POVERTY: Smart family planning improves women's health and cuts poverty

Lester Brown, 14 April 2011
Smart family planning improves women's health and cuts poverty
The costs to society of not filling the family planning gap may be greater than we can afford


  China Newsphoto/Reuters
A woman in rural China inspects a condom. Slowing world population growth means ensuring that women who want to plan their families have access to family planning services. This will help to cut poverty.
When it comes to population growth, the United Nations has three primary projections. The medium projection, the one most commonly used, has world population reaching 9.2 billion by 2050. The high one reaches 10.5 billion. The low projection, which assumes that the world will quickly move below replacement-level fertility, has population peaking at 8 billion in 2042 and then declining.
If the goal is to eradicate poverty, hunger, and illiteracy, then we have little choice but to strive for the lower projection.
Slowing world population growth means ensuring that all women who want to plan their families have access to family planning information and services. Unfortunately, this is currently not the case for 215 million women, 59% of whom live in sub-Saharan Africa and the Indian subcontinent.
These women and their families represent roughly 1 billion of the earth's poorest people, for whom unintended pregnancies and unwanted births are an enormous burden.
Former US Agency for International Development (USAID) official J Joseph Speidel notes that "if you ask anthropologists who live and work with poor people at the village level … they often say that women live in fear of their next pregnancy. They just do not want to get pregnant."
The United Nations Population Fund and the Guttmacher Institute estimate that meeting the needs of these 215 million women who lack reproductive healthcare and effective contraception could each year prevent 53 million unwanted pregnancies, 24 million induced abortions, and 1.6 million infant deaths.
Along with the provision of additional condoms needed to prevent HIV and other sexually transmitted infections, a universal family planning and reproductive health programme would cost an additional $21bn in funding from industrial and developing countries.
Shifting to smaller families brings generous economic dividends. In Bangladesh, for example, analysts concluded that $62 spent by the government to prevent an unwanted birth saved $615 in expenditures on other social services. For donor countries, ensuring that men and women everywhere have access to the services they need would yield strong social returns in improved education and healthcare.
Slowing population growth brings with it what economists call the demographic bonus. When countries move quickly to smaller families, growth in the number of young dependents – those who need nurturing and educating – declines relative to the number of working adults.
At the individual level, removing the financial burden of large families allows more people to escape from poverty. At the national level, the demographic bonus causes savings and investment to climb, productivity to surge and economic growth to accelerate.
Japan, which cut its population growth in half between 1951 and 1958, was one of the first countries to benefit from the demographic bonus. South Korea and Taiwan followed, and more recently China, Thailand and Vietnam have been helped by earlier sharp reductions in birth rates.
Although this effect lasts for only a few decades, it is usually enough to launch a country into the modern era. Indeed, except for a few oil-rich countries, no developing country has successfully modernised without slowing population growth.
Though many developing countries in Asia, Africa, and Latin America were successful in quickly reducing their fertility within a generation or so after public health and medical gains lowered their mortality rates, many others did not follow this path and have been caught in the demographic trap – including Afghanistan, Ethiopia, Iraq, Nigeria, Pakistan and Yemen. (Large families are a greater financial burden on both parents and governments, and more impoverished people and societies tend to produce larger families. Thus they become "trapped" in a cycle of poverty and high fertility.)
Countries that do not succeed in reducing fertility early on face the compounding of 3% growth per year or 20-fold per century. Such rapid population growth can easily strain limited land and water resources. With large "youth bulges" outrunning job creation, the growing number of unemployed young men increases the risk of conflict. This also raises the odds of becoming a failing state.
Put simply, the costs to society of not filling the family planning gap may be greater than we can afford.
The good news is that governments can help couples reduce family size very quickly when they commit to doing so. My colleague Janet Larsen writes that in just one decade Iran dropped its near-record population growth rate to one of the lowest in the developing world.
When Ayatollah Khomeini assumed leadership in Iran in 1979 and launched the Islamic revolution, he immediately dismantled the well-established family planning programmes and instead advocated large families. At war with Iraq between 1980 and 1988, Khomeini wanted to increase the ranks of soldiers for Islam. His goal was an army of 20 million.
Fertility levels climbed in response to his pleas, pushing Iran's annual population growth to a peak of 4.2% in the early 1980s, a level approaching the biological maximum. As this enormous growth began to burden the economy and the environment, the country's leaders realised that overcrowding, environmental degradation and unemployment were undermining Iran's future.
In 1989, the government did an about-face and restored its family planning programme. In May 1993, a national family planning law was passed. The resources of several government ministries, including education, culture and health, were mobilised to encourage smaller families.
Iran Broadcasting was given responsibility for raising awareness of population issues and of the availability of family planning services. Television was used to disseminate information on family planning throughout the country, taking advantage of the 70% of rural households with TV sets. Religious leaders were directly involved in what amounted to a crusade for smaller families.
Some 15,000 "health houses" or clinics were established to provide rural populations with health and family planning services. Iran introduced a full panoply of contraceptive measures, including the option of vasectomy – a first among Muslim countries. All forms of birth control, including the pill and sterilisation, were free of charge. Iran even became the only country to require couples to take a course on modern contraception before receiving a marriage license.
In addition to the direct healthcare interventions, Iran also launched a broad-based effort to raise female literacy, boosting it from 25% in 1970 to more than 70% in 2000. Female school enrolment increased from 60% to 90%. Women and girls with more schooling are likely to have fewer children, making their education a smart investment.
As a result of this initiative, family size in Iran dropped from seven children to fewer than three. From 1987 to 1994, Iran cut its population growth rate by half, an impressive achievement.
The bad news is that in July 2010, the Iranian president, Mahmoud Ahmadinejad, declared the country's family planning programme ungodly and announced a new pronatalist policy. The government would pay couples to have children, depositing money in each child's bank account until age 18. The effect of this new programme on Iran's population growth remains to be seen.
Nevertheless, Iran's history shows how a full-scale mobilisation of society that incorporates public outreach, access to family planning resources, and gender equality in education, can accelerate the shift to smaller families.
http://www.guardian.co.uk/global-development/2011/apr/14/smart-family-planning-reduces-poverty

