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

1
Introduction

The Population Jigsaw Fitting the pieces together for a healthy world

CONTEMPORARY POPULATION POLICIES GLOBAL POPULATION TRENDS GENDER AND HEALTH HIV/ AIDS

AN AGEING WORLD COUNTRY STUDIES

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.

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 Statistics inevitably become out of date, and we rely on the World Population Data Sheet, produced annually by the Population Reference Bureau, to update our educational materials and school talks.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

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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 nontherapeutic 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. 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 semipermanent 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

3

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 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.

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

The classic stages of demographic transition
Birth/death rates Stage 1 Stage 2 Stage 3 Stage 4

Birth rate

Death rate Time
Source: Population Reference Bureau, Population Bulletin, March 2004

environmental degradation. In LDCs.8 today. Currently. life expectancy rises. This has led to later marriage and delayed childbearing. For example. sex. 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. The availability of contraception. As mortality rates decline. large scale immigration from Mexico to the United States has kept birth rates there higher than other MDCs. however. Large and sustained migrant flows can alter fertility levels in receiving countries when migrants come from countries with higher fertility norms. with smaller families increasingly becoming the norm for social and economic reasons. growth continues due to this population momentum. 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. there is a large amount of rural-to-urban migration and by 2007 half the world’s population will be urban. Average life expectancy at birth worldwide is now 67 years. Decades of high fertility in LDCs have meant ever increasing numbers of young people. Couples are gaining the information and services they need to make informed decisions about the timing and spacing of children. abortion and the reduction in maternal. It should be noted that birth rates are declining virtually everywhere in the world. rates of increase are expected to slow and most demographers put a ceiling on it. but in many places the decline has been much slower and TFRs remain high in countries such as Yemen. 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. As access to education has increased. In LDCs life expectancy is lower and more variable. however. Europe hosted approximately 25% of the total. women have entered the labour force in large numbers. and a large proportion of employmentrelated migration occurs between countries where wages do not differ significantly. As access to education has increased. racial and other characteristics and can affect national rates of growth. Urbanization appears to accelerate the demographic transition to lower mortality and fertility. violent conflict or persecution. Most sought refuge in Asia or Africa. Most are looking for better economic opportunities. the urbanization of the past 50 years has strained the capacity of many governments Population momentum While global fertility rates have declined from 6. infant and child mortality are also contributing factors. but some are forced to leave their homes due to famine. Most migration is between neighbouring countries. In 2003. with HIV/AIDS reversing gains in some countries.Global population trends 4 to provide basic services to all but its most privileged residents. 2004. famine or other crises. Life expectancy at birth in Japan is the highest in the world at 82 (this represents an average of males and females). women have entered the labour force in large numbers. Close to half of all reported migrants move from one LDC to another.0 children per woman in the early 1960s to 2. Although the majority of young women today will have fewer children than their mothers. By contrast. natural disasters. there were approximately 14 million refugees or asylum seekers worldwide escaping war. about 40% of . with Iran and Pakistan being the most common destinations. cultural. but greater access to global information and cheaper transport mean that geography now poses less of a barrier to movement. Projections assume life expectancy will continue to rise in all regions. the age structure of the population in LDCs will ensure that absolute numbers continue to rise for some time. MDCs are now experiencing the highest life expectancies ever observed. It should be noted that birth rates are declining virtually everywhere in the world. Migration within and between countries affects the distribution of the population by age. This has led to later marriage and delayed childbearing.

0 3.0 5.6 4.1 2. with nearly one in ten children in Africa dying before their first birthday. Young brides are at risk of pregnancy through more of their reproductive years than those who marry later and delay the onset of sexual activity. as women with an extended education tend to have fewer children.5 5.6 ■■■■ No education ■■■■ Primary completed ■■■■ Secondary completed Source: Demographic and Health Surveys 1991-1999 .1 6. In particular. The shortage in contraceptive supplies poses a major challenge for development in the coming years.7 4. carry water and watch younger siblings.5 5. led to a massive decline in birth rates. and in some areas of Africa recent contraceptive shortages have begun to reverse fertility decline. There is a correlation between female education and fertility rates. the world faces a severe shortage of condoms (estimated at 8 billion a year). Children are often seen as an investment by families dependent on agriculture as they provide extra hands in the fields. but their influence in the MDCs is on the wane. Male children are particularly prized in countries where there is a lack of female participation in formal paid employment.9 3. For example.8 6.8 4. the world’s population live in countries where couples have so few children that numbers are likely to decline in the long Why fertility rates remain high Infant mortality remains unacceptably high in many parts of the world. The devastating impact of HIV/AIDS in subSaharan 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.6 3. Women with more education also have more opportunities outside the home and can see the benefits of education for their children. but the Church wields more influence in LDCs where it may be the only provider of care for the poor. are available and to have the confidence to use them. Also.6 5.Global population trends 5 term.9 4. Where women are unable to take a full and active part in the political and economic spheres of their country there tend to be higher birth rates. 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.6 7. and ultimately to have smaller families than women who marry in their teens. this can vary from country to country. Asia and Latin America. Contraceptive use remains taboo across many parts of Africa. The United Nations Population Fund (UNFPA) estimates that 350 million couples worldwide would like access to contraception but do not have it. Educated women are more likely to know which health services. coupled with developments in contraceptive technology. The increased liberation of women in Europe during the last century. gather firewood. Germany by 9% and Russia by 17% by 2050. This results in an average of three condoms per year for an African man and the shortage is fuelling the HIV/AIDS crisis.5 3.1 5.8 2. Children continue to be seen as an investment for the future in countries with little or no welfare state in place. Women who achieve a relatively high level of education are also more likely to enter the labour force before they marry or begin childbearing.1 4. in countries where the boy child is favoured women may undergo multiple births in the hope of having a boy.6 6.8 3. By six or seven years of age a child can herd livestock. however.7 4. Women’s education and TFR in selected countries. Catholic countries such as Italy and Spain record the highest usage of contraception in the world. Children who survive to adulthood ensure that parents can be supported in old age. including family planning. Culture and religion continue to exert influence on families in LDCs. 1990s Niger 1998 Guatemala 1999 Yemen 1997 Haiti 1995 Kenya 1998 Pakistan 1991 Philippines 1998 Jordan 1997 7. the population of Japan is expected to decline by 21%.6 4. Early marriage is associated with an early onset of sexual activity.

except in countries with significant HIV/AIDS epidemics. but will reach almost 33% by 2050.5 children per woman lower than the medium projection over the time period. The most recent medium variant projection of the world’s population in 2050 expects it to reach 8. The high projection is 10. March 2004 . Global population today ● World population.5. Nearly all growth takes place in LDCs. Population Division.4 billion.5%.3 billion. Demographers now predict that fertility in all countries will eventually decline to an average of 1. In many parts of the world. maintaining a continuous supply of modern contraceptives remains a challenge.7% means it is likely to bypass China as the most populous country in 25-50 years. adding approximately 76 million people each year. 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. India’s population is 1 billion 86 million. The high variant projection assumes a TFR of 0. ● Approximately 10% of the world’s population are aged 60 or older. World population according to different scenarios. It is likely that fertility will continue to fall in those LDCs where it is already declining and it will eventually begin to decline in places where it has remained high. however.Global population trends 6 Population Projections up to 2050 The United Nations regularly forecasts global population numbers. reached in the early 1970s. The low variant projection assumes a TFR of 0.5 children per woman higher than the medium variant projection over the time period. ● Almost one third of the world’s inhabitants are below age 15 and approximately one half of the population is below age 25. It is increasing at 0.3% annually. which assumes a TFR of 2. It is possible that the twochild average is a long way off or will never be reached in some countries or localities. in 2004 they contain 81% and by 2050 they are projected to contain 86%. while Europe will decline from 13% to 7%. mainly due to population momentum. ● At just over 1. This is considerably slower than the peak annual growth rate of over 2. In MDCs the proportion is about 20%. medium and low projections for the future. China is the world’s most populous country. However. Survey data from Bangladesh and Egypt shows little decline in TFRs between 1995 and 2000.6% each year. Yet. In LDCs about 8% of the current population is over 60 and projections expect a rise to 20% by 2050.9 billion. The medium variant projection is based on the assumption that fertility will reach replacement level by 2050. These projections assume life expectancy will increase in LDCs.4 billion. assuming a TFR of 2.5. ● By 2050 the share of the world’s population in sub-Saharan Africa will rise from 10% to 17%.6 billion. 2000-2300 40 35 30 Population (billions) 25 20 15 10 5 0 2000 2050 2100 2150 2200 2250 2300 Source: UN Department of Economic and Social Affairs. The low projection is 7. at 6. but its higher growth rate of 1. ● In 1950 LDCs contained 68% of the world’s population.85 children per woman before stabilising. is growing at a rate of 1. assuming a TFR of 1. at least 1 billion will be added to the world’s population by 2025. These projections have been adjusted downwards in recent years due to an increase in AIDS-related deaths and a reduction in fertility rates. They make high. the future size of the population will depend not only on whether fertility will fall but how fast it declines and to what level.

Over the next 50 years. population ageing is inevitable. . which occurs in the midlate stages of the demographic transition. fertility has declined from approximately 6 children per woman to 2. Despite the inevitability of ageing. the number of those in the working age group per elderly person has declined from 12 to 9 globally. Life expectancy at birth: world and development regions. The last 50 years witnessed a decline in the proportion of 0-14 year olds globally from close to 35% to 30%. lowering the balance of children compared to elderly.8 over the last 50 years and demographers expect it to reach the replacement level of 2. 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.1 over the next half-century. Ageing is therefore an important by-product of the demographic transition. At present it primarily affects more developed countries (MDCs). 1950-2050 90 80 70 60 50 40 30 20 10 0 1950-55 Source: UN Population Ageing Report. population ageing (growth in the proportion of people over 65) is inevitable. this figure is expected to decline by a third. As birth rates go down the base of the population pyramid gets smaller. 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. Over the last 50 years. The result is fewer people who will be able to support those in the elderly population. 2002 ■■■■■■■ ■■■■■■■ ■■■■■■■ ■■■■■■■ World More developed regions Less developed regions Least developed countries 1975-80 2000-05 2025-30 2045-50 Introduction As life expectancy increases and fertility rates decrease. Why does population ageing occur? The main driver of population ageing is fertility decline. and is projected to slip even further to only four in the working age population for every elderly person by 2050. policy makers have undertaken various measures to reduce its impact on societies.An ageing world 7 An ageing world As life expectancy increases and fertility rates decrease. Globally.

In addition. with declining numbers of working age people compared to the elderly. Although it is crucial that health services are properly funded.An ageing world 8 Improvements in life expectancy have also played an important role in the process of population ageing. The increased number of elderly people also heightens the need for more hospital beds and funding for high-tech operations. many elderly people do work past retirement age. all fuelling the fertility decline. with a declining proportion of younger people. Around the world there are increasing numbers of older people. 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 . In MDCs. Around the world. life expectancy at birth has increased to 76 years due to better healthcare. thereby raising fertility and increasing the ratio of those in the working age population compared to the elderly. diet and exercise. this remains problematic. retirement hotspots such as Bournemouth and other coastal regions generally have a higher proportion of elderly people. delayed age at first childbirth. especially in less developed countries (LDCs). increased female education and participation in the workforce. who are living for more years than ever before. For example. This compares with 50% in Mexico and 30% in Singapore. However. Japanese fertility rates have gone down to 1. 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. Both declining fertility and improvements in life expectancy have contributed towards the fast pace of population ageing already being witnessed in Japan. Japan has a female life expectancy at birth of 85 years. Forecasts show that by 2025 Japan’s population will consist of approximately one in three elderly people. The first involves encouraging couples to have more children in conjunction with family friendly policies (such as child care allowances). Furthermore. Across the world. However. Strategies used to cope with ageing societies Three broad approaches have been suggested to manage the complex impacts of population ageing. creating an imbalance in the ratio of workers to elderly in the population age structure left behind. the highest in the world.3 children per woman. Japan represents an extreme example of population ageing. average life expectancy at birth is now 80 years. Young people are more prone to migrate for work. In addition. in the late 1990s close to 65% of males over age 65 in Ethiopia were still working. average life expectancy at birth has increased to 67 years. governments are finding it increasingly difficult to take care of people financially in their old age. Migration may also have played a minor role in population ageing. For women in MDCs. frequently moving to cities. 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 The impacts of ageing As populations age. Other factors which may have contributed to global ageing include later marriage. In the UK. The second strategy encourages immigration of younger populations. especially at the country level. which will also boost numbers in the working age population. elderly people often retire to areas of a more relaxed nature. increased funding on the health service might be offset by a decline in funding on education. have to provide for a populace with longer lasting medical problems requiring high level monitoring over time.

