Geography Pack for Secondary Schools

The Population Jigsaw

Fitting the pieces together
for a healthy world

AN
AGEING
WORLD
COUNTRY
STUDIES

GLOBAL
POPULATION
TRENDS
CONTEMPORARY
POPULATION
POLICIES HIV/
AIDS

GENDER
AND
HEALTH
Contents

Contents

Introduction 1

Glossary of terms 2

Global population trends 3-6

An ageing world 7-10

Contemporary population policies:

Bringing sexual and reproductive
health and rights to all 11-16

HIV/AIDS: From health issue

to development crisis 17-22

Gender and health 23-26

Country studies:

Federative Republic of Brazil 27-30

People’s Republic of China 31-36

Republic of India 37-42

Islamic Republic of Iran 43-46

Republic of Kenya 47-50

Philippines 51-54
Introduction
Introduction
The
Population
CONTEMPORARY
Jigsaw POPULATION
POLICIES
Fitting
the pieces
together for GENDER
AND
HEALTH
a healthy
world
Interact Worldwide’s Education Department
has produced this resource on global
population and reproductive health at the
request of, and with input from, secondary
school Geography teachers and students.
To meet curriculum needs and promote our
work we have included updated information
regarding demographic trends and
projections, the impacts of ageing,
population policies, family planning, safe
motherhood, adolescent reproductive
health, HIV/AIDS, gender issues and
country studies, with an emphasis on less
developed countries. We believe that to
fully understand this complex subject
each of the above jigsaw pieces should
be explored and connected. In line with
the goals of the International Conference
on Population and Development (ICPD)
we focus not on numbers, but on each
individual’s right to a healthy life. Our
vision is a world where exercising the
right to sexual and reproductive health
contributes to the reduction of poverty
and a better quality of life.
1
AN
AGEING
WORLD
COUNTRY
STUDIES
GLOBAL
POPULATION
TRENDS
HIV/
AIDS
Over time this document will be updated
and expanded, so please check our
website. We have chosen a paper resource
because it is simple and flexible and hope
you will photocopy and distribute portions
of it to your students. Statistics inevitably
become out of date, and we rely on the
World Population Data Sheet, produced
annually by the Population Reference
Bureau, to update our educational materials
and school talks. Interact Worldwide
distributes the World Population Data
Sheet to schools in the UK.
The Population Jigsaw was researched
and written by Karen Rosen, Sarah Mackie
and Naomi Safir in the Education
Department at Interact Worldwide. In the
course of our research we consulted a
wide range of sources. A comprehensive
list of websites can be found on the
education section of our website at:
www.interactworldwide.org/education
If you have any queries about the
information contained within this
document please contact Karen Rosen,
Development Education Officer.
Glossary of terms
Glossary of terms
AIDS – Acquired Immune Deficiency Syndrome.
This is the late stage of infection caused by the Human
Immunodeficiency Virus (HIV). HIV steadily weakens the
body’s defence (immune) system until it can no longer fight
off life-threatening illnesses. These include infections such
as pneumonia and tuberculosis.
Anti-retroviral drugs (ARVs) – This is the main type of
treatment for those with HIV or AIDS. It is not a cure, but can
stop people from becoming ill for many years. The treatment
consists of drugs that have to be taken every day for the
rest of someone’s life.
Contraceptive prevalence rate (CPR) – The percentage
of married women of reproductive age (typically aged 15-49)
who are using a method of contraception. Contraceptive
prevalence usually refers to the use of all methods, but may
be given separately for modern methods.
Demographic transition – The shift from high levels of
fertility and mortality in a population to low levels. As the
decline in mortality usually precedes the fall in fertility, there
is rapid population growth during the transition period.
Family planning – The conscious effort by couples to
regulate the number and spacing of births through artificial
and natural methods of contraception.
Female genital mutilation (FGM) – This includes all
procedures which involve partial or total removal of the
external female genitalia or injury to the female genital
organs whether for cultural, religious or any other non-
therapeutic reasons.
HIV – Human Immunodeficiency Virus. The virus that
causes AIDS. The virus may be transmitted by sexual
contact, through blood and from mother to child (either
before or during birth or through breast feeding). While
some individuals experience mild HIV-related disease soon
after initial infection, nearly all remain well for several years.
As the virus gradually damages the immune system, those
with HIV begin to develop opportunistic infections of
increasing severity, including diarrhoea, fever, tuberculosis,
pneumonia, lymphoma and Kaposi’s sarcoma.
Infant mortality rate (IMR) – The number of deaths of
infants aged under one year per 1,000 live births in a given
period, usually a year.
International Conference on Population and
Development (ICPD) – UN conference held in Cairo in
1994. ICPD was the first population conference to move
away from setting demographic targets towards
emphasising people’s needs for, and rights to, sexual and
reproductive health. It also stressed the importance of
women’s interests as components of development. ICPD
has a deadline of 2015 to achieve the targets set in 1994
– targets that are reviewed at five-yearly intervals.
LDC – Less developed country
Life expectancy – The average number of additional years
a person would live if current mortality conditions were to
continue. Life expectancy at birth is most commonly used
and is the number of years a newborn can be expected to
live under prevailing mortality conditions.
2
Maternal mortality ratio – The number of women per
year who die as a result of pregnancy and childbirth per
100,000 live births during the same period.
MDC – More developed country
Migration – The movement of people across a specified
boundary for the purpose of establishing a new or semi-
permanent residence. It is divided into international
migration (migration between countries) and internal
migration (migration within a country).
Population momentum – The tendency for population
growth to continue beyond the time that replacement level
fertility has been achieved because of the relatively high
concentration of people in the childbearing years.
Population policy – Explicit or implicit measures used by
a government to influence population size, growth,
distribution or composition.
Population projection – A procedure to estimate or
project the size and characteristics of the population at
some future time. Demographers often set low, medium and
high projections of the same population based on different
assumptions of how these rates will change in the future.
Prenatal ultrasound – Ultrasound uses sound waves to
create pictures of a foetus. Early in pregnancy it is used to
establish the baby’s due date or that there has not been a
miscarriage. Later in pregnancy it can confirm that the baby
is growing properly in the uterus, the number of babies, the
size, position and any birth defects. Although ultrasound is
often accurate in predicting the sex of a baby in the later
stages of pregnancy, it is not foolproof.
Pronatalist – The policy of a government, society or social
group to increase population growth by attempting to raise
the number of births.
Replacement level fertility – The level of fertility at which
each woman will, on average, be succeeded by one
daughter who survives to have a daughter herself. This will
depend on mortality conditions, but in countries where
mortality below the age of reproduction is low, it is usually
taken to be 2.1 children per woman.
Sterilisation – This medical procedure blocks either the
oviducts (fallopian or uterine tubes) or the sperm ducts to
prevent the sperm and ovum from uniting. For women it is
referred to as a tubal ligation or ‘having your tubes tied’ and
for men it is called a vasectomy. It is among the most
effective contraceptive methods available for those who
desire no more children.
Total fertility rate (TFR) – The average number of
children born alive to a woman during her lifetime.
Unmet need – Estimates of women who would like to
prevent or delay pregnancy but are not using
contraception, either because they lack knowledge about
family planning or access to services, or because they face
cultural, religious or family obstacles.
Urbanization – The growth in the proportion of a
population living in urban areas.
Global population trends
The main factors which
determine global
population change are
fertility and mortality.
Between 1800 and 1930
global population doubled
from 1 to 2 billion.
It reached 3 billion in 1960,
4 billion in 1974, 5 billion
in 1987 and 6 billion in
1999. It is projected to
reach 8.9 billion by 2050.
The classic stages of demographic transition
Birth/death rates
Stage 1
Death rate
Source: Population Reference Bureau, Population Bulletin, March 2004
Global population
trends
The demographic transition
Historically, societies have gradually shifted
from small, slowly growing populations with
high mortality and fertility, to larger slowly
growing populations with lower mortality
and fertility. During the transition itself, the
population rapidly accelerates because the
decline in death rates precedes the decline
in birth rates, creating a sudden surplus of
births over deaths. In the now more
developed countries (MDCs) this transition
took place slowly over two centuries as
the food supply stabilised and housing,
sanitation and health care improved. In less
developed countries (LDCs) significant
mortality reductions have only taken place
since World War II, although they have
occurred much more rapidly. Therefore,
growth rates in these countries have been
high and have led to rapid global
population growth since the 1960s.
Stage 2 Stage 3 Stage 4
Birth rate
Time
3
The forces driving population change
One of the most important factors
influencing population growth is the extent
to which fertility remains above replacement
level. In demographic transition theory the
total fertility rate (TFR) should eventually
stabilise at the replacement level of 2.1
children per woman, leading to little future
growth. This number reflects one child born
for each parent plus a small amount extra
because more boys are born than girls and
some girls will die before reaching
reproductive age. Replacement level fertility
has already been reached throughout the
MDCs and in some LDCs including Sri
Lanka and Tunisia. Despite predictions that
the TFR would stabilise at replacement
level, in many MDCs fertility rates have
dropped significantly lower. Some
demographers call this unexpected trend
the second demographic transition.
While women in 59 MDCs now give birth
to fewer than 2.1 children each, women in
47 LDCs on average bear 5 or more children.
The TFR in Asia is now 2.6 (which is less
than half of the 1950 level, yet much of this
is due to China) and in Latin America the
TFR has declined from 5.9 in 1950 to 2.6
today. As a continent, Africa continues to
experience the highest birth rates in the
world. Niger, in Northwest Africa, has the
highest TFR in the world at 8 children per
woman and fertility rates remain high in Mali
and Uganda at 7 and 6.9. Furthermore,
according to the latest Demographic and
Health Survey fertility rates have slightly
increased in Kenya in recent years. Africa’s
future growth is subject to much
speculation, in part due to the devastating
impact of HIV/AIDS. The future growth of
the Middle East is also unclear. Iran’s TFR
has dropped from 6.7 in 1986 to 2.5 in
Global population trends
It should be noted that 2004, but in many places the decline has
birth rates are declining been much slower and TFRs remain high
virtually everywhere in in countries such as Yemen.
the world. As access to
education has increased, It should be noted that birth rates are
women have entered the declining virtually everywhere in the world.
labour force in large As access to education has increased,
numbers. This has led women have entered the labour force in
to later marriage and large numbers. This has led to later marriage
delayed childbearing. and delayed childbearing. The availability of
contraception, abortion and the reduction
in maternal, infant and child mortality are
also contributing factors. Couples are
gaining the information and services they
need to make informed decisions about
the timing and spacing of children, with
smaller families increasingly becoming the
norm for social and economic reasons.
As mortality rates decline, life expectancy
rises. Life expectancy at birth is a more
accurate indicator of current health and
mortality conditions than the death rate
because it is not influenced by a region’s
age structure. MDCs are now experiencing
the highest life expectancies ever observed.
Life expectancy at birth in Japan is the
highest in the world at 82 (this represents
an average of males and females). In LDCs
life expectancy is lower and more variable,
with HIV/AIDS reversing gains in some
countries. Average life expectancy at birth
worldwide is now 67 years. Projections
assume life expectancy will continue to
rise in all regions; however, rates of
increase are expected to slow and most
demographers put a ceiling on it.
Migration within and between countries
affects the distribution of the population
by age, sex, cultural, racial and other
characteristics and can affect national rates
of growth. Currently, there is a large amount
of rural-to-urban migration and by 2007
half the world’s population will be urban.
Urbanization appears to accelerate the
demographic transition to lower mortality
and fertility. Many rural-to-urban migrants
are unable to bear several children in urban
areas due to a lack of space and higher
costs of childrearing. In LDCs, however,
the urbanization of the past 50 years has
strained the capacity of many governments
4
to provide basic services to all but its
most privileged residents, and there is a
growing gap between rich and poor.
Approximately 175 million people (3% of
world population) are international migrants
who leave home in search of greater
human security for themselves and their
families. Most are looking for better
economic opportunities, but some are
forced to leave their homes due to famine,
natural disasters, environmental
degradation, violent conflict or persecution.
Most migration is between neighbouring
countries, but greater access to global
information and cheaper transport mean
that geography now poses less of a barrier
to movement. Close to half of all reported
migrants move from one LDC to another,
and a large proportion of employment-
related migration occurs between countries
where wages do not differ significantly.
In 2003, there were approximately 14
million refugees or asylum seekers
worldwide escaping war, famine or other
crises. Most sought refuge in Asia or
Africa, with Iran and Pakistan being the
most common destinations. Europe
hosted approximately 25% of the total.
Large and sustained migrant flows can
alter fertility levels in receiving countries
when migrants come from countries with
higher fertility norms. For example, large
scale immigration from Mexico to the
United States has kept birth rates there
higher than other MDCs.
Population momentum
While global fertility rates have declined
from 6.0 children per woman in the early
1960s to 2.8 today, the age structure of
the population in LDCs will ensure that
absolute numbers continue to rise for
some time. Decades of high fertility in
LDCs have meant ever increasing
numbers of young people. Although the
majority of young women today will have
fewer children than their mothers, growth
continues due to this population
momentum. By contrast, about 40% of
Global population trends 5
the world’s population live in countries term. For example, the population of Japan
where couples have so few children that is expected to decline by 21%, Germany
numbers are likely to decline in the long by 9% and Russia by 17% by 2050.

Why fertility rates remain high

Infant mortality remains unacceptably high in many parts of the
world, with nearly one in ten children in Africa dying before
their first birthday. The devastating impact of HIV/AIDS in sub-
Saharan Africa has reversed the trend of declining infant
mortality in many countries and in Sierra Leone nearly one in
five children will die before the age of one.
Children continue to be seen as an investment for the future in
countries with little or no welfare state in place. Children who
survive to adulthood ensure that parents can be supported in
old age. Male children are particularly prized in countries where
there is a lack of female participation in formal paid employment.
Children are often seen as an investment by families dependent
on agriculture as they provide extra hands in the fields. By six
or seven years of age a child can herd livestock, gather
firewood, carry water and watch younger siblings. Studies show
that by the age of five children may bring more money into their
families through their work in the fields than it costs to keep
them; however, this can vary from country to country.
There is a correlation between female education and fertility
rates, as women with an extended education tend to have fewer
children. Educated women are more likely to know which
health services, including family planning, are available and to
have the confidence to use them. Women with more education
also have more opportunities outside the home and can see the
benefits of education for their children. Women who achieve a
Culture and religion continue to exert influence on families in
LDCs, but their influence in the MDCs is on the wane. Catholic
countries such as Italy and Spain record the highest usage of
contraception in the world, but the Church wields more
influence in LDCs where it may be the only provider of care for
the poor. Contraceptive use remains taboo across many parts
of Africa, Asia and Latin America.
The United Nations Population Fund (UNFPA) estimates that 350
million couples worldwide would like access to contraception
but do not have it. In particular, the world faces a severe
shortage of condoms (estimated at 8 billion a year). This results
in an average of three condoms per year for an African man and
the shortage is fuelling the HIV/AIDS crisis. The shortage in
contraceptive supplies poses a major challenge for development
in the coming years, and in some areas of Africa recent
contraceptive shortages have begun to reverse fertility decline.
Women’s education and TFR in selected countries, 1990s
7.8
Niger
1998
6.7
4.6
7.1
Guatemala
5.1
1999
2.6
6.9
Yemen
4.6
1997
3.1

relatively high level of education are also more likely to enter Haiti
6.1
4.8
the labour force before they marry or begin childbearing, and 1995
2.5
ultimately to have smaller families than women who marry in
5.8
their teens. Kenya
4.8
1998
3.5

Where women are unable to take a full and active part in the 5.7
Pakistan
political and economic spheres of their country there tend to be 1991
4.9
3.6
higher birth rates. The increased liberation of women in Europe
5.0
during the last century, coupled with developments in Philippines
5.0
contraceptive technology, led to a massive decline in birth 1998
3.6
rates. Also, in countries where the boy child is favoured women 4.6
Jordan
may undergo multiple births in the hope of having a boy. Early 4.5
1997
marriage is associated with an early onset of sexual activity. 3.6

Young brides are at risk of pregnancy through more of their ■■■■ No education ■■■■ Primary completed ■■■■ Secondary completed
reproductive years than those who marry later and delay the
onset of sexual activity. Source: Demographic and Health Surveys 1991-1999
Global population trends 6
Population Projections up to 2050
Global population today
The United Nations regularly forecasts
global population numbers. They make high,
● World population, at 6.4 billion, is growing at a rate of 1.3%
medium and low projections for the future.
annually, adding approximately 76 million people each year. This
The medium variant projection is based on
is considerably slower than the peak annual growth rate of over
the assumption that fertility will reach
2.5%, reached in the early 1970s. Nearly all growth takes place in
replacement level by 2050. The low variant
LDCs, mainly due to population momentum.
projection assumes a TFR of 0.5 children
● At just over 1.3 billion, China is the world’s most populous country.
per woman lower than the medium
It is increasing at 0.6% each year. India’s population is 1 billion
projection over the time period. The high
86 million, but its higher growth rate of 1.7% means it is likely to
variant projection assumes a TFR of 0.5
bypass China as the most populous country in 25-50 years.
children per woman higher than the medium
● In 1950 LDCs contained 68% of the world’s population, in 2004
variant projection over the time period.
they contain 81% and by 2050 they are projected to contain 86%.
These projections assume life expectancy
● Almost one third of the world’s inhabitants are below age 15 and
will increase in LDCs, except in countries
approximately one half of the population is below age 25.
with significant HIV/AIDS epidemics.
● Approximately 10% of the world’s population are aged 60 or older.
In MDCs the proportion is about 20%, but will reach almost 33%
The most recent medium variant projection
by 2050. In LDCs about 8% of the current population is over 60
of the world’s population in 2050 expects
and projections expect a rise to 20% by 2050.
it to reach 8.9 billion, assuming a TFR of 2.
● By 2050 the share of the world’s population in sub-Saharan Africa
The low projection is 7.4 billion, assuming
will rise from 10% to 17%, while Europe will decline from 13% to 7%.
a TFR of 1.5. The high projection is 10.6
billion, which assumes a TFR of 2.5.
These projections have been adjusted
downwards in recent years due to an
World population according to different scenarios, increase in AIDS-related deaths and a
2000-2300 reduction in fertility rates.
40
Demographers now predict that fertility in
35
all countries will eventually decline to an
30 average of 1.85 children per woman before
stabilising. However, at least 1 billion will
Population (billions)

25
be added to the world’s population by
20 2025. It is likely that fertility will continue
to fall in those LDCs where it is already
15
declining and it will eventually begin to
10 decline in places where it has remained
high. Yet, the future size of the population
5
will depend not only on whether fertility will
0
2000 2050 2100 2150 2200 2250 2300
fall but how fast it declines and to what
level. Survey data from Bangladesh and
Source: UN Department of Economic and Social Affairs, Population Division, March 2004 Egypt shows little decline in TFRs between
1995 and 2000. It is possible that the two-
child average is a long way off or will never
be reached in some countries or localities.
The UN notes in publishing its projections
that the expected decline to low levels of
fertility is contingent upon ensuring couples
have access to family planning. In many
parts of the world, however, maintaining a
continuous supply of modern
contraceptives remains a challenge.
An ageing world 7
An ageing world

As life Life expectancy at birth: world and development regions, 1950-2050

expectancy 90

increases and 80

fertility rates 70

decrease, 60

50
population
40
ageing is 30
■■■■■■■ World
inevitable. 20
■■■■■■■
■■■■■■■
More developed regions
Less developed regions
■■■■■■■ Least developed countries
10

0
1950-55 1975-80 2000-05 2025-30 2045-50

Source: UN Population Ageing Report, 2002

Introduction Why does population ageing occur?

