Showing posts from category global health.
-
Afghanistan and Pakistan: Demographic Siblings? [Part Two]
›February 15, 2012 // By Elizabeth Leahy MadsenLate 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.
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. -
Afghanistan’s First Demographic and Health Survey Reveals Surprises [Part One]
›February 14, 2012 // By Elizabeth Leahy Madsen
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.
-
‘Marketplace’ and ‘NewsHour’ Highlight Population, Health, and Environment Program in the Philippines
›The Danajon reef is the only double barrier reef in the Philippines, “one of the richest marine biodiversity hot spots in the world,” and it’s being devastated as the country’s exploding population depends on its waters for their food and livelihoods, reported Sam Eaton in a recent two-part series on population, health, and environment issues in the Philippines broadcast last month for American Public Media’s Marketplace and the PBS NewsHour.
The report is part of joint project called Food for 9 Billion, with Homelands Productions, the Center for Investigative Reporting, APM, and PBS. Previous reports examined food security in East Africa and Egypt.
The Philippines “import more rice than any other country on the planet,” said Eaton. The “highest population growth rates in all of Southeast Asia” as well as dwindling natural resources – nearly 100 million people live in a land area the size of Arizona – have created a cycle of poverty. The first step to breaking that cycle, he said, is improving access to family planning.
Growing Families, Growing Poverty
The Canayong family, living on the edge of a garbage dump in a Manila slum, offers a vivid example of what poverty means in the Philippines. Clarissa Canayong has had 14 children – 4 died from measles and dengue fever, the remaining 10 spend their days alongside Clarissa, sifting through the dump for things they need and things they can sell. At the end of a good day, the family has earned around $7 to survive on. All in all, Clarissa’s “inability to provide enough food, and to pay for her children’s education, all but guarantees she and her family will remain poor,” said Eaton.
The archipelago adds about two million people every year, putting population on track to double in size sometime around 2080. “And that’s only if something is done to close the birth control gap,” said Eaton, as those projections build in an expectation that growth will slow.
“As cities all across the country expand, the displaced often end up migrating to urban slums,” he said. “Population growth among poor Filipinos is twice the national average,” meaning that once a family enters poverty, they end up in a cycle “that’s nearly impossible to break.”
The Difference Family Planning Can Make
If Clarissa had had access to family planning, she told Eaton, she would have wanted to have only two children. In Humayhumay, where residents have access to a community-based family planning distribution program started by PATH Foundation Philippines, Inc., families have that luxury of choice.
Working through local partners, the PATH Foundation identifies and trains community-based vendors to sell contraception – both pills and condoms, said Dr. Joan Castro, who began the program in Humayhumay. The idea is to make buying contraceptives “as easy as buying soft drinks or matches.”
Both Jason Bostero, a farmer and fisherman in Humayhuay, and his wife, Crisna, grew up in large families – so large, in Crisna’s case, that “sometimes, we would only eat once a day because we were so poor. We couldn’t go to school. I did not finish school because there were just so many of us,” she told Eaton.
Now that they have access to contraceptives, a smaller family size means their income is “just right” to feed everyone three times a day. For the community as a whole, smaller family sizes mean that the nearby fish stocks that provide the community with food and income have a chance to replenish themselves in the absence of overfishing.
“In just six years since the program was first established here,” reported Eaton, “family sizes have plummeted from as many as 12 children to a maximum of about 4 today.”
Exception to the Rule
Humayhumay is an exception to the rule in the Philippines. There is no state funding for birth control in the country, and over the past few years, major international donors like USAID and the United Nations have ended their family planning work in the country. More than a quarter of poor Filipinos have no access to any type of family planning service, and more than half of all pregnancies are unintended, said Eaton.
Family planning has long been a contentious issue in the country. Eaton spoke to Congressman Walden Bello, who has spent more than a decade trying to pass legislation to establish universal access to birth control and improve other family planning and reproductive services. The Catholic Church, said Bello, is a powerful (80 percent of Filipinos are Catholic) and consistent opponent. In October 2010, the Church went so far as to threaten President Benigno Aquino with excommunication after he voiced support for access to contraception.
Rather than limit population growth, the Church argues the country should increase food production. But land is limited, rice imports are already the highest in the world, and, “according to the World Bank, every major species of fish here shows signs of severe overfishing,” said Eaton.
Looking Forward and Abroad
Eaton pointed to the Philippines’ neighbors as examples to emulate: “A long history of government-supported family planning has…paved the way for Thailand to become one of the world’s biggest rice exporters” and helped to cut back poverty in the country, said Eaton.
Indonesia too, he pointed out, has largely avoided the population growth-resource depletion-poverty cycle, thanks in part to a state- and faith-backed family planning program. (As Elizabeth Leahy Madsen wrote in a recent New Security Beat post, the decision of Indonesia’s religious leaders to throw their support behind family planning in the 1960s was a key factor in success there.)
Considering the obstacles, the Philippines face an uphill battle before family planning services become similarly universal. But the political tides may already be turning: last April, the President said he would support the reproductive health legislation even if it meant excommunication.
