Posts by Elizabeth Leahy Madsen

By Elizabeth Leahy Madsen // Wednesday, August 8, 2012

In late July, Iran’s government announced that it would no longer fund family planning programs, a dramatic reversal following 20 years of support. The change is especially abrupt for a country that has been lauded as a family planning success story, with thorough rural health services and an educated female population contributing to one of the swiftest demographic transitions in history.

Although Iran’s government is headed by a conservative religious hierarchy and President Ahmadinejad had earlier implemented some pronatalist policies, the decision is still surprising for several reasons. It is also unlikely to meet its objectives; irrelevant to deeper economic concerns; unlikely to be popular; and most disheartening of all, a tremendous step backwards for individual empowerment and wellbeing.

Budget Cuts Ignore Demand and Counter Human Rights

Once family planning services are as widely available and adopted as they have been in Iran, demand for them is well entrenched and unlikely to ebb. Use of family planning offers several benefits that are tangible to individuals and families as well as societies: It improves the health of women and children while also promoting higher educational attainment and household incomes. Iranian women and couples are cognizant of these benefits and unlikely to cede them. Nearly 60 percent of Iranian women of reproductive age used an effective contraceptive method in 2002, the most recent year for which data is available.

Moreover, access to reproductive health services has been widely accepted as a human right for decades. Ironically, one of the first international accords “that couples have a basic human right to decide freely and responsibly on the number and spacing of their children and a right to adequate education and information in this respect” was affirmed in Tehran in 1968. The Iranian government’s decision to limit such access is a clear refutation of this right.

Unlikely Prospects for Success

From a demographic perspective, the government’s attempt to make family planning services unavailable or unaffordable is unlikely to meet their stated objective of motivating larger families and higher population growth.

The government has already tried a more common approach for boosting fertility rates, offering direct payments to families for each child at birth and each successive year until adulthood. Such financial incentives have been implemented in several other low fertility countries, but as demographer John May has noted, they are typically much less effective compared to more comprehensive approaches addressing child care, work-family balance, and housing.

It is unusual for a government to take the more draconian step of restricting public access to contraception, whether through economic or legal means. One parallel is Romania during the Ceausescu era. Contraception was banned in 1966 and without access to family planning, women turned to illegal abortion. After an initial jump, fertility rates began to fall steadily, and by 1989 the country had the highest rate of maternal mortality in Europe. Although Iran’s government has not outlawed contraception outright and it should remain available through the private sector, cutting back services will create serious implications for lower income women who rely on public services. As the Romanian experience demonstrates, the desire to determine family size does not dissipate when contraception becomes unavailable.

Iran’s Challenges Go Beyond Aging

The stated justification for the government’s decision is to avoid population aging and eventual decline if fertility rates remain below replacement level. However, this rationale overlooks the serious economic constraints that are affecting all Iranians, particularly those of childbearing age. Until recently, the number of people ages 15 to 24, who include most entrants to the labor market, was growing steadily due to past high fertility. Youth unemployment stands around 23 percent, and a RAND analysis described the challenge of ensuring that these young people find jobs as “one of the most pressing social and economic problems the government has faced.” As the country urbanizes, the cost of living has risen sharply, exacerbated by the inflationary effects of international sanctions.

“The cost of living has risen a lot and the currency has lost its value by half,” said Haleh Esfandiari, an Iranian-American who directs the Wilson Center’s Middle East Program. “So at this moment, where families are under economic pressure, the government is under economic pressure. To suddenly introduce the idea of having larger families and encouraging girls to get married at a much younger age – it’s one of the most un-thought, unplanned decisions taken by the Ahmadinejad government.”

As these challenges diminish young people’s economic prospects, they also serve to further tamp down fertility, limiting the government’s chances of success at markedly increasing population growth.

Esfandiari was surprised by the decision. “Iran was seen as a role model” of the demographic transition, she said. “It will not work. Iranian women are plucky, they are thoughtful. Sixty-five percent of entering classes at universities are women. How can you convince them to have a child every year?”

Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.

Sources: Associated Press, Crane et al. (2008), Financial Times, Gribble and Voss (2009), Hord et al. (1991), Kligman (1998), May (2012), New York Times, Roudi (2010), Singh and Darroch (2012), UN Population Division, World Bank.

Photo Credit: “MMN,” courtesy of flickr user Emdadi (Mohammad Emdadi).

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Topics: Guest Contributor, demography, economics, family planning, gender, global health, population …

Book Review: ‘World Population Policies’ Offers Sweeping Overview of a Complex Field

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By Elizabeth Leahy Madsen // Monday, July 2, 2012

With much attention in the international family planning community directed to the impending anniversary of the 1994 International Conference on Population and Development and the closing date of the Millennium Development Goals, the fact that 2012 is the 60th anniversary of two other milestones in population programming may have escaped notice. In 1952, the International Planned Parenthood Federation was created, and India became the first country to formulate a national policy to reduce population growth.

These and many other landmarks are highlighted in World Population Policies: Their Origin, Evolution and Impact, a new book by demographer John May that reviews several decades of policies, advocacy, and program interventions addressing the full range of diverse demographic trends seen globally.

May, who spent more than two decades working on population issues at the World Bank and other international institutions before recently assuming a fellowship at the Center for Global Development, is well-positioned to provide such an ambitious overview. Although the breadth of material included in the book means that some topics receive less coverage than a specialist might wish, it serves as a sound introduction to this diverse field, and offers some particularly interesting case studies.

The book’s main chapters begin with a summary of current population trends, including a comprehensive array of figures and statistics about population size, distribution, and projections. Some important concepts, such as the demographic transition and dividend, are perhaps covered too quickly, and in such cases the book would have benefited from more than a handful of figures, charts, and graphs. May classifies regions and countries as demographic “hotspots,” where the number of people outstrips available resources, and “coldspots,” which have too few residents. He makes an ambitious suggestion that high-density countries facing resource challenges, such as Bangladesh, should consider promoting rapid fertility decline below replacement level to stop population growth, then reverse course and increase to a rate that promotes a stable population – but such a reversal from low fertility is a feat that has stymied several countries in Europe and East Asia.

Evolution of the “Population Movement”

In addition to summarizing the ways that demographic issues have been framed in the past several decades, May briefly describes the long-running debate between demographers and economists about the ways in which population is theorized to affect economic development.

Three points in this chapter were particularly striking: First, the concept of family planning as a human right dates from well before the 1994 International Conference on Population and Development. In 1968, the Tehran International Conference on Human Rights defined the ability to choose family size and spacing as a fundamental right; still, some programs, such as India’s under the Emergency-era government of the late 1970s, adopted coercive practices. Second, population policies are not limited to official initiatives targeting fertility, mortality, and migration, but also encompass implicit or “passive” policy measures that arise without advance planning or that have an unintended effect on demographic trends. Related to this, May suggests that “contextual variables” such as education, health, gender, culture, and religion can have a greater impact on population policies’ effectiveness and demographic outcomes than government structures or funding.

Although population policies are most often designed at the national level, May’s discussion of the “population movement” highlights the influence of international networks and donors on such policies. By the late 1960s, the U.S. Agency for International Development had begun funding family planning programs overseas, and the United Nations Population Fund (UNFPA) was active. Although the United States has become less dominant over time, population programming remains a Northern-driven movement.

Beginning with a meeting in Belgrade in 1965, a series of international population conferences successfully raised the prominence of population issues on the global development agenda and built consensus around international goals, while also becoming increasingly political.

May’s cautions about such conferences are timely given this month’s London Family Planning Summit: “Consensus-building through international conferences and their preparatory meetings is often inefficient as a process, whereas such events could be used to promote learning among policymakers and experts…The gap between the conferences’ resolutions and the actual policies implemented at country level is important to remember” (110).

Growth and Aging Distinguish the Demographic Divide

In his chapter focusing on the developing world, May notes that population policies have become broader in the nearly 20 years since the Cairo conference, incorporating a reproductive rights framework while also addressing new issues such as the environment, HIV/AIDS, and poverty. But under this more holistic approach, national policies are susceptible to becoming overly diffuse, with an ambitious agenda not matched by concrete action plans.

The challenges expand to policy implementation as well. Kenya is profiled as emblematic of the difficulties facing population programs in fast-growing sub-Saharan Africa, particularly political disinterest, mismanagement, opposition from some religious groups, and commodity shortages. But when implemented well, such policies can be very successful. The book offers a thorough summary of research findings on the common features of effective family planning programs (such as leadership, monitoring performance data, and opening access to contraceptive methods at lower levels of the health system), as well as their demographic impact. Several country examples are cited to show that family planning programs reduce lifetime fertility rates by 0.5 to 1.5 children per woman, while also benefiting individual and social health, income, and well-being.

While population policies have been often effective at shaping demographic trends in high-fertility settings, even in changing cultural norms about family size, May notes that their impact has been notably weaker in reversing the trajectory of declining fertility in developed countries. While countries such as France have maintained a fertility rate close to, albeit still below, replacement level thanks to generous paid parental leave, housing initiatives and public child care facilities, policies that try to boost low fertility through financial compensation have been particularly ineffective.

Developed countries are less likely to have formal population policies and tend to address demographic issues through incentives and disincentives implemented by multiple agencies. Aging and immigration are receiving greater attention in such countries, along with low fertility rates. Population aging raises policy concerns that are both economic and social, and May focuses largely on the benefit of reducing incentives for early retirement. He notes that thanks to improvements in health and life expectancy, “today’s 65-year-old persons are young compared to their counterparts” of previous generations (180). Despite their economic soundness, government efforts to raise retirement ages are widely unpopular, and France’s newly elected president has promised to cut the retirement age from 62 to 60 for some workers.

What Comes Next

Some observations are intriguing and could have been further detailed. For example, May notes a recent “fragmentation” of organizations working on population issues, and suggests that “too many institutions and NGOs appear to support their own limited mandates as they also struggle for resources that are less abundant” (5). Decentralization and integration within health systems is a growing trend that could have been discussed in more detail, along with the legacy of pronatalist laws and attitudes by colonial powers in Africa, the effect of recent European efforts to tighten immigration policies, and the achievements of forums designed for collaboration on population policy issues (for example, the United Nations Commission on Population and Development or the Reproductive Health Supplies Coalition).

Looking towards the future, May foresees continued integration of demography with related development issues, such as poverty reduction and equitable growth, gender and youth perspectives, environmental issues, and conflict prevention. He notes a few challenges, including sub-Saharan Africa’s lag in fertility decline and the overall ineffectiveness of policies aimed at addressing the pressures of urbanization on infrastructure and resources.

In high-fertility settings, May recommends that instead of framing reproductive health writ large, policies should more specifically target family planning and women’s empowerment, including education and income-generation opportunities as well as legal rights. Bangladesh is presented as a model for other countries, as a setting where cultural change and economic development laid the groundwork for successful family planning outreach efforts. Most of all, May entreats government leaders to maintain a policy focus on population issues, regardless of where they stand in the demographic divide.

Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.

Photo Credit: “Crowded Shopping District,” courtesy of flickr user EnvironmentBlog.

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Topics: Africa, development, environment, family planning, global health, population, security …

The Year Ahead in Political Demography: Top Issues to Watch

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By Elizabeth Leahy Madsen // Friday, June 8, 2012

2011 and the first half of 2012 have been a remarkable period for political demography, with theories about the relationships between age structure and governance validated in real time by the events of the Arab Spring. Although such game-changers are rarely predictable, the year ahead promises to be eventful as well, with new demographic research and major policy initiatives on the horizon. Below are brief assessments of some of the top issues to watch between now and next summer.

1. The Evolving Story of the Arab Spring

The Arab Spring was anticipated by few observers, but for a handful of political demographers it was a watershed of sorts. As readers of this blog know, political demography research shows that countries with very young age structures are prone both to higher incidence of civil conflict and – most relevant to the outcomes of the Arab Spring – to undemocratic governance. This nuance escaped many observers of the region’s drama. Violence and conflict erupted not from raging citizens in the streets but from military and militia forces unleashed by autocrats unwilling to cede their grip on power. Young people, and their fellow protestors of all ages, were acting as a force for positive change in their demonstrations against corrupt and unrepresentative leadership. The difference in outcomes across the region, according to Richard Cincotta, can be attributed to the fact that as age structures mature, elites become less willing to trade their political freedoms to autocratic leaders in exchange for the promise of security and stability.