The benefits given to those with three or more children are higher. However.3. In the mid-late 1970s. however. After maternity leave. In response.7 children per woman. Initially. reflecting a less severe decline in fertility compared to most European countries and a lower impact of population ageing. Although there have been substantial changes over the last few decades. France’s pronatalist policy has been successful in that the fertility rate has not fallen to the low levels experienced in much of Europe. 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. the UK does not have a mandatory age of retirement. Furthermore. all children are entitled to a subsidised place in a full-day childcare centre called a crèche from the age of three months. in the early 1980s. 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. currently French women have paid. state pensions are payable at age 60 for women and 65 for men. a further 90 at a flat rate fee and a final 90 days unpaid. For example. with further expansion in the 1980s. the state played an essential role in targeting fertility increase. from the abolishment of a law against the free sale of contraceptives in 1967. In the 1970s. Individual companies. It appears that replacement migration is not a solution on its own. this might only be a short-term strategy as the migrants will eventually age themselves.9 children per woman. 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. may set their own. In Sweden. After this period the parent is entitled to their old job or a similar one. 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. parents were entitled to six months leave (fathers were entitled to a share of this). However. Sweden has seen major development in fertility policies since the 1970s. well before other MDCs. after the birth of a child parents were entitled to 390 days of income-related benefits. however. 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. Currently. Case studies: France. parental leave and an expansion of public healthcare was prominent in Swedish fertility policy. the UK’s 1.0.7. over the past 60 years France has implemented various policies to promote fertility which aim to reduce the societal impacts of ageing. Infant school can begin at age three. Sweden and Singapore France is commonly viewed as a pronatalist country. in the 1980s and into the 1990s the TFR increased to just over 2.An ageing world 9 flows are in the millions annually. In 2004 France’s TFR was 1. to priority for larger families in public housing . By the 1990s. the TFR in Sweden was already low at 1. to 24 months unpaid maternity leave with a guarantee of re-employment in 1977. with job security guaranteed. Government policies focused on the interests of children and the individual role of each parent. In 2004 the TFR was 1. However. Policies in France have been wide-ranging. as opposed to the couple. The longterm fertility decline prompted an ongoing concern about population. This is particularly relevant as by 2010 the number of elderly in France will outnumber those aged 0-14. the mother or father may take parental leave until the child is three years of age. which is among the highest in Europe.7 and Ireland’s 2. France’s fertility rates had already declined by 1850. this approach may ultimately only represent a short-term solution and simply delay the ageing phenomenon. By comparison Italy’s TFR was 1.

an economic recession in the early 1990s led the government to tighten some benefits. 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.3 children per woman. encouraging women to have two births in quick succession. enabling women to balance work and family life more easily. Furthermore. The completion of the demographic transition occurred over a lengthy period in MDCs. Sweden still has extremely family friendly policies compared to most countries.0 to 7.0 to 12.An ageing world 10 were eliminated. In August 2004. Managing the significant social and economic implications of the ageing phenomenon is likely to present a major development challenge for these societies in future years. With a TFR of 1.9 8. Furthermore. Percent aged 65 and over: 2000 Less than 3.9 8.9 13. Today. Childcare expenses increased and supplementary benefits for larger families Population ageing has occurred primarily as a result of fertility declines witnessed in the demographic transition. Singapore is also facing an ageing problem. Although policies implemented in the 1970s and 1980s may have kept fertility rates higher than many European countries. 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. By contrast. Singapore has recently implemented policies aimed at encouraging couples to have more children. this transition is taking place at a much faster pace in LDCs today.0 to 7. nearly 10% of the population already over 65 years and an average life expectancy at birth of 79 years. they are still well below replacement level.0 to 12.0 or more Source: An Ageing World: 2001. 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.0 3. childcare was widely available and heavily subsidised by the government. US Census Bureau Percent aged 65 and over: 2030 Conclusion Less than 3. the government introduced a $175 million package to give benefits such as larger housing to women and men who marry.9 13. which entitled couples to the same paid leave as the first child if a second was born within 30 months. .0 3. however. just as it currently poses very serious challenges for MDCs.0 or more In 1985 the government introduced a ‘speed premium’.

They can be implicit or explicit. After several years of low birth rates. Some people became convinced that unless couples could experience the benefits of development. These were often target driven. These may include free contraception. The first country to declare an official population policy was India in 1952. mortality and migration. They argued that rapid population growth was a consequence of under-development rather than the cause of it. 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. family allowances and generous maternity/ paternity leave policies. many MDCs are beginning to express concern with the societal implications of ageing populations. they . access to abortion services and rules and regulations on immigration. As government leaders grew concerned that rapid population growth would interfere with economic development. as a way to promote social and economic development. but have enacted laws and policy measures which influence demographic variables. Less developed countries (LDCs) tend to formulate explicit population policies which list measures to be taken in order to reach targets of annual growth rates or total fertility rates in a given time period. regulations. some provide incentives to encourage people to have more children such as government-subsidised crèches. at the Bucharest World Population conference in 1974 this viewpoint was questioned by several LDCs. programs — that try to influence the three agents of population change: fertility. As a result. an increasing number of countries adopted national policies to slow population growth. including better education and reduced infant mortality rates. However.Contemporary population policies 11 Contemporary population policies Bringing Sexual and Reproductive Health and Rights to all Introduction Population policies are deliberate government actions — laws. More developed countries (MDCs) tend to have implicit policies in that they have no formal declaration of a population policy.

It also stressed that men must take responsibility for their sexual behaviour and be fully involved in reproductive health and childrearing. sexual trafficking and violence against women. to encompass the social and cultural context surrounding sexual relations. Investment in family planning has helped reduce fertility rates in LDCs from 6 children per woman in 1960 to just over 3 today. in all matters relating to the reproductive system and to its functions and processes”. ● Prevention and treatment of infertility. Critics complained they were culturally insensitive or did not take into account the health of individuals. ICPD recognised the numerous social barriers many women still face which prevent them from controlling their own reproduction. While Family planning remains a core element in population policies and a central component of reproductive health. For the first time. childbearing and the use of contraceptives. achieve sustainable development and stabilise world population in the twenty-first century. The ICPD Programme of Action acknowledged that in order to raise the quality of life for all people. and ● Other women’s health services. and for family planning to be provided in the context of comprehensive reproductive health care. 179 countries agreed on a 20-year Programme of Action which called for investments in health. would not be motivated to have smaller families. such as diagnosis and treatment for breast and cervical cancers. Elements of reproductive health care ● Contraceptive information and services. provide universal access to primary education. ● Prenatal care. particularly for women. ● Elimination of harmful practices such as female genital cutting. education and rights. in all matters relating to the reproductive system and to its functions and processes”. ensure gender equality and take other poverty reduction measures. At this event. mental and social well-being and not merely the absence of disease or infirmity. Some demographers credit family planning programs with 40- . Many women’s groups and non-governmental organisations argued such policies needed to be broader. ● Prevention and treatment of sexually transmitted infections (STIs). such as providing contraception to the largest number possible of married women of reproductive age. safe childbirth and postnatal care. ● Abortion (where legal) and post-abortion care. governments must provide couples and individuals with the full range of reproductive health and family planning services. criticism of population policies surfaced on many fronts. 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 wellbeing. mental and social well-being and not merely the absence of disease or infirmity. Over time. Family planning Reproductive health is defined as “a state of complete physical. including HIV/AIDS. reproductive rights were acknowledged as human rights.Contemporary population policies 12 recognising the contributions of the first 40 years of contemporary population policies. Reproductive health is defined as “a state of complete physical. the use of incentives and targets in family planning was expressly rejected.

the risk of death a woman faces once becoming pregnant. Maternal mortality represents the greatest disparity between rich and poor countries.000 live births.000 live births. with 99% of these deaths occurring in LDCs. The UNFPA says every $1 million shortfall in funding for reproductive health. The Maternal Mortality Ratio (MMR). ● The large gap between needs and available resources has disastrous consequences. including contraceptives. This is caused by population momentum in LDCs. infection or disease such as anaemia. Safe motherhood Complications of pregnancy and childbirth are major causes of disability and death among women of reproductive age in LDCs. However.000 induced abortions. but should become part of fully integrated reproductive health services within the primary health care system.900 deaths per 100. couples want fewer children. 11.000 live births and Haiti – 680 deaths per 100. Afghanistan – 1. According to the United Nations Population Fund (UNFPA). condoms. pelvic pain. the UK – 13 deaths per 100. 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. is the number of maternal deaths during a given year per 100.000 live births.000 additional deaths of children under five. for each woman who dies due to pregnancy-related causes estimates show that another 15 to 30 suffer debilitating injury. Many barriers still remain to the use of family planning: the fear of side effects. 150. 800 maternal deaths. Every minute a woman dies from such complications – around 529. . The world MMR is estimated to be 400 per 100. and as women have achieved higher levels of education and have begun to marry later. religious reasons.000 live births. ● The need for education and contraception continues to increase dramatically. infertility. lack of choice and accessibility. Experts estimate that some 201 million women in LDCs have an ‘unmet need’ for contraception. cost. this number drops to less than 50% in LDCs and to 21% in sub-Saharan Africa.000 live births and Japan – 10 deaths per 100. incontinence and 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.000 live births. as well as the desire for smaller families. In addition. the need for family planning methods will increase by around 40% by 2015. The smaller family sizes reflect a transformation in attitudes about childbearing.000 per year. disapproval of men or families who want women to have more children. A few shockingly high examples from around the world are Sierra Leone – 2000 deaths per 100.Contemporary population policies 13 50% of the fertility decline in LDCs since the 1960s. which is becoming increasingly common around the world. As countries have modernized and become more urban.000 live births during the same period. particularly in Africa and Asia. Some facts about contraception ● 61% of couples around the world use some form of contraception today compared with 10% forty years ago. medical equipment and supplies results in an estimated 360. These can be compared with the US – 17 deaths per 100.000 unwanted pregnancies. At the Cairo conference states agreed that family planning programmes should not stand alone.000 infant deaths and 14. shortage of supply.

but can be treated. UNICEF. postpartum family planning and management Unsafe abortion The WHO estimates that 13% of maternal deaths. and an estimated 15% of pregnancies result in complications requiring medical care. hammered out at ICPD and refined during its five-year review. The consensus documents made clear that “.000 live births) 400 20 24 440 830 130 920 330 55 520 210 190 190 240 Number of maternal deaths WORLD TOTAL DEVELOPED REGIONS Europe DEVELOPING REGIONS Africa Northern Africa Sub-Saharan Africa Asia Eastern Asia South-central Asia South-eastern Asia Western Asia Latin America & the Caribbean Oceania Source: WHO.600 247.000 11. Adolescent reproductive health Of the 6. and UNFPA.000 live births in all countries. Such complications cannot be accurately predicted and most often cannot be prevented.000 4.400 61 20 210 16 94 840 46 140 120 160 83 Current surveys indicate that only 53% of women in LDCs give birth with the assistance of a skilled attendant (a nurse. including antenatal care. nearly half are under the age of 25 – the largest youth generation in history. Skilled attendants are necessary during all deliveries because they have the knowledge to manage and refer complications when necessary. neonatal care. even for healthy women.800 22.700 527. health providers should ensure it is safe and accessible. normal delivery care.000 2. blood transfusions and other specialised care.. In some countries the percentages are much lower. which usually occur where abortions are illegal or inaccessible. however. 1 in: obstetric fistula.Contemporary population policies 14 of STIs would cost just US $3.000 207. which includes surgery and anaesthesia.000 530 74 2.000 annually. Lifetime risk of maternal death. women should receive care for complications arising from them.000 253. 2000 Region Maternal mortality ratio (maternal deaths per 100. The Cairo Programme of Action recognised the urgent need to reduce maternal mortality and morbidity.000 25.000 9. calling for a reduction in maternal mortality levels to one half the 1990 level by 2000 and a further one half by 2015. midwife or doctor having midwifery skills).00 per person per year for a low income country. Many countries have not met these targets. These complications arise from unsafe procedures. The WHO estimates a comprehensive safe motherhood program. Whether or not abortions are performed legally. 2003. Where abortion is legal. is that unsafe abortion should be addressed to reduce its adverse health impacts. Abortion is possibly the most divisive women’s health issue that policy makers face.in no case should abortion be promoted as a method of family planning”. The World Health Organisation (WHO) estimates this number to be 20 million women per year. Skilled attendance during birth is crucially important as all pregnancies involve some risks.. essential care for obstetric complications. The current international consensus. The five-year review of ICPD added a new benchmark for high mortality countries: to ensure that at least 60% of births are assisted by trained health personnel. In lifethreatening cases women require emergency obstetric care. in September 2004 China announced that it had met and exceeded the Cairo target for maternal mortality. or about 70. Fortunately.800 2.000 251. and UNFPA Geneva: World Health Organisation 529. result from complications of abortion.500 1. Their numbers . UNICEF.4 billion people on earth. Maternal Mortality in 2000: Estimates Developed by WHO. and only 40% of women give birth in a hospital or health centre. reducing maternal mortality and morbidity does not cost much. Maternal mortality estimates by region. The Programme of Action also called on governments to close the gap in maternal death ratios between LDCs and MDCs and to aim for maternal mortality ratios below 60 deaths per 100.

Many teenage girls in LDCs will die during childbirth due to the stress on their bodies or a lack of medical attention. Early childbearing has lifelong physical. Most unwanted pregnancies among young unmarried women end in abortion. unsafe abortions and STIs. posing a serious public health concern as not all . there is little evidence that such programmes promote greater sexual activity among young people. governments agreed to a comprehensive set of measures to improve adolescents’ health including: providing sexual and reproductive health information to adolescents.Contemporary population policies 15 are safe. early marriage exposes girls to the risks of pregnancy. including the US. Others suffer permanent damage such as obstetric fistula. are often compelled to leave school and may never have any further educational or job opportunities. ● 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. the right of young people to gain access to contraception is controversial. Many have little knowledge of sexuality. Public health systems in most countries have neglected young people’s sexual and reproductive health needs due to taboos about young people’s sexuality. the sexual and reproductive experiences of young people vary but most become sexually active between the ages of 10-20. 35% of sexually active teenagers aged 15-19 use contraceptives. unmarried teens. ● 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. especially girls. carried out by untrained people without hygiene or proper care. are growing and they are often sexually active. However. but can delay first intercourse and lead to more consistent contraceptive use and safer sex practices. The growing gap between earlier puberty and later marriage has extended the period through which most girls must avoid premarital pregnancy. However. encouraging parental involvement.000 young people aged 15-24 contract an STI each day. which leaves a hole between the bladder and vagina or rectum leading to incontinence and sometimes death. providing integrated health services that include family planning for sexually active teens and taking measures to eliminate harmful practices and violence against young women. if not more than. many parents and policy makers are concerned that providing contraceptive information and services will promote promiscuity among unmarried teens. using peer educators to reach out to young people. therefore exposed to the risks of unwanted pregnancies. In many parts of the world. Reviews of sex education programmes worldwide have concluded that sex education does not encourage early sexual activity. abortion and sexual violence just as much. In countries with conservative values and traditions. In Latin America and the Caribbean. safer sexual practices or their rights to refuse and to abstain. in sub-Saharan Africa fewer than 20% do. By Facts about adolescent sexual and reproductive health ● Around the world. STIs including HIV. ● 300. social and economic consequences. In spite of the controversies surrounding adolescent sexuality at ICPD. Young parents. ● In many countries. ● 10% of all abortions occur among adolescents. adolescent childbearing is socially sanctioned within marriage. both within and outside of marriage.

largely because of the HIV/AIDS crisis.Contemporary population policies 16 drugs. Luxembourg. particularly in the poorest countries. in 1993 dollars.35 in 1996. and offering them the information and services they need to make informed decisions about their lives. However. which buys little modern health care or . In 1994. we are far from reaching many of the ICPD targets. overall levels of spending have been low. since 1994 a total of 131 countries have changed national policies. laws or institutions to recognise reproductive rights. the UN estimated that population and reproductive health programmes in LDCs would cost $17 billion a year by 2000 and $22 billion by 2015. hopefully the generational cycle of poverty can be broken and they can be ensured of a safer and healthier future. Norway. In Uganda. reproductive health care consumes about 60% of the government’s primary health care budget — a relatively high per centage. Between 1996-2001 the UK’s estimated fair share was over £1 billion 290 million. The Cairo Programme of Action called for one third of the proposed spending to come from international donors and two thirds from LDCs. if we are to bring sexual and reproductive health and rights to all by 2015. Although there have been many successes around the globe. particularly financially. annual per capita expenditures on reproductive health were only about $0. providing young people with education. Yet. The UN estimated that in 56 of the poorest countries. despite the financial crisis in Southeast Asia and the HIV/AIDS epidemic. LDCs have done better. Donor countries have fallen short with only Denmark. of this we still owe over £773 million. improve facilities and training and expand family planning method choices. for example. however. Sweden and the Netherlands meeting their financial commitments. For example. Where are we now? We have reached the ten year anniversary of ICPD and governments around the world have drafted an impressive array of new legislation and strategy documents related to population and reproductive health. the reproductive health budget amounts to only a few pounds per person annually. Many countries have begun to integrate reproductive health services into primary health care. Resource constraints are similar in most of Africa and South Asia. such policies require large sums of money and spending per person on health care in LDCs is far lower than in MDCs. Much remains to be done.

