›June 26, 2013 // By Elizabeth Leahy Madsen
October 31, 2011, was notable not only for the annual ritual of candy and costumes, but also for its designation by the United Nations as the date when global population reached seven billion. Although just an estimate – demographers are not able to count individuals in real time on such a large scale – the event was an important opportunity to present population trends to the media and public dialogue. Several babies born that day were named the “seven billionth;” in Russia, where various incentives have been implemented to try to boost an ultra-low fertility rate, Vladimir Putin visited a maternity ward to greet one of them.
Water is the foundation of human society and will become even more critical as population growth, development, and climate change put pressure on already-shrinking water resources in the years ahead. But will this scarcity fuel conflict between countries with shared waters, as some have predicted, or will it create more impetus for cooperation?
›“Family planning means healthier moms and kids – and it’s good for development too,” said Lindsay Morgan, a senior health analyst at Broad Branch Associates, a healthcare advocacy group. But any number of hurdles can keep women from accessing family planning services. Morgan spoke at a May 21 discussion about results-based financing (RBF) programs, which aim to address hurdles on both the supply and demand sides of the equation in developing countries by incentivizing the provision of a variety of quality services while removing barriers to access for women in need of those services.
Removing Barriers to Providing and Using Family Planning Services
Incentives in RBF programs can come in a variety of forms – like subsidies or fees paid to clinics or vouchers sold to women, said Morgan. In Burundi, for example, under a pilot program rolled out across three provinces in 2006, health facilities receive payments for each patient that uses a modern method of contraception. In 2009, the government and international partners began scaling up the program to a nationwide level. In addition to expanding the program’s geographic reach, the scale-up incorporated new payment criteria to better incentivize quality of care (as opposed to just quantity) and longer-lasting methods of contraception.
Since the RBF pilot began, maternal and child health indicators have improved. The number of children being fully immunized is up, as is contraceptive prevalence, said Morgan. Additionally, those immediate results can lead to a slew of additional benefits down the line. For instance, improving modern contraceptive prevalence is one of the most cost-effective interventions available for reducing maternal death, she said.
In nearby Kenya, the health ministry leads a voucher system across four districts and two Nairobi slums to help some of the country’s poorest women afford maternal healthcare, family planning, and gender-based violence services.
The program is “written into large policy documents [and] strategic pieces,” including Vision 2030, a long-term government-wide strategy document “unveiled in 2008 as a way to reach middle-income country status by 2030,” said Ben Bellows, a reproductive health associate at Population Council Kenya. The government’s emphasis on the voucher program as more than just a health initiative is an acknowledgment of the downstream impact that improved maternal and reproductive health can have on the country’s development, he said.
“An Equity Gap in Family Planning”
However, the fact that the voucher program is needed at all is evidence of “an equity gap in family planning,” Bellows said. Access to family planning services can be significantly skewed depending on a woman’s income level, he said, pointing to a recent article in The Lancet assessing health inequalities in 12 different maternal and child health services across 54 priority Millennium Development Goal countries.
The equity gap reflects “an interesting problem with development,” said Bellows: Though low-income countries are converging with higher income countries, in terms of economic growth rates and income levels “the benefits of growth aren’t being evenly distributed.” The Africa Progress Panel’s annual report, released last month, echoes that point, he said.
“Governments are failing to convert the rising tide of wealth into opportunities for their most marginalized citizens,” the report concludes, and “unequal access to health, education, water and sanitation is reinforcing wider inequalities.”
Kenya’s voucher system is designed to help shrink that gap. Among the poorest of the poor – those benefitting from the system – inequalities are dropping, even if on a broader scale, inequity still exists between poor and wealthy Kenyans. “We’re seeing lower inequalities of service in areas exposed to the voucher,” said Bellows.
“RBF supports progress on a path towards universal health coverage,” said Beverly Johnston, the senior policy advisor at USAID’s Office of Population and Reproductive Health. And within the context of family planning “the whole idea is to level the playing field” so that all contraceptive methods are equally readily available to the women seeking them.