When considered with this important distinction in mind, the initial events following the uprising in Tunisia that quickly spread across the region played out in a neatly linear fashion. Among the five countries where revolt took root, those with the earliest success in ousting autocratic leaders also had the most mature age structures and the least youthful populations.

In Tunisia, with a median population age of 29, one month passed between a fruit seller’s self-immolation and Zine El Abedine Ben Ali’s flight to exile. In Egypt and Libya, where median age is close to 25 years (identified by Cincotta as a threshold when countries are at least 50 percent likely to be democratic), Hosni Mubarak and Moammar Gaddafi took three weeks and eight months, respectively, to lose their titles. Ali Abdullah Saleh in Yemen (median age 17), took one year to be convinced to formally resign, while in Syria (median age 21), the 15-month uprising continues to be brutally repressed by Bashar Assad’s forces.

Of course, overthrowing a dictator, while inspiring and liberating to those whose rights have been repressed, is only the first step in achieving democracy. In the coming year, the countries that have already taken steps toward solidifying regime change will face continued tests as internal tensions surface. Even in Tunisia, recent clashes signal that political divisions and economic uncertainty have not been resolved. With potentially divisive elections ahead in Egypt and Libya, a holdover from the Saleh regime leading Yemen, and Syria’s fate unknown, the coming year should offer political demographers further evidence of the soundness of the age structure and democracy thesis.

2. New Commitments to Family Planning

Reproductive health and demography go hand-in-hand, and two milestones for family planning advocates are fast approaching: the 20th anniversary of the 1994 International Conference on Population and Development in Cairo, and the 2015 endpoint of the Millennium Development Goals.

These historic commitments by governments will be joined by a major initiative to generate new funding and political will this summer at an international family planning summit in London on July 11. The summit will be co-hosted by the Bill and Melinda Gates Foundation (Melinda made an impassioned TEDxChange speech in support of the issue in April), and the UK’s Department for International Development, for whom family planning is a priority in efforts to reduce maternal and child mortality.

Details of the summit have yet to be finalized and publicly released, but financial commitments from donors and developing countries are anticipated toward meeting a new and ambitious goal of generating $4 billion to fund contraceptives for 120 million women in developing countries by 2020. Assuming these are new users, rather than those who would be expected by projecting recent growth in contraceptive use forward, this would represent more than half of the estimated 215 million women with an unmet need for family planning.

Why does new family planning funding matter for political demography? Rates of contraceptive use are lowest and fertility highest in countries with youthful age structures. Such population dynamics exacerbate the challenges governments face in providing education, health, and basic infrastructure services, as well as supporting an economic climate conducive to industry diversification and job creation. In turn, the likelihood of civil conflict and undemocratic governance is higher in such countries.

While policies that recognize the benefits of family planning may be solid, funding and implementation often fall woefully short. In the least developed countries, less than one-third of reproductive-age women are using any contraception, and the rate has grown by just 0.4 percentage points annually over the past decade. Meanwhile, funding from all sources is less than half the amount required to meet unmet need. If the July summit motivates a new groundswell of financial support, 2012 could incite major strides toward improvements in individual health and well-being as well as demographic momentum in the remaining high-fertility countries.

3. Demographic Diversity in Sub-Saharan Africa

The current era of global demographic diversity has been distinguished by both record-low fertility rates in parts of Europe and eastern Asia and persistently high fertility across most of western, central, and eastern Africa. More than one-quarter of women in sub-Saharan Africa would like to postpone or avoid pregnancy, but are not using contraception, demonstrating a large unmet need for family planning.

The U.S. government-funded Demographic and Health Survey (DHS) program is the largest single source for detailed data on health status and behavior in high-fertility developing countries, and in turn informs estimates and projections of demographic trends. Recently, DHS reports have been released showing that contraceptive use over the past five years is growing much faster than the regional average in Ethiopia, Malawi, and Rwanda. In turn, fertility rates have dropped, ranging from a relatively modest 0.3 children per woman in Malawi and an unprecedented 1.5 children per woman in Rwanda.

Click here for the interactive version (non-Internet Explorer users only).

These findings suggest that the pattern of demographic stagnation in sub-Saharan Africa may be shifting, perhaps due to governments’ and donors’ investments in family planning. However, newer survey results for Mozambique, Uganda, and Zimbabwe present a more mixed picture, with modest gains in contraceptive use in Uganda, offset by declines in the other two countries.

Additional recent survey results show that use of modern contraceptive methods has barely increased in Senegal (from 10 percent in 2005 to 12 percent in 2010-11). And while modern contraceptive use increased in the Republic of Congo from 13 percent in 2005 to 20 percent currently, fertility also rose slightly, from 4.8 to 5.1 children per woman.

Approximately 10 countries in sub-Saharan Africa are slated for DHS fieldwork this year, including one of the continent’s giants, the Democratic Republic of the Congo, and several of the highest-fertility countries in the region. (Outside of sub-Saharan Africa, the demographic heavyweights in this year’s group of DHS reports are Bangladesh, Indonesia, and Pakistan.)

The upcoming surveys will provide greater clarity about whether the promising signs of family planning adoption and the potential for progress through the demographic transition in Ethiopia, Malawi, and Rwanda are initiating widespread change across the continent, or whether the need for commitments such as those generated by the London summit is even stronger.

4. New Population Projections

DHS reports are critical inputs for the world’s most comprehensive and readily accessible set of demographic data, the UN Population Division’s World Population Prospects. This database is fully updated and revised biannually, in large part due to the steady stream of newly available estimates from the DHS and related sources, such as national censuses. The next revision of World Population Prospects, based on estimates for mid-year 2012, is expected to be published in spring 2013.

The previous revision of World Population Prospects was notable for its methodological overhaul. In addition to extending the projections until 2100, the Population Division shifted to a probabilistic technique (as opposed to assuming convergence at a single fertility rate of 1.85 children per woman) that generates 100,000 possible fertility trajectories for each country and selects the median as the medium fertility variant, commonly cited as the most likely projection. Still, the basic parameters remain the same: With fertility rates the strongest driver of population projections, low, medium, and high fertility variants are constructed around the assumption that countries will converge towards replacement level fertility, around 2.1 children per woman.

In some cases, this results in projections that are vastly at odds with recent trends. For example, in Japan, fertility has fallen by 38 percent, from replacement level in the early 1970s to 1.3 children per woman in 2010, but the UN projects it to immediately reverse course and begin rising to 1.8 by mid-century. If the projection holds, Japan’s population will decline relatively modestly, from 127 million to 109 million. But if fertility stays constant at current levels, the population will fall below 100 million. For low-fertility countries like Japan, all UN scenarios assume constant or rebounding fertility rates, even though continued decline may be a plausible outcome in some cases.

When next year’s projections are released, a cluster of media articles will report the projected world population for 2050. In last year’s revision, the medium fertility variant resulted in a projection of 9.3 billion, an increase from the 9.1 billion projected two years earlier based on higher projected fertility in the future. Such reports often overlook the range of population totals possible depending on fertility paths: If the global fertility rate varies by 0.5 children per woman in either direction, the total population could be more than one billion higher or lower in 2050, with an even wider range possible by 2100.

Most of the projected growth in world population, and its potential range, will be driven by the high-fertility countries concentrated in sub-Saharan Africa. Population projections for these countries vary tremendously based on fertility scenarios informed by the recent DHS results described above.

In Nigeria, Africa’s most populous country, fertility has fallen over the past 40 years, but by a gradual 15 percent. The UN projects it to drop more than twice as fast, by more than two children per woman (39 percent), in the next four decades. In any scenario, Nigeria is on track for rapid population growth, but the potential range based on fertility outcomes is wide. If fertility declines as projected in the medium variant, the country would grow from 158 million to 390 million. And although unlikely, the constant fertility projection of 504 million Nigerians in 2050 should be kept in mind given the slow pace of fertility decline to date.

Population projections are highly wonky, but their careful production and regular revision are essential for accurate planning of economic and social needs in countries around the world. While governments with dedicated census agencies, such as those in the U.S., Japan, or India, rely on internally-generated estimates, the UN projections serve as the primary indication of population trends in countries with spottier data coverage and have tremendous utility in gauging future needs for infrastructure, housing, health care across the life cycle, education, jobs, and other investments.

By no means is this an exhaustive list of factors that will affect political demography research and policy over the coming year. Other events to watch for include the Rio+20 conference on sustainable development in June, where the priority issues of jobs, energy, infrastructure, and resources will be shaped by demographic trends, and continued attention to prospects for the demographic dividend in Africa. Political demography is inherently cross-disciplinary, and the field’s researchers and practitioners will be engaged on multiple fronts in the year ahead.

Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.

Sources: Al Jazeera, Bongaarts (2008), Cincotta (2008), Cincotta (2012), Cincotta and Leahy (2006), Grist, Guttmacher Institute, MEASURE DHS, The New York Times, NPR, Population Reference Bureau, UN Population Division, The Washington Post.

Image Credit: “The Face of a Tyrant,” courtesy of flickr user freestylee (Michael Thompson); video courtesy of TED; chart created by Schuyler Null, data from UN Population Division.

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Topics: Africa, demography, development, family planning, global health, population, security …

New Surveys Generate Mixed Demographic Signals for East and Southern Africa

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By Elizabeth Leahy Madsen // Tuesday, May 8, 2012

The pace of fertility decline in sub-Saharan Africa will be the single most important factor in whether the global population reaches the UN’s high projection of nearly 11 billion in 2050, or remains closer to the low projection of 8 billion. In recent years, the high projection has seemed more likely, as sub-Saharan Africa has been marked by stalled fertility declines and stagnant rates of contraceptive use. Survey results released over the past year showing dramatic increases in contraceptive use in Ethiopia, Malawi, and Rwanda therefore set demographers and the family planning community abuzz, signaling that concerted efforts to improve health services had paid off and fertility rates were on the decline. But in recent months, additional surveys from Mozambique, Uganda, and Zimbabwe have shown that those positive trends are not universal.

A Trio of Emerging Success Stories

For many countries in sub-Saharan Africa, rapidly growing populations concentrated among youthful ages are outpacing improvements in quality of life and testing governments’ capacities to provide basic health services, education, and jobs. For the region as a whole, the contraceptive prevalence rate (CPR) for modern methods increased by just 0.3 percentage points per year between 2000 and 2009, following similarly sluggish annual increases in the previous two decades.

At this growth rate, more than a century would pass before sub-Saharan Africa, which had an average CPR of less than 16 percent in 2009, achieves the same levels of contraceptive use seen today in North Africa.

Given this regional context, the release of three successive surveys showing rapid jumps in CPR was noteworthy. In Ethiopia, the percentage of married women using a modern contraceptive method jumped from just 6 percent in 2000 to 27 percent in 2011. Malawi, starting from a higher baseline, experienced an increase from 26 percent in 2000 to 42 percent in 2010. Both countries’ CPR rose at a pace of more than two percentage points per year, about seven times faster than the regional average. However, the changes reported in Rwanda were undoubtedly the most dramatic. Contraceptive use more than tripled in just five years, growing by seven percentage points annually. In turn, fertility fell by 25 percent, from 6.1 to 4.6 children per woman in just five years.

Fertility Rises Elsewhere

In March, demographic surveys carried out by MEASURE DHS and funded by USAID were published for Mozambique, Uganda and Zimbabwe (the available reports for Mozambique and Uganda are based on preliminary findings). While one of these countries had an increase in contraceptive use, the other two recorded showed no progress.

Uganda, which has one of the highest fertility rates and youngest populations in the world, experienced an uptick in contraceptive use, from a rate of 18 percent for modern methods in 2006 to 26 percent in 2011. Although not at the pace seen in Ethiopia, Malawi, or Rwanda, the average growth of 1.6 percentage points annually was above the regional average. Its fertility rate declined from 6.7 to 6.2 children per woman.