HIV/AIDS also brings economic and social problems for individuals. HIV (Human Immunodeficiency Virus) attacks the body’s immune system. In 2003. ultimately resulting in death. the World Health Organisation (WHO) estimated that only 7% of people in LDCs were able to access ARVs. While this treatment is routinely available in Europe and North America. anti-retroviral drugs (ARVs) have been developed which can slow the rate at which the virus progresses. The illness is classified as AIDS when the immune system becomes so weak that opportunistic infections such as pneumonia or tuberculosis occur.HIV/AIDS: From health issue to development crisis 17 HIV/AIDS: From health issue to development crisis “AIDS today in Africa is claiming more lives than the sum total of all wars. In Africa. . No cure exists for HIV/AIDS. In the most affected regions. making it hard to fight off infections. trapping the ill and vulnerable in the poverty cycle. this figure fell to 2%. As a result. It is spread from person to person through bodily fluids and can be transmitted during unsafe sex (sex without a condom). birth or breastfeeding or from exposure to infected blood (injecting drug users sharing needles or transfusions). An estimated 5-6 million people in LDCs will die in the next two years if they do not receive treatment. the cost places it out of reach of most people in less developed countries (LDCs). the body’s capacity to recover from these infections is diminished. Without medical treatment the HIV infection will lead to AIDS (Acquired Immune Deficiency Syndrome). however. WHO and partners have recently launched the ‘3 by 5’ initiative which aims to provide three million people with ARVs by 2005. famines and floods. Over time. pregnancy. First identified in the early 1980s. the HIV/AIDS epidemic is undermining health and education systems and reversing decades of progress in development.” Nelson Mandela Introduction HIV/AIDS is currently one of the world’s most critical challenges.

India has a relatively low prevalence rate (0.800.5 21.000-760. LDCs have so far borne the greatest burden of the epidemic and currently account for 95% of HIV infections.0 6.3 28.300.6 million (1.000 1.2-2.000 Source: 2004 Report on the global AIDS epidemic (UNAIDS) .200. but rising epidemics in India and China are of increasing concern.000-730. but its large population means millions are infected.0 million (520.000) Estimated HIV prevalence in adults (%) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Swaziland Botswana Lesotho Zimbabwe South Africa Namibia Zambia Malawi Central African Republic Mozambique Tanzania Gabon Cote d’Ivoire Cameroon Kenya 38.8 million people worldwide are currently infected with HIV/AIDS and at least 25 million people have already died of AIDS-related illnesses.HIV/AIDS: From health issue to development crisis 18 important to note that some of the countries with the highest prevalence rates also have relatively small populations so the total number of people infected may not be that high.000 (270.9 24.000 5.000 900.000-1.9 million) Caribbean 430.000 920. To fully assess the impact of HIV on a country’s infrastructure we can either look at the per centage of adults infected (HIV prevalence) or look at the total number of people infected in each country. growing concern exists about rising numbers of new HIV infections.000 North America 1.1-9.000 1.2 8.600.5 14.6-42.500.000-46.4 million) East Asia 900.8 8.6 21.5 12.000 (200.300.000 1.6 million) Latin America 1.000 660.8 (34.3) million Source: UNAIDS and WHO The global toll of HIV/AIDS Approximately 37.8 37.000-1.000 (21.7 Total: 37.5 million (4.9 6.1 million) Sub-Saharan Africa 25.100.000 (450.2 13.000 840.3 16.0 million (23. HIV/ AIDS is also having a devastating impact in parts of the Caribbean and Eastern Europe. It is Estimated total number of people living with HIV 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 South Africa India Nigeria Zimbabwe Tanzania Ethiopia Mozambique Kenya Democratic Republic of Congo USA Zambia Malawi Russia China Brazil 5. By contrast.000 860.00) North Africa & Middle East 480.9 million) Australia & New Zealand 32.3 million (860.6 million) (460.100.1-27.000 1.000 1.000 950.000 1. While looking at regional figures for the numbers of people living with HIV provides a general picture of the epidemic.9%). which increased by 20% in the UK in 2003. Adults and children estimated to be living with HIV as of end 2003 Western Europe 580.000-1. While Western Europe has so far escaped the severe outbreaks experienced in other parts of the world.1 7.00) Eastern Europe & Central Asia 1. Sub-Saharan Africa alone accounts for two thirds of the global figures. The two tables below list the top 15 countries for HIV prevalence and numbers infected.000 3. it does not adequately represent the levels of HIV in individual countries.000-1.5 million) South & South-East Asia 6.600.

women are disproportionately impacted by HIV due to biological. primarily because of AIDS. in the absence of a dramatic increase in the global response to the epidemic. Since 1999. Botswana 2020 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 140 120 100 80 60 40 Male ■■■ without AIDS ■■■ with AIDS Source: US Census Bureau 20 0 0 20 40 Population (thousands) 120 140 Female ■■■ with AIDS ■■■ without AIDS 100 60 80 The impact on women In the most affected countries. leaving the elderly to care for the young. there will be more women in their 60s and 70s than women in their 40s and 50s. sub-Saharan Africa faces the greatest demographic impact of the epidemic. This has a devastating impact on the population structures of the worst affected countries as millions of adults die. Marriage does not protect women from HIV and in some African countries married 15-19 year old females have higher rates of infection than their unmarried sexually-active peers. life expectancy at birth has fallen from 64 to 49 years and it is predicted to drop below 35 years in Swaziland. While women currently account for 50% of global HIV infections. In the worst affected countries of East and Southern Africa. In the seven countries with highest prevalence. Females tend to become infected in their late teens and early twenties. economic and social factors which render them particularly vulnerable. The differences in infection rates become more pronounced among young people. Zambia and Zimbabwe without the rapid expansion of prevention and treatment. Sexual transmission of HIV from a man to a woman is from two to ten times more likely than transmission from a woman to a man. Projected population structure with and without AIDS. life expectancy at birth has fallen in 38 African countries. while males are infected in their late twenties to early thirties. without widespread access to treatment. Furthermore. HIV disproportionately affects young adults. Zimbabwe and Lesotho are expected to be 40% lower than they would have been without AIDS. and a lack of female empowerment can make negotiating condom use difficult.HIV/AIDS: From health issue to development crisis 19 adult population as by 2020. The population structure will become significantly distorted as the economically active age groups decline. The projected population pyramid for Botswana clearly demonstrates the impact of AIDS on the . by 2025 the populations of Botswana. The base of the pyramid is also less broad as women become infected before their reproductive years and children born with HIV die in infancy. Women are also more vulnerable to sexual violence. AIDSrelated deaths usually occur 7-10 years after infection. this is likely to rise in future and in sub-Saharan Africa women make up almost 60% of the total number infected.4 times more likely to be infected than a male of the same age. The demographic impact of HIV/AIDS As the region with the highest HIV prevalence. up to 60% of today’s 15 year olds will not reach their 60th birthdays. Without treatment. as a 15-24 year old African woman is 3.

making it even more difficult to recover financially in future.000 by 2020. clothing and housing and may be forced to sell assets including land. However. household expenditure increases as a result of medical and funeral costs. which in turn makes women more vulnerable to HIV. Since the HIV epidemic began. with children either going to live with relatives or forced to live on the streets. many households are currently headed by children who provide for themselves and their younger siblings. Over 30% of teachers in Malawi and Zambia are infected with HIV. HIV/AIDS has a negative impact in both areas. including medical costs. . livestock and ploughs. the remaining teachers 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. While income decreases. A study in Zambia found that when a mother died of AIDS over 65% of households broke up. the epidemic is also taking away their parents. As schools find it difficult to replace teachers who fall ill. HIV/AIDS is taking more than wealth away from affected children. The impact on education The quality and accessibility of education has significant implications for the long term development of individual countries. “Like every other epidemic. this has serious consequences for the supply of teachers. AIDS care. Women may also be forced into selling sex in order to purchase food for their families.000 teachers by the year 2010 and 27. thus increasing their risk of contracting HIV themselves. can consume up to a third of the family budget. In a Ugandan study. one in four AIDS widows reported having her property seized by her late husband’s relatives. Women often face discrimination when their partners die of AIDS. and a World Bank study in Tanzania estimated that AIDS would kill almost 15. at least 15 million children have been orphaned. 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. the vast majority in sub-Saharan Africa. Grandmothers are also becoming primary carers for grandchildren as their own children die and leave behind orphans. families reduce spending on food. In the most affected countries. 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. The loss of a parent can cause the household to break up. As young adults form the age group most affected by HIV/AIDS. AIDS develops in the cracks and crevices of society’s inequalities.” A woman living with HIV/AIDS Women also bear the social and economic burden of the epidemic. These young children are vulnerable to sexual abuse. The cost of training replacement teachers places an extra burden on education systems already struggling to ensure every child is able to attend school. Women are more likely to care for those with AIDS-related illnesses and girls are often withdrawn from school to care for sick parents and younger siblings. To cover such costs. Discrimination decreases the empowerment of women and increases poverty.HIV/AIDS: From health issue to development crisis 20 Children are often withdrawn from school in order to supplement the family income.

Bed occupancy required for AIDS patients. The impact on health services In countries with high rates of HIV/AIDS. The UN’s Food and Agriculture Organisation predicts that by 2020 onefifth of agricultural workers in Southern Africa will have been lost to AIDS. agriculture accounts for 26% of the continent’s gross domestic product and for 70% of its employment. common infections associated with AIDS 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. Often referred to as the ‘brain drain’. 2000 ■ AIDS beds . Even countries outside of sub-Saharan Africa are witnessing the negative impact of HIV/AIDS on agriculture. Zimbabwe 1990 2000 ■ Non-AIDS beds Source: UNAIDS.HIV/AIDS: From health issue to development crisis 21 Health workers are also becoming infected with HIV. there may be little left over to cover school fees. Zimbabwe spends over 50% of its health budget on treating AIDS infections. 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. with over half of all hospital beds occupied by AIDS patients. and the UK has become the favoured destination for health staff from Malawi. health services struggle to meet the increased demands placed on them. As they become too ill to work they leave the remaining health workers to try and care for the ever growing number of patients. The strain on the health services limits their capacity to cope with other infectious diseases including TB and Malaria. 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. As the share of the household budget spent on medicine increases. In Africa. farmers are beginning to switch from cash crops to subsistence crops which are less labour intensive. combined with reduced wealth for families affected by HIV/AIDS. books and uniforms. The reduction in agricultural production. face increased workloads leading to poor morale and many leaving the profession. has led to food shortages for families in many of the most affected areas. the loss of their most able staff to MDCs has profound implications for countries finding it difficult to staff their clinics and hospitals. 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. The epidemic also affects children’s ability to participate in education. although private hospitals are not covered by the ban. As the number of workers available decreases. The UK has banned the NHS from recruiting medical staff from LDCs.

some countries do provide a glimmer of hope that the epidemic can be reversed. Researchers disagree on which aspect was the most effective. yet has managed to reduce the adult prevalence rate from 18. Our funding helped to set up a chicken farm run by HIV positive people. The future Uganda and Senegal demonstrate that while HIV/AIDS is one of the worlds most critical challenges. we might yet succeed in turning the tide. taking into account each individual’s illness and number of dependents. While the Muslim and Catholic leaders preached abstinence and fidelity. with all decisions taken collectively. The farm not only provides employment for people living with HIV. However. Senegal mounted a massive public information campaign to reduce risky sexual practices . The reasons for Uganda’s falling HIV rates are complex and subject to much debate. but also generates income which can be used to buy ARVs. Signs of hope Despite the devastating impact of HIV/AIDS worldwide. A strong team spirit exists at the chicken farm. have fewer sexual partners and use condoms when engaging in sexual practices. Uganda was one of the first countries to experience the full force of the epidemic. but President Museveni’s strong political leadership played a major role.HIV/AIDS: From health issue to development crisis 22 and to increase condom use. we are spending more time turning the bodies of the sick than we are turning the soil. The actions of today’s generation of young people will determine whether the HIV/ AIDS epidemic continues to grow or is eradicated for good. Senegal also successfully engaged religious leaders in the fight against HIV. Senegal is one of the few sub-Saharan African countries which has been able to limit the spread of HIV in the general population. but it is likely to have been a combination of the three. so as a team they must make the difficult decisions about who needs them most. With an HIV prevalence rate of 0. The profits from the farm are not enough to buy ARVs for everyone. there are ways to fight it. Interact Worldwide is working with the National Association of People Living with HIV/AIDS (NAPHAM) to increase access to nutritious food and ARVs for people living with HIV. it will take a global effort to defeat this epidemic. 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. countries rich and poor can ensure that everyone around the world has access to HIV prevention and treatment. Through widespread public information campaigns Ugandans were encouraged to delay sex until marriage. they did not oppose condom campaigns.3% in the early 1990s to around 4% today. Young people are the most critical age group as they offer a hope for the future. By working together and pooling resources.8% amongst adults. Like Uganda.” South African Farmer In Malawi. “Today.

Once the baby is weaned. Adopting family planning and improving women’s reproductive health can assist with the process of transforming gender relations in families and communities. vary widely within and among cultures and can be affected by factors such as education or economics. however. . The balance of power between men and women and younger and older people may not always be equal.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. This will enable women to take greater control over their lives and participate more fully in the development process. The man can just as easily do the job since there is nothing biological that prevents him from shopping. Empowering women helps them become involved in identifying and solving their own problems and makes them more aware of their rights. it often remains the woman’s job to feed the baby because society expects that from her. cooking food and feeding the baby. Gender roles are learned. which increases their choices. People treat gender roles as natural. Gender is not biological. but they are not. This is her gender role. they are dictated by society and are often oppressive to women. For example. and refers to a set of qualities and behaviours expected from a female or male by society. The fact that gender roles are socially determined means they can change to make a society more just and equitable. as well as being beneficial to society as a whole. a woman’s sex makes it her job to breast-feed a baby – no-one else can do it.