MALNUTRITION: PAKISTAN: Population growth rate adds to problems

 Photo: Jason Tanner/Save The Children:
Big families means more mouths to feed

ISLAMABAD, 18 January 2011 (IRIN) - Pakistan’s problems with militancy, a fragile economy and natural disasters such as the 2010 floods have often been discussed, but an even greater threat may be posed by the sheer numbers of people in the country.
According to official figures, the projected population for 2015 is 191 million, up from the current figure of 170 million, making it the sixth most populous nation on earth. By 2050 it is expected to climb into fourth place.
This is bad news for a country that has struggled to provide its people with adequate food, health care or education. Malnutrition rates are high and are linked to 50 percent of infant and child deaths; there is one doctor for every 1,183 people; and the literacy rate of 57 percent is among the lowest in South Asia.
“There is now increasing evidence that investments, among others, in education, health, including reproductive health, women's empowerment and slower population growth contribute towards poverty reduction. In general, it has also been found that where there is rapid population growth and high fertility rates, poverty incidence is also highest,” Rabbi Royan, the UN Population Fund (UNFPA) representative in Pakistan, told IRIN.
“More people, of course, means a further drain on resources,” Sikander Lodhi, an economic analyst, told IRIN. “Resources are already stretched to the limit,” he said.
The same principle holds true within individual households. “Allah [God] has given us eight children. We are fortunate,” said Rafiq Muhammad, 50, a labourer who earns around Rs 5,000 (US$59) a month. His wife, Parveen Bibi, told IRIN: “It is very hard to feed everyone. We do not even get one proper meal a day.”
“People believe large families mean more earning hands; but they do not realize they also mean more eating mouths,” said Rehana Nazeer, a service delivery manager at the Lahore-based Family Planning Association of Pakistan. She told IRIN the “closed, conservative nature of society” and also problems in tending to the health needs of women in rural areas on hormone-based contraception had led to difficulties in promoting birth control.
“If a woman develops a bleeding problem, she cannot get to a doctor on her own. Her husband or other man in the family must take a day off work to take her,” Nazeer said.
According to the Demographic Health Survey of Pakistan, conducted in 2006-07 by the Ministry of Population Welfare, while 96 percent of women who have ever been married are aware of at least one family planning method, fewer than half have ever used one, and less than 30 percent of married women currently use a contraceptive. The survey also shows 25 percent of married couples would like to use contraception but are not doing so, mainly because they lack access to advice or contraceptives.