More disheartening is the very unusual finding that fertility rates are increasing and contraceptive use is stagnant in both Mozambique and Zimbabwe. Over the past 15 years, CPR has increased slightly and since plateaued in Mozambique, while fertility has continued to rise. Between 1997 and 2003, contraceptive use jumped from 5 to 12 percent, where it remained in 2011. Meanwhile, fertility has risen from 5.5 to 5.9 children per woman since 2003.

Zimbabwe is one of the few countries in sub-Saharan Africa where more than half of married women use a modern contraceptive method, but the rate has dipped slightly, from 58 to 57 percent over five years. More surprising is the increase in the fertility rate, from 3.8 to 4.1 children per woman. Fertility among the youngest mothers, ages 15 to 19, is higher today than in the late 1980s and early 1990s.

Population Possibilities

The central characteristic of population trends today at the global level is their diversity. Some countries in East Asia and Europe are reaching unprecedented low fertility rates, near one child per woman, and many developing countries are nearing the later stages of the demographic transition, with family sizes around two or three children per woman. Yet most countries in sub-Saharan Africa have not followed the pattern of steady fertility decline. Do the mixed results from these recent surveys indicate that demographic diversity is becoming the norm within Africa too?

Although there is tremendous variance at the country level, on average, fertility declines by one child per woman for every 15 percentage point increase in contraceptive use. However, fertility changes have multiple determinants and the effect of changing contraceptive use is not immediate. In Malawi especially, the fertility rate remains relatively high given that contraceptive use has surpassed 40 percent, a puzzle that will be explored at a national family planning conference hosted by the government and several international partners this month.

Although it is unlikely that current trends will hold exactly, the figure below shows results if the most recent changes in fertility are projected forward at a steady rate. Most countries’ fertility rates would change by less than one child per woman over the next decade and all but Rwanda would remain at or above four children per woman.

The recent changes in contraceptive use therefore suggest that progress through the demographic transition will remain fairly slow in these countries. Populations will continue to grow rapidly and remain very youthful, and continued investments in family planning are necessary in order to promote the potential social and economic benefits of a more balanced age structure.

Lessons From Neighbors

The factors promoting success in the three countries where the pace of family planning use is ramping up have been carefully analyzed.

In Ethiopia, Mengistu Asnake of Pathfinder International attributes success to the government’s commitment to improve access to services in rural areas by constructing 15,000 health posts and training community members as health extension workers. The World Health Organization has identified the policy empowering local health workers to distribute injectable contraceptives, a popular method, as key to Malawi’s success. And Rwanda’s rapid growth in contraceptive use has been linked to tangible support from policymakers at the highest levels and the introduction of community-based insurance networks, as well as plentiful funding.

The divergent trends found in these six surveys are an important reminder that demographic trends do not operate in a vacuum. Countries do not progress through the demographic transition or achieve the demographic dividend at a predetermined pace. The policy environment, culture, and socioeconomic factors have tremendous influence on health outcomes and the behavioral determinants of fertility change.

If leaders in Mozambique, Uganda, Zimbabwe, or other countries wish to alter their current trajectories, the emerging successes of family planning programs in Ethiopia, Malawi, and Rwanda prove the tremendous impact of political support and intensive expansion of services to underserved areas and people.

Note: The figures reported for contraceptive use in Mozambique vary between StatCompiler and the DHS reports, and have been updated based on clarifying information received by the author. StatCompiler was used for all other fertility and contraceptive prevalence rates, except those not yet included in StatCompiler, in which case data was drawn from the relevant final DHS report (preliminary reports for Mozambique and Uganda).

Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.

Sources: Asnake (2011), Bongaarts (2008), Leahy Madsen (2011), Mack (2012), MEASURE DHS, Solo (2008), Tsui (2011 and 2001), United Nations Population Division, USAID, WHO.

Image Credit: “Psychosocial support group in Zimbabwe,” courtesy of U.K. Department for International Development. Chart Credit: Elizabeth Leahy Madsen.

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Topics: Africa, USAID, demography, development, family planning, global health, population …

Yemen: Revisiting Demography After the Arab Spring

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By Elizabeth Leahy Madsen // Tuesday, April 17, 2012

Along with other countries where the Arab Spring caught hold, Yemen has been gripped by major upheaval over the past year. Although President Ali Abdullah Saleh finally ceded power in February after his administration’s violent reprisals failed to deter protesters, the country remains at a crossroads. As its political future continues to evolve, the new government must also address a range of deep-seated economic and social challenges. In addition to claiming more than 2,000 lives, the crisis has undermined Yemenis’ livelihoods and even their access to food. A recent World Food Programme survey found that more than one-fifth of Yemen’s population is living in conditions of “severe food insecurity” – double the rate measured three years ago – and another fifth is facing moderate difficulty in feeding themselves and their families.

Yemen’s population trajectory is one of the underlying factors shaping its prospects for stability and the success of the movement towards democracy. Two years ago, I wrote a case study about the effect of demographic conditions on the prospects for development in Yemen. Political tumult aside, the country’s demographic picture remains the same, with UN projections showing that Yemen has the second-youngest population in the world after Uganda. “If we had dealt with the population issue seriously, we would have avoided the current problems and crises in Yemen,” Jamela Saleh Al-Raiby, the deputy minister of public health and population, recently commented in the Yemen Times.

The Demographic Challenge Continues

Countries with a very young age structure face higher vulnerability to civil conflict and lower chances of democratic governance. Among the countries where a push for democracy took root during the Arab Spring, Yemen has the youngest age structure. As political demographer Richard Cincotta noted last March, it was more likely than either Egypt or Tunisia to experience ongoing political violence when evaluated in demographic terms. Seventy-five percent of Yemen’s population is younger than 30, compared to 60 percent in Egypt and 52 percent in Tunisia, according to UN data. Driven by a fertility rate of about 5.5 children per woman – nearly twice as high as the regional average – each younger age group is larger than the last. If fertility remains constant, the population would double to 50 million by the early 2030s and triple by 2045. In the more hopeful scenario in which fertility declines toward three children per woman, the population would still double by 2040.

The number of children younger than 15, whose access to education is critical for the country’s development, has grown by two million (25 percent) in just 10 years. Likewise, the number of young people between the ages of 15 and 29, who are completing education, entering the job market, and often hoping to marry, grew from less than five million in 2000 to more than seven million in 2010.

Early marriage, which is a key driver of high fertility rates, is common in Yemen. Half of current reproductive-age women were married before they turned 18, and the government has stalled on attempts to institute a minimum age of marriage. About 28 percent of married women are using contraception and another 24 percent would prefer to avoid pregnancy but are not using contraception, demonstrating a substantial unmet need for family planning.

Unemployment, Poverty and a Water Crisis

Population trends are closely tied to three other key challenges for Yemen: economic underdevelopment, natural resource shortages, and declining health. Yemen’s economy has not kept pace with the employment needs of its youthful and rapidly growing population. As of 2008, the adult unemployment rate was 15 percent, reflecting the share of working age people who are actively seeking jobs. While the female labor force is small due to traditional gender roles, unemployment is much higher among women (41 percent) than men (12 percent), and twice as many women are illiterate as men. Even among working adults, income is often too low to meet basic living standards, as more than two-fifths of the population lives in poverty.

The oil and gas sector comprises half of the country’s GDP, according to the World Bank, but oil reserves and revenues are declining. Prior to Saleh’s ouster, the government had begun trimming fuel subsidies, which consume 20 to 25 percent of its expenditures. In addition, economic expansion has been hampered by the ubiquitous use of qat, a mild narcotic whose production employs about 15 percent of the workforce but consumes 10 percent of household budgets, 10 percent of land area devoted to agriculture, one third of all ground water extracted, and untold productivity lost due to daily use of the drug.

While both oil and agriculture are under strain, the most critical natural resource for Yemen is arguably water. While Yemen has always been an arid country without rivers or freshwater lakes to draw upon, population growth is one of the primary reasons that water shortages have reached such critical levels. At a Wilson Center seminar on Yemen last year, the founder of the Ministry of Water and the Environment noted that the country’s level of water availability is 14 times below the threshold for water scarcity. With unpredictable rainfall, farmers and families rely on water drawn from slow-regenerating aquifers, consuming it at a much higher rate than the groundwater can be replenished.

Civil Unrest Affects Health and Nutrition

Despite recent increases in the number of health clinics and hospitals, Yemen’s health system remains weak and out of reach for most of the population. The government spends six percent of its budget on health, less than one-third as much as it contributes in fuel subsidies. As of 2010, only 42 percent of the population could reach public health care, and the political crisis has further inhibited their access. According to the local office of Marie Stopes International, a non-governmental organization that provides family planning and reproductive health services, less than 10 percent of health facilities in a recent assessment had sufficient personnel or medicines and other supplies.

In addition to limiting people’s access to health facilities and to reducing the coverage of services, the recent instability has greatly increased already-high levels of malnutrition and hunger. Government and UNICEF surveys in two of the country’s governorates last year showed that more than 30 percent of children are malnourished, on par with areas in Somalia. Vaccination rates dropped after the 2011 unrest began, causing experts to raise concerns about the possibility of higher child mortality rates.

The Road Ahead

Ultimately, the future of Yemen’s demography will be driven in large part by the strength of reproductive health programming. Current efforts emphasize outreach, such as building support among religious leaders and disseminating messages through a weekly television program. “While 10 years ago, these issues were taboo…there is much improvement in [the] knowledge and attitude of the community,” said Deputy Minister of Public Health and Population Al-Raiby in a column for The Huffington Post.

Some observers counter the prevailing pessimism about Yemen’s prospects, suggesting that the recent power transition offers hope for political reform. Ongoing and proposed changes, such as opening doors to the opposition, promoting cooperation among powerful tribes, and increasing the role of regional institutions, are promising in their potential to tamp down current tensions. But successes in the political arena must be paired with investments in the structural factors – demographic, economic, and social development – that provide entrenched, long-term challenges to Yemen’s future.

Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.

Sources: Cincotta (2008-09), CS Monitor, Human Rights Watch, Huffington Post, ILO, IMF, IRIN News, Leahy Madsen (2010), Marie Stopes International Yemen, Ministry of Public Health and Population, New York Times, Sharp (2010), UNDP, UN Population Division, Urdal (2006), Washington Post, World Bank, Yemen Times.

Image Credit: “Yemen Protester,” courtesy of flickr user ssoosay (Surian Soosay); chart courtesy of Elizabeth Leahy Madsen.

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The Missing Links in the Demographic Dividend

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By Elizabeth Leahy Madsen // Friday, March 9, 2012

The “demographic dividend,” a concept that marries population dynamics and development economics, is on the rise in policy circles – Rajiv Shah, Melinda Gates, and African government ministers have all discussed it recently in high-level forums. Most notably for demographers, World Bank Chief Economist Justin Yifu Lin wrote a blog post that focuses on the demographic dividend’s potential to give developing countries a powerful economic boost through declining dependency ratios and a proportionately large working-age population.

However, as Lin’s post demonstrates, discussions about the dividend often give rise to two common misconceptions: one, that all youthful age structures open an opportunity for the dividend; and two, that once age structure changes are in place, economic benefits will accrue automatically.

When a Youth Bulge Is Not

Population age structure is the key link between demography and economic development. If countries wish to incur the potential economic benefits of the demographic dividend, their age structure must change. While Lin’s post describes these age structure changes in detail, it completely omits a critical step required for them to happen: fertility reduction.

Lin describes sub-Saharan Africa’s youthful population age structure as having a “youth bulge.” But this is a tricky term.

Most researchers use “youth bulge” to describe large cohorts of young adults (typically ages 15 to 29), regardless of the number of children under 15. But as Sarah Staveteig pointed out in ECSP Report 11, a “bulge” shape is only apparent in a population profile when the number of children is smaller than older age groups. For example, the U.S. age structure in 1980 (see figure below) shows a clear “bulge” of young adults due to the drop in average family size during the 1970s after the baby boom of the 1950s and early 60s. This type of youth bulge can trigger a demographic dividend, provided other sound policies are in place, because dependency ratios (the share of dependent children relative to working-age adults) decline, allowing increased savings, productivity, and investment.