Worldwide. young women are not allowed to seek health care without the permission of their husband or family members. one in every four women will experience sexual violence at the hands of a partner in her lifetime. Young women are often unable to make informed choices about their sexual and reproductive health due to a lack of information. often to older men. common in many countries. For example. According to the World Health Organisation (WHO). 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. and usually less than boys. In these places. and pregnancy remains the leading cause of death for 15-19-year-old girls around the world. 82 million girls will marry before their 18th birthday. may feel unable to leave a marriage. ● Married women may be pressured by husbands or families to have more children than they prefer. psychological or emotional including marital rape. Although this practice has been outlawed in both India and China. ● Adolescent girls may be pressured into having sex at an early age within an arranged marriage. boys are seen to make a greater contribution to the household. Around the world. Girls may be less likely than boys to receive health care when they are ill. taboos about discussing sex and expectations of passivity. dowries are often still demanded of a bride’s family in South Asia. and women may be unable to seek or use contraception. Early childbirth carries risks to both mother and baby. 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). it remains widespread. girls often eat last. young married women are usually unable to continue their education and face limited economic opportunities. In addition. Although their bodies may not be fully mature. many continue to be married off much younger. In several studies from around the world up to one third of adolescent girls reported their first sexual experience to be coerced. ● Women may be abused by male partners or family members. thereby exposing themselves to the risk of sexually transmitted infections (STIs). In Niger 76% of girls marry before age 18. gender discrimination starts at or before birth in the form of son preference. neglected or even killed. sometimes bolstered by cultural or religious beliefs. where young girls are seen as more likely to be virgins and therefore not infected with HIV. gender discrimination starts at or before birth in the form of son preference. many girls and women are subjected to harmful practices which threaten their health and well-being. How gender affects women’s health and well-being ● ● Where food is scarce. by adolescent boys proving their manhood or by older men offering gifts in exchange for sex. sexual. is early and forced marriage. due to household and childcare duties. There is an alarming increase in children being married to older men in countries with . Harmful practices In some parts of the world. Girls and women. This reinforces to parents that girls represent a burden on the household. and the fear of abuse can make women less willing to resist the demands of their husbands or families. ● Married and unmarried women may be unable to deny sexual advances or persuade partners to use a condom. who are often economically dependent on their husbands. sexual slavery and trafficking in women. Girls under 15 are five times more likely to die of pregnancy-related complications than women over 20.Gender and health 24 high rates of HIV/AIDS. The violence can be physical. young married women are often expected to start childbearing immediately. divorce or even the death of a bride. where tradition and religion value males over females. Sometimes the desire for sons leads girl babies to be abandoned. Domestic violence occurs in all countries and cultures. In some parts of the world. One such practice. Young brides are particularly susceptible to violence and exploitation. most from poor families. The increasing use of prenatal ultrasound for sex determination often leads to abortions of female foetuses. work on the farm and care of parents in old age. in Nepal 60% and in India 50%. as does having many children in a short span of time. where tradition and religion value males over females. despite laws against them. Moreover. In some societies. If unpaid it may lead to rejection.

even regarding which contraceptive to use. as well as the number and spacing of children. women usually bear the responsibility of using a contraceptive method. 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. ● Each year an estimated 340 million curable STIs occur. abortion or voluntary sterilisation. and completion of. 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. early marriage and childbearing. The World Bank calls women’s education the “single most influential investment that can be made in the developing world”. Although a much simpler procedure. mainly on young girls. eradicating poverty and enhancing development..000 women and to disability in a further five million. but remains significant in secondary education in many less developed countries (LDCs). today there are over 900 million illiterate people in the world. It is practiced in 28 African countries. The importance of education Education is essential to improving health. ● Approximately 201 million women today do not have access to a choice of safe and effective contraceptive methods. the man often decides whether contraception is used. The gap has been closing at the primary level. Although more young people are enrolling in school. Another traditional practice which harms women’s health is female genital mutilation (FGM). vasectomies for men are much less common around the world than female sterilisation. 115 million children currently do not attend primary school. ● Marriage does not necessarily protect women from infection. leading to the deaths of almost 70. ● Females are biologically more vulnerable to most STIs including HIV.Gender and health 25 Because only they can become pregnant. household duties. Girls are more likely than boys to discontinue their schooling for a number of reasons: cost of uniforms and books. ● The consequences of STIs are more serious for women and include infertility and transmission of illness to unborn children. girls and women can suffer difficulties urinating and menstruating in addition to severe pain and distress during sexual intercourse and childbirth. The 1994 International Conference on Population and Development (ICPD) called for universal access to. ● There are some 19 million unsafe abortions each year. to contract gonorrhoea from an infected man than the reverse. 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. in countries such as Mexico. in the longer term. . The cutting is usually performed by a female traditional practitioner with crude instruments. India and China. primary education and for reducing the gender gap in secondary education. as well as almost five million new incurable HIV infections. two thirds of whom are women. parents’ perceptions that education is more beneficial for sons.. in any unprotected sexual act. The influence of the extended family (including mother in laws) has also been shown to impact reproductive decision-making. In some countries HIV rates are highest amongst married women. A woman is twice as likely. parents’ perceptions that education is more beneficial for sons. Women bear the burden of unintended pregnancies. unsafe abortions and sexually transmitted infections. early marriage and childbearing. Women often require the consent of their husband before obtaining contraception. religious or any other nontherapeutic reasons. 57% of these are girls. within marriage. To some it is a way of ensuring virginity before marriage and guaranteeing fidelity during marriage. parts of the Middle East and Asia and some immigrant communities in the West. In some communities it is considered a rite of passage for girls. However. However. in others it is regarded as a cleansing procedure. Apart from the immediate consequences of pain and infection. in nonsterile conditions and without anaesthetic. Girls are more likely than boys to discontinue their schooling for a number of reasons: cost of uniforms and books. Transmission of HIV from male to female is as much as two to ten times more likely than the reverse. household duties.

staff members and clinic visitors of our partner organisation in Indonesia. Men should be involved in defining positive role models and helping boys become gender-sensitive adults. due to the realisation that both men and women have important roles to play. In more developed countries (MDCs). India. Men’s reproductive health services should be supported and ‘male-friendly’ reproductive health clinics should provide greater access to condoms. Indonesia and Thailand joined together to empower women in their local communities through participation in sexual and reproductive health programmes. delay of sexual activity. measures must be enacted to discourage gender-based violence and harmful practices against girls and women. including HIV. When male clinics have offered a wider range of reproductive health services. Bangladesh. Educated women gain the skills necessary to participate in public and economic life as well as looking after their families. Investment in education for girls provides numerous benefits. Community leaders in the widest sense of the word must be engaged to endorse equal partnerships between men and women. condom use and gender sensitivity. In sessions called ‘Couple Fairs’. many boys and men are socialised to believe they must be dominant over females and are applauded for risk taking and aggressive sexual behaviour by their peers. This was hailed as a major breakthrough in the process to empower women. Unfortunately. For example. In the past. hunger and disease and stimulate sustainable development. the programme’s focus on encouraging male participation successfully produced a change in attitude among community men. Yayasan Kusuma Buana. better child health and more education for girls of the next generation. In a conservative country governed by a patriarchal system. At the project end both groups had become more aware and were able to identify these issues and their negative consequences. Some communities link a man’s status to how many sexual partners and/or children he has. and too often men continue to make all decisions regarding sex and reproduction. immunisations and regular check-ups. most population and family planning programmes were directed towards women. where women routinely obtain education and pursue careers. greater use of contraception.Gender and health 26 Promoting women’s status across Asia Promoting gender equality and the empowerment of women are effective ways to combat poverty. Education is linked with later marriage. received gender sensitisation training along with family planning and maternal and child health services such as antenatal care. Interact Worldwide has recently been involved in an innovative pan-Asian project to impact positively on the status of women. men have become more informed and more willing to accept a share in family responsibility. Studies have shown that women who have at least seven years of education have fewer children than those who do not. Male involvement Women cannot achieve sexual and reproductive health without the participation of men. however. In addition. This has changed. Men must be informed and educated about the need for family planning. women and men voluntarily participated in an environment of equity and equality when discussing the reproductive rights of women. the importance of prevention of STIs. Moreover. community women and men were educated to identify harmful social practices related to sexual and reproductive health. . the organisation’s women’s group started a campaign against domestic violence. the age of marriage and first birth continue to increase while birth rates decline. a desire for smaller families. In Bangladesh. Partner organisations in Malaysia.

by the mid1970s the government launched a population redistribution policy aimed at targeting Brazil’s increasing population growth. more exposure to modern medical practices such as contraception and.000 (projected) Total fertility rate: 2. Population: 1985: 135. for example.2 Contraceptive use amongst married women 15-49 (all methods): 76% Life expectancy at birth: 71 Population policy Brazil has never had an explicit population policy to regulate fertility.000 2025: 211. The quality of services left much to be desired. the demand for contraceptives increased significantly. As a result. Until 1985. due to strong opposition from both the Catholic church and the military there were no measures to promote contraceptive use. At the same time.000 Mid 2004: 179. Concurrently. the richest 10% are almost 30 times better off than the poorest 40% of the population. Remarkably. however. when the public health system began to offer contraceptives. The late 1990s saw progress with the passage of a family planning law. reversible contraceptive methods became discredited by women.100. financial. These policies led to a preference for smaller families. one cannot ignore the large disparities in economic. which included nearly all of the elements of reproductive health care defined in the ICPD Programme of Action ten years later. life expectancy at birth increased from 45 years to nearly 70 during the same time period. with inadequate screening and information leading to contraceptive failures and side effects. since coercion in any sense is forbidden and family planning is seen as a basic human right. Before 1974 the government was officially pronatalist. Although economic growth rates were high. widened coverage of the health system and further developed communications systems. contraception has posed the greatest obstacle to an effective public health system in Brazil. political and economic factors hindered its progress. Its population growth fell from approximately 3% per year in 1950 to half that in 2000 and the total fertility rate (TFR) declined from close to 6 children per woman to 2. large social inequalities still existed. a 25% reduction in population growth. Despite clear improvements at the national level. The 1980s was a period of democratisation and the establishment of the Universal Health System. limits on .Federative Republic of Brazil 27 COUNTRY STUDY Federative Republic of Brazil Introduction Brazil has been cited as a success story with regard to population policy. Yet.2 over the same period. Women’s groups demanded the distribution of contraception by government agencies and attempted to legalize abortion.200. increased consumer credit. women depended primarily on the private market and NGOs. Brazil has some of the widest inequalities in the world. 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. as a result. Despite this. mainly for the pill. the government expanded the hospital network. In 1984 the Integral Programme for Women’s health (or PAISM) was launched. social and health indicators within a country that is comparatively only slightly smaller than the US. Between 1965 and 1984 Brazil was under military rule. Since the 1980s.600. expansion of availability of reversible contraceptive methods in the public sector.

In addition. breast and cervical cancer screening.4 million abortions (equivalent to one abortion for every two live births) were performed each year. One hospital in the mid-1980s estimated that 44% of admissions were related to complications due to unsafe abortions. ICPD had a significant impact on abortion policy in Brazil. in July 2004 abortion in babies with anencephaly (no brain) was legalized. However. many in unsafe conditions. For the past three decades sterilisation and the pill have been the most common contraceptive methods used by Brazilian women. The programme covers women of all ages. suggesting that there is a desire to limit family size which is not being met by the state.Federative Republic of Brazil 28 Female Male Brazil 2004 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 sterilisation remain widespread. one study suggested that 7. with services now in place to care for women who undergo unsafe abortions and public health facilities providing legal abortions for victims of rape or whose lives are threatened by the pregnancy. the Ministry of Health has been responsible for family planning. estimates in the early 1990s indicated that approximately 1. Until 1997 the legal status of sterilisation was debatable. including adolescents. who are actively involved in education campaigns. For example. it was prohibited by the code of ethics governing medical practice in Brazil except for precise reasons approved together by two doctors. abortion and . recent changes have made abortion more widely available where the baby’s life may be threatened. sexually transmitted disease (STI) testing and treatment of reproductive tract infections. Brazil has one of the highest 10 8 6 4 2 0 0 2 4 6 8 10 Population (in millions) Source: US Census Bureau. focusing on family planning education and services. However. with neither public nor private health insurance covering the procedure. Before this time. despite its illegality under Brazilian law except in cases of rape or danger to the life of the mother (until the 1980s women were allowed access to abortion only if their life was threatened and never due to rape).5 million women were sterilised when a C-section delivery was performed. Abortion and sterilisation Abortion is widely practiced. infertility services. Since the mid-1990s. to this day contraceptive choice remains limited with most women resorting to sterilisation or the pill. delivery and postpartum care. International Data Base Male Brazil 2025 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Female 10 8 6 4 2 0 0 2 4 6 8 10 Population (in millions) caesarean sections in public hospitals and efforts to regulate the contraceptives market. A common reason was if a woman had one or more caesarean deliveries (C-sections). Despite these positive moves towards improving family planning services. In 1992. often resulting in the woman’s death. Due to the limited legality of abortion it is difficult to capture exact figures. prenatal care.

1 Any folk method 0. Furthermore. Why the decline? The reasons behind Brazilian fertility decline are complex. as well as increasing their understanding of family planning overall. A 1986 survey indicated that the average age at which women were sterilised was 31. In the 19861996 period sterilisation among married Brazilian women in the 20-24 age group rose from 4% to 11%. 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. the irreversible effects of sterilisation are frequently misunderstood. the Brazil AIDS programme provided free and . The law permits sterilisation of women and men older than 25 (if married with spousal consent) or those with at least two living children. Despite the major turnaround in the mid1990s towards a comprehensive health care system which integrated reproductive health matters. This is partly because the cost of a C-section is covered in public hospitals and is more profitable for doctors than natural childbirth.6 Any traditional method 6. From as early as 1996.3 Any traditional/folk method 6. The legislation prohibits sterilisation at delivery or within 42 days (except in cases of medical necessity).2 0.0 Withdrawal 3. 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 2003.5 Not currently using contraception 23. high levels of sterilisation and abortion have been the two main driving forces behind the decline in fertility seen in Brazil. This gave women the incentive to visit a doctor to discuss their reproductive health needs. In 1997 a new federal sterilisation law was passed. improved education and lobbying for family planning amongst women’s groups helped achieve an overall desire to reduce family size. rates of C-sections in the world.Federative Republic of Brazil 29 in the public health system.3 Total 100 According to the Demographic and Health Survey (DHS) of 1996. Unfortunately. The doctor would then simultaneously perform a sterilisation which would be paid for by the woman. thus allowing them to perform a C-section. Contraceptive method use for all married women. Sterilisation is now reimbursable under the public health system at specifically approved hospitals.4 40. Even though abortion policy has been relaxed slightly and sterilisation laws have changed significantly since the late 1990s.3 20.4.7 1.1 1. and HIV/AIDS in Brazil Brazil has been unique in its response to HIV/AIDS. It also appears that women are being sterilised at younger ages. however.1 2. approximately 40% of married women in Brazil were sterilised. there is still an unmet need for a wide range of contraceptives today. indicating that women need to be made more aware what sterilisation entails. This arrangement benefited both the women (who could afford to pay for the procedure) and the underpaid doctors in the public health system.9.1 4. A common practice would be for a doctor to classify a patient as a high risk pregnancy. this has had little impact for low-income women who often do not know their rights and options around reproductive health. Furthermore.1 Periodic abstinence 3. Brazil DHS 1996 (percentages) Any method Any modern method Pill IUD Injections Diaphragm/foam/jelly Condom Female sterilisation Male sterilisation 76. 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.7 70. by 1996 this figure had decreased to 28.

