Showing posts from category USAID.
-
Book Review: ‘World Population Policies’ Offers Sweeping Overview of a Complex Field
›July 2, 2012 // By Elizabeth Leahy MadsenWith much attention in the international family planning community directed to the impending anniversary of the 1994 International Conference on Population and Development and the closing date of the Millennium Development Goals, the fact that 2012 is the 60th anniversary of two other milestones in population programming may have escaped notice. In 1952, the International Planned Parenthood Federation was created, and India became the first country to formulate a national policy to reduce population growth.
These and many other landmarks are highlighted in World Population Policies: Their Origin, Evolution and Impact, a new book by demographer John May that reviews several decades of policies, advocacy, and program interventions addressing the full range of diverse demographic trends seen globally.May, who spent more than two decades working on population issues at the World Bank and other international institutions before recently assuming a fellowship at the Center for Global Development, is well-positioned to provide such an ambitious overview. Although the breadth of material included in the book means that some topics receive less coverage than a specialist might wish, it serves as a sound introduction to this diverse field, and offers some particularly interesting case studies.
The book’s main chapters begin with a summary of current population trends, including a comprehensive array of figures and statistics about population size, distribution, and projections. Some important concepts, such as the demographic transition and dividend, are perhaps covered too quickly, and in such cases the book would have benefited from more than a handful of figures, charts, and graphs. May classifies regions and countries as demographic “hotspots,” where the number of people outstrips available resources, and “coldspots,” which have too few residents. He makes an ambitious suggestion that high-density countries facing resource challenges, such as Bangladesh, should consider promoting rapid fertility decline below replacement level to stop population growth, then reverse course and increase to a rate that promotes a stable population – but such a reversal from low fertility is a feat that has stymied several countries in Europe and East Asia.
Evolution of the “Population Movement”
In addition to summarizing the ways that demographic issues have been framed in the past several decades, May briefly describes the long-running debate between demographers and economists about the ways in which population is theorized to affect economic development.
Three points in this chapter were particularly striking: First, the concept of family planning as a human right dates from well before the 1994 International Conference on Population and Development. In 1968, the Tehran International Conference on Human Rights defined the ability to choose family size and spacing as a fundamental right; still, some programs, such as India’s under the Emergency-era government of the late 1970s, adopted coercive practices. Second, population policies are not limited to official initiatives targeting fertility, mortality, and migration, but also encompass implicit or “passive” policy measures that arise without advance planning or that have an unintended effect on demographic trends. Related to this, May suggests that “contextual variables” such as education, health, gender, culture, and religion can have a greater impact on population policies’ effectiveness and demographic outcomes than government structures or funding.
Although population policies are most often designed at the national level, May’s discussion of the “population movement” highlights the influence of international networks and donors on such policies. By the late 1960s, the U.S. Agency for International Development had begun funding family planning programs overseas, and the United Nations Population Fund (UNFPA) was active. Although the United States has become less dominant over time, population programming remains a Northern-driven movement.
Beginning with a meeting in Belgrade in 1965, a series of international population conferences successfully raised the prominence of population issues on the global development agenda and built consensus around international goals, while also becoming increasingly political.
May’s cautions about such conferences are timely given this month’s London Family Planning Summit: “Consensus-building through international conferences and their preparatory meetings is often inefficient as a process, whereas such events could be used to promote learning among policymakers and experts…The gap between the conferences’ resolutions and the actual policies implemented at country level is important to remember” (110).
Growth and Aging Distinguish the Demographic Divide
In his chapter focusing on the developing world, May notes that population policies have become broader in the nearly 20 years since the Cairo conference, incorporating a reproductive rights framework while also addressing new issues such as the environment, HIV/AIDS, and poverty. But under this more holistic approach, national policies are susceptible to becoming overly diffuse, with an ambitious agenda not matched by concrete action plans.
The challenges expand to policy implementation as well. Kenya is profiled as emblematic of the difficulties facing population programs in fast-growing sub-Saharan Africa, particularly political disinterest, mismanagement, opposition from some religious groups, and commodity shortages. But when implemented well, such policies can be very successful. The book offers a thorough summary of research findings on the common features of effective family planning programs (such as leadership, monitoring performance data, and opening access to contraceptive methods at lower levels of the health system), as well as their demographic impact. Several country examples are cited to show that family planning programs reduce lifetime fertility rates by 0.5 to 1.5 children per woman, while also benefiting individual and social health, income, and well-being.
