% of currently married women were using any contraceptive method, and only 31% were using a modern method.
Around one quarter of currently married women had an unmet need for family planning, and only 59% of total demand was satisfied. The gap was much wider among sexually active unmarried women, whose unmet need was estimated at about 65%. Meanwhile, 24% of births still occurred within two years of a previous birth, and teenage childbearing changed little over two decades, remaining at about 12% to 14%. These figures describe demand that the current system does not reliably serve.
Access to services is also unequal. Contraceptive use among married women was 50% in urban areas and 35% in rural areas. Women in the highest wealth quintile were about twice as likely to use contraception as women in the lowest quintile, 46% compared with 23%. The Highlands is the lowest-performing region, despite improvement over time.
Services also depend heavily on the public health system. About 89% of modern contraceptive users obtained their method from a public-sector source in 2016-18. If government facilities lack supplies, trained staff, privacy or reliable outreach, access fails right across the country.
The quality of services matters as much as their availability. The DHS shows that only 37% of women using contraception said they had been told about possible side effects, what to do if side effects occurred, and alternative methods. Among women not using contraception, 85% had not discussed family planning with a field worker or anyone at a health facility. Women need someone they can trust with confidential information.
Closing the gap would also bring economic benefits. The report’s scenario starts from an annual birth cohort of 230,000. That figure is PNG’s net annual population increase, births minus deaths, so treating it as a count of births obviously understates the true number: United Nations estimates put annual births at about 255,000, and the crude birth rate recorded in the DHS implies a figure closer to 290,000 at a population of 10 million. The scenario is therefore a very conservative one.
Of those births, the DHS indicates that at least 28% are unplanned, counting both births unwanted at the time and births wanted later. That definition is narrower than the one in related work putting the unplanned share at about one in three. On the report’s assumptions, a gradual reduction in the unplanned share to 10% would avert about 41,400 unintended births in a single year’s cohort. Using the report’s own estimate of K127,000 in household and public costs from birth to adulthood (see page 17), that amounts to about K5.26 billion in avoided future costs for that group of children. Recalculated on the United Nations birth estimate of 255,000, the same reduction would avert about 45,900 births and about K5.83 billion in costs. The per-child cost figure is an assumption made for the scenario rather than a published statistic, and the result is sensitive to it. This is a modelling scenario, not an immediate cash saving and not a valuation of a child. It shows the long-run resources that families and public systems must provide when intentions and outcomes diverge.
The policy environment is favourable. PNG has endorsed family planning through its population and sexual and reproductive health policies. But those policies have not been rolled out effectively. The third National Population Policy 2015-24 has expired. The focus should now be on developing a fourth National Population Policy and establishing a National Voluntary Family Planning Program as a funded delivery reform.
In sum, women and couples know about contraception but often cannot obtain a method they trust when they need it. Actual fertility remains higher than preferred fertility. Big Bet Three can close that gap through a funded national program that guarantees voluntary, free and informed access. That would improve maternal and child health, strengthen household investment in children and ease future pressure on public services.
Read the author’s full report and other ANU-UPNG contributions on the RESET@50 website.