Difficult to change attitudes
“Many women would like to practice birth control, but their husbands dislike the idea,” Farhat Bibi, a lady health worker, told IRIN. Run by the government’s National Programme for Family Planning and Primary Health Care, the lady health workers’ scheme was started in 1994 to reach out to rural communities and cater to the needs of women and children in particular.
“We offer advice on contraception, but some women are too scared of their husbands to even consider these methods,” she said. The belief that God determined family size, and in some cases that women on the pill may be tempted to have sex outside marriage, confident they would not become pregnant, were key factors in this attitude, Farhat said.
These factors explain why Pakistan has struggled to promote family size. Though the fertility rate has declined gradually over the last 15 years, according to the Demographic Survey, the fertility rate of 4.1 children per woman means the population continues to grow, with an increased strain placed on dwindling resources, including water.
“The high number of pregnancies also means women in particular, and children, suffer more health problems and this further drains resources,” said Samina Iqbal, a doctor who told IRIN: “I always advise my female patients to stick to one or two children, but they face acute family pressure to have more.”

http://www.irinnews.org/report.aspx?ReportID=91656

POVERTY: Helping the World’s Poorest, for a Change

TINA ROSENBERG
Tuesday’s Fixes column was about conditional cash transfers, a new and highly successful large-scale anti-poverty program. It pays poor women as long as they meet certain responsibilities, like keeping their children in school and taking their families for regular medical care. It’s in use in Brazil, Mexico and 38 other countries.
Many commenters were skeptical that programs to help the poor could actually work in corrupt or badly governed nations. It’s certainly rare to find successful social programs in places where laws and institutions are very weak. But conditional cash transfers have features that allow them to work even in badly governed countries. It’s useful to look at what these features are.
In 1994, a third of all Mexicans were living in extreme poverty, which meant their incomes did not cover even food alone.
These programs start with an idea that shouldn’t be unusual but, sadly, is — giving help to people who need it most. Social programs in many poor countries tend to benefit people who aren’t those in the greatest need. In health and education for instance, money is spent disproportionately on urban hospitals and universities, as these programs have powerful political constituencies. In most of the countries where they exist, conditional cash transfers are the first programs to truly focus on the poorest.
Before Brazil began Bolsa Familia, its only large social program was old-age pensions. These pensions only went to formal-sector workers; but the really poor of Brazil don’t have formal-sector jobs. Before Mexico had Oportunidades, its “help” for the poor took the form of a corrupt and wasteful network of shops selling subsidized milk, tortillas and bread. These programs were designed to please large dairy, corn and wheat farmers (something that should be familiar to anyone who takes a look at the U.S. farm bill.) Subsidies on bread? Poor Mexicans don’t even eat bread — they eat tortillas.
Mexico was able to change this because of the Tequila Crisis — the 1994 crash of the peso, when the economy contracted by six percent. A third of all Mexicans were living in extreme poverty, which meant their incomes did not cover even food alone. The government of Ernesto Zedillo knew that the food subsidy programs would do little to help. So it decided to find something better. Santiago Levy, then an undersecretary in the finance ministry, reasoned that subsidies were just an inefficient way to give the poor money — so why not give them money? At the time, this was considered a crazy idea. No other country did it.
Levy reasoned that the program would be much more effective if the money could be used as leverage. He set up a pilot project in a faraway state in secret — so as not to attract the attention of special interest groups. It worked. The pilot showed that it was logistically feasible to carry out the program; that families preferred cash over subsidies; that families did go to the doctor, and that, despite what skeptical Mexican cabinet members had warned, men did not beat up their wives, take the money and get drunk. Giving out cash proved to be hugely more efficient than the old food subsidies. Mexico found it could help many times more people with the same money it was spending on the old programs. One reason is that Opportunidades is careful to enroll only the people who need it most.