While population policies have been often effective at shaping demographic trends in high-fertility settings, even in changing cultural norms about family size, May notes that their impact has been notably weaker in reversing the trajectory of declining fertility in developed countries. While countries such as France have maintained a fertility rate close to, albeit still below, replacement level thanks to generous paid parental leave, housing initiatives and public child care facilities, policies that try to boost low fertility through financial compensation have been particularly ineffective.
Developed countries are less likely to have formal population policies and tend to address demographic issues through incentives and disincentives implemented by multiple agencies. Aging and immigration are receiving greater attention in such countries, along with low fertility rates. Population aging raises policy concerns that are both economic and social, and May focuses largely on the benefit of reducing incentives for early retirement. He notes that thanks to improvements in health and life expectancy, “today’s 65-year-old persons are young compared to their counterparts” of previous generations (180). Despite their economic soundness, government efforts to raise retirement ages are widely unpopular, and France’s newly elected president has promised to cut the retirement age from 62 to 60 for some workers.
What Comes Next
Some observations are intriguing and could have been further detailed. For example, May notes a recent “fragmentation” of organizations working on population issues, and suggests that “too many institutions and NGOs appear to support their own limited mandates as they also struggle for resources that are less abundant” (5). Decentralization and integration within health systems is a growing trend that could have been discussed in more detail, along with the legacy of pronatalist laws and attitudes by colonial powers in Africa, the effect of recent European efforts to tighten immigration policies, and the achievements of forums designed for collaboration on population policy issues (for example, the United Nations Commission on Population and Development or the Reproductive Health Supplies Coalition).
Looking towards the future, May foresees continued integration of demography with related development issues, such as poverty reduction and equitable growth, gender and youth perspectives, environmental issues, and conflict prevention. He notes a few challenges, including sub-Saharan Africa’s lag in fertility decline and the overall ineffectiveness of policies aimed at addressing the pressures of urbanization on infrastructure and resources.
In high-fertility settings, May recommends that instead of framing reproductive health writ large, policies should more specifically target family planning and women’s empowerment, including education and income-generation opportunities as well as legal rights. Bangladesh is presented as a model for other countries, as a setting where cultural change and economic development laid the groundwork for successful family planning outreach efforts. Most of all, May entreats government leaders to maintain a policy focus on population issues, regardless of where they stand in the demographic divide.
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.
Photo Credit: “Crowded Shopping District,” courtesy of flickr user EnvironmentBlog. -
Pop at Rio+20: Reproductive Rights Missing From Outcome Document – Assessing the Disappointment
›June 22, 2012 // By Sandeep Bathala
As heads of state get ready to sign on to the outcome document here in Rio, all eyes are on next steps – especially for the reproductive health and integrated development communities, which have seen their hopes of mainstreaming their issues with the sustainable development agenda dashed.
The final outcome document can be found here. USA Today reports that opposition from a group of countries in the 11th hour stripped the text of critical reproductive rights language:An initial draft of this conference’s outcome document stated, “We are committed to ensure the equal access of women and girls to education, basic services, economic opportunities, and health care services, including addressing women’s sexual and reproductive health and their reproductive rights.”
Absent entirely is any explicit connection between reproductive rights, population dynamics, and sustainable development.
In the final draft, the stronger wording “We are committed to ensure the equal access” was switched to the weaker “We are committed to promote the equal access.” The reference to reproductive rights was deleted altogether, after opposition from the G-77, a negotiating bloc of developing countries at the United Nations, and the Holy See.
But others, as we have heard repeatedly throughout the conference, insist that gender issues and reproductive rights have a strong and vital connection to sustainable development. Yesterday, USAID, the Aspen Institute, and the Center for Environment and Population held a discussion in the U.S. tent on this very issue, titled “Making Population Matter: The Demographic Dividend and Sustainable Development.”