As life expectancy increases and fertility
rates decrease, population ageing (growth
in the proportion of people over 65) is
inevitable. At present it primarily affects
more developed countries (MDCs), but in
time even parts of sub-Saharan Africa with
fertility rates currently in excess of 4 or 5
children per woman will experience the
ageing phenomenon. Over the last 50
years, the number of those in the working
age group per elderly person has declined
from 12 to 9 globally, and is projected to
slip even further to only four in the working
age population for every elderly person by
2050. Despite the inevitability of ageing,
policy makers have undertaken various
measures to reduce its impact on societies.
The main driver of population ageing is
fertility decline, which occurs in the mid-
late stages of the demographic transition.
Ageing is therefore an important by-product
of the demographic transition. Globally,
fertility has declined from approximately
6 children per woman to 2.8 over the last
50 years and demographers expect it to
reach the replacement level of 2.1 over the
next half-century. As birth rates go down
the base of the population pyramid gets
smaller, lowering the balance of children
compared to elderly. The result is fewer
people who will be able to support those
in the elderly population. The last 50 years
witnessed a decline in the proportion of
0-14 year olds globally from close to 35%
to 30%. Over the next 50 years, this figure
is expected to decline by a third, meaning
that for the first time in history there will
be a larger proportion of elderly as
compared to those in the 0-14 category.
An ageing world
Improvements in life expectancy have also
played an important role in the process of
population ageing. Across the world,
average life expectancy at birth has
increased to 67 years. In MDCs, life
expectancy at birth has increased to 76
years due to better healthcare, diet and
exercise. For women in MDCs, average
life expectancy at birth is now 80 years.
Around the world there are increasing
numbers of older people, who are living
for more years than ever before.
Japan represents an extreme example of
population ageing. Japan has a female life
expectancy at birth of 85 years, the highest
in the world. In addition, Japanese fertility
rates have gone down to 1.3 children per
woman. Forecasts show that by 2025
Japan’s population will consist of
approximately one in three elderly people.
Both declining fertility and improvements
in life expectancy have contributed
towards the fast pace of population
ageing already being witnessed in Japan.
Migration may also have played a minor
role in population ageing, especially at the
country level. Young people are more
prone to migrate for work, frequently
moving to cities, creating an imbalance in
the ratio of workers to elderly in the
population age structure left behind.
Furthermore, elderly people often retire to
areas of a more relaxed nature. In the UK,
retirement hotspots such as Bournemouth
and other coastal regions generally have a
higher proportion of elderly people.
Other factors which may have contributed
to global ageing include later marriage,
delayed age at first childbirth, increased
female education and participation in the
workforce, all fuelling the fertility decline.
The impacts of ageing
As populations age, a transition occurs from
primarily infectious diseases to degenerative
diseases related to ageing such as old age
diabetes and cardiovascular disease. This
places a burden on health services which
8
have to provide for a populace with longer
lasting medical problems requiring high
level monitoring over time. The increased
number of elderly people also heightens
the need for more hospital beds and
funding for high-tech operations. Although
it is crucial that health services are
properly funded, with declining numbers of
working age people compared to the
elderly, this remains problematic.
Around the world, governments are finding
it increasingly difficult to take care of
people financially in their old age. Financing
pension funds with fewer working age
people will place a greater burden on those
working to contribute towards both their
own pension and the pensions of those in
the elderly population. However, with a
declining proportion of younger people,
increased funding on the health service
might be offset by a decline in funding on
education. In addition, many elderly people
do work past retirement age, especially in
less developed countries (LDCs). For
example, in the late 1990s close to 65%
of males over age 65 in Ethiopia were still
working. This compares with 50% in
Mexico and 30% in Singapore.
Strategies used to cope with
ageing societies
Three broad approaches have been
suggested to manage the complex
impacts of population ageing. The first
involves encouraging couples to have
more children in conjunction with family
friendly policies (such as child care
allowances), thereby raising fertility and
increasing the ratio of those in the working
age population compared to the elderly.
The second strategy encourages
immigration of younger populations, which
will also boost numbers in the working age
population. However, the United Nations
examined the impact of migration as a
counterbalance to ageing and concluded
that for Europe the inflow of migrants will
not prevent future population declines or
rejuvenate national populations unless the
An ageing world
flows are in the millions annually. It appears
that replacement migration is not a solution
on its own, but could help buffer the
impact of ageing if used in conjunction
with other policies such as increased
labour force participation by women and
fertility incentives. However, this might only
be a short-term strategy as the migrants
will eventually age themselves.
The third strategy directly involves the
elderly and promotes an increase in
retirement age and the provision of
incentives for elderly people to work
longer. For example, the UK does not have
a mandatory age of retirement. Individual
companies, however, may set their own.
Currently, state pensions are payable at age
60 for women and 65 for men, yet this will
be equalised at age 65 for both men and
women by 2020 to encourage more women
to remain in the workforce until older ages.
However, this approach may ultimately
only represent a short-term solution and
simply delay the ageing phenomenon.
Case studies: France, Sweden
and Singapore
France is commonly viewed as a
pronatalist country. However, France’s
fertility rates had already declined by
1850, well before other MDCs. The long-
term fertility decline prompted an ongoing
concern about population. In response,
over the past 60 years France has
implemented various policies to promote
fertility which aim to reduce the societal
impacts of ageing. This is particularly
relevant as by 2010 the number of elderly
in France will outnumber those aged 0-14.
In 2004 France’s TFR was 1.9 children
per woman, which is among the highest in
Europe. By comparison Italy’s TFR was
1.3, the UK’s 1.7 and Ireland’s 2.0.
Policies in France have been wide-ranging,
from the abolishment of a law against the
free sale of contraceptives in 1967, to 24
months unpaid maternity leave with a
guarantee of re-employment in 1977, to
priority for larger families in public housing
9
in the early 1980s. Although there have
been substantial changes over the last
few decades, currently French women
have paid, protected maternity leave for
six weeks before and ten weeks after the
birth of the first two children and eight
weeks before and eighteen weeks after
the birth of the third child. After maternity
leave, the mother or father may take
parental leave until the child is three years
of age. After this period the parent is
entitled to their old job or a similar one.
The benefits given to those with three or
more children are higher. Furthermore, all
children are entitled to a subsidised place
in a full-day childcare centre called a
crèche from the age of three months.
Infant school can begin at age three.
France’s pronatalist policy has been
successful in that the fertility rate has not
fallen to the low levels experienced in
much of Europe. This is probably due to
the fact that the focus has been on
placing both family and work at the centre
of women’s lives.
Sweden has seen major development in
fertility policies since the 1970s. In the
mid-late 1970s, the TFR in Sweden was
already low at 1.7 children per woman;
however, in the 1980s and into the 1990s
the TFR increased to just over 2. In 2004
the TFR was 1.7, reflecting a less severe
decline in fertility compared to most
European countries and a lower impact of
population ageing.
In Sweden, the state played an essential
role in targeting fertility increase.
Government policies focused on the
interests of children and the individual role
of each parent, as opposed to the couple. In
the 1970s, parental leave and an expansion
of public healthcare was prominent in
Swedish fertility policy. Initially, parents were
entitled to six months leave (fathers were
entitled to a share of this), with further
expansion in the 1980s. By the 1990s, after
the birth of a child parents were entitled to
390 days of income-related benefits, a
further 90 at a flat rate fee and a final 90
days unpaid, with job security guaranteed.
An ageing world 10
were eliminated. Although policies
Percent aged 65 and over: 2000 implemented in the 1970s and 1980s may
have kept fertility rates higher than many
European countries, they are still well
below replacement level. Women now
choose to have smaller families for
personal and economic reasons and it is
unlikely that birth rates will ever return to
replacement level or beyond.

Singapore is also facing an ageing

problem. With a TFR of 1.3 children per
woman, nearly 10% of the population
already over 65 years and an average life
Less than 3.0 expectancy at birth of 79 years, Singapore
3.0 to 7.9
8.0 to 12.9
13.0 or more
has recently implemented policies aimed at
encouraging couples to have more children.
Source: An Ageing World: 2001, US Census Bureau In August 2004, the government introduced
a $175 million package to give benefits
Percent aged 65 and over: 2030 such as larger housing to women and men
who marry. Furthermore, subsidised prices
for baby products will be provided for
more than two children and extra paid
maternity leave (increasing from eight to
twelve weeks) is also on the agenda. The
‘baby bonus’ for having a second or third
child is also set to increase and there are
new tax breaks for nannies and
grandparents who take care of children.

Conclusion
Less than 3.0
3.0 to 7.9
8.0 to 12.9
13.0 or more
Population ageing has occurred primarily as
a result of fertility declines witnessed in the
demographic transition. The completion of
In 1985 the government introduced a the demographic transition occurred over
‘speed premium’, which entitled couples to a lengthy period in MDCs. By contrast,
the same paid leave as the first child if a this transition is taking place at a much
second was born within 30 months, faster pace in LDCs today. Managing the
encouraging women to have two births in significant social and economic
quick succession. Furthermore, childcare implications of the ageing phenomenon is
was widely available and heavily subsidised likely to present a major development
by the government, enabling women to challenge for these societies in future
balance work and family life more easily. years, just as it currently poses very
serious challenges for MDCs.
Today, Sweden still has extremely family
friendly policies compared to most
countries; however, an economic
recession in the early 1990s led the
government to tighten some benefits.
Childcare expenses increased and
supplementary benefits for larger families
Contemporary population policies
Contemporary
population policies
Bringing
Sexual and
Reproductive
Health and
Rights to all
Introduction
Population policies are deliberate
government actions — laws, regulations,
programs — that try to influence the three
agents of population change: fertility,
mortality and migration, as a way to
promote social and economic development.
They can be implicit or explicit. More
developed countries (MDCs) tend to have
implicit policies in that they have no formal
declaration of a population policy, but have
enacted laws and policy measures which
influence demographic variables. These
may include free contraception, access to
abortion services and rules and regulations
on immigration. After several years of low
birth rates, many MDCs are beginning to
express concern with the societal
implications of ageing populations. As a
result, some provide incentives to
encourage people to have more children
such as government-subsidised crèches,
family allowances and generous maternity/
paternity leave policies.
Less developed countries (LDCs) tend to
formulate explicit population policies which
11
list measures to be taken in order to reach
targets of annual growth rates or total
fertility rates in a given time period. The first
country to declare an official population
policy was India in 1952. Early population
policies in the 1950s-1960s attempted to
slow population growth by encouraging
couples to have fewer children and
providing access to family planning
services. These were often target driven.
As government leaders grew concerned
that rapid population growth would interfere
with economic development, an increasing
number of countries adopted national
policies to slow population growth.
However, at the Bucharest World
Population conference in 1974 this
viewpoint was questioned by several LDCs.
They argued that rapid population growth
was a consequence of under-development
rather than the cause of it. Some people
became convinced that unless couples
could experience the benefits of
development, including better education
and reduced infant mortality rates, they
Contemporary population policies
Reproductive health
is defined as “a state
of complete physical,
mental and social
well-being and not
merely the absence
of disease or infirmity,
in all matters relating
to the reproductive
system and to its
functions and processes”.
would not be motivated to have smaller
families. Over time, criticism of population
policies surfaced on many fronts. Critics
complained they were culturally insensitive
or did not take into account the health of
individuals. Many women’s groups and
non-governmental organisations argued
such policies needed to be broader, to
encompass the social and cultural context
surrounding sexual relations, childbearing
and the use of contraceptives.
12
recognising the contributions of the first
40 years of contemporary population
policies, such as providing contraception
to the largest number possible of married
women of reproductive age, the use of
incentives and targets in family planning
was expressly rejected.

ICPD: The move from demographic

targets to individual health and
rights

The 1994 International Conference on

Population and Development (ICPD) in
Cairo was a watershed that marked a
fundamental shift in population-related
policies away from demographic targets
and towards a new focus on individual well-
being. At this event, 179 countries agreed
on a 20-year Programme of Action which
called for investments in health, education
and rights, particularly for women, and for
family planning to be provided in the context
of comprehensive reproductive health care.
Elements of reproductive health care
● Contraceptive information and services;
● Prenatal care, safe childbirth and postnatal care;
● Prevention and treatment of sexually transmitted infections (STIs),
including HIV/AIDS;
● Abortion (where legal) and post-abortion care;
● Prevention and treatment of infertility;
● Elimination of harmful practices such as female genital cutting,
sexual trafficking and violence against women; and
● Other women’s health services, such as diagnosis and treatment
for breast and cervical cancers.
The ICPD Programme of Action
acknowledged that in order to raise the
quality of life for all people, achieve
sustainable development and stabilise
world population in the twenty-first
century, governments must provide
couples and individuals with the full range
of reproductive health and family planning
services, provide universal access to
primary education, ensure gender equality
and take other poverty reduction
measures. ICPD recognised the numerous
social barriers many women still face
which prevent them from controlling their
own reproduction. It also stressed that
men must take responsibility for their
sexual behaviour and be fully involved in
reproductive health and childrearing.

