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.

Changing Chinese demographics of labor force connected to worker protests from today’s Washington Post http://ow.ly/1V9R8

New research on desired family size and child mortality in Reading Radar on @NewSecurityBeat. From #USAID and The #Lancet http://ow.ly/1UgYj

Congrats to Suzanne Ehlers as new head of #PAI. Hoping for cont’d demography & security and population-environment work http://ow.ly/1TAzA

Practical maternal health lessons in transportation and referral w/ examples from #India, #Bolivia, & #Ghana @MHTF #UNFPA http://ow.ly/1TzQZ

Columbia University’s Grace Kodindo on @NewSecurityBeat with video interview on family planning in conflict zones http://ow.ly/1TzQg

Grace Kodindo of “Grace Under Fire” talks family planning in conflict zones. #Chad #refugees #conflict #WilsonCenter http://ow.ly/1TuN1

Follow Geoff Dabelko on Twitter for more population, health, environment, and security updates

Delivering Solutions for Girls and Women

“We know how to intervene; there does not need to be a magical solution,” said Søren Pind, Denmark’s minister for development cooperation, at the June 7 opening ceremony of Women Deliver 2010.

In its second year, the conference has gathered delegates from 146 countries representing hundreds of non-governmental organizations (NGOs), governments, and civil society organizations under the theme “Delivering Solutions for Girls and Women.” Delegates are working to share projects, policies, successes, and innovations in the field of maternal health and to develop strategies to meet Millennium Development Goal 5.

“Recent trends show great progress and this is very encouraging,” said Gamal Serour, president of the International Federation of Gynecology and Obstetrics (FIGO), speaking of a recent study by the Institute of Health Metrics and Evaluation (IHME). The study found that annual maternal mortality has dropped 34 percent–from 526,000 to 342,900–between 1980 and 2008. Nevertheless, Serour maintained that “we are far away from our goal for 2015.”

Overcoming Tradition and Religious Barriers

Investing in women’s health is not only the right thing to do, it is also economically advantageous. When women are healthy, they provide tremendous benefits to their families, communities, and countries. Women contribute to a majority of the small businesses and agricultural activities of developing countries and their unpaid work at home accounts for almost 33 percent of the world’s GDP. Unfortunately, over 215 million of these women do not have access to family planning services, resulting in unwanted pregnancies, childbirth, and maternal deaths.

There are many barriers to family planning in developing countries, not the least of which are cultural and social traditions that can uphold negative gender-based norms. Tailoring campaigns to address these gender inequities was the subject of discussion at the “Cultural Agents of Change Delivering for Women” session, where panelists acknowledged that collaboration and partnership with a wide-range of actors–from members of the local legislature to civil society organizations and actors in the health sector–are necessary to facilitate change.

Graciela Enciso of the Centro de Investigaciones y Estudios Superiores en Antropología Social-Sureste in Mexico, added that advocacy campaigns to increase support for family planning should be “linked with research.” In many traditional societies, strict interpretations of religion are used to control and disempower women; donors and NGOs “need to think outside the religious box at every point,” said Mary E. Hunt, co-director at the Women’s Alliance for Theology, Ethics, and Ritual.

Male Contraception, Gender Roles, and Family Planning

“I think it is important not to hide behind our cultures and religion,” said Ngozi Okonjo-Iweala, managing director of the World Bank. “We need to work with men and work together to overcome gender inequality.” “Male participation” has been a key theme echoed throughout Women Deliver and is often highlighted as a strategy for reducing maternal mortality.

At the “Men Deliver: Men’s Role in Family Planning” breakout session, experts addressed how new and existing technologies in male contraception and shifting gender roles can help to scale up family planning interventions. “Reducing unwanted pregnancies can also be carried out through male contraception,” said John Townsend, vice president of the reproductive health program at the Population Council.

Condoms are traditionally the main method of contraception for men, but usage rates quickly fall over time and to wear a condom “becomes the women’s responsibility,” said Townsend. To address issues around condom usage, development of alternative family planning technologies, such as gels and implants, is underway. As these technologies are being developed, however, it is important for program managers and donors to consider existing gender norms and the willingness of men to utilize new methods.

In researching gender roles in family planning in Zambia, Holo Hochanda, the chief technical administrator of the Planned Parenthood Association of Zambia, determined that there are many entry points for male intervention and increased family planning. “Men are clients, policymakers, and service providers. Each of these roles provides an opportunity to discuss utilization of male contraception and gender inequities in family planning,” he said. “Men can be key mobilizers and agents for change.”

For more coverage on Women Deliver 2010 click here and to learn more about the Wilson Center’s Maternal Health Dialogue Series visit the Global Health Initiative’s website here.

“Referral has been called an orphan cause,” said Patricia Bailey, public health specialist for Family Health International and Columbia University, because it is “everybody’s responsibility and therefore nobody’s responsibility.”

As part of the Maternal Health Dialogue Series the Woodrow Wilson International Center for Scholars’ Global Health Initiative convened a small technical meeting on May 19, 2010, with 25 experts from five countries to discuss their experiences and share lessons, challenges, and recommendations for improving transportation and referral for maternal health. Following the technical meeting, a public dialogue was held on May 20, 2010, to share the knowledge gaps and recommendations identified. The formal report from the technical meeting will be available in the near future.

“Displaced people are like every other human being, they want, they need the advantage of family planning. They are asking only for services to be available for them, affordable for them, and acceptable for them,” said Dr. Grace Kodindo in a recent interview with ECSP about the challenges of family planning in conflict regions. The OB/GYN from Chad calls for family planning services to be included in the provisions made for displaced and refugee communities.

Kodindo identified five key barriers to family planning for displaced people, including a lack of coherent policies for displaced people in host countries and a lack of awareness and attention by donors to family planning. Other barriers include the lack of access in remote areas, and a lack of knowledge and therefore demand.

However, in many cases family planning services are very much in demand. One refugee mother compared herself to a “hen being followed by many chicks,” said Kodindo, who “ask[s] the government and the donors to give and to make policy that can really facilitate the provision of services and to provide funding so that services can be available to all these people.”

Kodindo, who recently spoke at a Wilson Center panel on “Family Planning in Fragile States,” is also speaking in DC on Thursday, June 3 at a showing of the documentary about her work in the Democratic Republic of the Congo, Grace Under Fire.