Integrating a universal health care system with reproductive health and family planning has had a significant impact. . compared to other less developed countries (LDCs) Brazil has been successful in reducing and controlling its HIV/AIDS cases. rural women often lack the services provided to their urban counterparts. Since the beginning of the 1990s. In some rural regions. lubricants) which can be inserted in the vagina or rectum before sexual intercourse and would substantially reduce transmission of STIs including HIV. Experts estimate that there are 660. Furthermore. the number of new HIV cases decreased from 25. Remarkably. Although there have been significant increases in clandestine abortions and sterilisations amongst women. The Brazilian case illustrates how government input and community involvement. Brazil is at the forefront of new research and is involved in testing microbicides (creams. For example. 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).000 HIV positive people in the country today. It is estimated that AIDS-related deaths decreased by 70% in the region due to this programme. 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. gels.7% today and in the period 1996-2002 more than 60. adult prevalence is only 0. improve quality of life and reduce the economic impact associated with HIV/AIDS. The Brazilian HIV/AIDS strategy relies on 3 key principles – political leadership. universal access to anti-retroviral drugs (ARVs) in order to reduce deaths. a city in excess of 6 million people.521 in 2001 to Conclusion Brazil has shown that it is possible to limit its population growth without explicitly stating it wanted to do so. The main challenge Brazil faces is to provide wider contraceptive choice for all its citizens. can go a long way to stabilising the HIV/AIDS epidemic and improving health care in the overall population. mainly in poorer regions. Brazil has been successfully able to provide a diverse health care system to the vast majority of its population. Brazil provides hope to countries struggling to deal with the impact of the HIV/AIDS epidemic. Nevertheless. Alongside the national strategy providing free ARVs. 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. several prevention measures have been initiated including over 50 health facilities which provide drugs and others which provide condoms. The government response and community involvement in the HIV/AIDS programme are thought to be the key drivers of its success.Federative Republic of Brazil 30 22. films. It has shown that alongside a comprehensive health care system. However.000 deaths and 360. 90.000 HIV/AIDS related hospital visits were averted.000 cases. as well as universal health care and ARVs. suppositories. the first HIV/AIDS cases were recorded in the early 1980s.295 in 2002. In Rio de Janeiro. 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. it now targets men and women alike. involvement of civil society and local communities and the promotion of human rights. 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.

100.000 (projected) Total fertility rate: 1.7 Contraceptive use amongst married women 15-49 (all methods): 83% Life expectancy at birth: 71 1949 1959 1969 1979 1989 1999 2001 Source: China Population Information and Research Centre and US Census Bureau.000 2025: 1. However. despite dramatic economic progress.000. However. Chinese officials claim that the government population policy is essential to lift people out of poverty and bring individuals a better standard of living. 1949 to 2001 8 7 Children per woman 6 5 4 3 2 1 Population: 1985: 1. both of which are likely to become increasingly significant in the coming years.4 billion. International Data Base Introduction China is a Communist state with tight political controls but increasingly relaxed economic controls. sanitation and the extensive public health system underwritten and organised by the government. evidence exists that families increasingly desire fewer children. This was due to improved nutrition.000 Mid 2004: 1. In 1949 (the year of the formation of the People’s Republic). China currently faces several demographic challenges including its ageing population and the growing HIV/AIDS epidemic. Such a large populace presents both opportunities and threats.476. particularly in rural areas. China accounts for one fifth of the world’s population. and China’s national population policy presents a vivid example of the clash between society’s objectives and individual rights. China’s 1. chiefly for economic reasons. many concerns exist about its social and economic impacts and infringement of individual rights and choice. largely due to a seemingly endless supply of cheap labour.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.The People’s Republic of China 31 COUNTRY STUDY The People’s Republic of China Total fertility rate for China. China remains a low-income country with millions living in poverty. as in other parts of the world.000. the shift toward a . However. In 1980 it was 64 and by 2004 it reached 71. In recent years China has become an economic powerhouse.070. life expectancy was 35. yet it only produces less than 5% of the world’s Gross Domestic Product (GDP).300. China’s mortality rate has declined dramatically in the past 50 years. Although China’s infamous one-child policy has succeeded in dramatically reducing growth by approximately 300 million people in the last decade.

1 children per woman. Population policy development At the time of the Communist Revolution in China in 1949. housing and health care if you only had one child. In 1970. longer. International Data Base Male China 2025 100+ 95-99 90-94 85-89 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Female political strength and provide labour for economic development. The reduction in fertility rates in China started as far back as the 1950s1960s. Over the years the one-child policy has changed significantly. because China is so 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70 Population (in millions) market-orientated system since the early 1980s has meant the demise of guaranteed access to health care for all.8. women were encouraged to be sterilised after two births and rules of contraceptive use were strictly enforced. fewer’ which encouraged later marriage. Compliance was encouraged through a system of incentives and disincentives such as preferences in education.The People’s Republic of China 32 Female Male China 2004 100+ 95-99 90-94 85-89 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70 Population (in millions) Source: US Census Bureau. The goals were three children for rural couples and two for urban couples. At first. Yet. They were convinced the country could not grow economically if they did not curb the rapid population growth. the same did not occur in rural areas where most of the population lived. by the mid-1950s the government reversed its position due to fears that excessive growth would hinder development and a desire to improve maternal and child health. the Total Fertility Rate (TFR) was 6. In the 1950s the government promoted fertility control in the name of maternal and child health. the government argued China needed a large population to boost its . particularly in rural areas where mortality rates remain notably higher than urban areas. In the1960s the focus was on teaching rural people about the benefits of smaller families and the government tried to increase access to contraception and abortion. which initially allowed all couples only one child and required official approval before conceiving a child. However. mainly because the government started paying attention to birth rates in urban areas and people desired fewer children. The policy established national and provincial level targets for births. In the early days. In 1971. the TFR remained at 5. In 1979 the government launched the one-child policy. the government launched a campaign called ‘later. Although birth rates started to decrease in urban areas. by the end of the 1970s couples were encouraged to have only one child and the government began to believe that population control would require extreme measures. longer intervals between births and fewer births. Yet.

There are now 32 pilot counties where the State Population and Family Planning Commission. ICPD stressed the value of a comprehensive approach to reproductive health. the Chinese government reorientated the family planning program to be “driven by the people’s interest”. In August 2004. Services in family planning clinics have been upgraded and women and men have been given more choice when selecting contraceptive methods. in 1984 the government began to allow fertility regulation at the local level.The People’s Republic of China 33 years a new client-centred approach has taken hold in many parts of the country. have abandoned birth quotas and targets. including wider access to condoms. with officials encouraged to avoid heavy handed methods of enforcement. according to the government they are still too high. The law continues to include fines for having extra children. English translation: One child. 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. some Chinese demographers believe the real .7 and future projections assume this. which encouraged China to improve the quality and range of family planning services. In April 2004. However. In addition. 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. working with the Ministry of Health and China Family Planning Association. Each province enacted its own self-contained population planning programme. Although local officials still set family planning targets. Since that time. although initially they will retain birth quotas and targets. 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. Although fertility rates did fall in all parts of China.2 billion. the Chinese approach came under increasing scrutiny.26 billion. ethnic minorities are allowed two children and more recently urban couples who are both only children themselves may have two children. This programme is currently expanding to 880 counties (a third of the country). prosperous life Beijing Centre of Communication and Education for Family Planning vast and diverse. In 1995. prenatal care and counseling. which was above their ambitious goal of 1. 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. Consequently. Moving beyond coercion? The 1994 International Conference on Population and Development (ICPD) raised global awareness of population issues. Shanghai announced that divorced couples who remarry can have a second child. This has led to a large variation in the content of regulations among provinces. the concept of informed choice has started to gain ground in many counties. the one-child policy still officially exists in China and was reaffirmed in the 2002 National Population and Family Planning Law. pills and injectibles. While it adheres to the onechild policy. rural couples have been allowed a second child if their first is a girl. it allows local governments to define special groups of people who can have more children. reproductive health care. 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. Exceptions to the one-child policy have increased and changes have been made in pilot areas. Current figures show it is 1. Much debate exists regarding China’s actual TFR. but punishment is unevenly implemented. in recent China today The Census of 2000 showed the population to be 1. Inevitably.

with a declining proportion of the population in the active work force to support increasing numbers of elderly. fewer girls are born and orphanages in China are filled with girls. but the reality is probably closer to 120 or more. neglect or abandonment. coil) and after a second child they are sterilised. There are several significant demographic consequences of China’s birth planning policies. Consequently. Contraceptive use and child care remain the responsibility of women. the sex ratio of males to females is the highest in the world. In 2003 the average age at marriage for women was 22. If this trend continues. many females have been aborted. In addition. to underreporting of female births. The true population size is very difficult to determine as rural families may hide children to avoid penalties. but in many rural areas it is still well above 2. Doctors can be bribed. late marriage as a way to lower fertility and slow population growth. 83% of married women aged 1549 were using a method of contraception.1 up from 18. as boys are considered better able to provide for their families. These children have been referred to as ‘little emperors’ as many are doted on by parents and grandparents and described by critics as spoiled. to deaths of girls through female infanticide. Marriage has always been a significant institution in China. the family provides much of the support for old people. in years to come there will be many more men than women in China. and without indicating the sex may tell couples to “paint the baby’s room pink”. In the future. Rural families may be under particular pressure to kill baby girls. with less than 25% of the workforce receiving a pension. it increased from 1.3 children. Although identification of the sex of a foetus and sex-selective abortion are strictly illegal in China. It continues to be nearly universal for women but the age of marriage has increased.2 in the 1940s. There will be more elders for each child and the elders will be older and frailer. children will spend more time taking care of their parents and there will often be three generations in one English translation: Up agricultural production. Studies indicate that after a first child most women use an IUD (intrauterine device.The People’s Republic of China 34 house. adoption of female babies. The government encouraged. 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. In the 2000 census. Traditionally. but has changed profoundly in recent years. and now mandates. In 2004. Another serious outcome of the one-child policy is the ‘missing girls’ phenomenon. The 2000 census showed the sex ratio to be 118 boys for every 100 girls (the normal sex ratio is 105:100). by 2020 China number lies between 2. The explanations for these numbers range from sex-selective abortion. however. in the past two decades with the introduction of ultrasound screening of embryos. In 1982 the contraceptive prevalence rate among this group was 71%. down population increase Beijing Centre of Communication and Education for Family Planning . yet the UN projects they will increase to 15% in 2015.0 and 2. In 2004 adults aged over 60 make up 11% of the population. Condom use remains low. In China. Projections for 2050 suggest there will be nearly 100 million Chinese aged 80 or older. care for elderly relatives and continue the family line. 64% of elders aged 65 or older lived with their children. relatively few Chinese elders work compared with other Asian countries. 24% in 2030 and 28% in 2040. In some urban areas the TFR is as low as 1. The most serious may be the ageing of the population. As a result.4% in 1982 to 3. Demographers call this the ‘4-2-1’ problem – in many families one child will be expected to support two aged parents and four grandparents. Even in urban areas the tradition of son preference remains strong. self-centred and in need of discipline. Contraceptive use is high in China. Another consequence of the one-child policy is a generation of only children.4% in 1997.2.

men who have sex with men or the floating population of economic migrants. Outside major cities. Experts predict that without serious prevention measures 10-15 million Chinese could become infected with HIV by 2010. HIV tests were only available to the most stigmatised members of society such as sex workers and injecting drug users. sexual transmission of HIV is increasing.000 have died of AIDSrelated illnesses. Due to the shortage of women some men are turning to foreign women. However. 2000 Although the percentage of the population infected with HIV/AIDS in China remains low at less than 0. China has developed strict guidelines that all blood must be screened for HIV and other blood-borne diseases before clinical use. then injected the remaining red blood cells back into individual donors to prevent anaemia. HIV/AIDS in China English translation: Control our population at 1. In 2002. poverty (particularly in rural areas). but with the quick spread of the virus in the general population the government is making tests more available to the wider public. the government has started to allocate funds towards prevention and control of HIV/AIDS. free domestically produced ARVs and other medications to treat opportunistic infections. In addition. however. In recent years. there is a growing traffic in kidnapped brides and commentators worry about the potential destabilisation of Chinese society.200 million China Family Planning Association. Until recently. 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. The vast majority of people infected with the HIV virus in China are former plasma donors in seven central provinces. 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. by the end of 2003 over 5000 people were receiving antiretroviral treatment.000 people will need such treatment by 2008. in 2000 UNAIDS reported the amount to be one seventh that of could have up to 40 million men who can’t find a spouse.1%. It provides subsidised testing. it is estimated that four times more men than women in China are infected with HIV. Despite this. without . pre-marital sex is on the increase. Since 1995. the stigma attached to HIV testing results in many infections remaining undiagnosed. In Spring 2003. the government has recently admitted there are 840. the Chinese Ministry of Health estimated that 300. sex workers. This risky practice meant that infection from just one person could spread to many people. the risk factors exist in China for a generalised epidemic: a highly mobile population. However. These men are called ‘bare branches’ as they are unlikely to be able to continue the family line. there are still HIV cases reported through blood transfusions in rural areas. the ‘China Cares’ Programme (China Comprehensive AIDS Response) was launched to assist infected plasma donors. In addition. However. sex education is not taught in primary or middle school and cultural conservatism limits discussion of sexual matters. During the late 1980s to late 1990s. hospitals and clinics still reuse needles and medical equipment.The People’s Republic of China 35 being tested for hepatitis or HIV. low condom use and an increase in STIs. an increase in high risk behaviour such as needle sharing. No specific prevention or treatment programmes exist for drug users. Presently.000 people infected with HIV (up 30% in one year) and over 80. extracted the plasma. Under this programme. which contributes to the spread of bloodborne diseases. injecting drug users accounted for half of new HIV infections.