Reproductive health is defined as “a state
of complete physical, mental and social
well-being and not merely the absence of
disease or infirmity, in all matters relating
to the reproductive system and to its
functions and processes”. For the first
time, reproductive rights were
acknowledged as human rights. While
Family planning
Family planning remains a core element in
population policies and a central component
of reproductive health. Investment in family
planning has helped reduce fertility rates in
LDCs from 6 children per woman in 1960
to just over 3 today. Some demographers
credit family planning programs with 40-
Contemporary population policies
50% of the fertility decline in LDCs since
the 1960s. The smaller family sizes reflect
a transformation in attitudes about
childbearing. As countries have modernized
and become more urban, and as women
have achieved higher levels of education
and have begun to marry later, couples
want fewer children. At the Cairo
conference states agreed that family
planning programmes should not stand
alone, but should become part of fully
integrated reproductive health services
within the primary health care system.
Some facts about contraception
● 61% of couples around the world use some form of contraception
today compared with 10% forty years ago. However, this number
drops to less than 50% in LDCs and to 21% in sub-Saharan Africa.
● The need for education and contraception continues to increase
dramatically. According to the United Nations Population Fund
(UNFPA), the need for family planning methods will increase by
around 40% by 2015. This is caused by population momentum in
LDCs, as well as the desire for smaller families, which is becoming
increasingly common around the world.
● The large gap between needs and available resources has
disastrous consequences. The UNFPA says every $1 million
shortfall in funding for reproductive health, including contraceptives,
condoms, medical equipment and supplies results in an
estimated 360,000 unwanted pregnancies, 150,000 induced
abortions, 800 maternal deaths, 11,000 infant deaths and 14,000
additional deaths of children under five.
The number of people who need access
to family planning is growing even more
rapidly than the population of reproductive
age because an increasing share of this
age group want to limit their family size.
Experts estimate that some 201 million
women in LDCs have an ‘unmet need’ for
contraception. Demographers define a
woman as having an unmet need if she
says she would prefer to avoid a pregnancy
but is not using a contraceptive method.
Many barriers still remain to the use of
family planning: the fear of side effects,
disapproval of men or families who want
women to have more children, religious
reasons, cost, shortage of supply, lack of
choice and accessibility.
13
Safe motherhood
Complications of pregnancy and childbirth
are major causes of disability and death
among women of reproductive age in
LDCs. Every minute a woman dies from
such complications – around 529,000 per
year. The Maternal Mortality Ratio (MMR),
the risk of death a woman faces once
becoming pregnant, is the number of
maternal deaths during a given year per
100,000 live births during the same
period. The world MMR is estimated to be
400 per 100,000 live births.
Maternal mortality represents the greatest
disparity between rich and poor countries,
with 99% of these deaths occurring in
LDCs, particularly in Africa and Asia. A few
shockingly high examples from around the
world are Sierra Leone – 2000 deaths per
100,000 live births, Afghanistan – 1,900
deaths per 100,000 live births and Haiti –
680 deaths per 100,000 live births. These
can be compared with the US – 17 deaths
per 100,000 live births, the UK – 13
deaths per 100,000 live births and Japan
– 10 deaths per 100,000 live births.
In addition, for each woman who dies due to
pregnancy-related causes estimates show
that another 15 to 30 suffer debilitating
injury, infection or disease such as anaemia,
infertility, pelvic pain, incontinence and
Contemporary population policies 14
obstetric fistula. The World Health of STIs would cost just US $3.00 per
Organisation (WHO) estimates this person per year for a low income country.
number to be 20 million women per year.
The Cairo Programme of Action
recognised the urgent need to reduce
Maternal mortality estimates by region, 2000 maternal mortality and morbidity, calling for
Region Maternal mortality Number of Lifetime risk of
a reduction in maternal mortality levels to
ratio (maternal maternal deaths maternal death, one half the 1990 level by 2000 and a
deaths per 100,000 1 in:
live births)
further one half by 2015. The Programme
of Action also called on governments to
WORLD TOTAL 400 529,000 74
close the gap in maternal death ratios
DEVELOPED REGIONS 20 2,500 2,800 between LDCs and MDCs and to aim for
Europe 24 1,700 2,400
maternal mortality ratios below 60 deaths
DEVELOPING REGIONS 440 527,000 61 per 100,000 live births in all countries.
Africa 830 251,000 20
Northern Africa 130 4,600 210
The five-year review of ICPD added a new
Sub-Saharan Africa 920 247,000 16 benchmark for high mortality countries: to
Asia 330 253,000 94
Eastern Asia 55 11,000 840
ensure that at least 60% of births are
South-central Asia 520 207,000 46 assisted by trained health personnel. Many
South-eastern Asia 210 25,000 140
Western Asia 190 9,800 120
countries have not met these targets;
Latin America & however, in September 2004 China
the Caribbean 190 22,000 160
Oceania 240 530 83
announced that it had met and exceeded
the Cairo target for maternal mortality.
Source: WHO, UNICEF, and UNFPA, 2003,
Maternal Mortality in 2000: Estimates
Developed by WHO, UNICEF, and UNFPA Current surveys indicate that only 53% of
Geneva: World Health Organisation
women in LDCs give birth with the Unsafe abortion
assistance of a skilled attendant (a nurse,
midwife or doctor having midwifery skills), The WHO estimates that 13% of maternal
and only 40% of women give birth in a deaths, or about 70,000 annually, result
hospital or health centre. In some countries from complications of abortion. These
the percentages are much lower. Skilled complications arise from unsafe
attendance during birth is crucially important procedures, which usually occur where
as all pregnancies involve some risks, even abortions are illegal or inaccessible.
for healthy women, and an estimated 15% Abortion is possibly the most divisive
of pregnancies result in complications women’s health issue that policy makers
requiring medical care. Such complications face. The current international consensus,
cannot be accurately predicted and most hammered out at ICPD and refined during
often cannot be prevented, but can be its five-year review, is that unsafe abortion
treated. Skilled attendants are necessary should be addressed to reduce its adverse
during all deliveries because they have the health impacts. The consensus documents
knowledge to manage and refer made clear that “...in no case should
complications when necessary. In life- abortion be promoted as a method of family
threatening cases women require planning”. Whether or not abortions are
emergency obstetric care, which includes performed legally, women should receive
surgery and anaesthesia, blood care for complications arising from them.
transfusions and other specialised care. Where abortion is legal, health providers
should ensure it is safe and accessible.
Fortunately, reducing maternal mortality
and morbidity does not cost much. The
WHO estimates a comprehensive safe Adolescent reproductive health
motherhood program, including antenatal
care, normal delivery care, essential care Of the 6.4 billion people on earth, nearly
for obstetric complications, neonatal care, half are under the age of 25 – the largest
postpartum family planning and management youth generation in history. Their numbers
Contemporary population policies
Facts about adolescent sexual and reproductive health
● Around the world, the sexual and reproductive experiences of
young people vary but most become sexually active between the
ages of 10-20. The growing gap between earlier puberty and later
marriage has extended the period through which most girls must
avoid premarital pregnancy.
● In many countries, the right of young people to gain access to
contraception is controversial. In Latin America and the
Caribbean, 35% of sexually active teenagers aged 15-19 use
contraceptives; in sub-Saharan Africa fewer than 20% do.
● 14 million girls aged 15-19 give birth each year. Maternal
mortality rates are twice as high for this age group as for women
over age 20.
● 10% of all abortions occur among adolescents.
● 300,000 young people aged 15-24 contract an STI each day.
● Over 10 million people between the ages of 10-24 are infected
with HIV or have AIDS and half of new HIV infections each day
(about 6000) occur among young people aged 15-24.
are growing and they are often sexually
active, both within and outside of
marriage, therefore exposed to the risks of
unwanted pregnancies, unsafe abortions
and STIs. Many have little knowledge of
sexuality, safer sexual practices or their
rights to refuse and to abstain. Most
unwanted pregnancies among young
unmarried women end in abortion, posing
a serious public health concern as not all
15
are safe, carried out by untrained people
without hygiene or proper care.
Public health systems in most countries
have neglected young people’s sexual and
reproductive health needs due to taboos
about young people’s sexuality. In
countries with conservative values and
traditions, including the US, many parents
and policy makers are concerned that
providing contraceptive information and
services will promote promiscuity among
unmarried teens. However, there is little
evidence that such programmes promote
greater sexual activity among young
people. Reviews of sex education
programmes worldwide have concluded
that sex education does not encourage
early sexual activity, but can delay first
intercourse and lead to more consistent
contraceptive use and safer sex practices.
In many parts of the world, adolescent
childbearing is socially sanctioned within
marriage. However, early marriage
exposes girls to the risks of pregnancy,
STIs including HIV, abortion and sexual
violence just as much, if not more than,
unmarried teens. Early childbearing has
lifelong physical, social and economic
consequences. Many teenage girls in
LDCs will die during childbirth due to the
stress on their bodies or a lack of medical
attention. Others suffer permanent
damage such as obstetric fistula, which
leaves a hole between the bladder and
vagina or rectum leading to incontinence
and sometimes death. Young parents,
especially girls, are often compelled to
leave school and may never have any
further educational or job opportunities.
In spite of the controversies surrounding
adolescent sexuality at ICPD, governments
agreed to a comprehensive set of measures
to improve adolescents’ health including:
providing sexual and reproductive health
information to adolescents; encouraging
parental involvement; using peer educators
to reach out to young people; providing
integrated health services that include family
planning for sexually active teens and taking
measures to eliminate harmful practices
and violence against young women. By
Contemporary population policies 16
providing young people with education, and drugs. Resource constraints are similar in
offering them the information and services most of Africa and South Asia.
they need to make informed decisions about
their lives, hopefully the generational cycle Although there have been many
of poverty can be broken and they can be successes around the globe, we are far
ensured of a safer and healthier future. from reaching many of the ICPD targets.
Much remains to be done, particularly
financially, if we are to bring sexual and
reproductive health and rights to all by
2015. In 1994, the UN estimated that
population and reproductive health
programmes in LDCs would cost $17
billion a year by 2000 and $22 billion by
2015, in 1993 dollars. The Cairo
Programme of Action called for one third
of the proposed spending to come from
international donors and two thirds from
LDCs. Donor countries have fallen short
with only Denmark, Luxembourg, Norway,
Sweden and the Netherlands meeting
their financial commitments. Between
1996-2001 the UK’s estimated fair share
was over £1 billion 290 million; of this we
still owe over £773 million. LDCs have
done better, despite the financial crisis in
Southeast Asia and the HIV/AIDS
epidemic; however, overall levels of
Where are we now? spending have been low, particularly in the
poorest countries. The UN estimated that
We have reached the ten year anniversary in 56 of the poorest countries, annual per
of ICPD and governments around the capita expenditures on reproductive health
world have drafted an impressive array of were only about $0.35 in 1996.
new legislation and strategy documents
related to population and reproductive
health. For example, since 1994 a total of
131 countries have changed national
policies, laws or institutions to recognise
reproductive rights. Many countries have
begun to integrate reproductive health
services into primary health care, improve
facilities and training and expand family
planning method choices. Yet, such
policies require large sums of money and
spending per person on health care in
LDCs is far lower than in MDCs. In
Uganda, for example, reproductive health
care consumes about 60% of the
government’s primary health care budget
— a relatively high per centage, largely
because of the HIV/AIDS crisis. However,
the reproductive health budget amounts to
only a few pounds per person annually,
which buys little modern health care or
HIV/AIDS: From health issue to development crisis
HIV/AIDS: From health
issue to development crisis
“AIDS today
in Africa is
claiming more
lives than the
sum total of
all wars,
famines and
floods.”
Nelson Mandela
Introduction
HIV/AIDS is currently one of the world’s
most critical challenges. In the most
affected regions, the HIV/AIDS epidemic
is undermining health and education
systems and reversing decades of
progress in development. HIV/AIDS also
brings economic and social problems for
individuals, trapping the ill and vulnerable
in the poverty cycle.
First identified in the early 1980s, HIV
(Human Immunodeficiency Virus) attacks
the body’s immune system, making it hard
to fight off infections. It is spread from
person to person through bodily fluids and
can be transmitted during unsafe sex (sex
without a condom), pregnancy, birth or
breastfeeding or from exposure to infected
blood (injecting drug users sharing
needles or transfusions). Without medical
treatment the HIV infection will lead to
AIDS (Acquired Immune Deficiency
Syndrome). The illness is classified as
AIDS when the immune system becomes
17
so weak that opportunistic infections such
as pneumonia or tuberculosis occur. Over
time, the body’s capacity to recover from
these infections is diminished, ultimately
resulting in death.
No cure exists for HIV/AIDS; however,
anti-retroviral drugs (ARVs) have been
developed which can slow the rate at
which the virus progresses. While this
treatment is routinely available in Europe
and North America, the cost places it out
of reach of most people in less developed
countries (LDCs). An estimated 5-6 million
people in LDCs will die in the next two
years if they do not receive treatment. In
2003, the World Health Organisation
(WHO) estimated that only 7% of people
in LDCs were able to access ARVs. In
Africa, this figure fell to 2%. As a result,
WHO and partners have recently
launched the ‘3 by 5’ initiative which aims
to provide three million people with ARVs
by 2005.
HIV/AIDS: From health issue to development crisis 18
important to note that some of the
Adults and children estimated to be living with HIV countries with the highest prevalence
as of end 2003 rates also have relatively small populations
so the total number of people infected
Eastern Europe
& Central Asia may not be that high. By contrast, India
Western Europe
580,000 1.3 million has a relatively low prevalence rate
(860,000-1.9 million)
North America (460,000-730,00) (0.9%), but its large population means
1.0 million East Asia
(520,000-1.6 million) 900,000
millions are infected. The two tables below
North Africa
& Middle East (450,000-1.5 million) list the top 15 countries for HIV
Caribbean
430,000 480,000 South & South-East Asia prevalence and numbers infected.
(270,000-760,00) (200,000-1.4 million) 6.5 million
(4.1-9.6 million)
Latin America Sub-Saharan Africa
1.6 million 25.0 million Australia & New Zealand Estimated HIV prevalence
(1.2-2.1 million) 32,000
(23.1-27.9 million)
(21,000-46,000) in adults (%)

1 Swaziland 38.8
2 Botswana 37.3
3 Lesotho 28.9
Total: 37.8 (34.6-42.3) million 4 Zimbabwe 24.6
Source: UNAIDS and WHO
5 South Africa 21.5
6 Namibia 21.3
The global toll of HIV/AIDS 7 Zambia 16.5
8 Malawi 14.2
Approximately 37.8 million people 9 Central African Republic 13.5
worldwide are currently infected with 10 Mozambique 12.2
HIV/AIDS and at least 25 million people 11 Tanzania 8.8
have already died of AIDS-related 12 Gabon 8.1
illnesses. LDCs have so far borne the 13 Cote d’Ivoire 7.0
greatest burden of the epidemic and 14 Cameroon 6.9
currently account for 95% of HIV 15 Kenya 6.7
infections. Sub-Saharan Africa alone
accounts for two thirds of the global
figures, but rising epidemics in India and Estimated total number
China are of increasing concern. HIV/ of people living with HIV
AIDS is also having a devastating impact
in parts of the Caribbean and Eastern 1 South Africa 5,300,000
Europe. While Western Europe has so far 2 India 5,100,000
escaped the severe outbreaks 3 Nigeria 3,600,000
experienced in other parts of the world, 4 Zimbabwe 1,800,000
growing concern exists about rising 5 Tanzania 1,600,000
numbers of new HIV infections, which 6 Ethiopia 1,500,000
increased by 20% in the UK in 2003. 7 Mozambique 1,300,000
8 Kenya 1,200,000
While looking at regional figures for the 9 Democratic Republic
numbers of people living with HIV of Congo 1,100,000
provides a general picture of the 10 USA 950,000
epidemic, it does not adequately represent 11 Zambia 920,000
the levels of HIV in individual countries. To 12 Malawi 900,000
fully assess the impact of HIV on a 13 Russia 860,000
country’s infrastructure we can either look 14 China 840,000
at the per centage of adults infected (HIV 15 Brazil 660,000
prevalence) or look at the total number of
people infected in each country. It is Source: 2004 Report on the global AIDS epidemic (UNAIDS)
HIV/AIDS: From health issue to development crisis 19
adult population as by 2020, without
Projected population structure with and without AIDS, Botswana 2020
widespread access to treatment, there will
80 be more women in their 60s and 70s than
75
70
women in their 40s and 50s. The base of
65 the pyramid is also less broad as women
60
55 become infected before their reproductive
50 years and children born with HIV die in
45
40 infancy. The population structure will
35
30
become significantly distorted as the
25 economically active age groups decline,
20
15 leaving the elderly to care for the young.
10
5
0
140 120 100 80 60 40 20 0 0 20 40 60 80 100 120 140 The impact on women
Male Female
■■■ without AIDS ■■■ with AIDS
Population (thousands) ■■■ with AIDS ■■■ without AIDS
In the most affected countries, women are
Source: US Census Bureau
disproportionately impacted by HIV due to
The demographic impact of biological, economic and social factors
HIV/AIDS which render them particularly vulnerable.
Sexual transmission of HIV from a man to
As the region with the highest HIV a woman is from two to ten times more
prevalence, sub-Saharan Africa faces the likely than transmission from a woman to a
greatest demographic impact of the man. Women are also more vulnerable to
epidemic. In the worst affected countries sexual violence, and a lack of female
of East and Southern Africa, up to 60% of empowerment can make negotiating
today’s 15 year olds will not reach their condom use difficult. Marriage does not
60th birthdays. Since 1999, life expectancy protect women from HIV and in some
at birth has fallen in 38 African countries, African countries married 15-19 year old
primarily because of AIDS. In the seven females have higher rates of infection than
countries with highest prevalence, life their unmarried sexually-active peers.
expectancy at birth has fallen from 64 to 49 While women currently account for 50%
years and it is predicted to drop below 35 of global HIV infections, this is likely to
years in Swaziland, Zambia and Zimbabwe rise in future and in sub-Saharan Africa
without the rapid expansion of prevention women make up almost 60% of the total
and treatment. Furthermore, in the absence number infected. The differences in
of a dramatic increase in the global infection rates become more pronounced
response to the epidemic, by 2025 the among young people, as a 15-24 year old
populations of Botswana, Zimbabwe and African woman is 3.4 times more likely to
Lesotho are expected to be 40% lower be infected than a male of the same age.
than they would have been without AIDS.

HIV disproportionately affects young

adults. Females tend to become infected
in their late teens and early twenties, while
males are infected in their late twenties to
early thirties. Without treatment, AIDS-
related deaths usually occur 7-10 years
after infection. This has a devastating
impact on the population structures of the
worst affected countries as millions of
adults die. The projected population
pyramid for Botswana clearly
demonstrates the impact of AIDS on the
HIV/AIDS: From health issue to development crisis
Women also bear the social and economic
“Like every burden of the epidemic. Women are more
other likely to care for those with AIDS-related
illnesses and girls are often withdrawn from
epidemic, school to care for sick parents and younger
siblings. Grandmothers are also becoming
AIDS develops primary carers for grandchildren as their
in the cracks own children die and leave behind orphans.
and crevices Women often face discrimination when
their partners die of AIDS. In a Ugandan
of society’s study, one in four AIDS widows reported
having her property seized by her late
inequalities.” husband’s relatives. Women may also be
A woman living with forced into selling sex in order to purchase
HIV/AIDS food for their families. Discrimination
decreases the empowerment of women
and increases poverty, which in turn
makes women more vulnerable to HIV.
The household impact
Households affected by HIV/AIDS are
more likely to suffer extreme poverty as
incomes are lost and the remaining limited
resources are channelled into caring for the
sick. Studies of AIDS-affected households
in South Africa and Zambia found that
monthly income fell by 66-80% as
economically active members of the family
became sick. While income decreases,
household expenditure increases as a
result of medical and funeral costs.
20
Children are often withdrawn from school in
order to supplement the family income. A
recent study in Vietnam found one fifth of
children in AIDS-affected households had
been forced to start working and one third
had to provide care for family members.
AIDS care, including medical costs, can
consume up to a third of the family budget.
To cover such costs, families reduce
spending on food, clothing and housing
and may be forced to sell assets including
land, livestock and ploughs, making it even
more difficult to recover financially in future.
HIV/AIDS is taking more than wealth away
from affected children; the epidemic is also
taking away their parents. Since the HIV
epidemic began, at least 15 million children
have been orphaned, the vast majority in
sub-Saharan Africa. The loss of a parent
can cause the household to break up. A
study in Zambia found that when a mother
died of AIDS over 65% of households
broke up, with children either going to live
with relatives or forced to live on the streets.
In the most affected countries, many
households are currently headed by children
who provide for themselves and their
younger siblings. These young children are
vulnerable to sexual abuse, thus increasing
their risk of contracting HIV themselves.
The impact on education
The quality and accessibility of education
has significant implications for the long
term development of individual countries.
However, HIV/AIDS has a negative impact
in both areas. As young adults form the age
group most affected by HIV/AIDS, this has
serious consequences for the supply of
teachers. Over 30% of teachers in Malawi
and Zambia are infected with HIV, and a
World Bank study in Tanzania estimated
that AIDS would kill almost 15,000
teachers by the year 2010 and 27,000 by
2020. The cost of training replacement
teachers places an extra burden on
education systems already struggling to
ensure every child is able to attend school.
As schools find it difficult to replace
teachers who fall ill, the remaining teachers
HIV/AIDS: From health issue to development crisis
face increased workloads leading to poor
morale and many leaving the profession.
The epidemic also affects children’s ability
to participate in education. Many families
caring for someone infected with HIV/
AIDS may withdraw their children from
school to help in the home and to take up
paid work. As the share of the household
budget spent on medicine increases,
there may be little left over to cover school
fees, books and uniforms.
The impact on health services
In countries with high rates of HIV/AIDS,
health services struggle to meet the
increased demands placed on them.
Zimbabwe spends over 50% of its health
budget on treating AIDS infections, with
over half of all hospital beds occupied by
AIDS patients. The strain on the health
services limits their capacity to cope with
other infectious diseases including TB and
Malaria, common infections associated
with AIDS patients.
Bed occupancy required for AIDS patients, Zimbabwe
1990 2000
■ Non-AIDS beds ■ AIDS beds
Source: UNAIDS, 2000
21
Health workers are also becoming
infected with HIV. As they become too ill
to work they leave the remaining health
workers to try and care for the ever
growing number of patients. Many of the
health workers who have avoided infection
are being enticed overseas to meet the
shortages of doctors and nurses in MDCs
such as the UK. It is estimated that
between a third and a half of all doctors
trained in South Africa emigrate, and the
UK has become the favoured destination
for health staff from Malawi. Often referred
to as the ‘brain drain’, the loss of their
most able staff to MDCs has profound
implications for countries finding it difficult
to staff their clinics and hospitals. The UK
has banned the NHS from recruiting
medical staff from LDCs, although private
hospitals are not covered by the ban.
The impact on agriculture
and food security
A healthy agricultural sector is vital to the
social and economic well being of LDCs
where it is often the country’s largest
employer. In Africa, agriculture accounts
for 26% of the continent’s gross domestic
product and for 70% of its employment.
The UN’s Food and Agriculture
Organisation predicts that by 2020 one-
fifth of agricultural workers in Southern
Africa will have been lost to AIDS. As the
number of workers available decreases,
farmers are beginning to switch from cash
crops to subsistence crops which are less
labour intensive.
Even countries outside of sub-Saharan
Africa are witnessing the negative impact
of HIV/AIDS on agriculture. A study in
Thailand showed that in some areas a
third of rural households saw their
agricultural output halved by the effects of
HIV/AIDS. The reduction in agricultural
production, combined with reduced
wealth for families affected by HIV/AIDS,
has led to food shortages for families in
many of the most affected areas.
HIV/AIDS: From health issue to development crisis
“Today, we In Malawi, Interact Worldwide is
are spending working with the National Association
of People Living with HIV/AIDS
more time (NAPHAM) to increase access to
nutritious food and ARVs for people
turning the living with HIV. Our funding helped to
set up a chicken farm run by HIV
bodies of the positive people. The farm not only
sick than we provides employment for people
living with HIV, but also generates
are turning income which can be used to buy
ARVs. A strong team spirit exists at
the soil.” the chicken farm, with all decisions
South African Farmer taken collectively. The profits from
the farm are not enough to buy ARVs
for everyone, so as a team they must
make the difficult decisions about
who needs them most, taking into
account each individual’s illness and
number of dependents.
Signs of hope
Despite the devastating impact of
HIV/AIDS worldwide, some countries do
provide a glimmer of hope that the
epidemic can be reversed. Uganda was
one of the first countries to experience the
full force of the epidemic, yet has managed
to reduce the adult prevalence rate from
18.3% in the early 1990s to around 4%
today. The reasons for Uganda’s falling HIV
rates are complex and subject to much
debate, but President Museveni’s strong
political leadership played a major role.
Through widespread public information
campaigns Ugandans were encouraged to
delay sex until marriage, have fewer sexual
partners and use condoms when engaging
in sexual practices. Researchers disagree
on which aspect was the most effective,
but it is likely to have been a combination
of the three.
22
and to increase condom use. Senegal
also successfully engaged religious
leaders in the fight against HIV. While the
Muslim and Catholic leaders preached
abstinence and fidelity, they did not
oppose condom campaigns.
The future
Uganda and Senegal demonstrate that
while HIV/AIDS is one of the worlds most
critical challenges, there are ways to fight
it. However, it will take a global effort to
defeat this epidemic. By working together
and pooling resources, countries rich and
poor can ensure that everyone around the
world has access to HIV prevention and
treatment.
Young people are the most critical age
group as they offer a hope for the future.
The actions of today’s generation of young
people will determine whether the HIV/
AIDS epidemic continues to grow or is
eradicated for good. If young people
receive the information and services they
need to stay protected from HIV and are
provided with the support to make
responsible decisions about their own
health and actions, we might yet succeed
in turning the tide.

