Population: the forgotten priorityBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3750 (Published 16 September 2009) Cite this as: BMJ 2009;339:b3750
Talking about contraception puts Apio Christine Peace, a Ugandan health worker, in a pessimistic mood. Peace, who is currently working for Care International in a refugee camp in the war ravaged north of her country, would like more Ugandan women to be given the means to control their fertility, not least because Uganda has one of the world’s fastest growing populations, projected to triple by 2050 to about 103 million citizens.1 She highlights her concern about Uganda’s ability to sustain such a rapid growth in population by pointing out the gradual loss of the country’s natural forests. Poor agricultural practices and overpopulation are causing the erosion.
“Part of the forest reserve was recently given over to a soft drinks plant. I just think the government isn’t committed to the environment. There is poor provision of family planning services, and so the population is on the increase. Women do want control over their fertility, but many are in circumstances where they don’t have a choice. It is still a highly patriarchal society where men dictate how many children a wife has.” The average number of children per mother is 6.6 in Uganda, and there are 550 maternal deaths per 100 000 live births. Use of modern contraception remains low, at 18%.2
Peace’s perspective—that the lack of access to sexual and reproductive health services is a major spur to population growth—is unfortunately not one that attracts the big international aid dollars. In fact, international aid to family planning schemes has shrunk dramatically over the past 15 years. Between 1994 and 2008, funding for reproductive health as a proportion of global health aid dropped from 30% to 12%, according to World Bank analysis. Although actual aid for population and reproductive health increased from $901m in 1995 to $1.9bn in 2007, the increase is small compared with that in the global health budget for aid, which leapt from $2.9bn to $14.1bn during the same period.
Much of this is linked to shifting priorities in the United States under the Bush administration (box). In several countries, including the Dominican Republic, the US has ended funding for family planning. In other areas, the US ring fenced money for HIV, which according to one critic “has created booming, but vertical, programming.”
One obvious approach to unlocking more funding for family planning is to improve the links between sexual and reproductive health and HIV/AIDS programmes. Links include improving condom supplies, testing for sexually transmitted diseases, and integrating sexual and reproductive health information and services into HIV/AIDS programmes.
But newer voices are also arguing that sex and reproductive health has a lot to offer people wrestling with climate change. Current UN population projections, if aid for family planning doesn’t increase, point towards a world population of 11 billion by 2050,3 which will inevitably lead to a significant rise in greenhouse gas emissions. So why shouldn’t universal access to voluntary family planning services be one response to climate change?
Bob Engelman, an author of the UN Population Fund’s annual report on the state of the world population, which this year will focus on climate change and population, agrees. “There is very good emerging research that indicates that population dynamics are incredibly powerful—when you look after future population you get much lower levels of greenhouse gases. That is not surprising; it is intuitive. When you look at the cost of the sort of interventions that might have an impact on population—family planning, provision of contraception, safe abortion, female education—they are considerably cheaper over the long term than many of the things we would do otherwise.
“There is much less good research on adaptation. The UN population division did research on water scarcity—is it caused by population growth or climate change? They ended up concluding that in Africa population growth is probably more a factor in water scarcity than both predicted or existing climate change.”
Nevertheless, it’s unlikely that population will be discussed at the forthcoming UN climate change conference in Copenhagen. “If we went to people now, they would say, ‘Are you out of your mind, we only have the smallest chance of getting an agreement out of this conference that would be binding and would last. And you want us to talk about population control?’ We need to tell them why it is not about population control,” Engelman says.
Thoraya A Obaid, executive director of the UN Population Fund, adds: “We need to bring the focus away from multinational industry producing things to mitigate climate change [such as wind turbines] to actually investing in people and changing behaviour.”
Limited progress has been made in attempts to access funds from climate change budgets. The National Adaptation Programme of Action (NAPA) scheme, for example, channels funds from Organisation for Economic Cooperation and Development (OECD) member states to developing countries in need of support to adapt to the impact of climate change. Out of the 49 least developed countries that are eligible for funding, 27 are expected to double their population by 2050. But health projects are conspicuous by their absence. Karen Hardee, vice president of Population Action International, says environmental ministries have dominated the NAPA process. “A total of 448 projects have been approved so far in NAPA countries, but there is nothing on family planning. Only 7% of projects related to health, and so far zero projects are funded,” she said.