Even though it’s often described as having a youth bulge, a country that simply has many young people (like Iraq in the example below) will not incur the potential economic benefits of the demographic dividend. Whether the under-15 cohort is growing or shrinking is key – and for it to shrink, fertility rates must decline first. Dependency ratios do not decline when a large cohort of youth enters the labor market and those youth are followed by even larger, younger cohorts. In that case, a country’s youthful population is on track to continue unabated into the future.

Unfortunately, Lin conflates these two very different demographic scenarios. “In a country with a youth bulge, as the young adults enter the working age, the country’s dependency ratio – that is, the ratio of the non-working-age population to the working-age population – will decline,” Lin writes. He continues:

If the increase in the number of working-age individuals can be fully employed in productive activities, other things being equal, the level of average income per capita should increase as a result. The youth bulge will become a demographic dividend. However, if a large cohort of young people cannot find employment and earn satisfactory income, the youth bulge will become a demographic bomb, because a large mass of frustrated youth is likely to become a potential source of social and political instability.

At first, Lin is writing about populations with a true youth bulge – those where the dependency ratio has declined as fertility has declined. As the post correctly explains, the increase in the proportional size of the labor force, if productively employed, leads to increases in income and savings as families tend to have more workers and fewer dependents.

However, in the second part of the paragraph, Lin describes the potential “bomb” effect of a population with a large share of unemployed and frustrated youth. This is linked to a different kind of age structure, one where fertility rates remain high and the size of the cohorts entering the labor market grows year after year. As Henrik Urdal writes in his seminal study of age structure and conflict, “youth bulges in the context of continued high fertility and high dependency make countries increasingly likely to experience armed conflict.” Once dependency ratios decline – as a consequence of fertility decline – the risk of conflict goes down, even while there is still a large share of young adults.

Dependency Differences: South Korea and the DRC

To illustrate, it’s helpful to compare two different age structures that could be characterized by a “youth bulge” but face quite different development trajectories.

The World Bank post cites the example of South Korea, a frequent case study in the demographic dividend literature. South Korea and the other East Asian “Tigers” experienced annual increases in per capita income on the order of six percent between 1965 and 1990. Fertility in Korea declined over the same period from six children per woman to less than two. Studies indicate that such demographic changes were responsible for between one-fourth and two-fifths of the economic growth in the region.

In 1980, halfway through the dividend period, nearly half of South Korea’s total labor force was composed of young adults between the ages of 15 and 29, which certainly created a “youth bulge” in the job market. But, importantly, the dependency ratio was on the way down as well: There were 61 dependents (including children and older adults, but mostly children) per 100 working-age adults – down from 81 dependents for every 100 working-age adults in 1960. Children ages 14 and younger comprised about one-third of the country’s total population, a decline from 41 percent in 1960. You can see this “bulge” in the working-age population in South Korea’s population profile for 1980 (see figure to right).

In contrast, in the Democratic Republic of the Congo (DRC), young adults ages 15 to 29 comprised 54 percent of the total labor force in 2010, about five percentage points higher than South Korea’s share 30 years ago. The key difference is the size of the dependent younger cohort. Currently, children younger than 15 make up 46 percent of the DRC’s total population. Every 100 working-age adults has to economically support 96 dependents, nearly all of whom are children.

Of course, a dependency ratio provides an imperfect snapshot of a country’s labor market. Unemployment, income and wage levels, and the rate of female and child participation in the workforce also play important roles. But in a developing economy with a dependency ratio as high as that of the DRC, most families will be hard-pressed to build savings or to invest in their children’s education, and women’s opportunities to generate income will be limited by their child-care responsibilities.

Including the dependency ratio in any discussion of age structure reveals there is little comparison between South Korea 30 years ago and the DRC and many other youthful countries in sub-Saharan Africa today. Women in the DRC have had an average of six children each since 1950, and as long as that fertility rate remains constant, the ratio of dependents to working-age adults will remain essentially equal.

As only six percent of married women in the DRC are using an effective contraceptive method, it is very unlikely that fertility will decline. More than one-quarter of women have an unmet need for family planning, meaning that they have expressed a desire to avoid pregnancy but are not using any contraception. Unless this need is met, fertility will not decline, the dependency ratio will stay high, and the DRC will not have a chance to enjoy the benefits of the demographic dividend. But this caveat is absent from Lin’s post.

More Than Age Structure

The second key misconception about the demographic dividend is that once age structure changes are in place, economic benefits will accrue automatically. Lin thoroughly summarizes the major socioeconomic investments that governments wishing to capitalize on the dividend must make, such as educating young people beyond primary school, improving the health of the population, generating jobs for youth entering the labor market, and shifting employment from agriculture towards manufacturing and service industries.

Other scholars have reviewed the importance of trade openness, flexible labor markets, and stable financial systems that encourage savings and investment – factors that were lacking in Latin America, for example, as its countries achieved a lower dependency ratio in the 1980s and 90s.

As promising as the potential benefits of the demographic dividend may be, they will not be realized without several prerequisites. Before making investments in human capital and other areas of economic development, policymakers must establish policies and programs that promote age structure changes, such as education for girls and the provision of family planning.

In sub-Saharan Africa in particular, the preeminent scholars of the demographic dividend, David Bloom et al, said it best: “If policymakers can urgently place much more emphasis on educating and empowering African girls, who ultimately represent one of the continent’s most important sources of economic and social progress, they can expect their countries to reap corollary rewards.”

Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.

Sources: Bloom, Canning, and Sevilla (2003), Cincotta (2008-09), Gender Action (2011), Goldstone (2008-09), Lin (2012), MEASURE DHS, Staveteig (2005), Tsui and Hebert (2011), UN Population Division, Urdal (2006), World Bank.

Chart Credit: South Korean age structure, 1950, 2010, 2050 (medium variant estimate), data from UN Population Division; Panel A and B, Staveteig (2005); Figures 2 and 3 arranged by Sean Peoples, data from UN Population Division.

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Afghanistan and Pakistan: Demographic Siblings? [Part Two]

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By Elizabeth Leahy Madsen // Wednesday, February 15, 2012

Late last year, Afghanistan’s first-ever nationally representative survey of demographic and health issues was published, providing estimates of indicators that had previously been modeled or inferred from smaller samples. My first post on the survey focused on the methodology and results, which found that Afghanistan is not as much of a demographic outlier as many observers had assumed. But perhaps the most surprising finding is how the results compare to those of Afghanistan’s neighbor, Pakistan.

The political future of each country depends largely on the other and, with Afghanistan making progress on reproductive health issues that remain stalled in Pakistan, their demographic trajectories are heading toward closer synchronization as well. In one key measure – use of contraception among married women – Afghanistan is almost identical to Pakistan. The modern contraceptive prevalence rate is 19.9 percent, slightly lower than the rate of 21.7 percent in Pakistan.

While Pakistan faces its own serious political instability, it is widely regarded as more developed than its neighbor. Afghanistan is included in the UN’s grouping of least developed countries, and Pakistan is not. Pakistan’s GDP per capita is almost twice as high. On the surface, this should suggest lower fertility. There is a general negative relationship between economic development and fertility, though demographers are quick to point out its complexities, and David Shapiro and colleagues have found that countries with larger increases in GDP actually experience slower fertility declines.

Pakistan’s fertility rate of 4.1 children per woman is in fact 20 percent lower than Afghanistan’s, but the similarities in contraceptive use, which is one of the direct determinants of fertility, suggest that this gap could be shrinking. If Afghanistan’s median age at marriage (18 compared to 20 in Pakistan) was higher and more women were educated (76 percent of women have never been to school compared to 65 percent in Pakistan), the two fertility rates might be closer.

Pakistan’s Entrenched Challenge

Why are these indicators closer than might be expected? Relative to the other countries in South Asia, Pakistan has had considerably less success in promoting family planning use. Bangladesh has a per capita income about half that of India and one-quarter that of Sri Lanka, yet the three countries’ fertility rates are identical. Nepal has the lowest income in the region – even slightly below Afghanistan – yet more than 40 percent of married women use modern contraception and fertility is three children per woman. And then there is Pakistan. Despite a per capita income 90 percent that of India, only 22 percent of married women use modern contraception and fertility remains persistently high at over four children per woman.

Elizabeth Leahy Madsen on demography and civil conflict

The weaknesses of Pakistan’s family planning program have been well-documented. Government commitment has been lacking and cultural expectations and gender inequities are a powerful force to promote large family size. The country’s most recent DHS report cited disengagement with the program among local agencies, low levels of outreach into communities, and weak health sector support as likely causes for the stagnation of contraceptive use. In summer 2011, the Pakistani government abolished the federal Ministry of Health and empowered provincial governments with all responsibilities for health services. This transfer of authority could pay dividends by increasing local ownership of health care, but some in and outside Pakistan have raised concerns about the loss of regulatory oversight and information sharing entailed in total decentralization.

Compared to the Afghanistan survey, the most recent Pakistan Demographic and Health Survey provides more detail on women’s motivations and preferences regarding fertility and family planning. Overall, 55 percent of married women in Pakistan have a “demand” for family planning; that is, they wish to avoid pregnancy or report that their most recent pregnancy or birth was mistimed or unwanted. More than half of these women are using family planning, while the remaining 25 percent of married women have an “unmet need.”

Unintended pregnancies and births play a major role in shaping Pakistan’s demographic trajectory. The DHS survey finds that 24 percent of births occur earlier than women would like or were not wanted at all. If unwanted births were prevented, Pakistan’s fertility rate would be 3.1 children per woman rather than 4.1. Yet 30 percent of married women are using no contraceptive method and do not intend to in the future. The most common reasons for not intending to use family planning are that fertility is “up to God” and that the woman or her husband is opposed to it.

Linked Destinies

Just as Afghanistan and Pakistan’s political circumstances have become more entwined, their demographic paths are more closely in parallel than we might have expected. For Afghanistan, given the myriad challenges in the socioeconomic, political, cultural, and geographic environments, this is good news; for Pakistan, where efforts to meet family planning needs have fallen short of capacity, it is not. While Afghanistan is doing better than expected, Pakistan should be doing better.

Regardless, both countries are at an important juncture. With very young age structures and the attendant pressures on employment and government stability, each government must reduce unmet need for family planning or face mounting difficulties to providing for their populations in the future. In addition to rolling out health services, turning the share of women without education from a majority into zero would be an excellent way to start.

Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.

Sources: Afghanistan Ministry of Public Health, Bongaarts (2008, 1978), Cincotta (2009), Embassy of Afghanistan, Haub (2009), International Monetary Fund, MEASURE DHS, Nishtar (2011), Population Action International, Savedoff (2011), Shapiro et al. (2011), UN-OHRLLS, UN Population Division, U.S. Census Bureau, The Washington Post.

Image Credit: Chart arranged by Elizabeth Leahy Madsen, data from MEASURE DHS.

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Afghanistan’s First Demographic and Health Survey Reveals Surprises [Part One]

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By Elizabeth Leahy Madsen // Tuesday, February 14, 2012

Late last year, Afghanistan’s first-ever nationally representative survey of demographic and health issues was published, providing estimates of indicators that had previously been modeled or inferred from smaller samples. It shows that Afghan women have an average of five children each, lower than most experts had anticipated, and that their rate of modern contraceptive use is just slightly lower than that of women in neighboring Pakistan.

The Afghanistan Mortality Survey 2010 is based on interviews with nearly 48,000 Afghan women, ages 12 to 49, conducted over eight months in 2010. Due to conditions of extreme insecurity, 13 percent of the population, mostly living in the southern provinces of Helmand, Kandahar, and Zabul, had to be excluded from the survey. Although officially titled a mortality survey, it includes the topics most commonly addressed in other USAID-sponsored Demographic and Health Surveys (DHS), such as fertility, family planning, and maternal health. The survey objectives were to provide a knowledge base of health needs as the country continues to rebuild from constant conflict, as well as to demonstrate how international humanitarian and development investments have affected population well-being.