As Vicky Markham of the Center for Environment and Population reports on RH Reality Check, the side-event aimed to demonstrate the effects of population dynamics, both positive and negative:We have the largest youth demographic ever in the history of the world, and most developing nations have a “youth bulge.” This can be seen as a challenge, or opportunity, particularly if the focus is on providing development programs for child survival, family planning, reproductive health, and education. The importance of women’s empowerment was also central. But it’s not a given; it’s an opportunity only if we pay attention to these issues to increase the benefits of the “demographic dividend.”
The demographic dividend, as described by USAID Deputy Administrator and panelist Donald Steinberg in blog post earlier this week, “is an opportunity that arises when a country transitions from high to low rates of fertility and child and infant mortality.” But it’s not just about ensuring access to family planning and reproductive health; youth-focused economic and education policies are also needed: “Maximizing the dividend requires social and economic policies that reinforce inclusion, equity, and opportunity across the entire population,” he writes. USAID is making a point of creating youth-focused policies for this reason, he said in Rio.
Carmen Barroso, regional director of the International Planned Parenthood Federation’s Western Hemisphere Region, pointed out that Latin American countries could not take advantage of the demographic dividend before recent societal changes occurred, including decreased fertility, increased urbanization (which leads to smaller families), and greater schooling and employment of women.
Seventy percent of world population growth is likely to be generated by Africa this century, said Eliya Msiyaphazi Zulu, executive director of the African Institute for Development Policy – and it is the only continent projected to continue to grow in the next century, he said. He called for redefining growth as more than GDP as that measure does not consider environmental degradation and its costs: “We must have other means to measure development.”
As heads of state and negotiators consider their positions at this conference – which many were hoping would make a much stronger statement – they might do well to ponder today’s comments from Secretary of State Hillary Clinton:While I am very pleased that this year’s outcome document endorses sexual and reproductive health and universal access to family planning, to reach our goals in sustainable development we also have to ensure women’s reproductive rights. Women must be empowered to make decisions about whether and when to have children. And the United States will continue to work to ensure that those rights are respected in international agreements.
Sources: RH Reality Check, UN, U.S. Department of State, USA Today, USAID.
Now none of this is an abstract discussion. There is just too much at stake, too much still to be done. And many of you visited the U.S. Center here in Rio and saw practical solutions related to some of the work I’ve discussed and other goals we hold in common. We believe solutions require action by all of us. Governments, yes; let’s do our part. Let’s do more than our part.
Photo Credit: YouthPolicy.org. -
Pop at Rio+20: Text Finalized, Population-Sustainable Development Links Left Out?
›June 21, 2012 // By Sandeep BathalaWhile I was visiting with youth peer educators yesterday with the Brazilian Society for Family Welfare in the Cachoeirinha favela (see Vicky Markam’s post for details – we were on the same trip), UN member states reached consensus in the Rio+20 negotiations. But, according to reports, although the outcome document includes some mention of reproductive health, gender equality, and women’s empowerment, it fails to explicitly recognize the link between reproductive rights and sustainable development.
Many women’s rights and health observers have, from the start, encouraged this link.
Karen Newman, speaking to ECSP in April during the Planet Under Pressure conference – a precursor to Rio – said she hoped this week would offer an opportunity to look at “sustainable development in the round” and “re-identify family planning as a core development priority,” given its human rights and health implications and relationship to population growth.
Jenny Shipley (Former Prime Minister of New Zealand) wrote just yesterday on CNN that “we are at a moment in history where we still have time to make a difference. It is essential that the global discussion in Rio not be blind to the potential solutions that access to voluntary family planning could offer to many of the world’s problems.”
“We can no longer afford this outrageous oversight, driven by old-fashioned tradition, discrimination, and pure ignorance,” said Gro Harlem Brundtland (Former Prime Minister of Norway and Former Head of the World Health Organization) at a side event on Monday. “Now is the time to agree to unleash the largest untapped potential for sustainable development and stop all discrimination against women and girls.”
But now that preliminary agreement on the outcome text has been reached, reports have filed in that the connection many were hoping for is absent. Zonibel Woods, blogging on RH Reality Check, wrote:From the start of the negotiations, gender equality and women’s human rights, including reproductive rights, have continuously been challenged by a few governments, claiming that [these] had “nothing to do with sustainable development.”