With an HIV prevalence rate of 0.8%

amongst adults, Senegal is one of the few
sub-Saharan African countries which has
been able to limit the spread of HIV in the
general population. Like Uganda, Senegal
mounted a massive public information
campaign to reduce risky sexual practices
Gender and health 23
Gender and health
Women perform two
thirds of the world’s work

Women earn one tenth

of the world’s income

Women are two thirds

of the world’s illiterate

Women own less than

one hundredth of the
world’s property

United Nations statistics

Introduction

Sex is the physical difference between the
male and female sex – they are different
because they have different bodies and
women can have babies and men can only
help make them. Gender is not biological,
and refers to a set of qualities and
behaviours expected from a female or male
by society. Gender roles are learned, vary
widely within and among cultures and can
be affected by factors such as education
or economics. People treat gender roles as
natural, but they are not; they are dictated
by society and are often oppressive to
women. For example, a woman’s sex
makes it her job to breast-feed a baby –
no-one else can do it. Once the baby is
weaned, however, it often remains the
woman’s job to feed the baby because
society expects that from her. This is her
gender role. The man can just as easily do
the job since there is nothing biological
that prevents him from shopping, cooking
food and feeding the baby.
The fact that gender roles are socially
determined means they can change to
make a society more just and equitable.
Empowering women helps them become
involved in identifying and solving their
own problems and makes them more
aware of their rights, which increases their
choices. The balance of power between
men and women and younger and older
people may not always be equal. Adopting
family planning and improving women’s
reproductive health can assist with the
process of transforming gender relations
in families and communities, as well as
being beneficial to society as a whole.
This will enable women to take greater
control over their lives and participate
more fully in the development process.
Gender and health
How gender affects women’s health and well-being
● Where food is scarce, girls often eat last, and usually less than boys.
● Girls may be less likely than boys to receive health care when
they are ill.
● Adolescent girls may be pressured into having sex at an early age
within an arranged marriage, by adolescent boys proving their
manhood or by older men offering gifts in exchange for sex.
● Married women may be pressured by husbands or families to
have more children than they prefer, and women may be unable
to seek or use contraception.
● Married and unmarried women may be unable to deny sexual
advances or persuade partners to use a condom, thereby exposing
themselves to the risk of sexually transmitted infections (STIs).
● Women may be abused by male partners or family members,
and the fear of abuse can make women less willing to resist the
demands of their husbands or families.
Harmful practices
In some parts of the In some parts of the world, where tradition
world, where tradition and religion value males over females,
and religion value males gender discrimination starts at or before
over females, gender birth in the form of son preference. In these
discrimination starts at places, boys are seen to make a greater
or before birth in the contribution to the household, work on the
form of son preference. farm and care of parents in old age. The
increasing use of prenatal ultrasound for sex
determination often leads to abortions of
female foetuses. Although this practice
has been outlawed in both India and
China, it remains widespread. Sometimes
the desire for sons leads girl babies to be
abandoned, neglected or even killed.
Around the world, many girls and women
are subjected to harmful practices which
threaten their health and well-being. One
such practice, common in many countries, is
early and forced marriage. Despite laws in
most countries establishing 18 as the legal
age of marriage for females (with the legal
age of marriage for males almost always
higher), many continue to be married off
much younger, often to older men. In
Niger 76% of girls marry before age 18, in
Nepal 60% and in India 50%. Worldwide,
82 million girls will marry before their 18th
birthday, most from poor families. There is
an alarming increase in children being
married to older men in countries with
24
high rates of HIV/AIDS, where young girls
are seen as more likely to be virgins and
therefore not infected with HIV. In addition,
despite laws against them, dowries are
often still demanded of a bride’s family in
South Asia. This reinforces to parents that
girls represent a burden on the household. If
unpaid it may lead to rejection, divorce or
even the death of a bride.
Although their bodies may not be fully mature,
young married women are often expected to
start childbearing immediately. Early childbirth
carries risks to both mother and baby, as
does having many children in a short span of
time. Girls under 15 are five times more likely
to die of pregnancy-related complications
than women over 20, and pregnancy remains
the leading cause of death for 15-19-year-old
girls around the world. Young women are
often unable to make informed choices about
their sexual and reproductive health due to a
lack of information, taboos about discussing
sex and expectations of passivity. In some
societies, young women are not allowed to
seek health care without the permission of
their husband or family members. Moreover,
due to household and childcare duties,
young married women are usually unable
to continue their education and face limited
economic opportunities.
Young brides are particularly susceptible to
violence and exploitation. Domestic violence
occurs in all countries and cultures,
sometimes bolstered by cultural or religious
beliefs. The violence can be physical, sexual,
psychological or emotional including marital
rape, sexual slavery and trafficking in women.
According to the World Health Organisation
(WHO), one in every four women will
experience sexual violence at the hands of
a partner in her lifetime. In several studies
from around the world up to one third of
adolescent girls reported their first sexual
experience to be coerced. Girls and women,
who are often economically dependent on
their husbands, may feel unable to leave a
marriage. For example, women may not
seek care for gynaecological problems
because they fear their husbands will
divorce them for spending time and money
on their own health.
Gender and health
Women bear the burden of unintended pregnancies,
unsafe abortions and sexually transmitted infections.
● Approximately 201 million women today do not have access to
a choice of safe and effective contraceptive methods.
● There are some 19 million unsafe abortions each year, leading
to the deaths of almost 70,000 women and to disability in a
further five million.
● Each year an estimated 340 million curable STIs occur, as well
as almost five million new incurable HIV infections.
● Females are biologically more vulnerable to most STIs including
HIV. Transmission of HIV from male to female is as much as two
to ten times more likely than the reverse. A woman is twice as
likely, in any unprotected sexual act, to contract gonorrhoea from
an infected man than the reverse.
● The consequences of STIs are more serious for women and
include infertility and transmission of illness to unborn children.
● Marriage does not necessarily protect women from infection.
In some countries HIV rates are highest amongst married women.
25
Because only they can become pregnant,
women usually bear the responsibility of
using a contraceptive method. However,
within marriage, the man often decides
whether contraception is used, as well as
the number and spacing of children. The
influence of the extended family (including
mother in laws) has also been shown to
impact reproductive decision-making, even
regarding which contraceptive to use, in
countries such as Mexico, India and China.
Women often require the consent of their
husband before obtaining contraception,
abortion or voluntary sterilisation. Although
a much simpler procedure, vasectomies
for men are much less common around
the world than female sterilisation.
The importance of education

Education is essential to improving health,

Girls are more likely
than boys to discontinue
their schooling for a
number of reasons:
cost of uniforms and
books, household duties,
early marriage and
childbearing, parents’
perceptions that
education is more
beneficial for sons...
Another traditional practice which harms
women’s health is female genital
mutilation (FGM). This includes all
procedures which involve partial or total
removal of the external female genitalia or
injury to the female genital organs whether
for cultural, religious or any other non-
therapeutic reasons. It is practiced in 28
African countries, parts of the Middle East
and Asia and some immigrant
communities in the West, mainly on young
girls. It is estimated that over 100 million
girls and women have undergone FGM
and that each year a further two million
girls are at risk. In some communities it is
considered a rite of passage for girls, in
others it is regarded as a cleansing
procedure. To some it is a way of ensuring
virginity before marriage and guaranteeing
fidelity during marriage. The cutting is
usually performed by a female traditional
practitioner with crude instruments, in non-
sterile conditions and without anaesthetic.
Apart from the immediate consequences
of pain and infection, in the longer term,
girls and women can suffer difficulties
urinating and menstruating in addition to
severe pain and distress during sexual
intercourse and childbirth.
eradicating poverty and enhancing
development. The World Bank calls
women’s education the “single most
influential investment that can be made in
the developing world”. However, today
there are over 900 million illiterate people
in the world, two thirds of whom are
women. Although more young people are
enrolling in school, 115 million children
currently do not attend primary school,
57% of these are girls. The 1994
International Conference on Population
and Development (ICPD) called for
universal access to, and completion of,
primary education and for reducing the
gender gap in secondary education. The
gap has been closing at the primary level,
but remains significant in secondary
education in many less developed
countries (LDCs).
Girls are more likely than boys to
discontinue their schooling for a number
of reasons: cost of uniforms and books,
household duties, early marriage and
childbearing, parents’ perceptions that
education is more beneficial for sons,
worries about girls’ safety as they travel
to schools away from their villages and
limited job opportunities for women in
sectors that require higher education.
Gender and health 26
Promoting women’s status across Asia

Promoting gender equality and the empowerment of women are

effective ways to combat poverty, hunger and disease and stimulate
sustainable development. Interact Worldwide has recently been
involved in an innovative pan-Asian project to impact positively on
the status of women. Partner organisations in Malaysia, India,
Bangladesh, Indonesia and Thailand joined together to empower
women in their local communities through participation in sexual
and reproductive health programmes. For example, staff members
and clinic visitors of our partner organisation in Indonesia, Yayasan
Kusuma Buana, received gender sensitisation training along with
family planning and maternal and child health services such as Male involvement
antenatal care, immunisations and regular check-ups. In addition,
the organisation’s women’s group started a campaign against Women cannot achieve sexual and
domestic violence. In Bangladesh, community women and men were reproductive health without the participation
educated to identify harmful social practices related to sexual and of men. Unfortunately, many boys and men
reproductive health. At the project end both groups had become are socialised to believe they must be
more aware and were able to identify these issues and their dominant over females and are applauded
negative consequences. In sessions called ‘Couple Fairs’, women for risk taking and aggressive sexual
and men voluntarily participated in an environment of equity and behaviour by their peers. Some
equality when discussing the reproductive rights of women. In a communities link a man’s status to how
conservative country governed by a patriarchal system, the many sexual partners and/or children he
programme’s focus on encouraging male participation successfully has; and too often men continue to make all
produced a change in attitude among community men. This was decisions regarding sex and reproduction.
hailed as a major breakthrough in the process to empower women.
In the past, most population and family
planning programmes were directed
Investment in education for girls provides towards women. This has changed,
numerous benefits. Educated women gain however, due to the realisation that both
the skills necessary to participate in public men and women have important roles to
and economic life as well as looking after play. Men must be informed and educated
their families. Education is linked with later about the need for family planning, the
marriage, delay of sexual activity, greater importance of prevention of STIs, including
use of contraception, a desire for smaller HIV, condom use and gender sensitivity.
families, better child health and more Men’s reproductive health services should
education for girls of the next generation. be supported and ‘male-friendly’
Studies have shown that women who reproductive health clinics should provide
have at least seven years of education greater access to condoms. When male
have fewer children than those who do clinics have offered a wider range of
not. In more developed countries (MDCs), reproductive health services, men have
where women routinely obtain education become more informed and more willing to
and pursue careers, the age of marriage accept a share in family responsibility.
and first birth continue to increase while Community leaders in the widest sense of
birth rates decline. the word must be engaged to endorse
equal partnerships between men and
women. Men should be involved in defining
positive role models and helping boys
become gender-sensitive adults. Moreover,
measures must be enacted to discourage
gender-based violence and harmful
practices against girls and women.
Federative Republic of Brazil
COUNTRY STUDY
Federative
Republic of Brazil
Population: Introduction
1985: 135,600,000
Mid 2004: 179,100,000 Brazil has been cited as a success story
2025: 211,200,000 with regard to population policy. Its
(projected) population growth fell from approximately
3% per year in 1950 to half that in 2000
Total fertility rate: 2.2 and the total fertility rate (TFR) declined
from close to 6 children per woman to 2.2
Contraceptive use over the same period. Remarkably, life
amongst married expectancy at birth increased from 45
women 15-49 years to nearly 70 during the same time
(all methods): 76% period. Despite clear improvements at the
Life expectancy national level, one cannot ignore the large
at birth: 71 disparities in economic, social and health
indicators within a country that is
comparatively only slightly smaller than the
US. Brazil has some of the widest
inequalities in the world; for example, the
richest 10% are almost 30 times better off
than the poorest 40% of the population.
Between 1965 and 1984 Brazil was under
military rule. Although economic growth
rates were high, large social inequalities still
existed. Before 1974 the government was
officially pronatalist; however, by the mid-
1970s the government launched a
population redistribution policy aimed at
targeting Brazil’s increasing population
growth. Yet, due to strong opposition from
both the Catholic church and the military
there were no measures to promote
contraceptive use. Concurrently, the
government expanded the hospital network,
increased consumer credit, widened
coverage of the health system and further
developed communications systems. These
policies led to a preference for smaller
families, more exposure to modern medical
practices such as contraception and, as a
result, a 25% reduction in population
growth. At the same time, the demand for
contraceptives increased significantly. The
1980s was a period of democratisation and
27
the establishment of the Universal Health
System. Women’s groups demanded the
distribution of contraception by government
agencies and attempted to legalize abortion.
Population policy
Brazil has never had an explicit population
policy to regulate fertility, since coercion in
any sense is forbidden and family planning
is seen as a basic human right. Until 1985,
when the public health system began to
offer contraceptives, women depended
primarily on the private market and NGOs,
mainly for the pill. The quality of services
left much to be desired, with inadequate
screening and information leading to
contraceptive failures and side effects. As
a result, reversible contraceptive methods
became discredited by women.
Since the 1980s, contraception has posed
the greatest obstacle to an effective
public health system in Brazil. In 1984 the
Integral Programme for Women’s health
(or PAISM) was launched, which included
nearly all of the elements of reproductive
health care defined in the ICPD
Programme of Action ten years later.
Despite this, financial, political and
economic factors hindered its progress,
and the PAISM programme was not fully
integrated into the universal national
health system until 1995 when health
reform and decentralisation of the health
care system made it possible for the
programme to get underway. The late
1990s saw progress with the passage of
a family planning law, expansion of
availability of reversible contraceptive
methods in the public sector, limits on
Federative Republic of Brazil 28
sterilisation remain widespread, suggesting
Male Brazil 2004 Female
that there is a desire to limit family size
80+ which is not being met by the state.
75-79
70-74
65-69
60-64
55-59 Abortion and sterilisation
50-54
45-49
40-44 Abortion is widely practiced, despite its
35-39
30-34
illegality under Brazilian law except in
25-29 cases of rape or danger to the life of the
20-24
15-19 mother (until the 1980s women were
10-14 allowed access to abortion only if their life
5-9
0-4 was threatened and never due to rape).
10 8 6 4 2 0 0 2 4 6 8 10 Due to the limited legality of abortion it is
Population (in millions) difficult to capture exact figures. However,
estimates in the early 1990s indicated
Source: US Census Bureau, International Data Base that approximately 1.4 million abortions
(equivalent to one abortion for every two
Male Brazil 2025 Female
live births) were performed each year,
80+ many in unsafe conditions, often resulting
75-79
70-74
in the woman’s death. One hospital in the
65-69 mid-1980s estimated that 44% of
60-64
55-59 admissions were related to complications
50-54 due to unsafe abortions.
45-49
40-44
35-39
30-34
ICPD had a significant impact on abortion
25-29 policy in Brazil, with services now in place
20-24
15-19 to care for women who undergo unsafe
10-14 abortions and public health facilities
5-9
0-4 providing legal abortions for victims of
10 8 6 4 2 0 0 2 4 6 8 10 rape or whose lives are threatened by the
Population (in millions) pregnancy. In addition, recent changes have
made abortion more widely available where
the baby’s life may be threatened. For
caesarean sections in public hospitals and example, in July 2004 abortion in babies
efforts to regulate the contraceptives with anencephaly (no brain) was legalized.
market. However, to this day contraceptive
choice remains limited with most women For the past three decades sterilisation
resorting to sterilisation or the pill. and the pill have been the most common
contraceptive methods used by Brazilian
Since the mid-1990s, the Ministry of Health women. Until 1997 the legal status of
has been responsible for family planning, sterilisation was debatable, with neither
focusing on family planning education and public nor private health insurance
services, prenatal care, delivery and covering the procedure. Before this time,
postpartum care, infertility services, breast it was prohibited by the code of ethics
and cervical cancer screening, sexually governing medical practice in Brazil except
transmitted disease (STI) testing and for precise reasons approved together by
treatment of reproductive tract infections. two doctors. A common reason was if a
The programme covers women of all ages, woman had one or more caesarean
including adolescents, who are actively deliveries (C-sections). In 1992, one study
involved in education campaigns. Despite suggested that 7.5 million women were
these positive moves towards improving sterilised when a C-section delivery was
family planning services, abortion and performed. Brazil has one of the highest
Federative Republic of Brazil
rates of C-sections in the world. This is
partly because the cost of a C-section is
covered in public hospitals and is more
profitable for doctors than natural
childbirth. A common practice would be
for a doctor to classify a patient as a high
risk pregnancy, thus allowing them to
perform a C-section. The doctor would
then simultaneously perform a sterilisation
which would be paid for by the woman.
This arrangement benefited both the
women (who could afford to pay for the
procedure) and the underpaid doctors in
the public health system.
Contraceptive method use for all married women, Brazil
DHS 1996 (percentages)
Any method 76.7 Any traditional method 6.1
Any modern method 70.3 Periodic abstinence 3.0
Pill 20.7 Withdrawal 3.1
IUD 1.1 Any folk method 0.3
Injections 1.2 Any traditional/folk method 6.5
Diaphragm/foam/jelly 0.1 Not currently using
Condom 4.4 contraception 23.3
Female sterilisation 40.1
Male sterilisation 2.6 Total 100
According to the Demographic and Health
Survey (DHS) of 1996, approximately 40%
of married women in Brazil were sterilised.
It also appears that women are being
sterilised at younger ages. In the 1986-
1996 period sterilisation among married
Brazilian women in the 20-24 age group
rose from 4% to 11%. A 1986 survey
indicated that the average age at which
women were sterilised was 31.4; however,
by 1996 this figure had decreased to 28.9.
Furthermore, the irreversible effects of
sterilisation are frequently misunderstood,
indicating that women need to be made
more aware what sterilisation entails.
In 1997 a new federal sterilisation law was
passed. The law permits sterilisation of
women and men older than 25 (if married
with spousal consent) or those with at least
two living children. The legislation prohibits
sterilisation at delivery or within 42 days
(except in cases of medical necessity), and
29
in the public health system, imposes a 60
day waiting period after requesting
sterilisation during which time individuals are
counseled about alternative contraceptive
options and the possible side effects of
sterilisation. Sterilisation is now reimbursable
under the public health system at specifically
approved hospitals. Unfortunately, this has
had little impact for low-income women who
often do not know their rights and options
around reproductive health.
Why the decline?
The reasons behind Brazilian fertility
decline are complex, though urbanization
is undoubtedly a contributing factor since
it has reduced the desire to have large
families – approximately 80% of the
population were classed as urban in
2003. Furthermore, improved education
and lobbying for family planning amongst
women’s groups helped achieve an overall
desire to reduce family size.
An overarching factor which led to the
fertility decline witnessed in Brazil is the
integration of family planning into a
universal and free health service. This
gave women the incentive to visit a doctor
to discuss their reproductive health needs,
as well as increasing their understanding
of family planning overall.
Despite the major turnaround in the mid-
1990s towards a comprehensive health
care system which integrated reproductive
health matters, high levels of sterilisation
and abortion have been the two main
driving forces behind the decline in fertility
seen in Brazil. Even though abortion policy
has been relaxed slightly and sterilisation
laws have changed significantly since the
late 1990s, there is still an unmet need for
a wide range of contraceptives today.
HIV/AIDS in Brazil
Brazil has been unique in its response to
HIV/AIDS. From as early as 1996, the
Brazil AIDS programme provided free and
Federative Republic of Brazil
Brazil is a success story universal access to anti-retroviral drugs
in that it remains the (ARVs) in order to reduce deaths, improve
only large country to quality of life and reduce the economic
achieve universal access impact associated with HIV/AIDS.
to AIDS treatment and Remarkably, adult prevalence is only 0.7%
has been at the forefront today and in the period 1996-2002 more
of developing new than 60,000 cases, 90,000 deaths and
prevention methods. 360,000 HIV/AIDS related hospital visits
were averted.
The Brazilian HIV/AIDS strategy relies on
3 key principles – political leadership,
involvement of civil society and local
communities and the promotion of human
rights. The government response and
community involvement in the HIV/AIDS
programme are thought to be the key
drivers of its success. In Rio de Janeiro, a
city in excess of 6 million people, the first
HIV/AIDS cases were recorded in the
early 1980s, mainly in poorer regions.
Since the beginning of the 1990s, several
prevention measures have been initiated
including over 50 health facilities which
provide drugs and others which provide
condoms. It is estimated that AIDS-related
deaths decreased by 70% in the region
due to this programme.
Alongside the national strategy providing
free ARVs, other community-based
programmes aimed at reducing HIV/AIDS
were implemented such as education
programmes in schools which relate HIV
to other important issues such as violence
and drugs. Although the campaign started
with a focus on reducing prevalence
among men who have sex with men (those
with the highest prevalence in the early
stages of the epidemic), it now targets
men and women alike. Nevertheless, rural
women often lack the services provided to
their urban counterparts. In some rural
regions, nearly 90% of pregnant women
fail to go for antenatal care because it is
too far to travel – clearly these important
issues still need to be addressed.
However, compared to other less
developed countries (LDCs) Brazil has
been successful in reducing and
controlling its HIV/AIDS cases. For
example, the number of new HIV cases
decreased from 25,521 in 2001 to
30
22,295 in 2002. Experts estimate that
there are 660,000 HIV positive people in
the country today.
The Brazilian case illustrates how
government input and community
involvement, as well as universal health
care and ARVs, can go a long way to
stabilising the HIV/AIDS epidemic and
improving health care in the overall
population. Furthermore, Brazil is at the
forefront of new research and is involved
in testing microbicides (creams, gels,
films, suppositories, lubricants) which can
be inserted in the vagina or rectum before
sexual intercourse and would substantially
reduce transmission of STIs including HIV.
Conclusion
Brazil has shown that it is possible to limit
its population growth without explicitly
stating it wanted to do so. Integrating a
universal health care system with
reproductive health and family planning
has had a significant impact. Although
there have been significant increases in
clandestine abortions and sterilisations
amongst women, Brazil has been
successfully able to provide a diverse
health care system to the vast majority of
its population. The main challenge Brazil
faces is to provide wider contraceptive
choice for all its citizens.
Brazil provides hope to countries
struggling to deal with the impact of the
HIV/AIDS epidemic. It has shown that
alongside a comprehensive health care
system, even minor changes in the
education system to focus more on
HIV/AIDS and other related issues can
influence a reduction in HIV/AIDS cases.
Brazil is a success story in that it remains
the only large country to achieve universal
access to AIDS treatment and has been
at the forefront of developing new
prevention methods.
The People’s Republic of China 31
COUNTRY STUDY
The People’s
Republic of China
Population: Total fertility rate for China, 1949 to 2001
1985: 1,070,000,000
Mid 2004: 1,300,100,000 8