Afghanistan’s last census was conducted in 1979, the year of the Soviet invasion, which ushered in a decade of war followed by more insecurity. The population then was estimated at 15.6 million; in 2010, the UN Population Division estimated it had reached 31.4 million.

Contraceptive Use Higher Than Sub-Saharan Africa

Fertility in Afghanistan is estimated at an average of 5.1 children per woman. While still quite high – growing at 2.6 percent per year, the population is on pace to double every 26 years – this is significantly lower than estimates generated before the survey was conducted. Afghanistan was often grouped among countries with the highest fertility rates in the world. The most recent fertility estimates from the U.S. Census Bureau, UN Population Division, and Population Reference Bureau range from 5.8 to 6.6 children per woman. Even these estimates are lower than those for the 1990s, when the UN pegged the fertility rate at eight children per woman.

In 2009, demographers Richard Cincotta and Carl Haub noticed indications of demographic change in Afghanistan, with Haub suggesting that the national Basic Package of Health Services, introduced in 2003, was succeeding in bringing health care, including family planning, to rural areas. The Mortality Survey itself proposes that fertility rates may be falling due to urbanization and “exposure to modern means of communication,” as well as access to family planning.

Although women in Afghanistan are often restricted in their mobility outside the home, knowledge of effective family planning methods is, as in most countries, almost universal. However, current use of contraception remains relatively low: One-fifth of married women of reproductive age are using a modern contraceptive method, most commonly injectables or the pill. Following the typical pattern, contraceptive prevalence is higher among women who are educated, wealthier, and those who live in urban areas. Still, family planning use among rural women has more than tripled since 2003 and the overall rate is four points higher than the average for sub-Saharan Africa.

Household Indicators

Women in Afghanistan face conditions of widespread inequity, and this is reflected in the survey results. Seventy-six percent of women surveyed have never been to school, making education for girls and women a clear priority for government intervention. In a positive step, Afghanistan’s 2004 constitution promised that the government will provide them with education.

The median age of marriage is 18, and half of women surveyed gave birth while still teenagers. Age at marriage directly affects fertility patterns, and another sign that fertility is falling is reflected in the fact that age at marriage is rising among younger women.

Two-thirds of births occur at home, the vast majority of these without the assistance of a skilled provider. Still, the survey also reports much lower estimates of maternal mortality than those prepared by international agencies.

The survey also provides a snapshot of the housing circumstances and economic quality of life for Afghans. About 40 percent get their water from unprotected wells, surface water, and other non-improved sources. Households are large, averaging eight people each, and only five percent of homes have their own flush toilet. Nearly 60 percent of the population lives without electricity and in homes with mud or earthen floors. Although only eight percent of the population has a refrigerator, three-quarters have a mobile phone.

Per capita GDP is estimated at less than $600 annually. More than one-third of the population is unemployed, and agriculture remains the primary industry and source of income, even though most of the country’s land is not arable.

Moving Closer to Pakistan

Despite these dire statistics, given the rapid rise in contraceptive use, the health system has clearly succeeded in improving health care access among some Afghan women. For the demographic picture moving forward, the question is whether rapid jumps in contraceptive use will continue. Several developing countries have experienced an initial decline in fertility that has subsequently stalled. These stalls have been linked to slower improvements in female education, infant and child mortality, and contraceptive prevalence, compared to countries that are experiencing steadier fertility declines. Unfortunately, the Afghanistan survey does not include data on women’s and men’s fertility preferences, sources of contraception, and reasons for not using family planning, which would provide clues in planning priorities for future services and outreach.

The most important general finding of the new survey is that Afghanistan is not as much of a demographic outlier as many observers had assumed, given the challenging conditions of geographic remoteness, violence, poverty, and low status of women. While the sustainability of these improvements can’t be taken for granted in such fragile conditions, the public health system in Afghanistan is making strides against the odds and reaching closer to parity with neighboring Pakistan.

Update: In the second paragraph we originally stated that “nine percent of the population, living in the southern provinces of Helmand, Kandahar, and Zabul, had to be excluded from the survey.” However, there were several “enumeration areas” (units selected to be included in the survey sample), constituting another four percent, that were not surveyed during implementation, also primarily due to insecurity. The total non-covered portion of the population, therefore, is 13 percent.

Part two of Elizabeth Leahy Madsen’s look at the Afghanistan Mortality Survey 2010, compares the survey’s surprising results with those of Pakistan and others in South Asia.

Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.

Sources: Afghanistan Ministry of Public Health, Bongaarts (2008, 1978), Cincotta (2009), Embassy of Afghanistan, Guttmacher Institute, Haub (2009), International Monetary Fund, MEASURE DHS, Nishtar (2011), Population Action International, Savedoff (2011), Shapiro et al. (2011), UN-OHRLLS, UN Population Division, U.S. Census Bureau, The Washington Post.

Photo Credit: “View inside Afghan Apartment Block,” courtesy of United Nations Photo; charts courtesy of MEASURE DHS.

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Building Commitment to Family Planning:

Indonesia: Pioneering Community Outreach Creates Success Story

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By Elizabeth Leahy Madsen // Tuesday, January 31, 2012

This is the third post in a series profiling the process of building political commitment in countries whose governments have made strong investments in family planning. Previous posts have profiled Rwanda and Iran.

While the two other countries profiled in this series, Rwanda and Iran, have only reinvigorated their family planning programs within the past 20 years, Indonesia’s story begins in the 1960s. In this respect, the world’s fourth most populous country is classified among the pioneers of family planning in the developing world and has been described as a “world leader” and “one of the developing world’s best.” An extensive community outreach program combined with a centralized government that made family planning a priority were key to Indonesia’s success story.

Jakarta Pilot and Religious Support Motivates National Scale-up

For a decade and a half after the struggle for independence from the Dutch ended in 1949, the government of President Sukarno ruled out any government support for family planning. According to a Demographic and Health Survey (DHS) report, the rate of contraceptive use among married women at the time was essentially zero. Fertility rose slightly during this period, from an average of 5.5 in the early 1950s to 5.6 children per woman a decade later. However, in 1965, Sukarno was overthrown, and the next year, a military general named Suharto assumed power in an uprising that left as many as half a million people dead.

Suharto’s regime would last until 1998. Though he operated with a “heavy hand” amidst personal corruption, Suharto also aggressively pursued economic development and brought about a policy shift towards promoting family planning. Despite initial reservations – Suharto believed that the people would oppose family planning on religious grounds – various domestic and international advisers convinced him otherwise.

General Ali Sadikin, the governor of Jakarta – a city of three million even then – was particularly influential in convincing Suharto. According to Australian demographer Terence H. Hull, who has written extensively about population issues in Indonesia, Sadikin was “quickly learning demographic lessons in his attempts to renovate a city with poor housing, schooling, transport, and basic services,” and he began to regularly speak out about the challenges that rapid population growth posed to his goals of urban development.

Sadikin decided to support the Indonesian Planned Parenthood Association, which had a network of clinics offering family planning, but lacked the funding to meet more than a small amount of demand. With the public support of Sadikin, a Jakarta-wide pilot program was operational in 1967.

Hull reports that a second integral event in the early years was a 1967 meeting between government officials and Muslim, Protestant, Catholic, and Hindu leaders representing four of the country’s major religions. Following the meeting, a pamphlet called “Views of Religions on Family Planning” was published, representing “a tipping point when national consensus around the morality of birth control was turning from strongly negative to strongly positive.”

A Strong Coordinating Board Reaches out to Communities

By late 1968, efforts were in place to scale up the family planning program in Jakarta to the national level. The National Family Planning Coordinating Board (BKKBN in Indonesian) was created and quickly became entrenched throughout the country thanks to generous funding, including from international donors.

The BKKBN’s emphasis on the community level, which ensured that family planning services and awareness-generating activities were reaching people around the country through multiple channels, was a key factor in the program’s achievements. The organizations involved in promoting family planning messages at the community level included youth, women’s and religious groups, employers, and schools, with high-level support reiterated regularly by the president. Hull described the BKKBN’s efforts as “a true collaboration because the program emphasized institutions not normally associated with family planning, but did so in a way that was both socially acceptable and socially invigorating.”

In the program’s first two decades, the contraceptive prevalence rate for modern methods rose from almost nonexistent to 44 percent, and fertility subsequently fell from 5.5 to 3.3 children per woman. These changes are widely attributed to robust government sponsorship from the highest levels, together with effective grassroots implementation that fostered support from nearly all sectors of society.

In subsequent years, Indonesia experienced rapid economic and social development. Per capita income increased more than 20 times over between 1966 and 1996, with initial growth largely due to oil revenues. Other development indicators also improved dramatically. The literacy rate is now over 90 percent, nearly all girls attend school, and half of women are members of the labor force. However, Hull cautions against proclaiming the family planning program the primary causal factor in these successes. Family planning and other development programs would not have been as effective, he says, without changes in the political structure, which steadily became more centralized and stable in its oversight of a very heterogeneous society.

A Recent Plateau

As Indonesia continued to develop and its political system evolved, the family planning program has faced some challenges in the past 15 years. Suharto resigned in the face of widespread opposition in 1998, after more than 30 years in power. While this brought positive movement towards democracy, the ensuring political uncertainty shifted the government’s energies away from reproductive health and other aspects of social development.

In the early 2000s, the family planning program was decentralized to district and municipal levels, in line with political reforms aimed at diminishing the role of central hierarchy nationwide. District leaders were charged with planning, budgeting, and implementing family planning and other primary health services. In accordance, BKKBN modified its strategies to become even more community-oriented. Still, observers judge the family planning program to have “weakened” following decentralization.

With strong logistics, popular support, and donor assistance, contraceptive use continued rising during the years of political transition. By 2002-2003, 57 percent of married women were using a modern contraceptive method and the fertility rate had reached 2.6 children per woman. However, these indicators remained unchanged in the next national survey, conducted in 2007. Fertility in Indonesia is at the median for Southeast Asia – higher than Thailand and Vietnam and lower than Cambodia and the Philippines.

The Program Moves Forward

As democracy became more secure in the early 2000s, the country’s next generation of leaders kept sight of demographic issues. In 2005, President Susilo Bambang Yudhoyono stated, “High population growth without rapid economic growth will result in poverty and setbacks … Large numbers of children and high populations will only bring advantages if they are skilled.” BKKBN and the Ministry of Health worked with USAID, public health researchers, NGOs and others to develop national family planning standards for quality of care, which were devised and implemented in the early 2000s.

Judging the program’s achievements to have been substantial and its momentum sustainable, USAID graduated Indonesia from population assistance in 2006, after 35 years. Though gaps remain, women’s fertility preferences are largely being met.

Today, 80 percent of all births are intended, and unmet need for family planning – the share of married women who wish to delay or prevent pregnancy but are not using contraception – stands at nine percent, two percentage points below the average for Southeast Asia and all developing countries. Meanwhile, Indonesia’s demographic profile looks much different than it might have. At the time of graduation, USAID reported that without its long-standing and well administered family planning program, Indonesia’s 2006 population would have been larger by 80 million people, or 35 percent.

Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.

Sources: Demographic and Health Surveys; Hull (2007); Management Sciences for Health; New York Times; UN Population Division; USAID.

Photo Credit: “Jakarta,” courtesy of flickr user frostnova.

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Building Commitment to Family Planning:

Iran: A Seemingly Unlikely Setting for World’s Fastest Demographic Transition

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By Elizabeth Leahy Madsen // Wednesday, January 11, 2012

This is the second post in a series profiling the process of building political commitment in countries whose governments have made strong investments in family planning. Read the first post, on Rwanda’s recent rapid demographic changes, here.

To date, only 11 countries outside of the developed world, China, and a handful of small island states have reached the end of the demographic transition, with fertility rates declining from more than four children per woman to replacement level or lower.* Of these, only two countries have completed the transition in 15 years or less – and both might surprise you. One is Cuba, whose government dispensed family planning services to its relatively small population in the 1970s through accessible primary health care facilities and legalized safe abortion eight years before the United States did. The other: Iran.