“A Catalyst for Change” in Family Planning
In addition to addressing equal access concerns, RBF programs can serve as “a catalyst for change…to stimulate quality of care and quality of family planning counseling in particular,” said Johnston.
A commonly cited hurdle to better family planning access is social norms that support large family sizes or otherwise limit a woman’s ability to space or limit her pregnancies. Given community health workers’ unique roles within their communities – “often on the front lines…where many of these social taboos and barriers exist,” as Morgan described – simply strengthening their training, and in turn improving the quality of care that women receive, can help counter norms that might otherwise prohibit access to family planning.
As more women receive higher quality care, norms dissipate even further, said Morgan. “There is evidence that [quality of care] is strongly associated with a woman’s decision to choose a method to use, to continue to use it, and to recommend it to others.”
“Rights Are Tantamount”
One trap RBF programs need to be aware of is over-incentivizing expansion of coverage to the detriment of quality or individual women’s concerns about what makes sense for them, said Johnston.
“Rights are tantamount,” she said. In order to ensure that rights are upheld, programs must reflect and be sensitive to local histories and local needs – particularly given the fact that some countries have had “a history of coercive programs and policies.”
Ultimately, “we really look at RBF as just one tool,” said Johnston. “RBF is not for every place and every context,” and neither is family planning’s place in RBF programming.
As one tool of many, RBF programs are gaining prominence as a way to meet MDGs related to maternal and child health. Bellows sees RBF’s importance lasting long past that 2015 deadline, though.
“The high inequity that we witness across many low-income countries, and the ability of targeted mechanisms [like Kenya’s voucher program] to address that, suggest that this may be a kind of generalized solution,” he said. “Obviously it will be context specific in the way in which it is rolled out, but the strategy of incentivizing clients and providers suggests that there’s some sort of globalized solution that could be considered for this widespread challenge.”
Photo Credit: Sean Peoples/Wilson Center.
›January 9, 2012 // By Wilson Center StaffThe original version of “Governance, Security, and Culture: Assessing Africa’s Youth Bulge,” by Marc Sommers, first appeared in the International Journal of Conflict and Violence, Vol. 5 (2), 2011.
Although Africa has a youth-dominated population, African government policies are often not youth-centered and African governments and their international supporters are frequently under-informed about the priorities of most youth. Reliance on the “youth bulge and instability thesis” leads to distorted assessments of everyday realities. Examination of the lives, priorities, and cultural contexts of African youth, and the cases of youth in Rwanda and Burundi in particular, shows that the nature of relations between the state and massive populations of young, marginalized, and alienated citizens directly impacts the governance, security, and development prospects of African nations.
Learning from Liberia
If ever there was a youth-dominated conflict in modern times, it was Liberia’s long and grueling civil war (1989-1996 and again in 2000-2003). Ignited by Charles Taylor’s Christmas Eve incursion from neighboring Côte d’Ivoire late in 1989, together with perhaps one hundred other men, the conflict soon took the form of youth-led chaos. “What initially was seen as a revolution…fought with sticks and cutlasses,” Mats Utas writes, “was eventually transformed into a war of terror where young people started fighting each other” (2005: 55). In fact, some youth continued to view the war as their revolution, for as long as they were able to take advantage of the opportunity that armed conflict afforded. The civil war provided them with “a chance to become someone in a national system that had marginalized them, but also a chance to get rid of the load of work and expectations that the parental generation had laid on them” (65). Some of the more successful young soldiers, sometimes goaded by their girlfriends, “felt so affluent that they could wash their cars in beer – a beverage most could not even afford to drink prior to the war – and that they could drive a car until it ran out of gasoline and then just dump it for another one” (66). The result was a war that wreaked colossal destruction. By 1997, civil war had already left a nation of perhaps two and a half million with up to 200,000 dead, 700,000 refugees, and much of the remaining population internally displaced (Utas 2008: 113).
