“Family planning is to maternal survival what a vaccination is to child survival,” said Johns Hopkins professor Amy Tsui, quoting Khama Rogo of the World Bank, at the Woodrow Wilson Center event Maintaining the Momentum: Highlights From the Uganda International Conference on Family Planning on March 16. Rogo made the strong statement during the landmark November 2009 conference in Kampala, which has renewed interest in family planning and reproductive health among African leaders and development partners. Rhonda Smith of the Population Reference Bureau and Sahlu Haile of the David and Lucile Packard Foundation joined Tsui, the director of The Bill & Melinda Gates Institute of Population & Reproductive Health, to discuss their impressions of the Kampala conference and what it means for the future of family planning in Africa.

“An event that happened at the right time”

“Kampala was the work of a community,” said Tsui. More than 50 organizations—the U.S. Agency for International Development, the UN Population Fund, the World Bank, the World Health Organization, and the Gates and Packard Foundations—convened in Uganda, which was chosen not only for its central location, but also to highlight the country’s soaring unmet need for contraception—41 per cent—and rapid 3.1 percent population growth rate.

Panels focused on key issues in family planning, including:

• Integrating family planning into HIV/AIDS care
• Integrating family planning in post-abortion, postpartum, child, and other primary health care
• Expanding contraception delivery services by community health workers
• Increasing outreach to youth and men
• Capitalizing on private and public innovations in service delivery and financing

The conference also made a splash in the media. “If you want it to get a lot of media hype, you have to have someone ready to say ‘I’m giving money to X,’” said Tsui. Thus, the Johns Hopkins Bloomberg School of Public Health, David and Lucile Packard Foundation, USAID, and the Bill and Melinda Gates Foundation announced a new three-year, $12 million Advance Family Planning project to advance reproductive health and family planning efforts in regions with the greatest need—particularly, sub-Saharan Africa and Asia. The conference generated palpable excitement and renewed energy for family planning. Uganda was “an event that happened at the right time,” said Tsui. Conference organizers, who have been asked to replicate it in other parts of the world, are already looking for locations for 2011. The conference was not just a success in theory, but also in action, and several developments emerged in its wake:

• The United States announced its foreign assistance budget will increase support for family planning from $450 million to $715 million for the next fiscal year.
• The Global Health Initiative identified maternal/child health and family planning as one of its main priority themes.
• Secretary of State Clinton positively discussed girls’ education, family planning, and reproductive health at the ICPD + 15 anniversary.
• The Women Deliver 2010 Conference, to be held in June, has identified family planning as a third pillar of maternal health.

Uganda on the Move

Rhonda Smith’s presentation “Uganda on the Move”—which she also presented in Uganda—is a prototype of the Population Reference Bureau’s new ENGAGE (Eliminating National Gaps—Advancing Global Equity) project, which is designed to “engage policy audiences and promote policy dialogue around issues of high fertility and high unmet need for family planning and their costs, consequences, and solutions,” she said. By using stunning, innovative graphics and avoiding confounding technical terms, ENGAGE’s products are designed to reach non-technical policy audiences and influential decision-makers.

As one of the Uganda conference’s most talked about presentations, “Uganda on the Move” wows audiences with visuals created using Hans Rosling’s Trendalyzer software. The presentation shows that although Ugandans are increasingly healthier, have a higher life expectancy, and are more educated, maternal health remains in jeopardy. Tellingly, 46 percent of pregnancies in the country are unplanned, 6,000 women die each year from complications related to pregnancy, and 1,200 women die each year from undergoing unsafe abortions.

Maternal deaths, however, do not tell the whole story: For every one woman dying, Smith said, 20-30 women suffer from short-term disability, which places a major strain on economic growth. From 2004 to 2013, maternal death will cost Uganda US$350 million in lost productivity; and disability will cost and additional US$750 million.

What Next? The African Perspective

“After 10 years of virtual clandestine work, [family planning] is just coming out of the closet,” said Sahlu Haile. Over the last few decades, family planning advocates have been struggling to: 1) keep family planning alive—without it being affected by political considerations 2) make family planning a health priority, without any associations with rights violations; and 3) be in solidarity with pioneering organizations of the family planning movement, like the International Planned Parenthood Federation, that were victims of discriminatory funding decisions.

The Uganda conference changed all that, said Haile. In Uganda, conference attendees were “talking about family planning…not reproductive health, not maternal/child health.” This, he said, was “probably the single most important lesson…that I took from the Kampala conference.”

Following the conference, Haile said that African government officials stressed family planning as a priority at meetings in Ethiopia and Nigeria—the first time he had witnessed such high-level attention to family planning from those countries in his 30-year career.