2025: 1,476,000,000 7
(projected)
Children per woman

Total fertility rate: 1.7 5

Contraceptive use 4
amongst married
3
women 15-49
(all methods): 83% 2

Life expectancy 1
1949 1959 1969 1979 1989 1999 2001
at birth: 71
Source: China Population Information and Research Centre and US Census Bureau, International Data Base

Introduction

China is a Communist state with tight
political controls but increasingly relaxed
economic controls. China’s 1.3 billion
people make it the world’s most populous
country and it is projected to continue
growing until approximately 2030 when its
numbers will peak at over 1.4 billion. Such
a large populace presents both
opportunities and threats, and China’s
national population policy presents a vivid
example of the clash between society’s
objectives and individual rights. In recent
years China has become an economic
powerhouse, largely due to a seemingly
endless supply of cheap labour. However,
despite dramatic economic progress,
China remains a low-income country with
millions living in poverty, particularly in
rural areas. China accounts for one fifth of
the world’s population, yet it only
produces less than 5% of the world’s
Gross Domestic Product (GDP).
Although China’s infamous one-child
policy has succeeded in dramatically
reducing growth by approximately 300
million people in the last decade, many
concerns exist about its social and
economic impacts and infringement of
individual rights and choice. Chinese
officials claim that the government
population policy is essential to lift people
out of poverty and bring individuals a
better standard of living. However, as in
other parts of the world, evidence exists
that families increasingly desire fewer
children, chiefly for economic reasons.
China currently faces several demographic
challenges including its ageing population
and the growing HIV/AIDS epidemic, both
of which are likely to become increasingly
significant in the coming years.
China’s mortality rate has declined
dramatically in the past 50 years. In 1949
(the year of the formation of the People’s
Republic), life expectancy was 35. In
1980 it was 64 and by 2004 it reached
71. This was due to improved nutrition,
sanitation and the extensive public health
system underwritten and organised by the
government. However, the shift toward a
The People’s Republic of China 32
political strength and provide labour for
Male China 2004 Female
economic development. However, by the
100+ mid-1950s the government reversed its
95-99
90-94
position due to fears that excessive
85-89 growth would hinder development and a
80-84
75-79 desire to improve maternal and child
70-74 health. The reduction in fertility rates in
65-69
60-64 China started as far back as the 1950s-
55-59
50-54
1960s, mainly because the government
45-49 started paying attention to birth rates in
40-44
35-39 urban areas and people desired fewer
30-34 children. In the 1950s the government
25-29
20-24 promoted fertility control in the name of
15-19 maternal and child health. In the1960s the
10-14
5-9 focus was on teaching rural people about
0-4
the benefits of smaller families and the
70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70
government tried to increase access to
Population (in millions) contraception and abortion. Although birth
Source: US Census Bureau, International Data Base
rates started to decrease in urban areas,
the same did not occur in rural areas
Male China 2025 Female where most of the population lived. In
1970, the TFR remained at 5.8.
100+
95-99
90-94 In 1971, the government launched a
85-89
80-84 campaign called ‘later, longer, fewer’
75-79
70-74
which encouraged later marriage, longer
65-69 intervals between births and fewer births.
60-64
55-59 The policy established national and
50-54 provincial level targets for births. The
45-49
40-44 goals were three children for rural couples
35-39
30-34
and two for urban couples. Yet, by the end
25-29 of the 1970s couples were encouraged to
20-24
15-19 have only one child and the government
10-14 began to believe that population control
5-9
0-4 would require extreme measures. They
70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70 were convinced the country could not
Population (in millions) grow economically if they did not curb the
rapid population growth.

market-orientated system since the early
1980s has meant the demise of guaranteed
access to health care for all, particularly in
rural areas where mortality rates remain
notably higher than urban areas.
Population policy development
In 1979 the government launched the
one-child policy, which initially allowed all
couples only one child and required
official approval before conceiving a child.
Compliance was encouraged through a
system of incentives and disincentives
such as preferences in education, housing
and health care if you only had one child.

At the time of the Communist Revolution
in China in 1949, the Total Fertility Rate
(TFR) was 6.1 children per woman. In the
early days, the government argued China
needed a large population to boost its
Over the years the one-child policy has
changed significantly. At first, women were
encouraged to be sterilised after two
births and rules of contraceptive use were
strictly enforced. Yet, because China is so
The People’s Republic of China
English translation:
One child, prosperous life
Beijing Centre of Communication
and Education for Family Planning
vast and diverse, in 1984 the government
began to allow fertility regulation at the
local level. Each province enacted its own
self-contained population planning
programme, with officials encouraged to
avoid heavy handed methods of
enforcement. This has led to a large
variation in the content of regulations
among provinces. Since that time, rural
couples have been allowed a second child
if their first is a girl. In addition, ethnic
minorities are allowed two children and
more recently urban couples who are both
only children themselves may have two
children. In April 2004, Shanghai
announced that divorced couples who
remarry can have a second child.
Moving beyond coercion?
The 1994 International Conference on
Population and Development (ICPD)
raised global awareness of population
issues. Inevitably, the Chinese approach
came under increasing scrutiny. ICPD
stressed the value of a comprehensive
approach to reproductive health, which
encouraged China to improve the quality
and range of family planning services.
Exceptions to the one-child policy have
increased and changes have been made
in pilot areas.
In 1995, the Chinese government
reorientated the family planning program
to be “driven by the people’s interest”. The
State Family Planning Commission
introduced the reforms by selecting a few
rural and urban pilot counties where family
planning services would offer a range of
contraceptive method choices,
reproductive health care, prenatal care
and counseling. Although local officials
still set family planning targets, the
concept of informed choice has started to
gain ground in many counties.
The United Nations Population Fund
(UNFPA) has been influential in China in
stressing that a voluntary approach to
family planning is more effective than
coercive methods. Consequently, in recent
33
years a new client-centred approach has
taken hold in many parts of the country.
There are now 32 pilot counties where the
State Population and Family Planning
Commission, working with the Ministry of
Health and China Family Planning
Association, have abandoned birth quotas
and targets. Services in family planning
clinics have been upgraded and women
and men have been given more choice
when selecting contraceptive methods,
including wider access to condoms, pills
and injectibles. This programme is
currently expanding to 880 counties (a
third of the country), although initially they
will retain birth quotas and targets. In the
32 pilot counties contraceptive prevalence
is up to 90% and the abortion rate has
dropped by an average of 30%.
It is important to note that despite
changes, the one-child policy still officially
exists in China and was reaffirmed in the
2002 National Population and Family
Planning Law. While it adheres to the one-
child policy, it allows local governments to
define special groups of people who can
have more children. The law continues to
include fines for having extra children, but
punishment is unevenly implemented. In
August 2004, the Chinese government
adopted a new policy which rewards
farmers with a cash payment of 600 Yuan
annually (£40) from age 60 if they have
only one child or two girls. The policy will
be implemented on a trial basis in 15
provinces in western and central China
this year and is expected to be gradually
expanded nationwide.
China today
The Census of 2000 showed the
population to be 1.26 billion, which was
above their ambitious goal of 1.2 billion.
Although fertility rates did fall in all parts of
China, according to the government they
are still too high. Much debate exists
regarding China’s actual TFR. Current
figures show it is 1.7 and future
projections assume this. However, some
Chinese demographers believe the real
The People’s Republic of China
English translation:
Up agricultural
production, down
population increase
Beijing Centre of Communication
and Education for Family Planning
number lies between 2.0 and 2.3 children.
In some urban areas the TFR is as low as
1.2, but in many rural areas it is still well
above 2. The true population size is very
difficult to determine as rural families may
hide children to avoid penalties.
Contraceptive use is high in China. In
2004, 83% of married women aged 15-
49 were using a method of contraception.
In 1982 the contraceptive prevalence rate
among this group was 71%. Condom use
remains low; however, it increased from
1.4% in 1982 to 3.4% in 1997. Studies
indicate that after a first child most women
use an IUD (intrauterine device, coil) and
after a second child they are sterilised.
Contraceptive use and child care remain
the responsibility of women.
Marriage has always been a significant
institution in China, but has changed
profoundly in recent years. It continues to
be nearly universal for women but the age
of marriage has increased. The government
encouraged, and now mandates, late
marriage as a way to lower fertility and
slow population growth. In 2003 the
average age at marriage for women was
22.1 up from 18.2 in the 1940s.
There are several significant demographic
consequences of China’s birth planning
policies. The most serious may be the
ageing of the population, with a declining
proportion of the population in the active
work force to support increasing numbers
of elderly. In 2004 adults aged over 60
make up 11% of the population, yet the
UN projects they will increase to 15% in
2015, 24% in 2030 and 28% in 2040.
Projections for 2050 suggest there will be
nearly 100 million Chinese aged 80 or
older. There will be more elders for each
child and the elders will be older and
frailer. Traditionally, the family provides
much of the support for old people, with
less than 25% of the workforce receiving a
pension. In addition, relatively few Chinese
elders work compared with other Asian
countries. In the future, children will spend
more time taking care of their parents and
there will often be three generations in one
34
house. Demographers call this the ‘4-2-1’
problem – in many families one child will
be expected to support two aged parents
and four grandparents. In the 2000
census, 64% of elders aged 65 or older
lived with their children.
Another consequence of the one-child
policy is a generation of only children.
These children have been referred to as
‘little emperors’ as many are doted on by
parents and grandparents and described
by critics as spoiled, self-centred and in
need of discipline.
Another serious outcome of the one-child
policy is the ‘missing girls’ phenomenon.
In China, the sex ratio of males to females
is the highest in the world. The 2000
census showed the sex ratio to be 118
boys for every 100 girls (the normal sex
ratio is 105:100), but the reality is
probably closer to 120 or more. The
explanations for these numbers range from
sex-selective abortion, to underreporting of
female births, adoption of female babies,
to deaths of girls through female
infanticide, neglect or abandonment. Rural
families may be under particular pressure
to kill baby girls, due to the need to
produce a child that can cope with the
physical demands of farming and prevent
cash-strapped farming households from
plunging deeper into poverty. Even in
urban areas the tradition of son
preference remains strong, as boys are
considered better able to provide for their
families, care for elderly relatives and
continue the family line.
Although identification of the sex of a
foetus and sex-selective abortion are
strictly illegal in China, in the past two
decades with the introduction of
ultrasound screening of embryos, many
females have been aborted. Doctors can
be bribed, and without indicating the sex
may tell couples to “paint the baby’s room
pink”. As a result, fewer girls are born and
orphanages in China are filled with girls.
Consequently, in years to come there will
be many more men than women in China.
If this trend continues, by 2020 China
The People’s Republic of China
English translation:
Control our population
at 1,200 million
China Family Planning Association,
2000
could have up to 40 million men who can’t
find a spouse. These men are called ‘bare
branches’ as they are unlikely to be able
to continue the family line. Due to the
shortage of women some men are turning
to foreign women, there is a growing
traffic in kidnapped brides and
commentators worry about the potential
destabilisation of Chinese society.
HIV/AIDS in China
Although the percentage of the population
infected with HIV/AIDS in China remains
low at less than 0.1%, the government
has recently admitted there are 840,000
people infected with HIV (up 30% in one
year) and over 80,000 have died of AIDS-
related illnesses. However, the stigma
attached to HIV testing results in many
infections remaining undiagnosed. Experts
predict that without serious prevention
measures 10-15 million Chinese could
become infected with HIV by 2010.
In addition, the risk factors exist in China
for a generalised epidemic: a highly mobile
population, poverty (particularly in rural
areas), an increase in high risk behaviour
such as needle sharing, low condom use
and an increase in STIs. Possibly the most
significant risk factor in China is a lack of
HIV/AIDS-related knowledge and severe
social discrimination and stigma related to
the disease. In addition, pre-marital sex is
on the increase, sex education is not
taught in primary or middle school and
cultural conservatism limits discussion of
sexual matters.
Until recently, HIV tests were only
available to the most stigmatised members
of society such as sex workers and
injecting drug users, but with the quick
spread of the virus in the general
population the government is making tests
more available to the wider public.
The vast majority of people infected with
the HIV virus in China are former plasma
donors in seven central provinces. During
the late 1980s to late 1990s, without
35
being tested for hepatitis or HIV, many
farmers sold plasma (the liquid portion of
blood that provides critical proteins for
clotting and immunity) to unregulated and
often illegal collection centres who pooled
the blood of several donors of the same
blood type, extracted the plasma, then
injected the remaining red blood cells
back into individual donors to prevent
anaemia. This risky practice meant that
infection from just one person could
spread to many people.
Since 1995, China has developed strict
guidelines that all blood must be
screened for HIV and other blood-borne
diseases before clinical use; however,
there are still HIV cases reported through
blood transfusions in rural areas. Outside
major cities, hospitals and clinics still
reuse needles and medical equipment,
which contributes to the spread of blood-
borne diseases.
In Spring 2003, the ‘China Cares’
Programme (China Comprehensive AIDS
Response) was launched to assist
infected plasma donors. It provides
subsidised testing, free domestically
produced ARVs and other medications to
treat opportunistic infections. Under this
programme, by the end of 2003 over
5000 people were receiving antiretroviral
treatment. However, the Chinese Ministry
of Health estimated that 300,000 people
will need such treatment by 2008.
In 2002, injecting drug users accounted
for half of new HIV infections. However,
sexual transmission of HIV is increasing.
No specific prevention or treatment
programmes exist for drug users, sex
workers, men who have sex with men or
the floating population of economic
migrants. Presently, it is estimated that
four times more men than women in China
are infected with HIV.
In recent years, the government has
started to allocate funds towards
prevention and control of HIV/AIDS.
Despite this, in 2000 UNAIDS reported
the amount to be one seventh that of
The People’s Republic of China 36
Thailand’s. The Ministry of Health reports
there are only between 50-100 doctors in
China who can diagnose and treat HIV
infections and they are rarely in rural areas
where most sufferers live.