Meanwhile, PATH Foundation’s Castro is hopeful that Humayhumay’s success story will lay the seeds for widespread public support for family planning. “The vision of the project is in this community you see more children educated who are able to become leaders and speak out for themselves in the future and be able to become stewards of their own sexuality and the future environment,” said Castro. “This is the legacy.”
Sources: BBC, Bloomberg News, Catholic News Agency, The Guardian, Population Reference Bureau, TIME Magazine, US Agency for International Development, U.S. Catholic. -
Eric Zuehlke, Population Reference Bureau
Democratic Republic of Congo and Madagascar Connect Family Planning With Environmental Health
›February 10, 2012 // By Wilson Center StaffRemote rural communities in developing countries typically face the related challenges of extreme poverty, poor health, and environmental degradation. And population growth often exacerbates these challenges. In communities that face environmental challenges along with high fertility and high maternal and child mortality, health programs that include family planning can have great benefits for the health and well-being of women and families, with positive influences on the local environment. Meeting the reproductive health needs of women and ensuring environmental sustainability by connecting family planning with environment programs has proven to be a “win-win” strategy. Yet this connection has often been seen as controversial or irrelevant to environmental policymaking.
-
Political Demography: How Population Changes Are Reshaping International Security and National Politics (Book Launch)
›
“The world’s population is changing in ways that are historically unprecedented,” said Jack Goldstone, George Mason University professor and co-editor of the new book, Political Demography: How Population Changes Are Reshaping International Security and National Politics. [Video Below]
-
P.H. Liotta, Salve Regina University
The Real Population Bomb: Megacities, Global Security, and the Map of the Future (Book Preview)
›February 8, 2012 // By Wilson Center Staff
There was a time when the city was the dominant political identity. Centuries and even millennia ago, the most advanced societies in the Mediterranean, the Near East, and South America revolved around cities that were either states in themselves or were the locus of power for larger empires and kingdoms. The time of the city is coming again, though now in a considerably less benign way.From the introduction to The Real Population Bomb:There was a time when the city was the dominant political identity. Centuries and even millennia ago, the most advanced societies in the Mediterranean, the Near East, and South America revolved around cities that were either states in themselves or were the locus of power for larger empires and kingdoms. The time of the city is coming again, though now in a considerably less benign way.
This book is about where and how geopolitics will play out in the twenty-first century. Cumulatively it represents two decades of work from authors with seemingly dissimilar backgrounds: one is a poet, novelist, and translator; the other is a security analyst and expert in disaster response and management who has worked for two presidential administrations. Both were colleagues at the U.S. Naval War College in the early 2000s.
With the rise of massive urban centers in Africa and Asia, cities that will matter most in the twenty-first century are located in less-developed, struggling states. A number of these huge megalopolises – whether Lagos or Karachi, Dhaka or Kinshasa – reside in states often unable or simply unwilling to manage the challenges that their vast and growing urban populations pose. There are no signs that their governments will prove more capable in the future. These swarming, massive urban monsters will only continue to grow and should be of great concern to the rest of the world.
We have traveled widely and conducted fieldwork in places as disparate as the Altiplano of Bolivia; Caracas, Venezuela; Guayaquil, Ecuador; the autonomous Altai Republic in deep Siberia; and the massive slums of Egypt, India, Kenya, South Africa, and Brazil. What we share from this experience is the recognition that the world has changed before our eyes. Terms such as the “developed” and “developing” world – phrases that were always dangerous and loaded with false value – no longer have the relevance they seem to have had once. Concepts such as “first world” and “third world” are stubborn relics of Cold War thinking – just as our “mental maps” are grounded in the often difficult but known past. We must change our ways of seeing the world.
Traditionally there have been two general approaches to understanding societies and states. One is the humanitarian or ecological perspective in which the focus is on society – how people live and are affected by war, pollution, and economic globalization. The other is a realist perspective in which the focus is on the economic, political, and military relations among major powers such as the European Union, the United States, China, and Russia.
What these traditional approaches underemphasize is the overlap and natural alignment between them. To understand the map of the future, we need to critically appreciate how astonishing population growth in cities – particularly fast-growing megalopolises in weak or failing states in Africa, the Middle East, and Asia – is impacting ecology and ecosystems, human security, and the national security of Western states, as well as allies and trading partners.
For both better and worse, globalization and urban population growth have changed political and economic dynamics in ways that previous conceptions of how the world works cannot do justice. In this book we examine how developments below the nation-state level – at the municipal level – affect how we must see the world of the future. While this work is anything but a travelogue, we do visit some of the most alarming locations on the earth. Often these places have been viewed in impressionistic terms, as distant locations where “others” live – with whom “we” have little interaction. But we are far more connected than we think; whether Nigeria or Pakistan, Bangladesh or Egypt, their future is also ours. The odds seem stacked against those who live there. In the dense, overgrown neighborhoods and shantytowns of Lagos, Kinshasa, Cairo, Karachi, Lahore, or Dhaka, government authorities have failed to provide infrastructure and public services. We need urgent, collective, and innovative actions to help critical megacities weather the gathering storm.