In Ethiopia, African leaders pledged to:

• Prioritize family planning, since family planning is one of the most cost-effective development investments;
• Ensure access to contraception, as 40 percent of maternal deaths are associated with unwanted pregnancies; and
• Integrate MDG 5b, universal access to reproductive health, into their international development plans and budgets.

In Nigeria, West African ministers of health agreed that making abortion safe was essential to reducing maternal mortality. Across the board, at each meeting, family planning was discussed as “an investment, not an expenditure,” said Haile.

Haile credited the Kampala conference for spurring these efforts. In December, he joined a task force of 14 Ethiopian organizations to plan the next steps. They will jointly develop research capacities, generate evidence, and strengthen monitoring and evaluation practices, especially with regard to integrating population, health, and environment efforts. In addition, they will engage with wider audiences via new tools such as the blog RH RealityCheck and Gapminder Foundation’s Trendalyzer program.

Haile believes we need to “work together to encourage national-level efforts…to make sure family planning stays where it is now and make sure it is not abandoned.”

To be a part of the new online family planning community, join the Kampala Conversation.

Photo 1: A women and her children in Jinja, Uganda. Courtesy Flickr user cyclopsr. Photos of Amy Tsui, Rhonda Smith, and Sahlu Haile courtesy of Dave Hawxhurst, Woodrow Wilson Center.

“Even in the hardest moments of conflict there are opportunities for cooperation, and they need to be seized,” said Juan Dumas, senior advisor of Fundación Futuro Latinamericano during the Pathways to Peace: Stories of Environment, Health, and Conflict roundtable event co-hosted by the Wilson Center’s Environmental Change and Security Program and the Fetzer Institute on January 13th.

“Even as you were talking about the conflict potential,” said Aaron Wolf, professor of Geoscience at Oregon State University, “everywhere you looked there were people talking about water uniting together across boundaries and being able to share… [and] people being willing to talk about water when they wont talk about anything else.”

Dumas and Wolf were joined by Gidon Bromberg, co-director of Friends of the Earth Middle East (FoEME); Shewaye Deribe, project coordinator for the Ethio Wetlands and Natural Resources Association (EWNRA); and Joan Regina L. Castro, executive vice president of the PATH Foundation Philippines, Inc. (PFPI) to discuss work that demonstrates the positive impact multi-dimensional development and peacebuilding programs can have on environmental conflict arenas.

Water as an Entry Point

“In the academic world, there’s a growing documentation about the coming wars of the 21st century are going to be about water resources,” said Wolf, discussing how water resources are inherently intertwined with the Arab-Israeli and other regional conflicts. His research, however, suggests the opposite. In recent history, he said, cooperation for the resource, not conflict, was observed in nearly two-thirds of the world’s cross-boundary watersheds.

“Water is a wonderful way to have regional dialogue,” he continued, discussing how technical data and modeling are only part of any successful water conflict resolution. “A language that people have in common, and when we talk about water—because it’s connected to everything we do—we end up talking about our shared vision of the future.”

“We came out with a vision that is a shared vision,” echoed Bromberg in describing the Good Water Neighbors (GWN) project—a FoEME program seeking to improve water scarcity and quality in the Jordan River watershed by fostering cooperation between Israeli, Palestinian, and Jordanian leaders. “The Jordan office advocates that vision to the Jordanian government, the Israeli office to Israeli government, the Palestinian office to the Palestinian authority. That’s proven to be very effective because it’s the same vision.”

While hesitant to say the program could lead to or be a model for peace in the Middle East, Bromberg did underscore how multi-dimensional methods used in GWN could productively serve future peacebuilding efforts in the region.

“By empowering young people to go out and improve their own water reality with their own hands [through rainwater harvesting and grey water collection] they learn together, and then they build the facilities within their own communities,” said Bromberg. “…Not only does it empower the youths but it helps create peacemakers.”

Integrated PHE and Conflict Avoidance

“Water is common for all of us because it is the base of our life, of our survival,” said Deribe, linking ENWRA’s integrated population, health, and environment (PHE) wetland restoration program in Ethiopia to the greater discussion. “I think it is a lack of altruism, a lack of mutualistic thinking which leads us to this kind of conflict.”

Ethiopia’s 12 river basins serve more than 200 million people. Managing local wetlands and waterways with PHE approaches can therefore play an integral role in maintaining environmental quality and productivity for current and future generations while avoiding conditions that contribute to conflict, according to Deribe.