The government’s new centrepiece policy,

‘four frees and one care’, commits to
provide free ARVs to impoverished
citizens, free voluntary HIV counseling and
testing, free prevention of mother to child
transmission, free schooling for AIDS
orphans (of whom there are approximately
76,000) and care for AIDS patients and
their families. Provinces and counties are
required to raise funds locally for these
mandates. Unfortunately, the government
has had limited success in implementing
100% condom use and needle exchange,
as they do not want to be seen to
condone illegal or illicit activities. However,
condoms can now be advertised on
television and sex education is gradually
being introduced into secondary schools
in some parts of China.
Republic of India
COUNTRY STUDY
Republic of India
Population:
1985: 764,000,000
Mid 2004: 1,086,000,000
2025: 1,363,000,000
(projected)
Total fertility rate: 3.1
Contraceptive use
amongst married
women 15-49
(all methods): 48%
Life expectancy
at birth: 62
Introduction
In August 1999, India’s population passed
the 1 billion mark and it is predicted to
surpass China as the world’s most populous
nation in the next 25-50 years. The
population is expected to peak at around
1.6 billion by 2050. India’s growth has been
rapid, resulting from longer life expectancy
and lower infant mortality in recent decades.
Since India gained independence from
Britain in 1947, the average life expectancy
at birth has risen from just 28 years to 62
years. Family sizes have also fallen sharply.
In 1947 the average couple had six children,
while today the average couple has only just
over three. However, population momentum
means that in the same half century the
country’s population has nearly tripled.
India accounts for a sixth of the world’s
population but, according to the World
Bank, also accounts for 40% of the
world’s absolute poor (60% of whom are
female), and the world’s largest number of
illiterates. The high rates of poverty, low
literacy and lack of female equality,
coupled with high population growth rates,
37
have created a long running debate in India
about whether falling birth rates are a
prerequisite for development or if fertility
decline follows social and economic
development. Since the 1990s, India has
undergone a dramatic shift in its national
population policies away from a
demographic targets approach towards a
policy which promotes wider consideration
of human rights and individual needs.
From population numbers to
a target free approach: India’s
evolving population policies
In 1952, India became the first country in the
world to establish a national family planning
programme. Although originally aimed at
improving the health of mothers and children,
in the 1960s its focus shifted towards a
reduction in birth rates as a result of
increasing political concern about population
growth. The government set the first of many
over ambitious targets, aiming to reduce the
birth rate from 40 per 1000 to 25 per 1000
by the mid 1970s (this was only achieved
after the year 2000). Additionally, in 1966
the government introduced targets for
contraceptive usage including the sterilisation
of men and women. To many politicians
and government officials it represented a
permanent, more cost effective method of
fertility reduction. The new target orientated
approach dominated the field of population
and family planning until 1996. The central
government set sterilisation targets for states
and health workers to meet and introduced
financial incentives to reward health
workers who achieved them. Mass
vasectomy camps were organized across
India, including one in Ernakulam during
1972, at which 65,000 vasectomies were
carried out within a fortnight.
Republic of India 38
also amended the constitution to ‘freeze’
Male India 2004 Female
representation in parliament based on the
80+ 1971 Census until 2001. As political
75-79
70-74
representation in Parliament was based on
65-69 a state’s population size, this could have
60-64
55-59 provided a disincentive for states to
50-54 reduce their population. Ultimately, the
45-49
40-44 population programme resulted in a public
35-39
30-34
revolt against the government, which led
25-29 to its downfall in 1977. The aggressive
20-24
15-19 family planning programme was often
10-14 referred to as the first to ‘cause a
5-9
0-4 government to fall instead of the birth rate’.
70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70

Population (in millions) The excesses of the emergency years

caused a crisis for family planning in India.
Source: US Census Bureau, International Data Base The term family planning became
synonymous with coercion and forced
Male India 2025 Female
sterilisations and there was widespread
80+ public mistrust. The new government
75-79
70-74
renamed ‘family planning’ as ‘family
65-69 welfare’, revised the Population Policy to
60-64
55-59 reduce sterilisation targets and stated that
50-54 ‘compulsion in the area of family welfare
45-49
40-44 must be ruled out for all times to come’.
35-39
30-34
From 1978 until the 1990s, contraceptive
25-29 choice and the voluntary nature of family
20-24
15-19 planning were emphasised, although
10-14 targets remained in place for contraceptive
5-9
0-4 usage and for reducing the birth rate to
70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70 around 25 per 1000.
Population (in millions)