The lack of consensus among the wider international community may also undercut efforts to highlight reproductive rights in the post-2015 Millennium Development Goals/Sustainable Development Goals framework and as governments ready for the follow-on to the International Conference on Population and Development in 2014. A concrete link to “sustainable development,” whatever form that takes, would help ensure that reproductive health is not side-lined.
This debate continued until the last few hours of the negotiations. In the end, the text includes a re-affirmation of both the Cairo and Beijing agreements, but it falls short by failing to recognize that reproductive rights are also critical to the achievement of sustainable development. If a woman cannot decide if and when to have children and if she is not provided with the reproductive health care that is her human right, it is challenging to contribute to sustainable solutions for the planet.
Immediately following the adoption of the text, women gathered and protested at Rio Centro, the main venue for the conference, and advocacy continues.
Heads of state will in all likelihood sign on to the outcome document by tomorrow (it could technically still be changed, but that appears unlikely). I will keep you posted on the final outcome and will be taking notes at a side-event this afternoon by USAID, the Aspen Institute, and Center for Environment and Population on the demographic dividend and sustainable development, which promises to be spirited given today’s news. You can tune in live to the webcast of that event at 2:30 EST on Ustream.
Sources: AllAfrica, Aspen Institute, CNN, IRIN, RH Reality Check, U.S. Department of State, USAID.
Photo Credit: United Nations Photo. -
Nancy Lindborg, The Huffington Post
For Yemen’s Future, Global Humanitarian Response Is Vital
›June 12, 2012 // By Wilson Center StaffThe original version of this article, by Nancy Lindborg, appeared on The Huffington Post.
This weekend in Sana’a, I had dinner with a group of young men and women activists who are on the forefront of Yemen’s historic struggle for a better future. They turned out for change with great courage last year, and at dinner, with great eloquence they outlined for me the many challenges facing Yemen during this critical transition period: conflict in the north and south, weak government institutions, cultural barriers to greater women’s participation, an upended economy, and one of the world’s highest birthrates. And, as one man noted, it is difficult to engage the 70 percent of Yemeni people who live in rural areas in dialogue about the future when they are struggling just to find the basics of life: food, health, water.
His comment makes plain the rising, complex humanitarian crisis facing Yemen. At a time of historic political transition, nearly half of Yemen’s population is without enough to eat, and nearly one million children under the age of five are malnourished, putting them at greater risk of illness and disease. One in 10 Yemeni children do not live to the age of five. One in 10. This is a staggering and often untold part of the Yemen story: a story of chronic nationwide poverty that has deepened into crisis under the strain of continuing conflict and instability.
Unfortunately, in communities used to living on the edge, serious malnutrition is often not even recognized in children until they are so acutely ill that they need hospitalization.
Continue reading on The Huffington Post.
Nancy Lindborg is the assistant administrator of the Bureau for Democracy, Conflict, and Humanitarian Assistance at the U.S. Agency for International Development.
Sources: U.S. Department of State.
Photo Credit: Informal settlements near the Haddjah governorate, courtesy of E.U. Humanitarian Aid and Civil Protection. -
Family Planning and Results-Based Financing Initiatives
›“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.”
Event Resources
Photo Credit: Sean Peoples/Wilson Center. -
USAID’s New Global Health Framework and Delivering Equity in Health Interventions
›USAID’s new Global Health Strategic Framework, Better Health for Development, lays out the agency’s major health priorities for the next five years. “Core global health priorities” include reducing maternal mortality, ensuring child survival and nutrition, fostering an “AIDS free generation,” and fighting infectious diseases. Family planning and reproductive health is listed as a key area for bilateral engagement. In particular, the strategy hopes to continue to “graduate” countries from the agency’s family planning program, which since the 1980s has transitioned 21 countries into local ownership of family planning support. The strategy also takes stock of the shifting global health environment, noting the rise of the “BRICS” countries as new donors and the need to strengthen public health systems in developing countries. “Already, private payments account for 50-80 percent of total health spending in Africa and Asia, leading to system inefficiencies, inequitable access, and health costs that prove catastrophic to individuals and families,” the report reads. In order to achieve its priorities within this context, the document sets out a number of strategies, including a focus on program sustainability, the empowerment of women, and integrated approaches to development. Health, it says, “cannot be isolated from other development challenges.”