Castro, pointing to her own PHE experience with PFPI, found that multi-sectoral programs promote improved environmental quality and community stability. In the Philippines, her program targeted local youth, fishermen, and policymakers to promote food security through sustainable resource management, improved medical and family planning services, and expanded livelihood training.

Castro found that a PHE program could continue even after funding ran out. “A project can be sustained and can be owned by the local governments and local communities if they are provided the capacity to be able to continue to implement the programs and that they see the value of the programs that they do,” she said.

Lessons in Conflict Resolution

Funding, said Dumas, is the biggest limiting operating factor for organizations that facilitate dialogue in environmental conflict areas. The ability to travel across Latin America on short notice to help resolve conflict has been extremely beneficial to Dumas’ organization; but in an arena where funders require full proposals with specific outcomes and indicators, such availability over the long-term is “not financially sustainable.”

Dumas did, however, suggest ways to reduce the need for conflict resolution while opening accessibility to funding. He recommended that institutions mainstream environmental considerations into all sectors of decision-making, thereby improving capacity to respond to environmental conflicts within the given population. He also suggested the creation of “early action funds” – pools of money that his and other organizations can use on short notice for dialogue facilitation support.

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“Water disputes that can start at the local level—little things—have the potential, in extreme cases, to burgeon into something much bigger,” warned Ken Hackett, president of Catholic Relief Services (CRS), during a discussion at the Woodrow Wilson Center (Webcast) for the launch of CRS’ new publication, Water and Conflict: Incorporating Peacebuilding into Water Development. The report provides guidance to water development practitioners, civil society members, and others striving to incorporate water and peacebuilding into their project frameworks.

In recognition of water’s potential to drive conflict, Hackett—part of a panel featuring Jason Gehrig, Water and Conflict‘s primary author; William Hall, professor of conflict resolution at Georgetown University; and Tjip Walker, team leader of USAID’s conflict management and mitigation office‘s warning and analysis unit—urged those working on water to focus attention on identifying and diffusing areas of emerging disagreement while they are still manageable. “We must, in a proactive way, incorporate peacebuilding methodologies in water and sanitation work,” said Hackett.

Looking Beyond Tubes and Tanks

Prior to witnessing violent protests within the Altiplano region of Bolivia, Jason Gehrig assumed that the primary obstacles to successful water development efforts would be found in the technical phase of designing or building delivery systems. Local political developments, however, demonstrated that “we can’t just be looking at development without also looking at the structural issues at play,” said Gherig.

Emphasis on “social infrastructure” and the inclusion of peacebuilding paradigms allows for conflict transformation and the mitigation of future violence through heightened conflict sensitivity by local practitioners. Such understanding and sensitivity to local conflicts and structures, Gehrig asserted, can only be achieved by “listening, winning hearts and minds (beginning with our own) by getting close to the people so that their struggle for life, for dignity, for peace, becomes our own.”

Defining the Role of Environmental Conflict Resolution

William Hall noted that conflict sensitive practices apply several elements of environmental conflict resolution (ECR), such as in-depth social participation, context analysis, stakeholder involvement, and the use of neutral parties.

For Hall, the goal of ECR is not only conflict resolution, but “also how people will be involved.” Adapting a framework design from the International Association for Public Participation, Hall reminded the audience that decision-makers must clearly communicate both the goals of their intervention as well as the degree of public involvement required and desired. These issues are sensitive; Hall emphasized that, once a commitment has been made, it is extremely important “to be true to [one’s promises.]”

In situations such as those included in the CRS report, successful peacebuilding efforts—which result in high-quality agreements and improved working relationships between the affected parties—must include effective engagement of appropriate stakeholders, proper mediation, and high-quality information. While many of these factors may be seen as additional procedural complications and expenses, Hall countered that recent research has shown that, compared to standard methods, agreements reached within an ECR context grant economic and environmental benefits beyond those afforded by alternative processes.

Peacefully Managing the Commons

Tjip Walker noted that effective governance of water and other common pool resources, often magnets for mismanagement and contention, should be a pivotal concern for peacebuilders in fragile states. Drawing on research on governance and conflict, Walker explained that countries that are more democratic, and allow for greater social participation, are at a lower risk for violent conflict.

With regard to threats posed by common pool resources, Walker reminded the forum that Elinor Ostrom’s work demonstrates it is possible—providing a “enabling environment” for governance—to manage such resources without exposure to dire consequences. In many cases, however, Ostrom’s requirements for sustainable management are unfortunately difficult to achieve and are further complicated by pre-existing challenges stemming from economic dependencies and political arrangements.