1990s: Towards a target free

Slippages in achieving the reduction of
the birth rate led to an intensified drive to
promote sterilisation during the emergency
period of 1975-1977. A National
Population Policy was formulated and
adopted by the Parliament in 1976, which
called for a ‘frontal attack on the problems
of population’ and which inspired the state
governments to ‘pass suitable legislation
to make family planning compulsory for
citizens’. Incentives for health workers to
meet sterilisation targets were increased
and mass sterilisation events were carried
out in railway stations. There were reports
in the Northern states of Bihar and Uttar
Pradesh of men being forcibly subjected
to the procedure. Between April 1976 and
March 1977, over 8 million sterilisations
were carried out in India. The new policy
approach
By the 1990s, criticism of India’s
approach to population increased both at
home and abroad. Academics argued that
by focusing on population growth rates,
the success in the fall in fertility rates had
been overlooked. Fertility rates had almost
halved since independence; however,
death rates had fallen even faster (see box
below). They highlighted the fact that
since India was already undergoing
demographic transition, an enforced
approach to population was unnecessary.
The target orientated approach, which
relied on targets set by the central
government, was subject to particular
criticism. Firstly, by setting targets centrally
Republic of India
Birth and death rates per 1000 population
Year Birth rate (per 1000) Death rate (per 1000)
1901 49.2 42.6
1951 40.9 22.8
1991 29.1 9.4
it ignored the wide disparities between
states in terms of social and economic
development as well as culture and religion.
During the 1990s, India moved towards a
more decentralised power structure which
afforded more decision making to the
states. In 1992, the Panchayat Act created
a system of ‘local government’ through
elected Panchayats (village councils), with
a third of the seats reserved for females. It
no longer made sense to set central
targets for contraceptive uptake when
local structures existed which had a better
understanding of the needs in their area.
Secondly, the emphasis on achieving
targets to the exclusion of respecting
people’s choices and rights led to abuse
and exploitation by officials and created a
mistrust of family planning which is still
being overcome today. Aside from the
accusations of enforced sterilisation during
the ‘emergency’ years, the promotion of
sterilisation above other methods subjected
people to procedures carried out in
appalling conditions with no medical follow
up. As the levels of incentives for health
workers were highest for sterilisations,
workers would promote sterilisation at the
expense of other, less permanent
contraceptive methods which would enable
women to delay or space their childbearing.
Field studies by researchers indicated that
contraceptive usage rates reported by
health workers had been vastly inflated,
resulting in little impact on the birth rate.
The women’s movement was the most vocal
critic of the government’s family planning
programme in the 1990s. They argued that
focusing family planning targets on women
represented a violation of women’s rights
as women’s bodies were being used as a
39
conduit for meeting government aims. Poor
illiterate women were being pressurised
into accepting sterilisation without fully
understanding the implications of the
procedure. The women’s groups also
argued that women throughout India were
not empowered to make decisions about
spacing their families. They claimed that
by focusing on contraception without
attention to female empowerment, literacy,
poverty and violence against women, the
government demonstrated a total disregard
for their real needs and concerns.
The ‘gender gap’ in India was, and despite
progress still is, a significant issue in India.
The low status of women is a central factor
influencing high fertility rates, as surveys
show that only 51% of women are involved
in decisions about their own health care.
Despite a 1976 law stipulating 18 years as
the minimum age of marriage for females,
the National Family Health Survey (NFHS)
of 1998-1999 found that half of women
married before age 18, with the average age
of marriage being 16.7 years. Early marriage
significantly contributes to high fertility rates
as girls begin childbearing at an earlier age.
It also leads to high rates of pregnancy
complications and deaths, with 15-19 year
olds twice as likely to die in pregnancy or
childbirth than women over 20.
With a Maternal Mortality Ratio (MMR) of
540 maternal deaths per 100,000 live
births, maternal mortality affects women
of all age groups in India. Over half of all
women giving birth do not have the
assistance of a skilled health professional
and 66% of births take place at home.
When a woman dies or becomes disabled
by pregnancy, her surviving daughters will
often be required to leave school in order
to care for their younger siblings. Through
their lack of education they are, in turn,
more likely to marry and begin
childbearing early, which increases their
own risk of maternal mortality.
Another major rights issue for women in
India is the Dowry system. Originally a
method for passing on a share of family
inheritance to daughters at their marriage,
Republic of India
over the years Dowry evolved into a large
quantity of gifts given by the bride’s family
to the groom’s family at marriage. In most
areas of India, when women get married
they leave their family to live with their
husband’s family and the marriage
preparations include detailed negotiations
between the families as to the exact level of
dowry gifts required. These often include
luxury goods such as vehicles and
televisions and may be paid in instalments
for the first few years of marriage by the
bride’s family. Although officially banned in
1961, the practice remains common
across India and it can be difficult to marry
off daughters without the promise of a
large dowry. The system has contributed
to a belief that daughters are a burden on
families due to the costs of their dowries.
The practice of a woman leaving her family
to join her husband’s family at marriage also
impacts on the level of female education. As
her family will not reap the benefit of their
investment in her education, schooling of
sons is often prioritised over daughters.
The NFHS 1998-1999 reported a female
illiteracy rate (age 6+) in India of 48.6%,
with state-wide female illiteracy rates ranging
from 14.9 % in Kerala to 62.9% in
Rajasthan. Low rates of female literacy
directly impact upon infant mortality. A report
from 1995, by the Indian Institute for
Population Studies, found the infant mortality
rate for children born to literate women was
just over 60 per 1000, compared to 100
per 1000 children born to illiterate mothers,
as educated women are more likely to
understand the benefits of good nutrition
and health care for children. Low levels of
infant mortality correlate with lower fertility
rates, as parents become more confident
their children will survive to adulthood.
The low status of women has created an
environment where sons are prized over
daughters and a common blessing in India
is ‘May you be the mother of a hundred
sons’. Son preference has led to a serious
gender imbalance in India. The 2001
Census showed the number of women had
fallen to 933 per 1000 men. The sex ratio of
0-6 year olds demonstrates that this trend
40
is only getting worse as there are 927
females to 1000 males in this age group
in India. In some states the imbalance is
even greater, with the Punjab only
registering 793 female 0-6 year olds to
1000 males. A number of factors reduce
the presence of female children including
sex-selective abortion (although illegal, it
remains widespread), neglect of the girl
child and female infanticide, with the
overriding cause remaining the low status
of women. The gender imbalance is
leading to a shortage of females of
marriageable age, which will only increase
in future years. There has already been a
rise in the trafficking of young females
from across India and surrounding
countries to meet the demand for brides.
India’s preparations for the International
Conference on Population and Development
(ICPD) in 1994 brought arguments about
gender equality increasingly into the public
spotlight. At the conference, women’s
groups from India joined forces with women
from other countries to call for a new
approach which put the needs of women
and children above demographic goals. As
ICPD also influenced major donors,
including the World Bank, to change their
funding priorities, the Indian government
came under increasing pressure to
radically revise their approach to
population. As one Indian Observer noted,
“Whoever went to Cairo came home
convinced that change was necessary”.
In 1995, the Indian Government decided
to experiment with a Target Free Approach
(TFA) in one or two districts in selected
states across India before making the entire
nation target-free in 1996. The TFA removed
all government-set targets for contraceptive
usage and left states to assess what family
planning and health services people actually
wanted and plan their workloads around this.
By planning health care provision at a local
level, in consultation with the community, it
was hoped that services would better
meet the needs of ordinary people. The
emphasis was to be on making a choice of
contraceptives available and on the quality,
as opposed to quantity, of services provided.
Republic of India
“Whoever went to The success of the new approach varied
Cairo came home across the districts selected for the pilot.
convinced that change
was necessary.” While some districts took time to plan and
adequately train and support their health
workers to deliver the new approach, the
speed of the change in policy left some
districts struggling to make sense of the
new way of working. In some districts,
extensive surveys were carried out in the
community in order to assess the needs of
people using family welfare services.
Health workers’ caseloads were calculated
based on the results of the surveys. In
these districts the quality of services
improved significantly. Child immunisation
and the per centage of births attended by
a trained health worker increased as
workers were able to address the wider
needs of women rather than focusing on
meeting their family planning targets.
However, despite the removal of central
targets, other districts imposed their own
targets and did not attempt to engage the
community in assessing the need for
family welfare services.
Despite the mixed success of the pilot year,
in 1996 the government scrapped centrally
determined targets for all the states in India.
In 1997, statistics showed the number of
family planning users declined in India,
largely because previous statistics had been
inflated. By 1998, however, use of all
methods had increased, which allayed the
fears of many sceptics that contraceptive
use would decline without targets.
Current challenges
In 2000, the Indian Government launched
a new National Population Policy which
formalised the new broad based approach
to population. Although it retains a medium
term objective to reach replacement level
fertility by 2010 and a long-term objective
to achieve a stable population by 2045, its
immediate aims are to “address the unmet
needs for contraception, health care
infrastructure, and health personnel, and
to provide integrated service delivery for
basic reproductive and child health care”.
41
It has set ambitious goals to be met by
2010, including making school education
up to the age of 14 free and compulsory,
lowering infant and maternal mortality and
promoting delayed marriage for girls,
preferably after the age of 20.
The Population Policy also sets out a
number of practical measures to help
achieve the overall aims. These include a
cash reward of 500 Rupees for the birth of
a girl, if she is the first or second child, in an
attempt to redress the sex ratio. A further
incentive of 500 Rupees is promised to
women who give birth to their first child
after the age of 19 as long as they attend
ante natal care, give birth supported by a
trained birth attendant and immunise the
child. Couples living below the poverty line
will be rewarded for undergoing sterilisation
after the birth of their second child and
crèches are promised for urban slums and
rural areas to encourage the participation
of women in paid employment.
The new Population Policy embraces a
human rights approach to population and
development but it faces many challenges
in its future implementation. Sustained
political commitment will be critical in
reaping the long term developmental
benefits of the plan, as it will take decades
for the full effects to be felt in areas such
as female empowerment and population
stabilisation. Even after the announcement
of the new policy in 2000, the coalition
government of the time, led by the BJP,
began to openly advocate for a two-child
policy in India. In their 2004 election
manifesto they proposed to ban anyone
with more than two children from public
office and government jobs. The elections
of 2004 saw the BNP-led coalition lose
office to be replaced by a coalition led by
the Indian National Congress. They appear
to be supporting the principles of the
Population Policy and in July 2004
announced extra assistance to the 170
districts of India with the highest birth rates
(largely located in the poorest Northern
states). Their aim is to provide extra family
planning and reproductive health facilities
in the poorest communities and to seek
Republic of India
support from all sectors of the community
in improving the quality of health services.
Reducing the wide disparities between
states will continue to be a critical
challenge for India. Poverty, gender
equality and access to health and
education vary greatly between states,
with an increasing gulf opening between
the poorer Northern states, including Bihar
and Uttar Pradesh (where fertility rates are
4.7 and 4.5 respectively), and the more
prosperous Southern states such as
Kerala and Tamil Nadu, where fertility rates
have fallen dramatically to 1.8 and 2.1
respectively. Concern about population
growth has led some of the Northern
states to introduce extreme policies to
promote fertility reduction.
The states of Haryana and Madhya
Pradesh have introduced legislation which
prohibits people running for election to the
local Panchayats if they have more than
two children. In Madhya Pradesh,
compliance with the minimum age of
marriage has been made a prerequisite for
applying for government jobs. Sterilisation
incentives have also been introduced and
in August 2004 it was announced that
District Magistrates in Uttar Pradesh will
offer gun licenses to men who undergo
sterilisation. Such policies have been
widely criticised, particularly the elements
which discriminate against those with
more than two children. Critics argue that
those most likely to have large numbers of
children are the poor and these policies
marginalise them further. As women often
have little choice over their childbearing or
age of marriage, debarring them from jobs
and education further disempowers them.
As awareness of the full range of
contraceptive methods has increased
across India, the government now faces
pressure to ensure that supplies meet the
growing demand. The NFSH 1998-1999
reported that nearly 16% of married
women in India had an unmet need for
contraception. In some states, including
Uttar Pradesh, Meghalaya and Arunachal
Pradesh, between a quarter and a third of
42
married women had an unmet need. India’s
large numbers of adolescents will create
further pressure to meet unmet need in the
future. With 36% of its population aged
under 15, India has more adolescents
than any country in the world. These
young people will soon be entering their
childbearing years and the government
faces an enormous task in meeting their
sexual and reproductive health needs. The
United Nations Population Fund (UNFPA)
has recently launched a five year initiative
in India to meet the needs of adolescents.
A final major challenge for the government
of India is the need to scale up their
response to the HIV/AIDS, crisis which
has the potential to threaten the public
health and development gains of recent
years. India currently has around 5 million
people infected with HIV and will soon
overtake South Africa as the country with
the most HIV cases. Recently, the World
Bank warned that without progress on
prevention HIV/AIDS would become the
single largest cause of death in India,
accounting for 17% of all deaths and 40%
of infectious deaths by 2033.
The six states with the highest prevalence
(including Andhra Pradesh, Maharashtra and
Tamil Nadu) account for 80% of all reported
HIV cases in India. However, it is likely that
HIV is prevalent elsewhere but remains
undiagnosed. While awareness of HIV and
how it is transmitted is relatively high in
some Southern states and urban areas such
as Delhi, awareness remains low in the rural
areas where the majority of India’s
population lives. In Bihar, less than 12% of
adult women had ever heard of AIDS and
there is growing concern that an epidemic
may take root in rural areas. Currently,
there are more males infected with HIV
than females, but it is likely that should HIV
become embedded across the country,
females living with HIV will eventually exceed
males. Lack of equality in relationships
renders many women unable to protect
themselves and only 3% of Indian women
currently use condoms. A major public
information effort will be required for India to
prevent HIV reaching sub-Saharan levels.
The Islamic Republic of Iran
COUNTRY STUDY
The Islamic
Republic of Iran
Introduction
Population:
1985: 48,400,000
Despite the common belief that Islamic
Mid 2004: 67,400,000
societies prefer larger families, Iran has
2025: 84,700,000
shown that this is not necessarily true and
(projected)
has often been cited as a success story with
regard to population policy. Remarkably, Iran
Total fertility rate: 2.5
reduced its population growth from 3.4%
Contraceptive use in 1986 to just over 1% in 2004 and has
amongst married sustained a reduction in its total fertility rate
women 15-49 from around 6.5 births per woman in 1986,
(all methods): 74% to 2.5 today – one of the fastest declines
in history. This has been achieved through
Life expectancy
several pathways, not least because of a
at birth: 69
unique political and religious commitment.
Despite an explicit pronatalist position
adopted from 1979-1989, the country
made a dramatic turnaround during the
1990s to achieve the low fertility rates
experienced today.
The Islamic Revolution
From 1941-1979 Iran was ruled by the
Shah (King). However, his autocratic style
of rule was unpopular with many Iranians
and in 1953 he was briefly overthrown,
but reinstated with the support of the US
Central Intelligence Agency (CIA). During
the following period in power, the Shah
introduced a number of social, economic
and political reforms which gave more
freedom to women and restricted the
influence of religious leaders. These
included the introduction of a population
policy in 1967, with a view to improving
the health and wealth of the country
through a reduction in population growth.
The introduction of this policy, along with
the close relationship the Shah enjoyed
with the US, led to accusations from many
sections of society that Iran was becoming
too westernised and that the Iranian identity
43
and culture were under threat. When the
economic reforms were seen to benefit only
the urban elite, critics of his economic
policies joined together with religious leaders
and pro-democracy campaigners to oppose
his rule. By 1978 the opposition took to the
streets, and despite some bloody battles with
the Shah’s security forces, in January 1979
the Shah was forced to flee Iran. A new
constitution appointed Ayatollah Khomeini
as the Supreme Leader of the country and
the Islamic Republic of Iran was born.
Religious clerics held great power in the
new republic. Although there was an elected
parliament, legislation could be overturned
by the Council of Guardians, a group of
religious clerics tasked with ensuring that
all legislation passed was consistent with
Islamic values and teachings. The influence
of the religious clerics, coupled with a
backlash against seemingly western
influences, led the family planning
programme to become effectively paralysed.
While contraceptives were not banned they
were not distributed, and the programme
was not promoted as it was seen by many
to be un-Islamic. Early and universal
marriage was endorsed and the minimum
age lowered to 9 for girls and 12 for boys.
When Iran went to war with Iraq in 1980
(a conflict which lasted eight years and
involved large scale casualties), opponents
to family planning became even more vocal
and called for Iranians to do their duty by
having more children in order to build a
‘twenty million man army’. In addition,
throughout the war period larger families
were entitled to a greater proportion of basic
commodities and consumer goods via a
rationing system. Babies meant an additional
share of rationed goods, which included
not only food but modern consumer goods.
The Islamic Republic of Iran 44
amongst politicians about how they would
Male Iran 2004 Female
meet the basic needs of an ever increasing
80+ populace. Due to the sensitive nature of the
75-79
70-74
topic, many behind the scenes discussions
65-69 and negotiations took place to win support
60-64
55-59 from the religious clerics for a population
50-54 programme. A series of conferences were
45-49
40-44 held to discuss the relationship between
35-39
30-34
Islam and population policies and to
25-29 highlight the implications of continued
20-24
15-19 population growth. Several newspapers
10-14 and radio stations broadcast articles in
5-9
0-4 favour of fertility decline, which generated
5 4 3 2 1 0 0 1 2 3 4 5 public support and brought family planning
Population (in millions) to the forefront of debate. Despite their
previous support of a pronatalist policy,
Source: US Census Bureau, International Data Base the religious leaders were forced to be
pragmatic. The success of the Islamic
Male Iran 2025 Female
republic would rest on their being able to
80+ provide services and an increased standard
75-79
70-74
of living for Iranians. Moreover, they realised
65-69 that should population growth make this
60-64
55-59 impossible to achieve they might be forced
50-54 to accept support and aid from countries
45-49
40-44 in the West, thus allowing western
35-39
30-34
influence to return to Iran. Consequently,
25-29 the religious clerics were able to reconcile
20-24
15-19 the idea of a population policy with Islamic
10-14 values. It was every Iranian’s duty to check
5-9
0-4 the birth rate to ensure that Iran did not
5 4 3 2 1 0 0 1 2 3 4 5 become dependent on ‘imperialist aid’.
Population (in millions)
With the support of religious leaders on
board, in 1989 the parliament approved a
The demographic consequences of this new National Family Planning Policy with
policy were soon evident. Population growth three main goals. The first encouraged
averaged 3.9% per year between 1976 and births to be spaced three to four years apart
1986 and the population almost doubled in an attempt to increase infant and child
in the period 1968-1988. Part of the survival and reduce maternal mortality. This
increase could be accounted for by the led to a reduction in large family size and
influx of around 2 million refugees from improved economic development at the
Afghanistan and Iraq during this period. Yet, national level. The second goal strongly
even when excluding immigrants from the discouraged births to women under age
official figures, the natural growth rate was 18 and over age 35. At the lower end, this
above 3.2% per year and estimates for aimed to increase the age at first marriage
fertility rates ranged from 6.4 to 7.7. and reduce total fertility. It also encouraged
adolescents (particularly girls) to finish
Following the publication of the 1986 schooling, bringing about a reduction in
census, political attention became focused gender inequality which in turn improved
on the implications of such a high growth the status of women. This led to a trend
rate for the future development of Iran. towards later marriage and a decline in
The Iran-Iraq war had crippled the country arranged marriages, further aiding fertility
financially and growing concern existed decline. The final goal of the 1989
The Islamic Republic of Iran
population policy stated that couples should
aim to have no more than three children.
Summary – Why Iran was so successful
1. Universal access to health care and family planning services
2. Rise in female literacy through literacy programmes in the most deprived areas
3. Education aimed at teaching pupils specifically about reproductive health
and family planning introduced in schools
4. Pre-marital compulsory contraceptive counseling classes
5. Strong political will
6. Support from religious leaders
7. Creation of disincentives for women to have several children through reduced
maternity leave benefits, housing subsidies and so forth after the third child
The religious clerics worked to dispel the
belief that population programmes were a
Western ideal. Leaders such as Ayatollah
Khomeini were highly influential, preaching
reduced family size in sermons and
religious proclamations (known as fatwas).
Furthermore, they argued in favour of
contraceptives such as the Intrauterine
device (IUD), the pill and condoms, stating
that limitations of births would improve the
well-being of children, education and overall
development. Unlike the Chinese one-child
policy, the Iranian government did not
introduce draconian measures; rather, they
wanted to indicate the importance of
every couple having a choice about how
many children to have and when.
In the early 1990s, the government
expanded the 1989 policy to create
disincentives to have more than three
children. In May 1993 it passed a National
Family Planning law which restricted
maternity leave benefits, health insurance
and housing subsidies to couples with
more than three children. The money saved
by these measures was ploughed into an
educational programme where school
pupils were taught about vital issues such
as maternal and child health, reproductive
health and family planning (within the
context of marriage – pre-marital sex
remains taboo). Between 1993-1998 a
plan to increase contraceptive prevalence
to over 70%, reduce population growth to
1.5% and reduce the TFR to 2.5 was
introduced, further limiting births. As it
developed in conjunction with improving
45
primary health care, little stigma attached
to contraceptive use. Furthermore,
contraceptives such as the condom and
the pill were available free of charge.
Compulsory contraceptive classes were
also implemented before couples were
married, which gave women and men more
equal involvement in childbearing decisions.
The promotion of family planning has been
accompanied by other measures to
improve the standard of living for Iranians.
Large investments have taken place in
education and health, which have
increased female literacy from 35% in
1976 to over 70% today. Similarly, infant
mortality has fallen from around 135 infant
deaths per 1000 births in 1976 to 32
today. ‘Health Houses’ have been
developed to serve rural villages. The
success of these is highlighted by the fact
that Iran is one of the few countries where
contraceptive prevalence rates are almost
identical for both rural and urban areas.
The developments in health and education
accelerated the progress towards the
targets of the population policy.
Despite Iran’s success in promoting
smaller families and reducing population
growth, it is speculated that the total
fertility rate was already declining even
prior to the Iran-Iraq war. The sudden
increase in fertility during the 1980s may
have been a temporary psychological
reaction to the turmoil of the Revolution
and the war years. Therefore, it is possible
that population growth would have
stabilised even without the Revolution.
Nevertheless, the pace of fertility decline in
the past 25 years in Iran is still impressive.
Contraceptive prevalence has risen to 74%
amongst married women from 50% in the
mid-1970s and fertility rates are predicted
to drop below replacement level by 2010.
While there has been tremendous
progress in recent years, Iran still must
address several issues. The fertility decline
has not reduced some of the ongoing
issues of poverty. Although population
decline has helped alleviate the problem,
severe water shortages still exist, with
The Islamic Republic of Iran
almost 40 million people lacking adequate
supply. Moreover, as a result of the 1980s
‘baby boom’, 33% of Iran’s population is
under 15 years old and population
momentum will continue for several years
Islam, women and family planning
The media coverage of the treatment of women in Afghanistan
by the Taliban has led many in the West to believe that under
the Islamic faith men and women are not equal. It is a common
misconception that the lives of Muslims are the same wherever
they are in the world, despite the differences in their history,
culture, economics and politics. There are over 1 billion
Muslims worldwide and they make up the majority of the
population in countries as diverse as Iran, Senegal, Pakistan
and Albania. In contrast to the lives of women under the
Taliban in Afghanistan, in many other Muslim countries women
are free to work, learn and participate in politics. Attitudes to
gender and family planning are as varied amongst Muslims
worldwide as they are amongst Christians in the UK, Bolivia
and the Philippines.
Unlike Catholicism, where the Vatican is the authority on the
interpretation of the Bible, in Islam there is no central
authority. Therefore, in various cultures and religious sects the
Qu’ran (the holy text) is often interpreted in different ways by
religious scholars and leaders. Muslims also look to the
examples of Muhammad (the Prophet). His actions (sunnah)
and sayings (hadith) are also interpreted to provide guidance in
day to day life.
The Qu’ran repeatedly states that men and women are equal;
however, it also states that they have distinct roles to play in
life. While the vast majority of Muslims use the writings in the
Qu’ran to promote gender equality, a small minority interpret
the references to distinct gender roles in order to keep women
in the home or out of formal employment. The Qu’ran states
that children are the ‘decoration of life’ (or a gift from God) and
some Muslims interpret this to mean that contraception should
never be used. However, most Muslims support the use of
temporary contraception (including condoms and the pill),
believing that spacing births enables greater care to be given
to existing children. Some Muslims are against sterilisation as
the Qu’ran states that Muslims should cause no harm to their
bodies; however, others argue it is acceptable as long as it is
reversible. For example, sterilisation is legal in Iran and Tunisia
but illegal in Egypt and Jordan.
46
to come. Male participation in the family
planning program is still comparatively low,
and adolescents are still sensitive and feel
embarrassed to discuss reproductive
health issues openly with elders.
Muslims generally accept abortion only when there is a serious
threat to the life of the woman in continuing the pregnancy.
Even then, it is usually only allowed before the 120th day of the
pregnancy when it is believed that ‘life is breathed’ into the
foetus. Despite the common misconception that female genital
mutilation (FGM) is promoted by Islam, there is no reference to
it in the Qu’ran. Although FGM is practiced in some
predominantly Muslim countries (including Sudan and Burkina
Faso), the tradition predates Islam and is a cultural, as
opposed to religious, phenomenon.
The diverse interpretations of the Qu’ran and the hadith can
create a barrier to family planning, as there may be confusion
about whether it is un-Islamic. Programmes which aim to
provide family planning services to Muslim communities are
most successful when they work with religious leaders to
communicate messages. The support of religious clerics was a
critical factor in the success of Iran’s family planning
programme, and religious leaders in the Philippines have
recently issued fatwas proclaiming that family planning is not
against Islamic practice. The Family Planning Association of
Pakistan, supported by Interact Worldwide, has been
successful in the conservative Northern regions by working
closely with religious leaders in the community to win their
support for family planning activities.
Kenya 47
COUNTRY STUDY
Kenya

Population: Population policy: 1967-1979

1985: 19,759,000
Mid 2004: 32,400,000 In 1967, shortly after independence from
2025: 39,900,000 Britain, the government launched the
(projected) National Family Planning Programme, with
the aim of reducing population growth. The
Total fertility rate: 5.0 programme’s goals were to reduce fertility,
decrease the population growth rate from
Contraceptive use 3.3% to 3% and reduce child mortality
amongst married (deaths in children aged under five) by
women 15-49 1979. It focused on the provision of family
(all methods): 39% planning in clinics and emphasised spacing
Life expectancy children, as opposed to limiting family size.
at birth: 51 However, when the results were reviewed
in 1979 the findings were disturbing. While
child mortality had decreased, fertility rates
and the population growth rate had actually
increased during the period of the plan.

Introduction The failure of the policy during this period

Kenya, in East Africa, was the first African
country to introduce a family planning
programme with the aim of reducing
population growth. The results of the first
programme in 1967 were disastrous;
however, from 1979 the population
programme was strengthened and
achieved significant successes through the
1980s and 1990s. The accomplishments
of this period have recently begun to be
reversed, with fertility rates rising for the
first time since the 1970s, and the effects
of a significant HIV epidemic eroding
infrastructure. Kenya provides an
interesting case study for examining the
role of international donors in population
programmes in less developed countries
(LDCs) and for assessing the impact of
HIV on country development.
was the result of a number of factors.
First, it was influenced by government
demographers who highlighted the
negative economic consequences of
continued high population growth. In 1965,
they invited a team of American experts to
Kenya to study population issues and make
recommendations for a future policy. After
spending only three weeks in Kenya, the
team recommended that the government
adopt a goal of halving fertility rates from
6.8 children per woman (recorded in the
1962 Census) to 3.4 within the space of
15 years. However, it is unlikely they fully
understood the cultural context in the
country nor the value placed on high
fertility. Furthermore, many Kenyans were
still very sensitive to the influence of
Westerners on their country, there was
little government discussion or debate
about the aims of the programme and few
politicians would publicly support it.

The failure of the 1967 policy also

stemmed from the fact that population
Kenya 48
However, many Kenyans still viewed
Male Kenya 2004 Female
children as economic and social assets and
80+ contraceptive use remained low. Christian
75-79
70-74
and Muslim leaders also argued that using
65-69 contraception was against the will of God.
60-64
55-59
50-54 While spending on health care increased
45-49
40-44 during the time of the plan, little health
35-39
30-34
care expenditure was set aside for family
25-29 planning. Most of the costs were met by
20-24
15-19 private organisations and by Western
10-14 donors, including the governments of the
5-9
0-4 US and UK, along with the UN and the
2.5 2.0 1.5 1.0 0.5 0 0 0.5 1.0 1.5 2.0 2.5 World Bank.
Population (in millions)
The central argument behind the policy was
Source: US Census Bureau, International Data Base that economic growth would not occur
without restraining population growth.
Male Kenya 2025 Female
However, during the 1960s and 1970s
80+ Kenya’s economy grew much faster than the
75-79
70-74
population did. In 1967, economic growth
65-69 averaged 9.5% compared to a population
60-64
55-59 growth rate of 3.3%. As the government
50-54 also invested heavily in creating free
45-49
40-44 education and health care, many Kenyans
35-39
30-34
simply did not believe there was an
25-29 economic need to reduce population.
20-24
15-19
10-14
5-9
0-4 Population policy: 1980-1993
2.5 2.0 1.5 1.0 0.5 0 0 0.5 1.0 1.5 2.0 2.5