The region of sub-Saharan Africa has the most youthful population in the world. Of the 46 countries and territories where at least 70 percent of the population is under the age of 30, only seven are not in sub-Saharan Africa. With this in mind, one of the most striking aspects of contemporary Africa is how male African youth have so frequently been viewed as threats to their own societies. However, the view from below differs dramatically from the largely quantitative analyses from above and from outside the continent. Again, the Liberian example is illuminating. A nation long renowned for grasping leaders and withered government institutions has more recently provided truly upbeat signs of forward movement. That said, most youth continue to be left far, far behind. Fieldwork in rural Liberia uncovered a widespread fear of “rebel behavior youth” – youth who had assumed the attitudes of wartime combatants and became socially sidelined. Liberia’s post-war youth unemployment has been estimated at the astonishing rate of 88 percent. Taking all of this into account – a widespread sense of estrangement and social distance felt by many youth and an economic recovery that is passing most of them by – one could certainly argue that Liberian youth are among the world’s most peaceful populations.
Continue reading in the International Journal of Conflict and Violence.
Marc Sommers is a fellow with the Woodrow Wilson Center’s Africa Program and visiting researcher at Boston University’s African Studies Center.
Sources: Government of Liberia, Population Action International, Sommers (2007), Utas (2005 and 2008).
Photo Credit: “RPF rally in Gicumbi, Rwanda,” courtesy of flickr user noodlepie (Graham Holliday).
›The original version of this article, by Robert Draper, appeared on National Geographic.
The mwami remembers when he was a king of sorts. His judgment was sovereign, his power unassailable. Since 1954 he, like his father and grandfather before him, has been the head of the Bashali chiefdom in the Masisi District, an undulating pastoral region in eastern Democratic Republic of the Congo (DRC). Though his name is Sylvestre Bashali Mokoto, the other chiefs address him as simply doyen – seniormost. For much of his adult life, the mwami received newcomers to his district. They brought him livestock or other gifts. He in turn parceled out land as he saw fit.
Today the chief sits on a dirty couch in a squalid hovel in Goma, a Congolese city several hours south of Masisi. His domain is now the epicenter of a humanitarian crisis that has lasted for more than a decade yet has largely eluded the world’s attention. Eastern Congo has been overtaken by thousands of Tutsi and Hutu and Hunde fighting over what they claim is their lawful property, by militias aiming to acquire land by force, by cattlemen searching for less cluttered pastures, by hordes of refugees from all over this fertile and dangerously overpopulated region of East Africa seeking somewhere, anywhere, to eke out a living. Some years ago a member of a rebel army seized the mwami’s 200-acre estate, forcing him, humiliated and fearing for his safety, to retreat to this shack in Goma.
The city is a hornet’s nest. As recently as two decades ago Goma’s population was perhaps 50,000. Now it is at least 20 times that number. Armed males in uniform stalk its raggedy, unlit streets with no one to answer to. Streaming out of the outlying forests and into the city market is a 24/7 procession of people ferrying immense sacks of charcoal on bicycles or wooden, scooter-like chukudus. North of the city limits seethes Nyiragongo volcano, which last erupted in 2002, when its lava roared through town and wiped out Goma’s commercial district. At the city’s southern edge lies the silver cauldron of Lake Kivu – so choked with carbon dioxide and methane that some scientists predict a gas eruption in the lake could one day kill everyone in and around Goma.
The mwami, like so many far less privileged people, has run out of options. His stare is one of regal aloofness. Yet despite his cuff links and trimmed gray beard, he is not a chief here in Goma. He is only Sylvestre Mokoto, a man swept into the hornet’s nest, with no land left for him to parcel out. As his guest, a journalist from the West, I have brought no gifts, only demeaning questions. “Yes, of course my power has been affected greatly,” the mwami snaps at me. “When others back up their claims with guns, there is nothing I can do.”
Continue reading on National Geographic.
Photo Credit: “Aerial View of Goma,” courtesy of UN Photo/Marie Frechon.
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