Driving from Kigali into rural Rwanda, the hills that flank either side of the paved road are covered with bananas, maize, coffee, and beans under cultivation. Most Rwandans are farmers, using any bit of available land to feed their families and generate income. In this country—the most densely populated in Africa—little arable land is left untended.

In Islamabad yesterday, Secretary of State Hillary Clinton acknowledged longstanding Pakistani concerns that the U.S.’s ongoing mission in the country is solely military in nature. However, Clinton asserted at the opening of the second U.S.-Pakistan Strategic Dialogue that the “future demands a comprehensive human security, a security based on the day-to-day essentials like jobs, schools, clinics, food, water, fuel, equal access to justice, [and] strong, accountable public institutions.” To that end, she announced a $500 million assistance package earmarked largely for new agricultural and hydroelectric infrastructure development, as well as the construction of new hospitals and other health infrastructure.

Leaders from 49 African countries are meeting today in Kampala, Uganda, at the start of a scheduled week-long African Union (AU) summit on maternal and child health. Uganda is a fitting location, as it faces some of the toughest health and demographic challenges in Africa, including a very young and rapidly growing population and poor maternal health services. However, with the memory of last week’s twin bomb blasts still fresh, peace and security issues will surely be on the agenda as well.

Around the world, countries from Afghanistan to Papua New Guinea to the United States are taking part in their decadal census, leading the UN Population Fund (UNFPA) to select the theme “Everyone Counts” for World Population Day 2010, which was celebrated on July 11.

Everyone has the right to be counted, because “censuses and population data play a critical role in development and humanitarian response and recovery,” said UNFPA Executive Director Thoraya Ahmed Obaid in her World Population Day message. Obaid added that “with quality data we can better track and make greater progress to achieve the Millennium Development Goals, and promote and protect the dignity and human rights of all people,” especially among vulnerable populations like women, girls, the poor, and the marginalized.

USAID similarly supports quality data collection, which it says plays a critical role in advancing voluntary family planning in the developing world. For the last 25 years, USAID has funded the Demographic and Health Surveys (DHS) program, which collaborates with national health ministries to collect data on family planning, child and maternal health, disease prevalence, and other health indicators.

This invaluable data is made freely available for public use, which can foster new research in the field and stimulate innovative approaches to addressing public health issues. Praising the DHS program, Gapminder Foundation Director Hans Rosling told a Wilson Center audience last year that “statistics should be the intellectual sidewalks of a society, and people should be able to build businesses and operate on the side of them.”

Accurate census counts are also important elements of “good governance, transparency and accountability,” said UN Secretary-General Ban Ki Moon in his World Population Day message. “Population data helps leaders and policy-makers to make informed decisions about policies and programmes to reduce poverty and hunger, and advance education, health and gender equality,” he said.

But no one is suggesting that coming up with reliable population data is an easy task. As Sean Peoples and Elizabeth Leahy point out in the May/June 2009 issue of World Watch magazine, issuing population projections can be a risky business:

In the 2008 Revision of World Population Prospects, the UN Population Division projects that our planet will grow to 9.15 billion people by 2050. Yet this medium-variant projection is just one of several possible scenarios released in this latest round of number crunching. The low- and high-variant projections—7.96 billion and 10.5 billion, respectively—could instead become reality, given uncertainties in the developing world due to factors such as inconsistent data collection, weak health system infrastructure, and low government capacity.

The goal, then, is to make sure everyone counts.

A new documentary film released recently by Population Action International brings attention to the plight of women across sub-Saharan Africa who lack access to basic reproductive health supplies, such as condoms and contraceptives. Funded with the support of the Reproductive Health Supplies Coalition, “Empty Handed” documents the unmet need for family planning services in the region, which has some of the world’s highest fertility rates.

This Tuesday, Dr. Rajiv Shah, administrator for U.S. Agency for International Development gave a major speech at the Center for Strategic & International Studies on USAID’s Global Health Initiative. With $63 billion earmarked for GHI over the next six years, there are high expectations for the program.

Shah laid out some details of GHI’s main priorities, which include improving family planning services, enhancing nutrition initiatives, and building stronger and broader-based healthcare systems across the developing world, with special attention paid to the health needs of mothers and their young children. He offered a number of examples of the benefits of integrating family planning with other health services for women and children, including maternal health and nutrition.

Shah did not, however, mention integrating family planning with environmental programs, the benefits of which USAID-funded programs have amply demonstrated. He also did not delve into the emerging nexus of family planning, population growth, and climate change, a subject of much discussion at last month’s Women Deliver conference in Washington, D.C.

On the other hand, Shah did say that GHI’s emphasis on improving nutrition for the world’s poor will complement another major Obama administration outreach effort, the Feed the Future initiative—repeating a point he made at the recent launch of the food security effort.

Shah also highlighted the need for establishing benchmarks for measuring success that revolve around people, not diseases. He suggested one way of achieving this would be to ensure that clinics—particularly in rural areas—broaden their mandate to offer a variety of health-prevention services, rather than providing resources that treat primarily one type of illness.