Population (in millions) By 1979, Kenya’s economy was beginning to

Goals and achievements – National Family Planning Programme
1967-1979
Goal (1967) 1969 1979
1. Reduce population growth rate from 3.3% to 3% in 1979 3.3 3.8
2. Reduction of total fertility rate 7.6 8.0
3. Reduce child mortality 192 157
growth was viewed as a medical problem
during this period, with no attention paid
to the connection between population,
education, poverty and gender. The Ministry
of Health focused on providing clinic-based
services and left the Family Planning
Association of Kenya (FPAK), a non
governmental organisation, to concentrate
on increasing demand for contraception.
run into difficulties. The prices of coffee and
tea (Kenya’s major exports) had declined
worldwide and a drought badly affected
maize production. The economy became
increasingly dependent on foreign financial
assistance and fees had to be introduced for
schooling and healthcare. In 1979 President
Kenyatta died and was replaced by
President Moi, who was more supportive
of arguments regarding the link between
population and economic development.
Individual politicians also began to speak
out on population, including the Minister
for Constitutional and Home Affairs who
declared that, “Kenyans could do well to
learn from birds who do not lay eggs until
they have built nests”. In 1982, the National
Council for Population and Development
(NCPD) was established to formulate a
population policy and coordinate activities
aimed at reducing population growth.
Kenya
Goals and achievements – National Population Policy 1984-1993
Goal (1984) 1989 1993
1. Reduce population growth rate from 3.8% to 3.3% by 1993 3.4 3.1
2. Reduction of total fertility rate from 7.9 6.7 5.4
3. Reduce child mortality from 140 per 1000 91 96
In 1984, 2000 politicians, civil servants
and NGO leaders met to discuss
population issues in Kenya. They eventually
set a target of reducing population growth
from 3.3% to 3% by the end of 1998. The
new National Population Policy was wider
in its approach than the previous family
planning programme. It aimed to increase
contraceptive usage and expand the
network of clinics offering family planning.
In 1986 a community-based distribution
system started, where people living in rural
communities were trained to educate others
in their area about the benefits of smaller
families and provide contraceptives. The
policy also included goals to increase female
education and expand the number of
women in formal employment. Foreign
donors were targeted for money to expand
activities and fund research into population
and family planning. The new policy also
included campaigns to sensitise political and
religious leaders to the problems created by
unchecked population growth. By gaining
the support of these leaders they were able
to mobilise the population to support the
family planning programme. By 1993, the
policy had achieved considerable success.
Contraceptive rates rose from 7% in 1980
to 33% in 1993. Fertility and population
growth also declined faster than anticipated.
Increased political support, expansion of
family planning services (particularly in
rural areas) and public information
campaigns were some of the most
important reasons for the success of the
population policy. However, Kenyan
attitudes to large family sizes were already
changing during this period. Since
independence, Kenya had invested heavily
in public health and education. As access
to health services improved, infant and
child mortality rates dropped steadily and
49
parents became more confident about the
survival of their children. In addition, the
post-independence governments strongly
promoted education as a means for
ensuring economic prosperity. Yet, due to
the economic difficulties of the decade
and conditions imposed on Kenya by
external donors (including the International
Monetary Fund), fees had been introduced
for education. Many parents chose to have
fewer children to ensure they were able to
educate the children they already had.
Population policy: 1993 to the
present
In 1995, following the International
Conference on Population and
Development (ICPD), the government
reviewed its population policy in order to
strengthen initiatives to empower women
and improve reproductive health services
as recommended by the conference. The
population policy continued to make
progress during the 1990s and the results
of the National Demographic Health Survey
(NDHS) in 1998 indicated that fertility rates
had fallen further to 4.7 and contraceptive
usage had increased to 38.3%.
Some facts about reproductive
health in Kenya:
● 24% of women in Kenya who want
to limit or space their childbearing
are not using family planning.
● 44% of Kenyan’s are under 15 years
old, indicating that there will be an
increased demand on reproductive
health in the future.
● If all women who wanted family
planning were given it, the
contraceptive prevalence rate
would increase from the current
figure of 39% to 66%.
● Nearly 11,000 women die in Kenya
each year due to pregnancy-
related causes.
● One in ten teenage girls aged 15-19
gives birth each year.
Kenya
However, by the late 1990s and early
twenty-first century, the progress began to
falter as the impact of the rising HIV
epidemic began to be felt and the country
struggled to lower the rates of maternal
mortality which stood at 1000 deaths per
100,000 live births. The preliminary results
of the 2003 NDHS indicate the total
fertility rate rose from 4.7 in 1998 to 4.9
in 2003. This is a worrying trend after so
many years of decline. These difficulties
were compounded by the withdrawal of
US funding for leading family planning
organisations and shortages in
contraceptive supplies.
The impact of the Global Gag Rule on Kenya
On his first day in office in 2001, President George W. Bush
reinstated the Global Gag Rule. This prohibits non-US family
planning organisations from receiving US assistance for sexual and
reproductive health if they provide any abortion services (including
campaigning for abortion), even if the money used is not directly for
abortion-related work. The policy has led to the withdrawal of
crucial funds aimed at improving the sexual and reproductive rights
of women in LDCs such as Kenya. For many Kenyans, this has
significantly reduced their access to family planning facilities and
supplies. FPAK has already closed three of its clinics as a result of
the withdrawal of US funds previously used to help maintain clinic
buildings and train nurses – who provided many sexual and
reproductive health services, not just abortion. Another half of the
clinics are set to close by the end of the year. FPAK has also lost
most of its Community Based Distributors in rural areas, as it can
no longer afford to pay their salaries.
Abortion is illegal in Kenya except when there is a severe threat to the
health of the mother, with severe prison penalties for both the mother
and abortion provider. Each year approximately 300,000 abortions
are carried out illegally in Kenya, leading to the injury and deaths of
thousands of women. Family planning workers in Kenya report that
the incidence of unsafe abortion has been increasing since funding for
family planning activities has been withdrawn by the US government,
as many women have been unable to prevent pregnancies.
HIV/AIDS in Kenya
HIV arrived in Kenya in the late 1970s.
Despite low rates during the early 1980s,
infection rates steadily increased during
the late 1980s and early 1990s. Currently,
1,200,000 people are living with HIV in
50
Kenya, with 6.7% of the adult population
infected (down from 8% in 2001). Kenyan
Ministry of Health statistics indicate that
1.5 million Kenyans have already died of
AIDS (around 700 per day) and over a
million children have been orphaned.
The majority of infections in Kenya are
transmitted sexually. More women are
infected than men (8% compared to 6.7%).
In younger age groups the disparity is even
more pronounced, with many more young
women infected than young men. This is
largely due to the fact that older men tend
to go out with younger females; however,
it is also because many young women
experience rape and forced sex. In a
Kenya-wide study of females aged 12 to
24 years old, 25% reported losing their
virginity because they had been forced.
The peak ages for HIV in Kenya are 25-29
for females and 30-34 for males. As this
age group is the most economically
productive, illness and death have serious
economic and social impacts on families
and communities. This is the age when
investments in education should start to pay
off for society and is also the age when
people are most likely to be raising children.
The epidemic also seriously affects the
government’s ability to deliver services as
teachers, health workers and government
officials fall sick and die. A recent study
found that AIDS accounted for 58% of all
staff deaths in the last five years in Kenya’s
Ministry of Agriculture. The high levels of
illness place the health service under
extreme pressure. In 1992, around 15%
of hospital beds were occupied by AIDS
patients; by 2000 this had risen to 51%.
One dramatic impact of HIV/AIDS is the
decline in life expectancy at birth amongst
Kenyans. Life expectancy at birth should
currently be around 65 years; however, it is
actually only 51 as a direct consequence
of HIV/AIDS. Infant and child mortality
rates have also risen as a result of the
epidemic. The infant mortality rate was
expected to fall to around 50 deaths per
1000 live births by 2005; however, in
2004 it has actually increased to 78.
Philippines
COUNTRY STUDY
Philippines
Introduction
Population:
Mid 2005: 85,000,000
The Philippines consists of more than 7,000
Mid 2006: 87,000,000
islands, but the bulk of the population lives
(projected)
on just 11 of them. It is the world’s 12th
2025: 115,700,000
most populous state, with a rising
(projected)
population of 85 million people. The
Philippine population is expected to reach
Total fertility rate: 3.5
142.2 million by 2050. Some 10 per cent
Contraceptive use of the population are abroad on temporary
amongst married job contracts and in 2005 contributed
women 15-49 $10.7 billion, 13.5% of overall GDP. Forty
(all methods): 49% per cent of the Philippines’ population lives
below the poverty line. It is saddled with
Life expectancy
huge foreign debt and a ballooning budget
at birth: 70
deficit that take away resources from health
Infant 29 deaths and education programmes. Unemployment
mortality per 1,000 is also high, particularly in the countryside.
rate (2005): live births
The Philippines is a majority Roman
Maternal 240 deaths
Catholic country, established over 500
mortality per 100,000
years of Spanish colonial rule. It gained
ratio (2004): live births
independence from the United States in
1946. Ferdinand Marcos stayed in power
for 21 years, and in 1967 officially linked the
Philippines to international population policy
and programmes by signing the United
Nations Declaration on Population and in
1970 launched the Philippine population
program (POPCOM). Even after Marcos
declared martial law in 1972, a wide range
of modern contraceptive methods were
available throughout the country.
In 1986, People Power I ended the
Marcos dictatorship and put Corazon
Aquino in power, beginning a heated
interplay between the government and the
Catholic Church over population policy.
The Aquino Cabinet was split on the
population issue. While Aquino herself said
in a State of the Nation Address that family
planning was among her priorities, some
officials cited the right of the unborn as
51
essential. From the National Economic and
Development Authority, POPCOM was
transferred to the Department of Social
Welfare and Development headed by
Mamita Pardo de Tavera, who supported
the Catholic Church’s view that there was
no need to promote contraceptives. Health
Secretary Alfredo R.A. Bengzon disagreed,
and the Department of Health took over
the family planning component of the
population programme.
In l992, Fidel Ramos became president and
appointed Juan Flavier as health secretary
and put POPCOM back with the NEDA.
Flavier ignited the public’s enthusiasm for
reproductive health services, the family
planning component of which promoted
birth control pills, IUDs, condoms, and
abstinence. An alarmed Catholic Church
launched an attack on Flavier and the
contraceptive part of the programme,
costing Flavier first place in the Senate
elections of 1996. Nonetheless, the
population programme remained a major
component of the Ramos government’s
anti-poverty social reform agenda.
From 1992 to 1996, the population
programme received many liberal ideas and
inputs from international conferences where
the Philippines participated, including the
1994 International Conference on
Population and Development in Cairo. In
1998, Joseph Estrada become president
and continued a population programme
based on responsible parenthood. There
was close cooperation among NEDA,
POPCOM, the Department of Health and
other agencies. People Power II intervened
and Estrada was overthrown by Gloria
Macapagal Arroyo in January 2001.
Estrada’s programmes did not have time
to create the desired impact.
Philippines 52
The phase-out began in 2004 and will be
Male Philippines 2005 Female
completed in 2007. While President
80+ Arroyo lobbied the United Nations for
75-79
70-74
support for her government’s natural family
65-69 planning campaign, the state-run
60-64
55-59 Philippine Health Insurance Corporation
50-54 (Philhealth) was implementing the two-
45-49
40-44 child policy and promoting tubal ligation
35-39
30-34
for women and vasectomy for men. At
25-29 least 53 million Filipinos are covered by
20-24
15-19 Philhealth, which covers hospital room and
10-14 board, prescription medicine, doctor’s
5-9
0-4 fees, outpatient services and family
6 5 4 3 2 1 0 0 1 2 3 4 5 6 planning surgical procedures. Pura Carño,
Population (in millions) Philhealth foreign assistance coordinating
officer, said only the first two normal
Source: US Census Bureau, International Data Base deliveries are covered by the Philhealth
card. “It is for the well-being of the mother
Male Philippines 2025 Female
and child. We do not want to encourage
80+ our women to get pregnant more often
75-79
70-74
than their health could permit.”
65-69
60-64
55-59 A recent study by the University of the
50-54 Philippines (UP) School of Economics
45-49
40-44 showed that the Philippines managed to
35-39
30-34
reduce its birth rate from three percent in
25-29 the 1970s to 2.4 percent in the 1990s.
20-24
15-19 The government says for the past five
10-14 years the growth rate has been 2.1 per
5-9
0-4 cent and that this year it has gone down
6 5 4 3 2 1 0 0 1 2 3 4 5 6 to 1.95 per cent. There has been a
Population (in millions) marked decline in the Total Fertility Rate
(TFR) amongst women since the first
National Demographic and Health Survey
in 1968, when the TFR was 6 children per
“It is for the well-being The current government response to the woman, to 3.5 children per woman today.
of the mother and child. need for population control measures has However, a TFR of 3.5 is still considered
We do not want to remained ambiguous, with the Arroyo high among Southeast Asian countries
encourage our women administration toeing the line of the where Indonesia has a birth rate of 2.6,
to get pregnant more influential Catholic Bishops Conference of Malaysia 3.3 and Vietnam 2.2.
often than their health the Philippines to promote only natural
could permit.” methods of family planning and at the The continuing growth of the population
same time implementing anti-Church has pitted advocates of birth control
measures such as the two-child policy and against the Church. Gains made in
sterilization. This “flip-flopping” position reducing the TFR are undermined by the
has prompted the United States and other country’s weak economy, which worsened
donor-countries to withdraw P840 million under the corruption of the Marcos
($16 million) in annual donations of dictatorship. The Catholic Church, due to
contraceptives and other birth control its crucial role in removing Marcos and
devices until the Philippine government later Estrada, became even more
has clearly defined how it intends to bring influential among the Filipino people and
down the rapid population growth. the government.
Philippines
“Asking the Government legislation
international donor
community to stop Lowering birth rates through expanded
funding this service is a choices of contraceptive methods and
human rights violation providing sex education are a few of the
to the 35 per cent of immediate aims of HB 3773 (the
women who are using Responsible Parenthood and Population
modern methods of Management Act of 2005 popularly known
contraception (31 per as the two-child policy that was consolidated
cent of whom are poor with other bills into HB 3773). The legislation
women) and to the rest has so incensed the church that it has
of the women who are threatened not to administer communion to
not using any method any government worker promoting the bill.
at all due to lack of
informed choices.” House Deputy Majority Leader Edcel
Lagman, the author of the two-child policy,
stated, “Asking the international donor
community to stop funding this service is a
human rights violation to the 35 per cent of
women who are using modern methods of
contraception (31 per cent of whom are
poor women) and to the rest of the women
who are not using any method at all due
to lack of informed choices.” The more
important requirement is to respond to
women’s individual needs to control their
own fertility as a prerequisite for sustainable
development based on women’s
empowerment and gender equity. Provision
of the full range of choices, including
modern contraceptives, is a right, which the
Philippines subscribed to under the ICPD.
Arroyo has stated she is leaving the issue
of addressing population growth to the
discretion of local government executives,
and her conservative stand creates a
situation where the capitol and local
governments may be moving in different
directions. Empowered by the 1991 Local
Government Code, some provinces, cities,
and towns have reproductive health services
with strong family planning components in
partnership with non-government
organisations and barangay (village) youth
councils. Most of the programmes are
funded by bilateral or multilateral grants,
but some communities are adding regular
gender and development budgets to fund
the family planning and safe motherhood
needs of poor women in the barangay. The
Conservative Mayor of Manila, Lito Atienza,
by contrast, has ordered public health clinics
53
to stop offering family planning. “Population
control and the distribution of contraceptive
materials in government facilities is a
continuing illegal act,” argues Atienza.
This has forced many NGOs who provide
family planning information and
contraceptives in the capitol underground.
Natural family planning methods
In April 2005, Mrs. Arroyo signed the
ICPD document promoting “informed
choice” and shortly after that, giving in to
pressures from the Catholic bishops,
declared before the United Nations that
the funding donated by the UN for family
planning would be used in promoting
natural methods in the Philippines.
In 2004, 14.2 per cent of married women
were reported as using traditional
contraceptive methods (calendar, rhythm
and periodic abstinence, and withdrawal).
Natural family planning, the only method
that requires the cooperation of both
parties, is inexpensive and produces no
side effects. However, doctors are
reluctant to prescribe it because of its
high failure rate – as much as 20 per cent
by some estimates. It is worse for women
with irregular menstrual cycles.
The LAM (Lactational Amenorrea Method) of
exclusive breastfeeding after childbirth for
6 months has a failure rate of 1 per cent
or less in clinical studies performed to
date. However, it is effective only under
the following circumstances: (1) The infant
is less than six months old; (2) The mother
should be exclusively or almost exclusively
breastfeeding, which means that no other
liquid or solid food is given to the infant or
90 per cent of all the infant’s food intake is
through breastfeeding; and (3) There has
been no return of menses for the mother
since delivery (a sign of the return of fertility).
Myths surrounding modern family planning
methods have become widespread, and are
compounded by lack of access to accurate
information. Among these are rumours the
birth control pill could cause psychological
illnesses, and that the IUD, or intra-uterine
Philippines
“Statistics show very device, could cause cervical cancer. “One
clearly that many of the reasons the population programme
Filipinos are afraid has not been effective is because the
of contraceptives.” scare tactics are very effective,” said
Michael Tan, a population expert at UP.
“Statistics show very clearly that many
Filipinos are afraid of contraceptives.”
Abortion
In the predominantly Roman Catholic
Philippines, there is no legal divorce or
abortion, except to save the life of the mother.
Despite these legal barriers, 70 per cent of
unwanted pregnancies end in abortion, with
an estimated 400,000 illegal abortions
performed in the Philippines every year. Many
are carried out under unsafe conditions,
and about a quarter of them result in
hospitalization for complications. When
women get to the hospital for treatment they
often face hostile health-care providers. The
Department of Health of the Philippines
reported that 12% of all maternal deaths in
1994 were the result of illegal abortion.
Evidence from the mid-1990s indicates
that Filipino women of all social classes and
backgrounds are having induced abortions.
They do so under varying circumstances,
ranging from safe medical procedures
performed for better-off women by trained
personnel, to procedures in extremely
unsafe conditions for poor women who
cannot afford to pay for a surgical abortion.
The evidence of a survey of health
professionals in the mid-1990s suggests
that about one-third of women seeking an
abortion obtain it from a doctor or nurse,
but a high proportion of women consult
traditional practitioners (hilots) or attempt
to induce the abortion themselves. This is
predominantly due to the lack of access to
professional health services in rural areas.
Regrettably, because induced abortion is
punishable by law in the Philippines, the
subject tends to be masked by silence and
consequently, public attention to the issue
is minimal. The general secrecy surrounding
induced abortion does not mean, however,
that the subject has not been of concern
over the past 30 or more years. A number
54
of medical professionals, lawyers, social
scientists, legislators and women’s health
advocates, among others, have written on
the subject and worked toward improving
health policies and services. In addition, the
Philippines Department of Health provided
official guidelines for a post-abortion care
programme, Prevention and Management
of Abortion and its Complications, and
pilot tested such programs in 17
government hospitals in late 2003.
HIV/AIDS
The provision of modern family planning
methods, particularly condom use, not
only addresses the problem of unwanted
pregnancies but also the prevention of a
possible HIV/AIDS epidemic that
threatens the most vulnerable sectors of
the population including women, children,
young adults and migrant workers.
According to the latest Department of
Health statistics there are 11,168 HIV
positive people aged 15-49 in the
Philippines. Sexual intercourse remains
the main method of transmission (86% of
cases) and of those 62 per cent through
heterosexual sex. The widespread practice
of unprotected sex makes HIV/AIDS a
serious threat, particularly where many
people are not aware of their status.
According to a recent survey by the
Department of Health, three in five young
people between the ages of 14 and 20
believe they cannot contract HIV. One in
five believes incorrectly that the virus can be
contracted by drinking contaminated water,
kissing or mosquito bites. Because of this
the Department of Health is seeking money
for an intensive HIV/AIDS awareness and
education campaign aimed at young people.
The Philippine government has set aside
$383,000 to stockpile anti-retroviral drugs
for HIV positive people. The most pressing
dilemma for the Department of Health is to
manage opposition from the Catholic
Church because it views condoms as a
family planning method and not just a tool
against HIV/AIDS.
 vision
Our vision is a world where exercising the right to
sexual and reproductive health contributes to the
reduction of poverty and a better quality of life.

mission
Our mission is to build support for and
implement programmes which enable
marginalised people to exercise their right
to sexual and reproductive health.

values
Efficiency and effectiveness through accountability,
transparency and a strong focus on relevant activi-
ties which provide value for money. High profes-
sional standards which incorporate Best Practice,
responsiveness to perceived needs, innovative
approaches to problem solving and commitment to
quality outcomes.

(formerly Population Concern)

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