Speaking of health interventions, a team of researchers led by Aluisio Barros of the Federal University of Pelotas, Brazil, recently compared coverage data from more than 50 countries against an index of household wealth to estimate the most and least equitable interventions. The study, “Equity in Maternal, Newborn, and Child Health Interventions in Countdown to 2015: A Retrospective Review of Survey Data From 54 Countries,” published in The Lancet, found that “interventions with similar levels of overall coverage often have very different degrees of inequality.” According to the data, “the most inequitable indicator was skilled birth attendant, followed by four or more antenatal care visits, whereas the most equitable was early initiation of breastfeeding.” For example, though the average for attendance by a skilled birth attendant was 53.6 percent across the entire sample, the wealthiest fifth had an 84.4 percent coverage rate and the poorest stood at 32.3 percent. “Interventions that are usually delivered in fixed health facilities…tend to be the most inequitably distributed,” write the authors, with geographical access, financial barriers, and discrimination appearing as likely obstacles for the poor. The authors conclude that, although “concern about inequalities in maternal and child health in poor countries was conspicuously absent from the global agenda in the past,” the availability of new, intervention-specific data provides a means of targeting equity issues in health delivery more successfully.
-
Learning From Success: Ministers of Health Discuss Accelerating Progress in Maternal Survival
›“The gains we have made [in reducing maternal mortality rates] are remarkable; however, gains are fragile and donor resources are declining. Substantial investments must be maintained to safeguard these hard-wins,” said Afghan Minister of Health Suraya Dail at the Wilson Center on April 23. [Video Below]
As part of the Wilson Center’s Global Health Initiative, the Advancing Dialogue to Improve Maternal Health series partnered with the U.S. Agency for International Development to co-host Minister Dail, along with Honorable Dr. Mam Bunheng, Minister of Health, Cambodia; Honorable Dr. Bautista Rojas Gómez, Minister of Health, Dominican Republic; and Dr. Fidele Ngabo, Director of Maternal and Child Health, Ministry of Health, Rwanda.
These ministers spoke about the lessons learned in countries where there has been tremendous progress under challenging circumstances.
In the Dominican Republic, Bautista Rojas Gomez said the first challenge was to address the “Dominican paradox,” where maternal mortality rates were high despite the fact that 97 percent of women received prenatal care and delivered in hospitals. The government created a zero tolerance policy that included a comprehensive surveillance system, mandatory maternal death audits, and community oversight of services, which assured better quality services.
Similar political commitment improved indicators in Cambodia, where maternal mortality rates dropped from 472 to 206 per year from 2005 to 2010. “It takes a village…and the prime minister has inspired the country to act,” said Mam Bunheng. Through increased access to contraception the number of children per woman went from seven to three and commitment to family planning, education, technology, infrastructure, and community have been the key drivers of success.
“In Rwanda, the big challenge we are having is education,” said Fidele Ngabo. “Many of the maternal health indicators depend on education.” When women and girls are educated they are twice as likely to utilize modern contraception. The efforts of Rwanda’s government have been instrumental in facilitating positive change, he said, particularly the efforts of First Lady Jeannette Kagame, who he called a “champion” for women and girl’s health.
As witnessed throughout the Advancing Dialogue to Improve Maternal Health series – and reiterated by the ministers of health – the interventions to improve maternal mortality rates exist, what’s left is to generate the needed political willpower.
Event Resources
Photo Credit: David Hawxhurst/Wilson Center. -
New Surveys Generate Mixed Demographic Signals for East and Southern Africa
›May 8, 2012 // By Elizabeth Leahy Madsen
The pace of fertility decline in sub-Saharan Africa will be the single most important factor in whether the global population reaches the UN’s high projection of nearly 11 billion in 2050, or remains closer to the low projection of 8 billion. In recent years, the high projection has seemed more likely, as sub-Saharan Africa has been marked by stalled fertility declines and stagnant rates of contraceptive use. Survey results released over the past year showing dramatic increases in contraceptive use in Ethiopia, Malawi, and Rwanda therefore set demographers and the family planning community abuzz, signaling that concerted efforts to improve health services had paid off and fertility rates were on the decline. But in recent months, additional surveys from Mozambique, Uganda, and Zimbabwe have shown that those positive trends are not universal.