Following the 1979 revolution, Iran’s new theocracy adopted a socially conservative, pro-natalist outlook. Half of the population lived in rural areas, which typically constrains access to health services. In addition, abortion was illegal in most circumstances. According to the UN, Iranian women had an average of 6.5 children each in the early 1980s and the population was growing nearly four percent annually, a rate high enough for it to double in 19 years.

But, by the early 2000s, Iran’s fertility rate had dropped below two children per woman. The swift changes can be attributed to the efforts of government officials concerned about meeting the employment needs of a growing population, supported by public health experts who wanted to rebuild the eroded family planning program.

A Dramatic Policy Shift

The turning point came after the end of Iran’s eight-year war with Iraq in 1988. With military demands high – several hundred thousand people were killed during the war – population growth was viewed positively. But as the war ended, policy directives did an about-face.

Although public health officials had framed the need for reinvigorated family planning programs in health-related terms for years, the motivation for government officials to change policy appears to have been economic. The national budget agency informed the prime minister that after nearly a decade of conflict, the country lacked adequate funding to both rebuild and to meet the needs of its people. The prime minister responded quickly, directing that demographic factors be integrated into the new development plan and stating that “Iranians’ standard of living was being eroded by the growth of the country’s population.”

“Pragmatism Has Prevailed Over Pure Ideology”

After convincing their superiors, Iranian government officials who supported family planning faced the added challenge of garnering the backing of the influential religious establishment. Shortly after the revolution, Ayatollah Khomeini officially sanctioned the use of contraception, though his perspective was not universal among clerics. Once the prime minister decided to introduce a national family planning program, officials sought support from additional religious authorities. Opposition was minimal after two key institutions offered endorsements. The High Judicial Council determined that there was “no Islamic barrier to family planning” in late 1988, and the Expediency Council approved the government’s plans soon after.

By late 1989, a new family planning program had been officially introduced. The program’s aims were to lengthen spacing between births; limit pregnancies in the early and late reproductive years; and lower fertility by educating the population and ensuring access to free and diverse contraceptive methods. By the mid-1990s, the government had fully integrated family planning into the existing primary health system.

Iran thus followed the example of other majority-Muslim countries where religion was not an impediment to family planning, including Egypt, Indonesia, Jordan, and Oman. Just as in countries where highly Catholic populations have low fertility rates (Italy, Poland, Spain, and many others), religious guidance has been interpreted in varying ways in different settings and is not necessarily a central factor in individual fertility decisions. As Akbar Aghajanian and Amir H. Merhyar write in a summary of Iran’s family planning program, “Pragmatism has prevailed over pure ideology when necessary.”

The Contributions of Women’s Education and a Strong Health System

A new policy orientation was the critical first step, but successful implementation was necessary for Iran’s demographic trajectory to change in response. Fortunately, the government had some advantages in rolling out its new program, namely a strong existing health system, a history of past efforts to promote family planning, and an educated female population among whom demand for contraception was high.

Rural development became a priority of the government after the revolution and resulted in improved access to an array of services. In rural areas, community health workers receive two years of training to provide family planning services along with other preventative care and treatment. Services are also available at rural health “houses,” urban clinics, and higher-level centers around the country.

The status of women has also played a major role. A research exercise conducted by IIASA estimated that improvements in educational attainment among women were responsible for about one-third of Iran’s fertility decline between 1980 and 2005. Women’s literacy was already rising during the period of the revolution and reached 74 percent by 1996, while attitudes toward female employment became more supportive. By the late 1990s, new classes of university students included more women than men. The response to the 1989 program indicated that women clearly had an unmet demand for family planning. Use of modern contraception jumped from 31 percent in 1989 to 51 percent just five years later, then rose more slowly over the subsequent decade.

A Dividend Squandered?

The rapid changes in Iran’s age structure, thanks to declining fertility, have opened a window of opportunity for the country to boost economic growth through lower dependency ratios – a phenomenon called the demographic dividend. However, the dividend is not an automatic bonus, and Iran’s capacity to capitalize on its demographic change is questionable.

The unemployment rate among young people today is over 20 percent, indicating that the economy is not generating sufficient jobs, which is a prerequisite to improving productivity. This inopportune climate may even contribute to a further decline in the fertility rate: Some observers have suggested that the country’s economic troubles and rising costs of living have motivated young people to delay marriage and have smaller families. “Unemployment and high costs of living, coupled with social and political restrictions, have made [life] increasingly difficult for young Iranians,” Farzaneh Roudi of the Population Reference Bureau (PRB) explained in a blog post last year.

Given Iran’s challenges in producing adequate jobs and other economic benefits for its population, President Mahmoud Ahmadinejad’s recent unusual pronouncements on population issues are especially puzzling. Last year, Ahmadinejad introduced a pro-natalist policy offering direct payments to each child born, continuing until they reach adulthood, and later suggested that girls should marry at age 16 or 17.

But despite a high level of international media attention, most observers expect the policy to have little impact. Widespread adoption of family planning has become entrenched in society: 60 percent of Iranian women now use a modern contraceptive method. As PRB’s Roudi wrote in response to Ahmadinejad’s proposal, “Iranian women and men have gotten used to exercising their reproductive rights and would expect to be able to continue to do so.”

*The 11 countries that have achieved replacement fertility or lower outside of developed regions, China, and small island states are Brazil, Chile, Costa Rica, Cuba, Iran, Lebanon, Myanmar, Thailand, Tunisia, and the United Arab Emirates.

Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.

Look for related analysis on the political implications of Iran’s changing age structure by Richard Cincotta on New Security Beat soon.

Sources: Abbasi-Shavazi, Lutz, Hosseini-Chavoshi and Samir (2008), Abbasi-Shavazi (2002), Aghajanian and Merhyar (1999), Christian Science Monitor, GlobalSecurity.org, The New York Times, Noble and Potts (1996), Population Reference Bureau, Roudi-Fahimi (2002), UN Population Division, World Bank.

Image Credit: “بیست و پنجم خرداد ۸,” courtesy of flickr user Recovering Sick Soul (Nima Fatemi); charts arranged by Sean Peoples and Elizabeth Leahy Madsen.

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Three New Reports Highlight Ongoing Significance of Youth Demographics in Global Trends

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By Elizabeth Leahy Madsen // Monday, January 2, 2012

Amidst world population reaching seven billion and last year’s Arab Spring, which in some nations is continuing into this winter, it can be easy to miss emerging pieces of research that tell us something relatively objective about youth and instability. Three new studies give practitioners and policymakers a stronger foundation of evidence to highlight the challenges and opportunities facing the world’s largest generation of young people.

Results of a recent UNICEF staff survey indicate that the people responsible for the UN’s efforts targeting children and youth are seriously concerned about demographic and economic dynamics. Asked to review a list of 20 “global trends,” UNICEF staff rated “growing disparities” and “youth bulge and youth unemployment” as the most significant to children. The results, which the agency will soon publish in a paper on “The Next Generation and Global Trends,” also indicate that staff members feel that UNICEF has a strong capacity to influence the future of these trends.

UNICEF’s recent “Child Outlook” report on global trends discusses the issues highlighted in the survey. The report notes that although many countries are moving toward middle-income status, poverty rates remain stubbornly high, indicating that economic development does not benefit all equally. Income and consumption in such countries tend to be concentrated among the wealthiest households. “While many families will prosper, others are being left behind,” the report explains.

“Tensions and discouragement arising from youth unemployment, combined with higher food prices and fiscal contractions, may have contributed to increased civil unrest, protests, and political instability,” UNICEF asserts. In many developing countries, the number of young people entering the labor market far surpasses the number of available jobs. Although some youth are not working because they are enrolled in secondary or tertiary education, low rates of youth participation in the workforce often are not a matter of choice. Young people, especially those with low levels of education and from poorer families, are often unable to find secure, decent jobs. More than one-quarter of all young people with jobs worldwide live below the poverty line of $1.25 per day.

Economic Pressures on Youth in East Africa

Two other research projects – one published, one still underway – provide additional context to the combination of demographic and economic challenges that face the world’s young people. In the first, part of a recent special U.S. Institute of Peace series on South Sudan, Stephanie Schwartz and Wilson Center fellow Marc Sommers probe the expectations of and obstacles faced by youth in the newly created country.

According to the incipient government’s statistics agency, 72 percent of South Sudan’s population is younger than 30, which places it among the 20 youngest age structures in the world. Only 40 percent of youth ages 15 to 24 are literate, and nearly 80 percent of households depend on agriculture for their income. Based on interviews conducted with urban and rural youth in three areas of South Sudan, the authors find that the pressure of paying rising dowry costs is the most salient issue facing young men, while young women are treated as economic assets with no influence in their own future. The authors’ research suggests that “some young men join armed gangs, at least in part, because they believe it will help them pay dowries.”

Elizabeth Leahy Madsen explains demographic security in brief

Although many young people in South Sudan aspire to the stability of government work, the limited number of jobs and shortage of relevant skills inhibit their aspirations. With an underdeveloped private sector, few opportunities for training, and nepotistic practices in hiring, there is little work for those living in towns and urban areas beyond manual labor and selling goods. The authors recommend that education and job training be expanded, with a focus on equitable access among young people from varied geographic backgrounds.

Across the border in northern Uganda, Chris Blattman, an associate professor of political science at Yale, has been studying the social effects of the government’s youth employment program started in 2007. The program offered grants to small groups of young people for vocational training or to fund the costs of starting a new business. Although a full paper has not yet been published, preliminary findings indicate strong economic benefits of the program which in turn improve social cohesion and community participation while diminishing aggression and “disputes with authorities” among young men. If they bear out, the results may well confirm the oft-repeated policy recommendation that focusing on youth employment is critical to improving national development as well as reducing the likelihood of instability and conflict.

In the year of seven billion, we heard much about the need to invest in young people and the tremendous potential they embody, for demographic dividends as well as overall development. Yet 2011 was also a year of tremendous upheaval, much of which was driven by young people – and their older counterparts – seeking representative and democratic governance. This should serve as a reminder that youth can be a remarkable force for positive change, but in too many places – South Sudan among them – their opportunities, prospects, and contributions are constrained. As the UNICEF survey results reiterate how important this issue is to development programming, the Uganda research may be another important piece of evidence that direct investment in young people reaps tangible results not only for them, but also for society.

Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group. She was previously a senior research associate at Population Action International.

Sources: Bill and Melinda Gates Institute for Population and Reproductive Health, Chris Blattman, ILO, Sommers and Schwartz (2011), South Sudan National Bureau of Statistics, UNICEF, World Bank.

Photo Credit: “UNAMID Peacekeeper Speaks with Sudanese Youth,” courtesy of UN Photo/Albert Gonzalez Farran.

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Topics: Africa, demography, development, economics, population, security, video …

In Somalia, Beyond the Immediate Crises, Demography Reveals a Long-Term Challenge

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By Elizabeth Leahy Madsen // Wednesday, December 21, 2011

In the nearly 20 years since the infamous intervention that resulted in the deaths of dozens of American and UN peacekeeping soldiers on the streets of Mogadishu, Somalia has become the epitome of a “failed state.” Neighboring countries, global bodies, and aid agencies are rushing to respond to the country’s rapidly evolving political, security and humanitarian crises.

Diplomatic attention has focused on decentralized, weak governance that is divided among the Al Shabab insurgency, clan warlords, and a hamstrung and largely ineffective Transitional Federal Government, whose control does not extend beyond the capital. Foreign militaries have had to devote naval resources to curtailing daring and far-reaching acts of piracy against civilian and military vessels from networks based in Somalia. Aid groups have been stymied in their efforts to stem famine as access to populations in the hardest-hit areas has been cut off by Al Shabab and food aid has been stolen. Most recently, Kenyan and, reportedly, Ethiopian forces have crossed the border, extending the reach of the country’s political crisis. Hundreds of thousands of have fled conditions of hunger, illness, and violence into neighboring countries.

Perhaps the deepest woe of a “failed state” is that its problems are deep-seated and cannot be solved during the brief span of a UN meeting or the news cycle following the latest terrorist attack. Amid the extraordinary efforts to battle the country’s crises, one of the most important underlying structural factors is often overlooked: the country’s unusual demographic picture.