Meanwhile, there is a high unmet need for family planning in those countries hardest hit by the effects of climate change. Among countries in Sub-Saharan Africa where data were available, the percentage of women with an unmet need for family planning ranges from 41% in Uganda and Togo, to 13% in Zimbabwe, and 15% in South Africa. The unmet need for effective contraception results in a high proportion of unintended pregnancies.
Countries such as Iran, South Korea, Thailand, and Bangladesh have made huge health gains through investment in family planning schemes. Ashkan Alavi, chief executive of the Family Planning Association in Tehran, points out that in Iran the total fertility rate dropped from 8 to 1.7 in less than two decades. “We now have the only condom manufacturer in the whole of the Middle East,” he says. “Key to our success was the strong backing of the religious leadership. Without that support it would never have worked. In Friday prayers they emphasised it is not the quantity of the Muslim nation, but the quality.”
The need to increase funds is not just about containing population growth. In Berlin earlier this month, a conference co-sponsored by the UN Population Fund, attempted to reinvigorate the goal of “universal access to reproductive health.” The goal, to be reached by 2015, was set at the 1994 international conference on population and development in Cairo and has since been incorporated into one of the millennium development goals—to reduce maternal mortality by 75% by 2015. It is the goal on which the least progress has been made.
“Cairo is still an unfinished agenda,” said Obaid. “Still a woman dies every minute because of pregnancy and complications. There are women who want to plan families but who have no access to contraception. Wider access to contraception is important because the largest numbers of young people in human history are entering reproductive age. If we continue at this speed we will not reach the goals set in Cairo. We need to talk about budget lines.
“An additional dollar invested in voluntary family planning comes back at least four times in saved expenses. It would cost the world only $23bn a year to stop women having unintended pregnancies and dying in childbirth, and to save millions of newborns—this is equal to less than 10 days of global military funding,” she said.
But these goals are largely being ignored by funders, despite commitments made at various G8 summits. At the 2007 G8 summit in Germany a pledge was taken to take “concrete steps” to promote knowledge about sexuality and reproductive health, especially to girls. A year later, in Japan, the G8 nations made a similar commitment but crucially no financial guarantees.
Helen Clark, the former prime minister of New Zealand, now head of the United Nations Development Programme, says the time has come to start making links: “Sexual and reproductive health needs to be brought together with population issues and integrated into the development agenda. It impacts on everything we do. As long as 200 million women have an unmet need, they have a reduced chance of breaking out of poverty and finding work.” Gill Greer, director general of the International Planned Parenthood Federation, said: “The challenges today are perhaps greater than in 1994, including a world financial crisis, climate change, the HIV/AIDs pandemic, increasing conservatism, and fragmented health systems.”
Engelman adds: “I think we need to frame this debate differently, and just say: ‘Should women have more children than they want?’ If the answer is no, then we should fund interventions to help change the law and culture that effectively force women to have more children than they want. We should also do more research asking what would be the results of intentional fertility, when women are in control of their reproduction. Would it be a world of growing population or a world where the population stabilises and eventually declines? All the evidence points to the latter.”
Ghana: family planning hostage to US politics
Ghana had one of the first national policies on voluntary family planning in Africa. Since 1988, the use of contraception among married women has doubled to 25.2% and the use of modern methods more than tripled to 18.7%. But in rural areas, contraception use remains low and the fertility rate is high. Half of adolescents aged 12 to 19 live in rural areas and cannot afford contraceptive and family planning services or the journey to the nearest town. The pregnancy rate of young women in rural areas is double that of those living in the city. One in 35 will die during pregnancy or in childbirth.
In 2002, the Planned Parenthood Federation of Ghana distributed more than 6.5 million condoms. This was achieved in part with the help of US taxpayers and a $2.8m grant from USAID. However, in 2004 the Bush administration made funding conditional on agreeing to the so called “global gag rule,” preventing doctors and nurses from even talking about abortion options, Abortion is legal in Ghana, and the federation lost $2m in funding because it refused to accept the rule. It also lost USAID donated contraceptive supplies and experienced shortages, with no supplies in some regions. The federation could no longer afford to hand out free contraception to those most in need, and condom distribution fell by 40% in less than a year.
President Obama has since reversed the Bush policy, announcing $50m of funding for the UN Population Fund during his first two months in office.
Cite this as: BMJ 2009;339:b3750
Competing interests: None declared.
Log in using your username and password
Log in through your institution
Register for a free trial to thebmj.com to receive unlimited access to all content on thebmj.com for 14 days.
Sign up for a free trial