For a full transcript of Shah’s speech, click here.

More analysis of Shah’s speech and USAID’s Global Health Initiative to come in the weeks ahead.

Photo Credit: “Statesman Forum: Dr. Rajiv Shah, USAID Administrator,” courtesy of flickr user CSIS: Center for Strategic & International Studies.

According to the UN’s latest mid-range demographic projections for Pakistan, the country’s population–currently about 185 million–will rise to 335 million by 2050. This explosive increase, however, represents the best-case scenario: Should fertility rates remain constant, the UN estimates this figure could approach 460 million. Such soaring population growth, coupled with youthful demographics, a dismal education system, high unemployment, and a troubled economy, pose great risks for Pakistan. Predictably, many observers depict Pakistan’s population situation as a ticking time bomb.

At the same time, some demographers contend that the country’s population profile can potentially bring great benefits to the country. If young Pakistanis can be properly educated and successfully absorbed into the labor force, such experts explain, then the country could experience a “demographic dividend” that boosts social well-being and sparks economic growth. On June 9, the Wilson Center’s Asia Program, Environmental Change and Security Program, and Comparative Urban Studies Project, along with the Karachi-based Fellowship Fund for Pakistan, hosted a day-long conference to examine both the challenges and opportunities of Pakistan’s demographics, and to discuss how best to tackle the former and maximize the latter.

Pakistan at a Crossroads

In her opening address, Zeba A. Sathar of the Population Council declared that Pakistan is “at a crossroads.” Demography will play a key role in determining the country’s future trajectory, she said, yet there is presently little discussion about demographics in Pakistan. Sathar’s presentation traced Pakistan’s recent demographic trends. Despite its high population growth, Pakistan’s fertility rates have actually been in decline since the early 1990s–a fact that Sathar attributed to progressively higher ages at marriage (for both men and women), but also to the “reality” of abortion. However, Pakistan’s pace of fertility decline has slowed in the last few years–a consequence, Sathar argued, of Islamabad’s failure to promote social development (particularly education) and of the international donor community’s prioritizing of HIV/AIDS funding over that of family planning since 2000. Sathar concluded that achieving Pakistan’s “demographic dreams” will require more educational and employment opportunities (particularly for women) and better access to family planning in rural areas.

In the following panel, Wilson Center Senior Scholar Shahid Javed Burki noted the long-standing failure of demographers and economists in Pakistan to work together on the country’s population issues. This failure, Burki asserted, has resulted in poor choices and bad policy. He also criticized officials and scholars for being reactive in their population proposals, rather than proactive. Burki emphasized that good policy choices can produce favorable results. If, for instance, the population policies launched in Pakistan’s early decades had been sustained to the present, the country today would have 30 million fewer people. Similarly, had Pakistan followed the Bangladeshi approach and concentrated on the economic empowerment of women, today there would be more than 40 million fewer Pakistanis. Good policies matter, Burki repeatedly asserted, and Pakistan’s large and growing population, if dealt with wisely, can be an asset rather than a burden.

Development Through the Bangladeshi Model and Education

Like Burki, Yasmeen Sabeeh Qazi of the Packard Foundation pointed to Bangladesh as a relative success story. She highlighted Bangladesh’s reproductive health services system, which has served to increase the health of Bangladeshis and reduce their poverty. Indonesia and Iran, whose fertility rates are one-half Pakistan’s, provide other examples in the Muslim world where official policy has made a significant difference. Qazi’s presentation emphasized the linkages between family planning, reproductive health, and development. Noting that one-third of pregnancies in Pakistan are unplanned, she underscored the correlation between smaller family size and higher gross national income. She urged the government to fashion a population policy that expands access to reproductive health services, strengthens the health system generally, promotes education (especially for girls), and creates more jobs.

Moeed Yusuf of the U.S. Institute of Peace examined the prospects for radicalization of Pakistan’s youth. Pakistan’s stratified education system, Yusuf cautioned, is not training productive, employable members of society. Only graduates of elite private schools or of foreign schools are prepared for the economy of the 21st century. Meanwhile, the economy is not producing the quality jobs the young expect, leading to an “expectation-reality disconnect” that fosters not only un- or underemployment, but also anger and alienation. Moreover, the state, by deliberately cultivating the ultra-right elements in Pakistani society who most want to radicalize the country’s youth, is part of the problem. Still, Yusuf added, echoing the hopefulness of other speakers, it is not too late. These disturbing trends can be reversed, with help from outside friends like the United States, which, Yusuf counseled, should focus on assisting Pakistan’s education system, support rural private schools, and allow more Pakistani students to study in the United States.