A Demographic Outlier

Somalia is a global outlier in demographic terms, with rates of fertility (6.4 children per woman), infant mortality (107 deaths per 1,000 births), and maternal mortality (1,200 deaths per 100,000 live births) all above the already-high averages for sub-Saharan Africa. These demographic indicators are both a reflection of the abysmal state of health care in the country and a warning that its economic and security challenges are unlikely to be easily resolved.

Research shows that where at least 60 percent of the population is younger than 30 years old, countries are more prone to outbreaks of civil conflict, and the risk increases as the proportional size of the “youth bulge” grows. In Somalia, 70 percent of the population is younger than 30, a level comparable to Iraq and the Palestinian Territories. With little to no improvements in health care, Somalia’s age structure has remained unchanged over the past 40 years. Unlike dozens of other countries where fertility has declined significantly in recent decades, Somali women have nearly as many children on average today as they did in the 1970s. The current total fertility rate of 6.4 children per woman is only a 12 percent decline from the 1970 rate.

Despite high infant mortality – more than 10 percent of children die before turning one – this sustained high fertility rate has generated rapid population growth, with each successive generation larger than the next. Somalia’s population has almost tripled since 1970, from 3.6 to 9.3 million, although population density remains low (one-third the world average). If the fertility rate remains constant at the current level – not an unreasonable projection considering how stagnant it has been over past decades – Somalia would be home to 33 million people by 2050. Even if the fertility rate drops to near four children per woman, as projected in the UN’s medium variant, the population would still triple to 28 million by mid-century given the demographic momentum of decades of high fertility.

The fertility decline built into the UN’s medium variant projection – which would still place Somalia among the highest total fertility rates in the world by 2050 – is unlikely without steady and major improvements in the country’s health system, particularly women’s health. But with decades of conflict, weak governance and little investment, the environment for reproductive health services is dire.

A recent World Health Organization assessment described “unacceptable levels of unmet need, extreme inequities in access…slow progress…[and] underinvestment and poorly coordinated actions.” Pregnancy and childbirth are major risks to women’s well-being. Somali women have a one in 14 chance of dying from maternal causes over their lifetimes, the second-highest risk in the world. Funding to improve reproductive and maternal health care remains too low to meet demand. The United Nations Population Fund reports that donors spent about $6 million on population and reproductive health programs in 2008, about one-third as much as was spent in Benin and Burundi, which have smaller populations.

The Future for Youth

Instability and violence have become entrenched in Somalia; according to the Armed Conflict Dataset, civil conflict occurred in 12 of the past 20 years. The direct causes of the conflict are typically recorded as struggles for power and resources among competing clans. But in considering the underlying causes of conflict, demographic security scholars have suggested that very young age structures such as Somalia’s can create both motive and opportunity for recruitment into a violent uprising. As ever-growing numbers of young people face adulthood with few prospects for employment, hopelessness or desperation can make them vulnerable to the promise of well-being and identity offered by a political faction or rebel group.

There are 1.7 million people between the ages of 15 and 24 in Somalia today, with another 2.5 million following in the next ten-year age cohort. With opportunities for education, jobs, and equitable participation in society, these youth would represent a promising future for their country. Unfortunately, such opportunities are not afforded to most of them. A United Nations survey found that the secondary school enrollment rate is just six percent, with poverty and early marriage keeping many young people out of school. World Bank data from 2002 show that two-thirds of urban working-age adults and 41 percent of those in rural areas were unemployed. Nearly half of the population lives on less than $1 per day.

Youth Education, Economic Opportunities Could Increase Stability

While global attention centers on the government’s commitment to a new roadmap for peace and the efforts of the African Union’s peacekeeping forces to drive Al Shabab out of Mogadishu, development agencies have recognized demographic security as an important component of Somalia’s future.

The United Nations Children’s Fund is supporting schools for displaced children in Mogadishu, saying in a press release that “providing them with learning opportunities in a safe environment is critical for the country’s long-term stability and growth.”

The U.S. Agency for International Development (USAID) has announced plans for a new program called the Somali Youth Leaders Initiative, which aims to improve young people’s access to secondary education and economic opportunities and to increase their civic participation. In designing the program, USAID noted “the recruitment of boys and men by extremist organizations and piracy networks” and “the common perception that an increasing youth population is a potentially destabilizing force.”

As the October 4 bombing at the Education Ministry in Mogadishu showed, young people are often the victims of the country’s instability. Programs such as those of UNICEF and USAID that empower young people to capitalize on their potential should be a greater focus among initiatives to address Somalia’s long-term future as well as its immediate crises.

Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and former senior research associate at Population Action International.

Sources: BBC, Population Action International, The New York Times, UCDP/PRIO, UNICEF, UNESCO, UN Population Division, UN Population Fund, Urdal (2006), USAID, World Bank, World Health Organization.

Image Credit: “Somalia Suffers from Worst Drought in Century,” courtesy of flickr user United Nations Photo/Stuart Price; charts arranged by Elizabeth Leahy Madsen, data from the UN Population Division and World Health Organization.

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Book Preview: In ‘War and Conflict in Africa’, GWU Scholar Skeptical That Natural Resources Play a Leading Role

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By Elizabeth Leahy Madsen // Wednesday, November 30, 2011

While there is widespread agreement that the incidence of conflict in Africa is high, scholars and development agencies alike debate its driving forces and how to move toward solutions. Paul Williams, associate professor in the Elliott School of International Affairs at George Washington University and collaborator with the Wilson Center’s Africa Program, recently published a book that aims to both quantify African conflicts and devise a framework of their causes. In War and Conflict in Africa, Williams evaluates which factors explain the frequency of conflict in Africa during the post-Cold War era and how the international community has tried to build peace and prevent future conflict.

Although there have been promising trends toward establishing peace and democracy in some African countries, the continent still accounts for about one-third of all armed conflicts annually – more than Europe, the Middle East, and the Americas combined. International responses to these events range from focused humanitarian and conflict resolution efforts, to new regional organizations and global strategic and defense partnerships.

Seven of the 16 current UN peacekeeping missions operate in Africa, more than any other continent. The UK government has elected to spend nearly one-third of its development assistance in conflict-affected areas, and more than half of its “focus” countries are in Africa. In 2008, the Department of Defense created the U.S. Africa Command (AFRICOM), whose commander, General Carter Ham, in a speech to Congress earlier this year, described “an insidious cycle of instability, conflict, environmental degradation, and disease that erodes confidence in national institutions and governing capacity,” as motivation for American military attention. “This in turn often creates the conditions for the emergence of a wide range of transnational security threats,” he said.

Evaluating the Ingredients of Conflict

Williams rejects earlier theses that attribute conflict across the continent to a single factor, such as the boundary legacies of colonialism, greed, or ethnicity. Instead, he characterizes African conflicts as “recipes” composed of case-specific mixes of factors, many of which are underlying and only some of which are sufficient triggers for conflict. “Collier is wrong,” Williams explained in an email interview. “Governance structures are always an important part of the buildup to war.”

Lou Rios and Amy Krakowka on teaching environment and security at West Point.

Five “ingredients” of conflict are examined in-depth: neo-patrimonial governance structures; natural and human resources; sovereignty and self-determination; ethnicity; and religion. Among these, the book presents a fairly skeptical view of resources, ethnicity, and religion as immediate drivers of conflict. This assessment that environmental and identity issues are not sufficient to generate conflict on their own aligns with the book’s overarching argument: The decisions of political actors can instigate conflict or motivate peace from virtually any context, manipulating factors such as ethnicity and religion for their own advantage.

Effects of Natural Resources Are “Open-Ended”

A widely publicized thread of peace and conflict studies posits that resources, either when scarce or abundant, have an important role in triggering wars. A 2009 UN Environment Programme report found that 40 percent of all internal conflicts since 1950 “have a link to natural resources.” Recent peer-reviewed research has suggested that certain environmental changes increase the likelihood of civil conflicts or are directly responsible for it. Yet the question remains a source of much debate. For his part, Williams asserts that natural resources alone are insufficient to cause conflict.

War and Conflict in Africa presents several reasons that researchers and policymakers should avoid linking resources directly to conflict without considering the influence of intervening factors. Chief among them is that the value of any resource is socially constructed – no stone or river carries worth until humans decide so. Therefore, Williams argues that “it is political systems, not resources per se, that are the crucial factor in elevating the risk of armed conflict.”

The book suggests that two extant theories successfully demonstrate the connection between resources and conflict. The first body of research finds that conflict is more likely in regions that face a combination of resource abundance and a high degree of social deprivation. The second theory suggests that the link between resources and conflict lies in bad governance, whether exploitative or unstable. Both theories have explanatory power for Williams’s central line of thinking: Resources can be either a blessing or a curse, depending on leadership.

“Inserted into a context where corrupt autocrats have the advantage, resources will strengthen their hand and generate grievances,” he writes (p. 93). “Inserted into a stable democratic system, they will enhance the opportunities for leaders to promote national prosperity.”

Population and the Environment

Williams does accede that particular resource factors – land and demography, for example – may play a more significant role than others in conflict, but calls for more research. In a brief discussion of population age structure, the book suggests that there is no single relationship between demography and conflict but multiple ways that the two can relate. Williams mentions the theory that “large pools of disaffected youth” with few opportunities can raise the risk of volatility. However, he then notes other research showing that the most marginalized members of certain African societies are less likely to participate in political protests and more likely to tolerate authoritarian rule than those who are better off.

“The most marginalized from society are the truly destitute without patrons and suffering from severe poverty. They may well be inclined to join an insurgency movement once it begins to snowball but they will not usually play a key role in establishing the rebel group in the first place,” Williams said. However, “any time there are large pools of poor and unemployed youth there is the potential for leaders to manipulate them.”

On environmental resources, the book argues that land should be a central feature of quantitative research on the relationship between resources and conflict. Most African economies continue to rely on agriculture, and Williams observes that land has been “at the heart” of many conflicts in the region through a variety of governance-related mechanisms relating to its management and control. He places less emphasis on water scarcity as a potential factor in conflict, noting that the 145 water-related treaties signed around the world in the past decade auger well for cooperation rather than competition.

Williams is also dubious of emerging arguments that climate change could directly increase the incidence of conflict, either through changing weather patterns or climate-induced migration.

“Because armed conflicts are, by definition, the result of groups choosing to fight one another, any process, including climate change, can never be a sufficient condition for armed conflict to occur,” he argued. “Armed conflicts result from the conscious decisions of actors which might be informed by the weather but are never simply caused by it.”

No Simple Formula

Williams is not the only observer to find the narrative that resource shortage (or abundance) precipitates conflict too simplistic. His message to policymakers is a common refrain from academics and analysts seeking to counteract policymakers’ quest for simple formulas: We need more data.

“When deciding how to spend our money, we need to spend more of it on developing systems which deliver accurate knowledge about what is happening on the ground, often in very localized settings,” Williams said. War and Conflict in Africa contributes to a more complex understanding of the political actors and systems that catalyze or prevent conflict and offers a cautionary tale to those who seek only proven, easy predictions.

Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group. She was previously a senior research associate at Population Action International. Full disclosure: She was a graduate student of Paul Williams’ in 2007.

Sources: DFID, Englebert and Ron (2004), Ham (2011), Hsiang et al (2011), Kahl (1998), Leysens (2006),Østby et al (2009), Radelet (2010), Themnér and Wallensteen (2011), UNEP (2009), UN Peacekeeping, Williams (2011)

Image Credit: Conflicts in Africa 2000-09, reprinted with permission courtesy of P.D. Williams, War and Conflict in Africa (Williams, 2011), p.3.

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Building Commitment to Family Planning:

Rwanda: Dramatic Uptake in Contraceptive Use Spurs Unprecedented Fertility Decline

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By Elizabeth Leahy Madsen // Tuesday, November 8, 2011

This post is the first in a series profiling the process of building political commitment in countries whose governments have made strong investments in family planning.