Referring to previous trans-boundary river conflict projects, Walker noted that “most of them have been positive…[which] seems to suggest that we are all in this together.” Successes such as these grant hope for the future, yet also demonstrate a need for negotiated agreements across political boundaries. “Under the right circumstances,” Walker concluded, “we do have the ability to manage these resources effectively in ways that are perceived as generally being effective and legitimate.”

For more information about water, conflict and cooperation, as well as other events and publications under ECSP’s Navigating Peace Initiative, please visit www.wilsoncenter.org/water.


Photo: Courtesy David Hawxhurst, Woodrow Wilson Center.

“Water shortages,” warns South Asia scholar Anatol Lieven, “present the greatest future threat to the viability of Pakistan as a state and a society.

This warning may be overstated, but Pakistan’s water situation is deeply troubling, as described in a new report from the Woodrow Wilson Center’s Asia Program, Running on Empty: Pakistan’s Water Crisis.

Water availability has plummeted from about 5,000 m3 per capita in the early 1950s to less than 1,500 m3 per capita today. As Simi Kamal reports in the first chapter of Running on Empty, Pakistan is expected to become “water-scarce” (below 1,000 m3 per capita) by 2035—though some experts project this could happen in 2020, if not earlier.

In an unstable nation like Pakistan, water shortages can easily become security threats. In April 2009, alarm bells sounded when the Taliban pushed southeast of Swat into the Buner district of the Northwest Frontier Province. Not only is Buner close to Islamabad, it lies just 60 kilometers from the prized Tarbela Dam, which provides Pakistan with billions of cubic meters of precious water for irrigation each year.

Soaked, Salty, Dirty, and Dry

According to Kamal, Pakistan faces significant and widespread water challenges:

• Inefficient irrigation.
• Abysmal urban sanitation.
• Catastrophic environmental degradation.
• Lack of water laws to define water rights.
• Lack of a sound policy on large dams.

An arid country dependent on agriculture, Pakistan allocates more than 90 percent of its water resources to irrigation and other agricultural needs. Unfortunately, intensive irrigation and poor drainage practices have waterlogged and salinized the soil.

Women and Water in Rural Pakistan

Rural women and small farmers are particularly affected by Pakistan’s water crisis. Women bear the primary responsibility for obtaining water, but have been traditionally been shut out of government water-planning and decision-making processes. However, government and media initiatives, described by Sarah Halvorson in Running on Empty’s chapter on water and gender, are increasingly highlighting the importance of women’s participation.

Meanwhile, Adrien Couton reports that Islamabad’s water projects mainly benefit large and wealthy farmers—even though Pakistan has approximately four million farms smaller than two hectares.

Pakistan’s Thirsty Cities

With most of Pakistan’s water dedicated to agriculture, less than 10 percent is left for drinking water and sanitation. A quarter of Pakistanis lack access to safe drinking water—and many of them reside in the country’s teeming cities.

Worse, the drinking water that does exist is quickly disappearing. Lahore, which relies on groundwater, faces water table declines of up to 65 feet, as described by Anita Chaudhry and Rabia M. Chaudhry in their chapter on the city.

The scarcity of clean water in the cities—exacerbated by a lack of wastewater treatment—is a leading cause of deadly epidemics. At least 30,000 Karachiites (of whom 20,000 are children) perish each year from unsafe water.

Pakistan Must Act Now To Solve the Water Crisis

Pakistan arguably has the technological and financial resources to provide clean water. So what’s the hold-up? In her chapter on public health, Samia Altaf argues that the problem is the absence of a strong political lobby to advocate for water—and that no one holds Islamabad accountable for fixing the problem.

The report offers more recommendations for addressing Pakistan’s water:

• Invest in existing infrastructure and in modest, indigenous technology.
• Strike appropriate balances between centralized and decentralized management.
• Devote more attention to water allocation and distribution on local/individual levels.
• Understand the links between agricultural and urban water pressures.
• Embrace the role of the private sector.
• Conserve by favoring water-saving technology; less water-intensive crops; and water-conserving urban building design.
• Address structural obstacles like systemic inequality and gender discrimination.
• Take immediate action. Tremendous population growth and rapidly melting glaciers in the Himalayas ensure that the crisis will deepen before it eases.

The need for immediate action cannot be overstated. While Pakistan’s water crisis may not threaten its viability, it is undeniable that so long as the crisis rages on, essential components of the nation—such as the vital agricultural economy, the health of the population, and political and economic stability—lie very much in the balance.

Michael Kugelman is the Wilson Center’s South Asia specialist. He is co-editor, with Robert M. Hathaway, of the recently published Wilson Center book Running on Empty: Pakistan’s Water Crisis, on which this post is based. Much of his work has focused on resource shortages in Pakistan and India.

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