Plugging Public Sector Holes with Private Initiatives

Saba Gul Khattak focused her luncheon address on the work of the Pakistan government’s Planning Commission, of which she is a member. In recent years, Pakistan’s population programs have been devolved from the federal to the provincial and sub-provincial levels. This decentralization, she averred, has opened the way for a genuine reform agenda. But it has also contributed to a situation where no one at the federal level feels any “ownership” over the country’s population programs. Implementation has always been the most vulnerable point in the policy process–and the lack of “ownership” only accentuates this problem today. Khattak emphasized the linkages between population, health, education, and development. Today, she asserted, children are seen by their parents as a source of old age security. Only when the government fills this void through the establishment of an effective social security structure will Pakistan be able to reduce its fertility rates. Development must accompany a truly effective population program.

In the afternoon panel, Sohail Agha of Population Services International discussed the role of the private sector in family planning in Pakistan. He argued that this sector has made a “substantial contribution” to Pakistan’s increased use of condoms: In 2006-07, a period when condom use spiked by nearly 8 percent, about 80 percent of this increase was covered by contraceptives provided by the private sector. Additionally, he noted that a 2009 survey found that urban Pakistanis exposed to social marketing campaigns about condom utilization increased their use of the contraceptive by 10 percent. Furthermore, he described private-sector-led health financing plans for women’s fertilization–a method of contraception that, like condoms, has increased over the last 30 years in Pakistan.

Engaging Youth and Political and Religious Leaders

Shazia Khawar of the British Council discussed the “Next Generation” report, a 2009 Council study about Pakistan’s youth. The report, based on a survey of 1,500 young people across both rural and urban Pakistan, concludes that young Pakistanis are deeply disillusioned about their country and its institutions, with three-quarters of those surveyed saying they regard themselves as “primarily” Muslims, not Pakistanis. The report’s “critical point,” said Khawar, is that Pakistani youth participation in policy development is nonexistent. To this end, the British Council has spearheaded several initiatives to engage the country’s youth in Pakistani politics and to spark dialogue between young Pakistanis and policymakers. Khawar concluded, however, that success is possible only if Pakistan’s top political leaders “pledge themselves to this agenda.”

Mehtab S. Karim of the Pew Research Center offered a comparative perspective, discussing demographics in the broader Muslim world, with particular emphasis on Bangladesh and Iran. Why, he asked, has Pakistan experienced less fertility decline than most of its fellow Muslim-majority nations? He suggested that the answer lies in the failure of Pakistan’s political and religious leaders to make early and sustained commitments to family planning. In Bangladesh, he explained, the country’s very first government made lower population growth rates a “prime goal.” And in Iran, spiritual leader Ayatollah Khomeini issued a fatwa in support of contraceptive use soon after the Islamic Revolution. Yet in Pakistan, according to Karim, religious figures have consistently opposed Islamabad’s family planning efforts, and the government has proven unwilling or unable to combat this resistance.

Scott Radloff of USAID discussed his agency’s family planning and reproductive health (FP/RH) projects in Pakistan. FP/RH aid to Pakistan was largely cut off during much of the 1990s due to the Pressler Amendment–a 1985 modification to the U.S. Foreign Assistance Act that banned most U.S. military and economic assistance to Pakistan unless the U.S. president certified that Pakistan had no nuclear weapons. President George W. Bush waived this prohibition in 2001, and since then USAID FP/RH assistance has risen to nearly $45 million. Current interventions focus on strengthening services within Pakistan’s Ministry of Health and Ministry of Population Welfare; improving contraceptive supplies and logistics; expanding community-based services; and increasing awareness and commitment, including among religious leaders.

Participants concurred that Pakistan’s demographic situation is fraught with risk. Yet they also highlighted a series of hopeful signs. Yusuf noted the absence of an “imminent” danger of youth radicalization; Khawar pointed to the testimonies of “many young leaders determined to do their part” that flow from the “Next Generation” report; and both Karim and Qazi cited Bangladesh and Iran as proof that successful family planning programs are possible even in countries marked by deep poverty or conservative Islam. The presenters were also in accord about the necessary policies moving forward: more extensive family planning and reproductive health services, better education, and more job opportunities (particularly for women). At the same time, speakers repeatedly underscored the profound challenges facing the implementation of such policies. Still, for all the talk about major obstacles and challenges, there was recognition that more modest and simple steps can be taken as well–such as promoting more discussion about demographics within Pakistan, and especially among experts from different disciplines.

Michael Kugelman is program associate and Robert M. Hathaway is director of the Wilson Center’s Asia Program.

Photo credit: Traffic in downtown Karachi, courtesy Flickr user Ali Adnan Qazalbash.

The landmark Women Deliver conference, which concluded last week, reinvigorated the global health community’s commitment to improve reproductive health at both the grassroots and global levels. Providing a major boost was the Gates Foundation’s announcement that it will commit an additional $1.5 billion over the next five years to support maternal and child health, family planning, and nutrition programs in developing countries.

“We haven’t tried hard enough,” said Gates Foundation co-founder Melinda Gates. “Most maternal and newborn deaths can be prevented with existing, low-cost solutions.” Examples of these efficient and effective solutions were presented at the three-day conference’s dozens of panels on a wide range of issues, including climate change, contraceptive commodities, fistula, gender inequities, adolescent family planning, communications and technology, and much more.