However. free schooling for AIDS orphans (of whom there are approximately 76. the government has had limited success in implementing 100% condom use and needle exchange. . free prevention of mother to child transmission. free voluntary HIV counseling and testing. Unfortunately. commits to provide free ARVs to impoverished citizens. as they do not want to be seen to condone illegal or illicit activities. 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. ‘four frees and one care’.The People’s Republic of China 36 Thailand’s.000) and care for AIDS patients and their families. The government’s new centrepiece policy. condoms can now be advertised on television and sex education is gradually being introduced into secondary schools in some parts of China. Provinces and counties are required to raise funds locally for these mandates.

000. India’s growth has been rapid.000 Mid 2004: 1. The high rates of poverty.000 vasectomies were carried out within a fortnight. at which 65. according to the World Bank. and the world’s largest number of illiterates. The new target orientated approach dominated the field of population and family planning until 1996. India accounts for a sixth of the world’s population but. Family sizes have also fallen sharply. . COUNTRY STUDY Population: 1985: 764. Since India gained independence from Britain in 1947. The government set the first of many over ambitious targets. In 1947 the average couple had six children. In 1952.000 (projected) Total fertility rate: 3. Although originally aimed at improving the health of mothers and children. However.Republic of India 37 Republic of India 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.363. 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. resulting from longer life expectancy and lower infant mortality in recent decades. India became the first country in the world to establish a national family planning programme. The population is expected to peak at around 1. Since the 1990s.1 Contraceptive use amongst married women 15-49 (all methods): 48% Life expectancy at birth: 62 From population numbers to a target free approach: India’s evolving population policies Introduction In August 1999. Additionally.000.000. including one in Ernakulam during 1972.6 billion by 2050. the average life expectancy at birth has risen from just 28 years to 62 years. 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. while today the average couple has only just over three. The central government set sterilisation targets for states and health workers to meet and introduced financial incentives to reward health workers who achieved them. low literacy and lack of female equality.000 2025: 1. coupled with high population growth rates.086. in the 1960s its focus shifted towards a reduction in birth rates as a result of increasing political concern about population growth. population momentum means that in the same half century the country’s population has nearly tripled. also accounts for 40% of the world’s absolute poor (60% of whom are female). more cost effective method of fertility reduction. Mass vasectomy camps were organized across India. To many politicians and government officials it represented a permanent. 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). in 1966 the government introduced targets for contraceptive usage including the sterilisation of men and women.

the population programme resulted in a public revolt against the government. Incentives for health workers to meet sterilisation targets were increased and mass sterilisation events were carried out in railway stations. which relied on targets set by the central government. however. was subject to particular criticism. The target orientated approach. by setting targets centrally . International Data Base Male India 2025 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Female 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70 Population (in millions) Slippages in achieving the reduction of the birth rate led to an intensified drive to promote sterilisation during the emergency period of 1975-1977. The term family planning became synonymous with coercion and forced sterilisations and there was widespread public mistrust. death rates had fallen even faster (see box below). Firstly. although targets remained in place for contraceptive usage and for reducing the birth rate to around 25 per 1000.Republic of India 38 India 2004 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Male Female also amended the constitution to ‘freeze’ representation in parliament based on the 1971 Census until 2001. contraceptive choice and the voluntary nature of family planning were emphasised. Fertility rates had almost halved since independence. From 1978 until the 1990s. As political representation in Parliament was based on a state’s population size. which led to its downfall in 1977. The new government renamed ‘family planning’ as ‘family welfare’. The new policy 1990s: Towards a target free approach By the 1990s. They highlighted the fact that since India was already undergoing demographic transition. revised the Population Policy to reduce sterilisation targets and stated that ‘compulsion in the area of family welfare must be ruled out for all times to come’. an enforced approach to population was unnecessary. The aggressive family planning programme was often referred to as the first to ‘cause a government to fall instead of the birth rate’. the success in the fall in fertility rates had been overlooked. this could have provided a disincentive for states to reduce their population. criticism of India’s approach to population increased both at home and abroad. 70 60 50 40 30 20 10 0 0 10 20 30 40 50 60 70 Population (in millions) Source: US Census Bureau. A National Population Policy was formulated and adopted by the Parliament in 1976. Academics argued that by focusing on population growth rates. Between April 1976 and March 1977. over 8 million sterilisations were carried out in India. Ultimately. The excesses of the emergency years caused a crisis for family planning in India. There were reports in the Northern states of Bihar and Uttar Pradesh of men being forcibly subjected to the procedure. 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’.

with a third of the seats reserved for females. Another major rights issue for women in India is the Dowry system. literacy. India moved towards a more decentralised power structure which afforded more decision making to the states. The women’s movement was the most vocal critic of the government’s family planning programme in the 1990s. the National Family Health Survey (NFHS) of 1998-1999 found that half of women married before age 18.7 years. the government demonstrated a total disregard for their real needs and concerns. poverty and violence against women.6 22. more likely to marry and begin childbearing early. It also leads to high rates of pregnancy complications and deaths. Originally a method for passing on a share of family inheritance to daughters at their marriage. As the levels of incentives for health workers were highest for sterilisations. in turn. Aside from the accusations of enforced sterilisation during the ‘emergency’ years. Early marriage significantly contributes to high fertility rates as girls begin childbearing at an earlier age.1 it ignored the wide disparities between states in terms of social and economic development as well as culture and religion. resulting in little impact on the birth rate. Through their lack of education they are. with 15-19 year olds twice as likely to die in pregnancy or childbirth than women over 20. workers would promote sterilisation at the expense of other. the promotion of sterilisation above other methods subjected people to procedures carried out in appalling conditions with no medical follow up. as surveys show that only 51% of women are involved in decisions about their own health care. 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. the Panchayat Act created a system of ‘local government’ through elected Panchayats (village councils).000 live births. which increases their own risk of maternal mortality. 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. In 1992. 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. 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 . The ‘gender gap’ in India was. The women’s groups also argued that women throughout India were not empowered to make decisions about spacing their families. Field studies by researchers indicated that contraceptive usage rates reported by health workers had been vastly inflated. When a woman dies or becomes disabled by pregnancy. During the 1990s. They claimed that by focusing on contraception without attention to female empowerment.4 conduit for meeting government aims.8 9.Republic of India 39 Death rate (per 1000) 42. maternal mortality affects women of all age groups in India. The low status of women is a central factor influencing high fertility rates.2 40. Despite a 1976 law stipulating 18 years as the minimum age of marriage for females. Poor illiterate women were being pressurised into accepting sterilisation without fully understanding the implications of the procedure. and despite progress still is. Secondly. a significant issue in India. less permanent contraceptive methods which would enable women to delay or space their childbearing. Birth and death rates per 1000 population Year 1901 1951 1991 Birth rate (per 1000) 49. with the average age of marriage being 16.9 29. With a Maternal Mortality Ratio (MMR) of 540 maternal deaths per 100. her surviving daughters will often be required to leave school in order to care for their younger siblings.

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 practice remains common across India and it can be difficult to marry off daughters without the promise of a large dowry. found the infant mortality rate for children born to literate women was just over 60 per 1000.9% in Rajasthan. 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. to change their funding priorities. The practice of a woman leaving her family to join her husband’s family at marriage also impacts on the level of female education. 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’. with state-wide female illiteracy rates ranging from 14. by the Indian Institute for Population Studies. as educated women are more likely to understand the benefits of good nutrition and health care for children. The 2001 Census showed the number of women had fallen to 933 per 1000 men. The NFHS 1998-1999 reported a female illiteracy rate (age 6+) in India of 48.6%.9 % in Kerala to 62. in consultation with the community. In 1995. As ICPD also influenced major donors. including the World Bank. In most areas of India. “Whoever went to Cairo came home convinced that change was necessary”.Republic of India 40 over the years Dowry evolved into a large quantity of gifts given by the bride’s family to the groom’s family at marriage. . with the overriding cause remaining the low status of women. By planning health care provision at a local level. it remains widespread). As one Indian Observer noted. Son preference has led to a serious gender imbalance in India. The system has contributed to a belief that daughters are a burden on families due to the costs of their dowries. There has already been a rise in the trafficking of young females from across India and surrounding countries to meet the demand for brides. As her family will not reap the benefit of their investment in her education. 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. 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. 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. of services provided. which will only increase in future years. neglect of the girl child and female infanticide. The gender imbalance is leading to a shortage of females of marriageable age. In some states the imbalance is even greater. the Indian government came under increasing pressure to radically revise their approach to population. 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. with the Punjab only registering 793 female 0-6 year olds to 1000 males. Although officially banned in 1961. The sex ratio of 0-6 year olds demonstrates that this trend is only getting worse as there are 927 females to 1000 males in this age group in India. schooling of sons is often prioritised over daughters. A number of factors reduce the presence of female children including sex-selective abortion (although illegal. as opposed to quantity. as parents become more confident their children will survive to adulthood. A report from 1995. Low levels of infant mortality correlate with lower fertility rates. At the conference. India’s preparations for the International Conference on Population and Development (ICPD) in 1994 brought arguments about gender equality increasingly into the public spotlight. Low rates of female literacy directly impact upon infant mortality. compared to 100 per 1000 children born to illiterate mothers.

These include a cash reward of 500 Rupees for the birth of a girl. if she is the first or second child. which allayed the fears of many sceptics that contraceptive use would decline without targets. in an attempt to redress the sex ratio. 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). the speed of the change in policy left some districts struggling to make sense of the new way of working. In their 2004 election manifesto they proposed to ban anyone with more than two children from public office and government jobs. The Population Policy also sets out a number of practical measures to help achieve the overall aims. In some districts. give birth supported by a trained birth attendant and immunise the child. 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. use of all methods had increased. While some districts took time to plan and adequately train and support their health workers to deliver the new approach. as it will take decades for the full effects to be felt in areas such as female empowerment and population stabilisation. The elections of 2004 saw the BNP-led coalition lose office to be replaced by a coalition led by the Indian National Congress.Republic of India 41 The success of the new approach varied across the districts selected for the pilot. largely because previous statistics had been inflated. despite the removal of central targets. extensive surveys were carried out in the community in order to assess the needs of people using family welfare services. led by the BJP. however. In 1997. statistics showed the number of family planning users declined in India. preferably after the age of 20. It has set ambitious goals to be met by 2010. Health workers’ caseloads were calculated based on the results of the surveys. the coalition government of the time. the Indian Government launched a new National Population Policy which formalised the new broad based approach to population. The new Population Policy embraces a human rights approach to population and development but it faces many challenges in its future implementation. and to provide integrated service delivery for basic reproductive and child health care”. Sustained political commitment will be critical in reaping the long term developmental benefits of the plan.” Current challenges In 2000. its immediate aims are to “address the unmet needs for contraception. lowering infant and maternal mortality and promoting delayed marriage for girls. . Their aim is to provide extra family planning and reproductive health facilities in the poorest communities and to seek “Whoever went to Cairo came home convinced that change was necessary. By 1998. Even after the announcement of the new policy in 2000. including making school education up to the age of 14 free and compulsory. began to openly advocate for a two-child policy in India. health care infrastructure. However. in 1996 the government scrapped centrally determined targets for all the states in India. In these districts the quality of services improved significantly. other districts imposed their own targets and did not attempt to engage the community in assessing the need for family welfare services. 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. 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. Despite the mixed success of the pilot year. and health personnel. 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.

debarring them from jobs and education further disempowers them. Currently. Recently. Critics argue that those most likely to have large numbers of children are the poor and these policies marginalise them further. . but it is likely that should HIV become embedded across the country.7 and 4. A major public information effort will be required for India to prevent HIV reaching sub-Saharan levels. While awareness of HIV and how it is transmitted is relatively high in some Southern states and urban areas such as Delhi. including Uttar Pradesh. The NFSH 1998-1999 reported that nearly 16% of married women in India had an unmet need for contraception. crisis which has the potential to threaten the public health and development gains of recent years. Poverty. awareness remains low in the rural areas where the majority of India’s population lives. compliance with the minimum age of marriage has been made a prerequisite for applying for government jobs. Such policies have been widely criticised. Concern about population growth has led some of the Northern states to introduce extreme policies to promote fertility reduction. India currently has around 5 million people infected with HIV and will soon overtake South Africa as the country with the most HIV cases. India has more adolescents than any country in the world.1 respectively. With 36% of its population aged under 15. there are more males infected with HIV than females. 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. 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. it is likely that HIV is prevalent elsewhere but remains undiagnosed. the government now faces pressure to ensure that supplies meet the growing demand. between a quarter and a third of married women had an unmet need. 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. The United Nations Population Fund (UNFPA) has recently launched a five year initiative in India to meet the needs of adolescents. 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. where fertility rates have fallen dramatically to 1. the World Bank warned that without progress on prevention HIV/AIDS would become the single largest cause of death in India. Maharashtra and Tamil Nadu) account for 80% of all reported HIV cases in India.5 respectively). with an increasing gulf opening between the poorer Northern states. In Bihar. However.8 and 2. As awareness of the full range of contraceptive methods has increased across India. and the more prosperous Southern states such as Kerala and Tamil Nadu. Meghalaya and Arunachal Pradesh. gender equality and access to health and education vary greatly between states. In some states.Republic of India 42 support from all sectors of the community in improving the quality of health services. India’s large numbers of adolescents will create further pressure to meet unmet need in the future. The six states with the highest prevalence (including Andhra Pradesh. including Bihar and Uttar Pradesh (where fertility rates are 4. Reducing the wide disparities between states will continue to be a critical challenge for India. particularly the elements which discriminate against those with more than two children. 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. As women often have little choice over their childbearing or age of marriage. accounting for 17% of all deaths and 40% of infectious deaths by 2033. A final major challenge for the government of India is the need to scale up their response to the HIV/AIDS.