With over 400 people per square kilometer, the highest rate on the African mainland, population density is perhaps the most widely-discussed factor of Rwanda’s demography. Some scholars, notably Jared Diamond, have argued that it played a primary role in sparking the 1994 genocide through competition for land (although others present a more complex theory based in policies and governance). Now, less than 20 years after the genocide, the country is experiencing demographic change of another sort, thanks to the government’s emerging reputation as one of the most committed to family planning on the African continent. Newly released preliminary data show a fertility decline that is unprecedented in its magnitude for sub-Saharan Africa. In 2010, Rwanda’s fertility rate was estimated at 4.6 children per woman, which represents a decline of 1.5 children per woman from the rate measured in 2005.

The Post-Conflict Years

In the early 1990s, Rwanda’s government stated support for family planning, publishing a National Population Policy that aimed to increase contraceptive use from two to 48 percent and consequently lower the average number of children born to each woman by more than half. However, fertility remained high (over six children per woman) and contraceptive use, low.

The 1994 genocide had a radical effect on Rwanda’s health system and skewed its demographic trajectory for several years. After nearly one million people were killed and even more displaced or fled, the population fell from 7.1 million in 1990 to 5.6 million in 1995.

This decline was short-lived. Use of modern contraceptives among married women fell from an already-low 13 percent before the genocide to just four percent by 2000. In addition to the practical challenges presented by a decimated health system and widespread poverty, traditional cultural and religious preferences for large families were accompanied by a strong desire to rebuild the population in the face of tragic losses. Rwanda’s population grew by 90 percent in 15 years, to 10.6 million in 2010.

Innovative Approaches Help Renew the Health Sector

In the second half of the 1990s, efforts to rebuild health services after the devastating toll of the genocide began gradually, and family planning was not a primary focus. However, in response to declining use of health services following the introduction of user fees, the Ministry of Health in 2001 implemented a national network of mutuelles, innovative community-based health insurance schemes supported by member premiums and government funding. Over the past decade, mutuelles have been a major factor in improving Rwandans’ access to and use of health services, including family planning.

In the 2000s, projects targeting the health sector were scaled up and international donors began implementing family planning projects, including service delivery and logistics and technical support. USAID’s contributions to family planning more than tripled, from less than $3 million in 2004 to $9 million in 2009. By 2005, increased demand for family planning was evident in the results of a Demographic and Health Survey. Although women were having an average of 6 children each, the reported desired family size was 4.3. Nearly 40 percent of married women did not wish to become pregnant but were not using contraception.

Government Commitment to Family Planning

In May 2005, the USAID-supported RAPID model, which was developed by Futures Group and quantifies the implications of family planning on other sectors, was presented to Rwandan parliamentarians, an event cited by many as pivotal in building support for family planning. The RAPID presentation served as a wake-up call, but with a positive message: besides making poverty reduction easier, having smaller families also increases health and education opportunities.

Parliamentarians were not the only political leaders who became interested in family planning. Ministry of Finance officials – whose influence over budgets is crucial in translating rhetoric to funding – also became convinced that high rates of population growth would inhibit their poverty reduction efforts. Rwanda’s current Economic Development and Poverty Reduction Strategy describes high population density as a pressure on the environment and on land use reforms.

The strategy establishes a target of reducing total fertility rate to 4.5 children per woman by 2012 (which preliminary survey results for 2010 indicate has nearly been achieved). The strategy also sets a bold goal to increase the rate of use of modern contraceptives to 70 percent among women of reproductive age. In addition, the strategy focuses on raising the proportion of the population with access to health centers and to improving the breadth of health care services offered at such facilities.

Dramatic Demographic Changes

In the past five years, concerted efforts have met much of this need, and are reflected in remarkable changes in demographic and reproductive health indicators. The five-year fertility decline of 25 percent is noteworthy for being the first decline of such magnitude in the region. (Similar fertility declines of 25 to 30 percent over five-year periods have occurred elsewhere since 1980 – Algeria, Cuba, Iran, the Maldives, Mauritius, Mongolia, Spain, and parts of East Asia, Eastern Europe and the Persian Gulf – but never in sub-Saharan Africa.)

Even more striking is the rapid increase in the share of married/partnered women using modern contraception, from 10 percent in 2005 to 45 percent in 2010. Improvements in the country’s health system are also reflected in other indicators: The share of mothers delivering in health facilities has increased from 45 percent in 2007-08 to 69 percent in 2010, and mortality rates have correspondingly improved. Infant mortality has fallen from 86 to 50 deaths per 1,000 live births, and the maternal mortality rate dropped by half between 2000 and 2008.

Rwanda’s centralized political hierarchy has been described as a key factor in the transmission of pro-family planning policies. As the most detailed study of political support for family planning in Rwanda has explained, “The government recognized the need to address population issues, so the policies were not imposed from the outside but were embraced and supported internally.”

The continuity of political support for family planning extends all the way to President Paul Kagame. After declaring the issue “priority number one” in 2007, he told an interviewer, “We recognize we are late on this.” Reflecting on the goal of increasing contraceptive prevalence from 10 to 70 percent in just four years, which many observers might judge unrealistic, a UN official observed, “Here you don’t say never when there is government commitment.”

An Emerging Success Story, But Not Yet Complete

While the recent trends indicating improved access to and utilization of health services are a major triumph for Rwanda, development challenges remain for the densely populated, agriculture-dependent economy. Only 21 percent of men and 16 percent of women have attended school beyond the primary level. And although Rwanda has made concerted efforts to rebuild social cohesion since the genocide, it remains at the center of a region where simmering conflicts flare up regularly across borders. Former perpetrators of Rwanda’s genocide continue to drive conflict and attack civilian populations in the eastern Democratic Republic of the Congo. In addition, international observers are raising increased concerns about authoritarian tendencies and limits on political opposition within Rwanda’s government.

Within the health sector, staffing levels have reportedly been low, and though progress so far has been remarkable, government funding for contraceptives must grow dramatically to meet rising demand. Despite the recent rapid decline in fertility rates and increased use of family planning, Rwanda remains a high-fertility country, and demographic momentum will drive continued population growth. Even if average family size falls below four children per woman, the population is projected to nearly double over the next 25 years.

Rwanda’s government has shown extraordinary interest in demographic issues and health system improvements, but as this is sustained, it must be matched with provision of education and jobs for the still-growing youthful population.

Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group. She was previously a senior research associate at Population Action International.

Sources: Boudreaux (2009), Brookings Institution, Freedom House, Health Policy Initiative, Hewlett Foundation, MEASURE DHS, National Geographic, The New York Times, Pulitzer Center on Crisis Reporting, Rwanda Ministry of Finance and Economic Planning, Solo (2008), UN Population Division, USAID, Washington Post, World Health Organization.

Image Credit: Adapted from “Rwanda: Population Density, 2000,” courtesy of flickr user SEDACMaps; chart by Elizabeth Leahy Madsen.

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Topics: Africa, development, environment, family planning, global health, population, security …

How Did We Arrive at 7 Billion – and Where Do We Go From Here? [Part Two]

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By Elizabeth Leahy Madsen // Wednesday, October 26, 2011

The world’s women will determine whether the global population in 2050 is as low as 8 billion or as high as 11 billion through their choices (or lack thereof) about the number and timing of their children. Women in developing regions of the world will have the greatest effect on these potential population trajectories. Even if fertility rates remain constant at current levels (which is unlikely), developing regions would grow from 5.7 billion in 2010 to 9.7 billion in 2050, but the total population of developed countries would remain essentially unchanged.

The UN estimates that the seven billionth person alive today will be born on October 31. Demographer Elizabeth Leahy Madsen explains how we got to that number, its significance, and where our demographic path might take us from here. Read part one here.

The world’s women will determine whether the global population in 2050 is as low as 8 billion or as high as 11 billion through their choices (or lack thereof) about the number and timing of their children. Women in developing regions of the world will have the greatest effect on these potential population trajectories. Even if fertility rates remain constant at current levels (which is unlikely), developing regions would grow from 5.7 billion in 2010 to 9.7 billion in 2050, but the total population of developed countries would remain essentially unchanged.

The way that people decide the timing and number of their children is not easily distilled into a simple formula with a single solution. Still, some basic and important facts are known. In the developing world, where more than 80 percent of the world’s population lives, women in rural areas, those who have little or no education, and those who are poor, have larger families. As demographers have shown in modeling the determinants of fertility, women tend to seek contraception once they are confident that their children will survive to adulthood and when socioeconomic development increases the “costs” of having children, for example by motivating parents to send them to school rather than to work.

One of the most direct reasons for past declines in fertility rates was the rapid expansion of family planning and reproductive health programs, supported by country governments and international donors, that enabled women and men to more effectively choose the size of their families. But today, about 215 million women across the developing world would like to delay or avoid pregnancy but are using ineffective contraception or none at all. Funding programs to meet the family planning needs of these women, which would cost about $3.6 billion annually, would both empower them and help fertility rates continue to decline.

Beyond Access: Gender Inequality Inhibits Contraceptive Use

While increasing support for family planning programs tops the list of demographers’ recommended policies, ensuring that contraceptives are available and accessible will not alone achieve the fertility declines projected in most of the UN’s range of possibilities. Many women who are having or planning to have large families know about family planning and where to find it, but are choosing not to use contraception for cultural reasons that are often deeply engrained.

Joel E. Cohen on how many people can the Earth support.

In sub-Saharan Africa, the region with the highest global fertility rate, only 16 percent of married/partnered women of reproductive age are using effective contraception. In comparison, between 62 and 75 percent of their peers in Ireland, the United States, and Uruguay – countries whose fertility rates are almost exactly at replacement level – are using it.

Logically, sub-Saharan Africa needs similar levels of contraceptive use to bring its average fertility rate towards replacement level as the UN projects, so the region’s average prevalence rate for modern contraception would need to rise by at least 10 percentage points in each of the next four decades. However, contraceptive use in the region has grown by only 0.5 percentage points or less over the past 30 years.

What is inhibiting the use of contraception? Demographic and health surveys find in Nigeria, for example, that 10 percent of married women are using an effective contraceptive method, while twice as many have an unmet need for family planning. This low use of family planning demonstrates high potential for change in the country’s demographic future, which, as the most populous in Africa, will greatly influence global and regional trends. Yet among women who do not intend to use contraception, 39 percent report that they or their family members are opposed to family planning, and another 16 percent fear side effects or have other health-related concerns. If Nigeria’s fertility rate remains unchanged, the country will be home to 500 million people by 2050.

In Pakistan, where 24 percent of births are unintended, surveys show similar barriers. Ninety-six percent of married women know about effective contraceptive methods, but only 22 percent are using one. More than one-quarter of women who do not plan to use contraceptives report that their fertility is “up to God” and 23 percent report that they or their family members are opposed to family planning. Pakistan’s population would more than double from 174 million to 379 million by 2050 if current fertility trends hold constant.

Peak Planet? Population Growth and Consumption Strain Environmental Resources

Because Nigeria, Pakistan, and other countries’ demographic trajectories may not follow the path laid out in population projections, we can’t take a world of nine billion for granted. While human ingenuity and technological advancements have improved standards of living in many countries, scientists caution that the combination of rising human numbers and growing consumption has serious environmental implications. Already, the quantity and quality of fresh water supplies are under strain, and forests in many developing countries are being rapidly depleted.

Population projections are much more than wonkish speculation – they foreshadow the serious problems that lie ahead if health, environment, and development policies aren’t strengthened. If the UN projections of our demographic future are to bear any semblance of reality, we must move beyond the status quo. While improving physical access to family planning should remain a top priority, meeting unmet need will also require addressing the deep-seated challenges of women’s education and empowerment.

Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and former senior research associate at Population Action International.

Sources: Bongaarts and Sinding (2009), Bongaarts (2006), Futures Institute, Guttmacher Institute and UN Population Fund, Measure DHS, O’Neill, Dalton, Fuchs, Jiang, Shonali Pachauri, and Katarina Zigova (2010), UN Population Division, Washington Post.

Photo Credit: “Afghan Internally Displaced Persons,” courtesy of flickr user United Nations Photo.

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Topics: Africa, demography, environment, family planning, global health, population, water …

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