But there is hope and strength. Though time is running short, solutions are still possible. In the end, this book is about the power and resilience of the human spirit.
P. H. Liotta’s latest book is The Real Population Bomb: Megacities, Global Security, and the Map of the Future, with James F. Miskel. As a member of the United Nations Intergovernmental Panel on Climate Change UN’s IPCC, he shared the 2007 Nobel Peace Prize.
Photo Credit: “Urban View: the Republic of Korea’s Second Largest City,” courtesy of United Nations Photo. -
Water and Population: Limits to Growth?
›February 3, 2012 // By Laurie Mazur
Water – essential, finite, and increasingly scarce – has been dubbed “the new oil.” Experts debate whether human societies are approaching “peak water,” beyond which lies a bleak future of diminishing supplies and soaring demand. Others observe that, for many, the water crisis has already arrived.
-
What Would It Take To Help People ‘and’ the Planet?
›February 1, 2012 // By Geoffrey D. DabelkoThe original version of this article first appeared in the “Scientist’s Soapbox” column of Momentum magazine’s special issue on “what would it take” to craft solutions to some of the Earth’s toughest challenges.
People living in the most biodiverse areas of the world tend to be poor, isolated, and dependent on natural resources. They often lack reliable access to alternative livelihoods and health services and thus can place stress on these ecologically unique regions.
Conservation efforts will merely slow habitat loss if they don’t fundamentally address the living conditions of the human residents as well as the flora and fauna. But programs to assist these communities have commonly focused on one problem at a time, reflecting the interests of the funders: Environmental groups focus on conservation, while health organizations concentrate on disease. We must ask whether investments to protect biologically rich areas are effective and sustainable if they don’t respond to the many needs of the people who live there.
But the problems faced by people in these remote areas don’t fit our traditional sectors. The way we disburse our funds, divide our bureaucracies, demarcate our disciplines, and measure success ignores the reality of intersecting needs. Such stovepiping can disrespect the communities’ scarce resources, especially their time. It can waste development aid on duplicate supplies and staff. And it can lead us to miss how the solution to one problem (e.g., providing antiretroviral drugs to treat HIV/AIDS) can be undercut by another (e.g., lacking access to safe water with which to take the pills).
So, what would it take to help particularly vulnerable populations while protecting particularly important ecological systems?
We need to strategically target our help by addressing HELP – health, environment, livelihoods, and population – through a truly integrated approach to sustainable development in these areas. Evidence suggests tackling problems concurrently can be more efficient and effective. Key donors such as the U.S. Agency for International Development are increasingly prioritizing integrated responses, providing some funding for sustainable development innovators and supporting evaluation of the results. But we need more evidence that these efforts can achieve results that match or exceed the outcomes of single-sector projects. To rigorously test this approach, more projects must be funded, implemented and analyzed, over longer periods of time and at bigger scales.
To date, some promising projects and research in diverse locations – Ethiopia, Nepal, Madagascar, Rwanda, the Philippines, and Uganda – suggest that the HELP approach offers greater benefits than traditional programs.
In the Philippines, for example, the PATH Foundation Philippines’ Integrated Population and Coastal Resource Management (IPOPCORM) program addresses pressing needs for both family planning services and sustainable environmental stewardship in densely populated coastal communities, where local fisheries have been depleted because of increased demand for food. IPOPCORM helps create marine protected areas and promotes alternative economic livelihoods such as seaweed harvesting, thus allowing critical local fish stocks to recover. Concurrently, the initiative mitigates human-induced pressures on the environment and lowers the vulnerability of this underserved population by providing voluntary family planning services. Since its launch in 2001, the IPOPCORM program’s approach has yielded measurable benefits, simultaneously reducing program costs and improving health and environmental outcomes – and outperforming compartmentalized, side-by-side sector interventions.
How can we bring HELP to biodiversity-rich communities? First, we can encourage scholars, practitioners, and policy-makers to step outside their stovepipes by producing and distributing manuals, for example, based on lessons learned from existing cross-disciplinary projects. Second, we must bridge the gap between analysis and field-based programs by developing new metrics that better assess the impact of integrated programs. Third, we must open up bureaucratic funding structures by demonstrating not only the short-term savings but also the synergies that bolster long-term sustainability.
The challenges are significant, but I see promising new opportunities for overcoming them. For example, the new Pathfinder International-led projects around Lake Victoria in Uganda and Kenya mark the entry of a respected health organization into the environmental arena and the return of a leading private funder – the MacArthur Foundation – to HELP programs. With some of Africa’s highest population densities, poverty, ethnic diversity, and biodiversity, the Great Lakes region is one of the most volatile intersections of human development and environmental change.
Through these and other community-based, integrated projects, we can truly help people and the planet at the same time.
Photo Credit: “Boy on road east of Addis,” courtesy of Geoff Dabelko/Wilson Center.