Early and universal marriage was endorsed and the minimum age lowered to 9 for girls and 12 for boys. and despite some bloody battles with the Shah’s security forces. economic and political reforms which gave more freedom to women and restricted the influence of religious leaders.5 today – one of the fastest declines in history.The Islamic Republic of Iran 43 COUNTRY STUDY The Islamic Republic of Iran Introduction Despite the common belief that Islamic societies prefer larger families.000 2025: 84. not least because of a unique political and religious commitment. his autocratic style of rule was unpopular with many Iranians and in 1953 he was briefly overthrown. along with the close relationship the Shah enjoyed with the US. Iran has shown that this is not necessarily true and has often been cited as a success story with regard to population policy. The influence of the religious clerics. the Shah introduced a number of social. to 2. However.400.5 births per woman in 1986. legislation could be overturned by the Council of Guardians. 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’. Despite an explicit pronatalist position adopted from 1979-1989. led to accusations from many sections of society that Iran was becoming too westernised and that the Iranian identity . Remarkably. but reinstated with the support of the US Central Intelligence Agency (CIA). in January 1979 the Shah was forced to flee Iran. with a view to improving the health and wealth of the country through a reduction in population growth. In addition. and the programme was not promoted as it was seen by many to be un-Islamic. This has been achieved through several pathways. coupled with a backlash against seemingly western influences.400. When the economic reforms were seen to benefit only the urban elite. a group of religious clerics tasked with ensuring that all legislation passed was consistent with Islamic values and teachings. While contraceptives were not banned they were not distributed.5 Contraceptive use amongst married women 15-49 (all methods): 74% Life expectancy at birth: 69 The Islamic Revolution From 1941-1979 Iran was ruled by the Shah (King). led the family planning programme to become effectively paralysed. By 1978 the opposition took to the streets.700. Religious clerics held great power in the new republic.000 Mid 2004: 67. and culture were under threat. Babies meant an additional share of rationed goods. These included the introduction of a population policy in 1967. Iran reduced its population growth from 3. When Iran went to war with Iraq in 1980 (a conflict which lasted eight years and involved large scale casualties). Although there was an elected parliament. which included not only food but modern consumer goods. During the following period in power.000 (projected) Total fertility rate: 2. the country made a dramatic turnaround during the 1990s to achieve the low fertility rates experienced today.4% in 1986 to just over 1% in 2004 and has sustained a reduction in its total fertility rate from around 6. The introduction of this policy. throughout the war period larger families were entitled to a greater proportion of basic commodities and consumer goods via a rationing system. critics of his economic policies joined together with religious leaders and pro-democracy campaigners to oppose his rule. Population: 1985: 48. A new constitution appointed Ayatollah Khomeini as the Supreme Leader of the country and the Islamic Republic of Iran was born.

It was every Iranian’s duty to check the birth rate to ensure that Iran did not become dependent on ‘imperialist aid’. The first encouraged births to be spaced three to four years apart in an attempt to increase infant and child survival and reduce maternal mortality.The Islamic Republic of Iran 44 Female Male Iran 2004 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 5 4 3 2 1 0 0 1 2 3 4 5 Population (in millions) Source: US Census Bureau. Yet. which generated public support and brought family planning to the forefront of debate. It also encouraged adolescents (particularly girls) to finish schooling. bringing about a reduction in gender inequality which in turn improved the status of women. This led to a reduction in large family size and improved economic development at the national level. further aiding fertility decline. even when excluding immigrants from the official figures. Population growth averaged 3. This led to a trend towards later marriage and a decline in arranged marriages. Following the publication of the 1986 census. Due to the sensitive nature of the topic. The Iran-Iraq war had crippled the country financially and growing concern existed . A series of conferences were held to discuss the relationship between Islam and population policies and to highlight the implications of continued population growth.4 to 7. the religious leaders were forced to be pragmatic. International Data Base Male Iran 2025 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Female 5 4 3 2 1 0 0 1 2 3 4 5 amongst politicians about how they would meet the basic needs of an ever increasing populace.2% per year and estimates for fertility rates ranged from 6. The second goal strongly discouraged births to women under age 18 and over age 35. the religious clerics were able to reconcile the idea of a population policy with Islamic values. the natural growth rate was above 3. this aimed to increase the age at first marriage and reduce total fertility. Consequently. The final goal of the 1989 Population (in millions) The demographic consequences of this policy were soon evident.9% per year between 1976 and 1986 and the population almost doubled in the period 1968-1988. thus allowing western influence to return to Iran. Moreover. Several newspapers and radio stations broadcast articles in favour of fertility decline.7. political attention became focused on the implications of such a high growth rate for the future development of Iran. The success of the Islamic republic would rest on their being able to provide services and an increased standard of living for Iranians. in 1989 the parliament approved a new National Family Planning Policy with three main goals. Despite their previous support of a pronatalist policy. Part of the increase could be accounted for by the influx of around 2 million refugees from Afghanistan and Iraq during this period. many behind the scenes discussions and negotiations took place to win support from the religious clerics for a population programme. At the lower end. With the support of religious leaders on board. they realised that should population growth make this impossible to achieve they might be forced to accept support and aid from countries in the West.

infant mortality has fallen from around 135 infant deaths per 1000 births in 1976 to 32 today. The fertility decline has not reduced some of the ongoing issues of poverty. reduce population growth to 1. housing subsidies and so forth after the third child The religious clerics worked to dispel the belief that population programmes were a Western ideal. health insurance and housing subsidies to couples with more than three children. contraceptives such as the condom and the pill were available free of charge. 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. As it developed in conjunction with improving . the Iranian government did not introduce draconian measures.5 was introduced. 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. Support from religious leaders 7. Universal access to health care and family planning services 2. ‘Health Houses’ have been developed to serve rural villages. Compulsory contraceptive classes were also implemented before couples were married. little stigma attached to contraceptive use. Furthermore. Unlike the Chinese one-child policy. rather. 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. Despite Iran’s success in promoting smaller families and reducing population growth. severe water shortages still exist. they wanted to indicate the importance of every couple having a choice about how many children to have and when. it is possible that population growth would have stabilised even without the Revolution. In May 1993 it passed a National Family Planning law which restricted maternity leave benefits. Large investments have taken place in education and health. stating that limitations of births would improve the well-being of children. further limiting births. they argued in favour of contraceptives such as the Intrauterine device (IUD). The developments in health and education accelerated the progress towards the targets of the population policy. Pre-marital compulsory contraceptive counseling classes 5. the pill and condoms. While there has been tremendous progress in recent years. Education aimed at teaching pupils specifically about reproductive health and family planning introduced in schools 4.The Islamic Republic of Iran 45 primary health care. In the early 1990s. Summary – Why Iran was so successful 1. Furthermore. Therefore. The promotion of family planning has been accompanied by other measures to improve the standard of living for Iranians. Rise in female literacy through literacy programmes in the most deprived areas 3. education and overall development. reproductive health and family planning (within the context of marriage – pre-marital sex remains taboo). which have increased female literacy from 35% in 1976 to over 70% today. which gave women and men more equal involvement in childbearing decisions. Nevertheless. with population policy stated that couples should aim to have no more than three children. the government expanded the 1989 policy to create disincentives to have more than three children. Similarly. it is speculated that the total fertility rate was already declining even prior to the Iran-Iraq war.5% and reduce the TFR to 2. Strong political will 6. Creation of disincentives for women to have several children through reduced maternity leave benefits. preaching reduced family size in sermons and religious proclamations (known as fatwas). Between 1993-1998 a plan to increase contraceptive prevalence to over 70%. Leaders such as Ayatollah Khomeini were highly influential. Although population decline has helped alleviate the problem. 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. Iran still must address several issues. the pace of fertility decline in the past 25 years in Iran is still impressive.

sterilisation is legal in Iran and Tunisia but illegal in Egypt and Jordan. phenomenon. others argue it is acceptable as long as it is reversible. in Islam there is no central authority. Muslims also look to the examples of Muhammad (the Prophet). there is no reference to it in the Qu’ran. Even then. as there may be confusion about whether it is un-Islamic. however. supported by Interact Worldwide. and adolescents are still sensitive and feel embarrassed to discuss reproductive health issues openly with elders. in many other Muslim countries women are free to work. . The support of religious clerics was a critical factor in the success of Iran’s family planning programme. as a result of the 1980s ‘baby boom’. Muslims generally accept abortion only when there is a serious threat to the life of the woman in continuing the pregnancy. Unlike Catholicism. culture. Senegal. learn and participate in politics. almost 40 million people lacking adequate supply. however.The Islamic Republic of Iran 46 to come. 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. Pakistan and Albania. While the vast majority of Muslims use the writings in the Qu’ran to promote gender equality. However. Some Muslims are against sterilisation as the Qu’ran states that Muslims should cause no harm to their bodies. Moreover. It is a common misconception that the lives of Muslims are the same wherever they are in the world. a small minority interpret the references to distinct gender roles in order to keep women in the home or out of formal employment. in various cultures and religious sects the Qu’ran (the holy text) is often interpreted in different ways by religious scholars and leaders. it also states that they have distinct roles to play in life. Male participation in the family planning program is still comparatively low. 33% of Iran’s population is under 15 years old and population momentum will continue for several years Islam. believing that spacing births enables greater care to be given to existing children. The diverse interpretations of the Qu’ran and the hadith can create a barrier to family planning. 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. and religious leaders in the Philippines have recently issued fatwas proclaiming that family planning is not against Islamic practice. Although FGM is practiced in some predominantly Muslim countries (including Sudan and Burkina Faso). Programmes which aim to provide family planning services to Muslim communities are most successful when they work with religious leaders to communicate messages. Despite the common misconception that female genital mutilation (FGM) is promoted by Islam. Attitudes to gender and family planning are as varied amongst Muslims worldwide as they are amongst Christians in the UK. 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 usually only allowed before the 120th day of the pregnancy when it is believed that ‘life is breathed’ into the foetus. The Qu’ran repeatedly states that men and women are equal. despite the differences in their history. His actions (sunnah) and sayings (hadith) are also interpreted to provide guidance in day to day life. economics and politics. where the Vatican is the authority on the interpretation of the Bible. Bolivia and the Philippines. as opposed to religious. In contrast to the lives of women under the Taliban in Afghanistan. For example. the tradition predates Islam and is a cultural. There are over 1 billion Muslims worldwide and they make up the majority of the population in countries as diverse as Iran. Therefore. most Muslims support the use of temporary contraception (including condoms and the pill). The Family Planning Association of Pakistan.

with fertility rates rising for the first time since the 1970s.Kenya 47 Kenya Population policy: 1967-1979 In 1967.8 children per woman (recorded in the 1962 Census) to 3.4 within the space of 15 years. it was influenced by government demographers who highlighted the negative economic consequences of continued high population growth. they invited a team of American experts to Kenya to study population issues and make recommendations for a future policy. there was little government discussion or debate about the aims of the programme and few politicians would publicly support it. shortly after independence from Britain. However. it is unlikely they fully understood the cultural context in the country nor the value placed on high fertility. The programme’s goals were to reduce fertility. Furthermore. as opposed to limiting family size. After spending only three weeks in Kenya.759. was the first African country to introduce a family planning programme with the aim of reducing population growth. and the effects of a significant HIV epidemic eroding infrastructure. It focused on the provision of family planning in clinics and emphasised spacing children.400. First. decrease the population growth rate from 3. however. In 1965.000 Mid 2004: 32. fertility rates and the population growth rate had actually increased during the period of the plan. with the aim of reducing population growth.000 2025: 39. in East Africa. The accomplishments of this period have recently begun to be reversed. many Kenyans were still very sensitive to the influence of Westerners on their country. While child mortality had decreased. 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.0 Contraceptive use amongst married women 15-49 (all methods): 39% Life expectancy at birth: 51 Introduction Kenya. The results of the first programme in 1967 were disastrous. from 1979 the population programme was strengthened and achieved significant successes through the 1980s and 1990s. the team recommended that the government adopt a goal of halving fertility rates from 6.000 (projected) Total fertility rate: 5.900. the government launched the National Family Planning Programme. The failure of the policy during this period was the result of a number of factors. when the results were reviewed in 1979 the findings were disturbing.3% to 3% and reduce child mortality (deaths in children aged under five) by 1979. However. COUNTRY STUDY Population: 1985: 19. The failure of the 1967 policy also stemmed from the fact that population .

5% compared to a population growth rate of 3. Reduce child mortality 1969 3. . including the governments of the US and UK.5 0 0 0.0 157 growth was viewed as a medical problem during this period. 2.0 2. The economy became increasingly dependent on foreign financial assistance and fees had to be introduced for schooling and healthcare. many Kenyans simply did not believe there was an economic need to reduce population.5 2.6 192 1979 3. with no attention paid to the connection between population. The central argument behind the policy was that economic growth would not occur without restraining population growth. By 1979. poverty and gender. “Kenyans could do well to learn from birds who do not lay eggs until they have built nests”. Reduction of total fertility rate 3. International Data Base Male Kenya 2025 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Female Population policy: 1980-1993 0 0. While spending on health care increased during the time of the plan.5 2.0 0.3 7.5 1. economic growth averaged 9. In 1967.3% to 3% in 1979 2.8 8. However. who was more supportive of arguments regarding the link between population and economic development.0 1. Individual politicians also began to speak out on population.5 1.5 0 Population (in millions) Goals and achievements – National Family Planning Programme 1967-1979 Goal (1967) 1. In 1982. including the Minister for Constitutional and Home Affairs who declared that.0 1. Christian and Muslim leaders also argued that using contraception was against the will of God. the National Council for Population and Development (NCPD) was established to formulate a population policy and coordinate activities aimed at reducing population growth.5 1. In 1979 President Kenyatta died and was replaced by President Moi.5 2.5 Population (in millions) Source: US Census Bureau. during the 1960s and 1970s Kenya’s economy grew much faster than the population did. many Kenyans still viewed children as economic and social assets and contraceptive use remained low.Kenya 48 Kenya 2004 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Male Female However.5 2. The Ministry of Health focused on providing clinic-based services and left the Family Planning Association of Kenya (FPAK).0 0. Most of the costs were met by private organisations and by Western donors. As the government also invested heavily in creating free education and health care.3%. to concentrate on increasing demand for contraception.5 2. Kenya’s economy was beginning to run into difficulties.0 2. a non governmental organisation. along with the UN and the World Bank. little health care expenditure was set aside for family planning. The prices of coffee and tea (Kenya’s major exports) had declined worldwide and a drought badly affected maize production.0 1. education. Reduce population growth rate from 3.5 1.0 1.

9 3. the policy had achieved considerable success.4 6. Reduction of total fertility rate from 7. Contraceptive rates rose from 7% in 1980 to 33% in 1993. Kenya had invested heavily in public health and education. Yet. the government reviewed its population policy in order to strengthen initiatives to empower women and improve reproductive health services as recommended by the conference. Reduce child mortality from 140 per 1000 In 1984. In addition.3%. fees had been introduced for education. Fertility and population growth also declined faster than anticipated.8% to 3. indicating that there will be an increased demand on reproductive health in the future. Since independence. In 1986 a community-based distribution system started. However. Reduce population growth rate from 3. The new policy also included campaigns to sensitise political and religious leaders to the problems created by unchecked population growth. where people living in rural communities were trained to educate others in their area about the benefits of smaller families and provide contraceptives. ● One in ten teenage girls aged 15-19 gives birth each year. As access to health services improved. Increased political support.4 96 Goals and achievements – National Population Policy 1984-1993 Goal (1984) 1. due to the economic difficulties of the decade and conditions imposed on Kenya by external donors (including the International Monetary Fund). 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. ● If all women who wanted family planning were given it.Kenya 49 1989 3. By gaining the support of these leaders they were able to mobilise the population to support the family planning programme.7 91 1993 3. It aimed to increase contraceptive usage and expand the network of clinics offering family planning. Population policy: 1993 to the present In 1995. 2000 politicians. the contraceptive prevalence rate would increase from the current figure of 39% to 66%. following the International Conference on Population and Development (ICPD). By 1993. Kenyan attitudes to large family sizes were already changing during this period. ● 44% of Kenyan’s are under 15 years old.7 and contraceptive usage had increased to 38. They eventually set a target of reducing population growth from 3. .000 women die in Kenya each year due to pregnancyrelated causes. The new National Population Policy was wider in its approach than the previous family planning programme. 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. infant and child mortality rates dropped steadily and parents became more confident about the survival of their children. civil servants and NGO leaders met to discuss population issues in Kenya. 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.3% to 3% by the end of 1998.3% by 1993 2.1 5. The policy also included goals to increase female education and expand the number of women in formal employment. ● Nearly 11. the post-independence governments strongly promoted education as a means for ensuring economic prosperity. Many parents chose to have fewer children to ensure they were able to educate the children they already had. Foreign donors were targeted for money to expand activities and fund research into population and family planning.

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.7 in 1998 to 4. however.200. The high levels of illness place the health service under extreme pressure. health workers and government officials fall sick and die. Each year approximately 300. More women are infected than men (8% compared to 6. around 15% of hospital beds were occupied by AIDS patients. 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. leading to the injury and deaths of thousands of women.Kenya 50 However. These difficulties were compounded by the withdrawal of US funding for leading family planning organisations and shortages in contraceptive supplies. This is largely due to the fact that older men tend to go out with younger females. President George W. with 6. however. it is actually only 51 as a direct consequence of HIV/AIDS. however. 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). in 2004 it has actually increased to 78. by 2000 this had risen to 51%. In younger age groups the disparity is even more pronounced. The preliminary results of the 2003 NDHS indicate the total fertility rate rose from 4. The infant mortality rate was expected to fall to around 50 deaths per 1000 live births by 2005. Abortion is illegal in Kenya except when there is a severe threat to the health of the mother. with many more young women infected than young men.7%). even if the money used is not directly for abortion-related work. Life expectancy at birth should currently be around 65 years. 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.9 in 2003. 25% reported losing their virginity because they had been forced. Despite low rates during the early 1980s.000 live births. as many women have been unable to prevent pregnancies. this has significantly reduced their access to family planning facilities and supplies. 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. This is a worrying trend after so many years of decline. 1. Currently. Bush reinstated the Global Gag Rule.5 million Kenyans have already died of AIDS (around 700 per day) and over a million children have been orphaned. with severe prison penalties for both the mother and abortion provider. by the late 1990s and early twenty-first century. HIV/AIDS in Kenya HIV arrived in Kenya in the late 1970s. 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. For many Kenyans.7% of the adult population infected (down from 8% in 2001). as it can no longer afford to pay their salaries. Kenya. In 1992. Kenyan Ministry of Health statistics indicate that 1. Another half of the clinics are set to close by the end of the year. One dramatic impact of HIV/AIDS is the decline in life expectancy at birth amongst Kenyans. 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. FPAK has also lost most of its Community Based Distributors in rural areas. not just abortion. The epidemic also seriously affects the government’s ability to deliver services as teachers. 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 abortions are carried out illegally in Kenya.000 people are living with HIV in . A recent study found that AIDS accounted for 58% of all staff deaths in the last five years in Kenya’s Ministry of Agriculture. infection rates steadily increased during the late 1980s and early 1990s. The majority of infections in Kenya are transmitted sexually. The impact of the Global Gag Rule on Kenya On his first day in office in 2001. Infant and child mortality rates have also risen as a result of the epidemic.

The Philippine population is expected to reach 142.000 Mid 2006: 87.7 billion. particularly in the countryside.5% of overall GDP.700. Some 10 per cent of the population are abroad on temporary job contracts and in 2005 contributed $10. who supported the Catholic Church’s view that there was no need to promote contraceptives. Joseph Estrada become president and continued a population programme based on responsible parenthood.000 (projected) Total fertility rate: 3. Health Secretary Alfredo R. the population programme received many liberal ideas and inputs from international conferences where the Philippines participated.A.000. Unemployment is also high. POPCOM was transferred to the Department of Social Welfare and Development headed by Mamita Pardo de Tavera. Estrada’s programmes did not have time to create the desired impact. The Aquino Cabinet was split on the population issue. and abstinence. with a rising population of 85 million people. the family planning component of which promoted birth control pills. It is saddled with huge foreign debt and a ballooning budget deficit that take away resources from health and education programmes. Forty per cent of the Philippines’ population lives below the poverty line. IUDs.Philippines 51 Philippines Introduction The Philippines consists of more than 7. the population programme remained a major component of the Ramos government’s anti-poverty social reform agenda. beginning a heated interplay between the government and the Catholic Church over population policy. COUNTRY STUDY Population: Mid 2005: 85. 13. Fidel Ramos became president and appointed Juan Flavier as health secretary and put POPCOM back with the NEDA.000.000 ratio (2004): live births .000 islands. but the bulk of the population lives on just 11 of them. An alarmed Catholic Church launched an attack on Flavier and the contraceptive part of the programme. It is the world’s 12th most populous state. The Philippines is a majority Roman Catholic country. including the 1994 International Conference on Population and Development in Cairo. People Power II intervened and Estrada was overthrown by Gloria Macapagal Arroyo in January 2001. Even after Marcos declared martial law in 1972. and the Department of Health took over the family planning component of the population programme. a wide range of modern contraceptive methods were available throughout the country. established over 500 years of Spanish colonial rule. In 1998.5 Contraceptive use amongst married women 15-49 (all methods): 49% Life expectancy at birth: 70 29 deaths Infant per 1. In 1986.2 million by 2050. While Aquino herself said in a State of the Nation Address that family planning was among her priorities. Nonetheless. Bengzon disagreed. It gained independence from the United States in 1946. From 1992 to 1996. Flavier ignited the public’s enthusiasm for reproductive health services. the Department of Health and other agencies. POPCOM. People Power I ended the Marcos dictatorship and put Corazon Aquino in power. costing Flavier first place in the Senate elections of 1996. In l992. 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). There was close cooperation among NEDA. Ferdinand Marcos stayed in power for 21 years.000 (projected) 2025: 115.000 mortality rate (2005): live births 240 deaths Maternal mortality per 100. condoms. From the National Economic and Development Authority. some officials cited the right of the unborn as essential.

with the Arroyo administration toeing the line of the influential Catholic Bishops Conference of the Philippines to promote only natural methods of family planning and at the same time implementing anti-Church measures such as the two-child policy and sterilization.5 is still considered high among Southeast Asian countries where Indonesia has a birth rate of 2. At least 53 million Filipinos are covered by Philhealth.95 per cent. Gains made in reducing the TFR are undermined by the country’s weak economy. which covers hospital room and board. 6 5 4 3 2 1 0 0 1 2 3 4 5 6 Population (in millions) “It is for the well-being of the mother and child.4 percent in the 1990s. said only the first two normal deliveries are covered by the Philhealth card.3 and Vietnam 2. While President Arroyo lobbied the United Nations for support for her government’s natural family planning campaign. . There has been a marked decline in the Total Fertility Rate (TFR) amongst women since the first National Demographic and Health Survey in 1968. to 3. due to its crucial role in removing Marcos and later Estrada. The Catholic Church. Malaysia 3. which worsened under the corruption of the Marcos dictatorship.5 children per woman today. We do not want to encourage our women to get pregnant more often than their health could permit.2. “It is for the well-being of the mother and child.Philippines 52 Philippines 2005 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Male Female 6 5 4 3 2 1 0 0 1 2 3 4 5 6 Population (in millions) Source: US Census Bureau.6.1 per cent and that this year it has gone down to 1. Philhealth foreign assistance coordinating officer. Pura Carño. However. outpatient services and family planning surgical procedures. doctor’s fees. when the TFR was 6 children per woman.” A recent study by the University of the Philippines (UP) School of Economics showed that the Philippines managed to reduce its birth rate from three percent in the 1970s to 2. became even more influential among the Filipino people and the government. International Data Base Male Philippines 2025 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 Female The phase-out began in 2004 and will be completed in 2007. prescription medicine.” The current government response to the need for population control measures has remained ambiguous. the state-run Philippine Health Insurance Corporation (Philhealth) was implementing the twochild policy and promoting tubal ligation for women and vasectomy for men. The government says for the past five years the growth rate has been 2. We do not want to encourage our women to get pregnant more often than their health could permit. a TFR of 3. The continuing growth of the population has pitted advocates of birth control against the Church. This “flip-flopping” position has prompted the United States and other donor-countries to withdraw P840 million ($16 million) in annual donations of contraceptives and other birth control devices until the Philippine government has clearly defined how it intends to bring down the rapid population growth.

rhythm and periodic abstinence. giving in to pressures from the Catholic bishops. some provinces. 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. cities.” argues Atienza. Arroyo has stated she is leaving the issue of addressing population growth to the discretion of local government executives. Provision of the full range of choices.2 per cent of married women were reported as using traditional contraceptive methods (calendar. This has forced many NGOs who provide family planning information and contraceptives in the capitol underground. However. Natural family planning. “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. 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. The Conservative Mayor of Manila. is a right. the only method that requires the cooperation of both parties. doctors are reluctant to prescribe it because of its high failure rate – as much as 20 per cent by some estimates. and withdrawal). Lito Atienza. and towns have reproductive health services with strong family planning components in partnership with non-government organisations and barangay (village) youth councils. and that the IUD. In 2004. Empowered by the 1991 Local Government Code. Most of the programmes are funded by bilateral or multilateral grants. and her conservative stand creates a situation where the capitol and local governments may be moving in different directions. 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. “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 author of the two-child policy. and are compounded by lack of access to accurate information. “Population control and the distribution of contraceptive materials in government facilities is a continuing illegal act.Philippines 53 Government legislation Lowering birth rates through expanded choices of contraceptive methods and providing sex education are a few of the immediate aims of HB 3773 (the Responsible Parenthood and Population Management Act of 2005 popularly known as the two-child policy that was consolidated with other bills into HB 3773). The legislation has so incensed the church that it has threatened not to administer communion to any government worker promoting the bill. stated. Mrs. including modern contraceptives. is inexpensive and produces no side effects. (2) The mother should be exclusively or almost exclusively breastfeeding. Arroyo signed the ICPD document promoting “informed choice” and shortly after that. 14. it is effective only under the following circumstances: (1) The infant is less than six months old. and (3) There has been no return of menses for the mother since delivery (a sign of the return of fertility). However. by contrast. which the Philippines subscribed to under the ICPD. 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. or intra-uterine . Myths surrounding modern family planning methods have become widespread. Among these are rumours the birth control pill could cause psychological illnesses. has ordered public health clinics to stop offering family planning.” Natural family planning methods In April 2005.” 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. House Deputy Majority Leader Edcel Lagman.

. The widespread practice of unprotected sex makes HIV/AIDS a serious threat. particularly where many people are not aware of their status. have written on the subject and worked toward improving health policies and services. but a high proportion of women consult traditional practitioners (hilots) or attempt to induce the abortion themselves. The Department of Health of the Philippines reported that 12% of all maternal deaths in 1994 were the result of illegal abortion. however. When women get to the hospital for treatment they often face hostile health-care providers. 70 per cent of unwanted pregnancies end in abortion.000 illegal abortions performed in the Philippines every year. public attention to the issue is minimal. could cause cervical cancer.” of medical professionals. except to save the life of the mother. legislators and women’s health advocates. 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. and about a quarter of them result in hospitalization for complications. Sexual intercourse remains the main method of transmission (86% of cases) and of those 62 per cent through heterosexual sex. Prevention and Management of Abortion and its Complications. Because of this the Department of Health is seeking money for an intensive HIV/AIDS awareness and education campaign aimed at young people. with an estimated 400. because induced abortion is punishable by law in the Philippines. three in five young people between the ages of 14 and 20 believe they cannot contract HIV. ranging from safe medical procedures performed for better-off women by trained personnel.” said Michael Tan. A number HIV/AIDS The provision of modern family planning methods. lawyers. among others. According to a recent survey by the Department of Health. to procedures in extremely unsafe conditions for poor women who cannot afford to pay for a surgical abortion. One in five believes incorrectly that the virus can be contracted by drinking contaminated water. “One of the reasons the population programme has not been effective is because the scare tactics are very effective. The general secrecy surrounding induced abortion does not mean. young adults and migrant workers. the Philippines Department of Health provided official guidelines for a post-abortion care programme. particularly condom use. In addition.” Abortion In the predominantly Roman Catholic Philippines. According to the latest Department of Health statistics there are 11. the subject tends to be masked by silence and consequently. kissing or mosquito bites. a population expert at UP. “Statistics show very clearly that many Filipinos are afraid of contraceptives. Many are carried out under unsafe conditions. Despite these legal barriers. The Philippine government has set aside $383.Philippines 54 device. 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. This is predominantly due to the lack of access to professional health services in rural areas. and pilot tested such programs in 17 government hospitals in late 2003.168 HIV positive people aged 15-49 in the Philippines. there is no legal divorce or abortion. social scientists. Regrettably. Evidence from the mid-1990s indicates that Filipino women of all social classes and backgrounds are having induced abortions. children.000 to stockpile anti-retroviral drugs for HIV positive people. “Statistics show very clearly that many Filipinos are afraid of contraceptives. that the subject has not been of concern over the past 30 or more years. 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. They do so under varying circumstances.

mission Our mission is to build support for and implement programmes which enable marginalised people to exercise their right to sexual and reproductive health. 1001698 .org W: www. transparency and a strong focus on relevant activities which provide value for money.org Registered Charity No.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. London NW5 1TL.interactworldwide. values Efficiency and effectiveness through accountability. High professional standards which incorporate Best Practice. Highgate Studios. responsiveness to perceived needs. Studio 325. (formerly Population Concern) Interact Worldwide. UK T: +44 (0)20 7241 8500 F: +44 (0)20 7267 6788 E: info@interactworldwide. 53-79 Highgate Road. innovative approaches to problem solving and commitment to quality outcomes.

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