People will be corrupt when they have the chance. But Oportunidades aims to minimize the possibilities for patronage and corruption.
The program uses census data to find the poorest rural areas and urban blocks, and within those areas, gives out questionnaires about people’s income and possessions. What do you make? Do you have a dirt or cement floor? Do you own a hot-water heater? The homes of those who qualify are visited to verify their answers. Families must be recertified every three years, and according to Salvador Escobedo, the current director, about 10 percent leave each year — either because they have failed to complete their responsibilities, or they graduate and are no longer extremely poor. Mexico checks on whether families are keeping up with their responsibilities by having schools and clinics keep computerized track of attendance.
What about corruption in a country like Mexico? People will be corrupt when they have the chance. Amy from Los Angeles reports that in the Mexico City slum where she lived, people had to march with and vote for the locally-governing political party in order to get Oportunidades money. But the program aims to minimize the possibilities for patronage and corruption.
When I went back to Mexico, where I used to live, to report on Oportunidades in 2008, I was at first puzzled by the ubiquity of signs announcing “Oportunidades is a program of the federal government.” But there was a good reason for these signs — they were telling people that they shouldn’t give in to pressure from local leaders in order to get their payments. All program criteria are national – no decisions get made on the local level. If Amy is right, some local governments trick their people into thinking that they have influence. But it’s not many.
Oportunidades has no shops. No goods move, only money — and much of that electronically. The money is handled by banks; staff do not touch it. There is very little infrastructure — 95 percent of the program’s budget goes directly to beneficiaries. They get their cash, then patronize local businesses that sell food, clothing or school supplies. (The program is hugely popular with small businesses in poor towns. This is one way Oportunidades is helping even people who are not its beneficiaries, and one response to the complaint that simply redistributing money can’t possibly do anything.)
Susan Parker, an economist who has studied Oportunidades’ effects extensively, echoes a common perception that the program is remarkably clean. “It’s partly because of the design. The money gets to individuals — there isn’t any intermediary. It’s not the local politician who distributes money.”
Some readers asked whether society as a whole reaps benefits from conditional cash transfer programs. It does. Giving money to the very poor creates more economic growth than keeping it in the pocket of the wealthy, because the beneficiaries spend it all, and spend it on things their almost-as-poor neighbors make and sell. They also use it as microcredit to start businesses — I visited one woman in Veracruz, Mexico, whose living room was half-full of Tupperware-style products that she sells door to door, all bought with her Oportunidades money. The program drives growth in other ways, as more educated workers are more productive. Preventive health checkups are also cost-saving, as they can head off expensive chronic illnesses later. One very important benefit is that in the Mexican villages I visited, the program has liberated women to a certain extent; wives now have their own money and must get out of the house to attend meetings.
Oportunidades can save Mexicans from extreme poverty, but $123 a month does not put a family on easy street.
Then there is the contraception issue. A lot of commenters felt the solution to third-world poverty was for the poor to have fewer children. Some phrased the request crudely — RC from Minnesota, for example, called the poor “unneeded but passively supported humans.” Let us, however, find a less repellent way to express the sentiment that people should have the power to limit their families to the number of children they can support. If that’s your goal, then this is your program, folks. There are caps on the benefits, so it does not encourage larger families — in Mexico, for example, three children is the limit. More important, education for girls is the most effective contraceptive. The more educated the mother, the fewer the children.
If Oportunidades is so great, many readers wrote, why are so many Mexicans still coming illegally to the United States? One reason is that Oportunidades can save them from extreme poverty, but $123 a month does not put a family on easy street. Prices in Mexico are lower than in the U.S., but not by much. It doesn’t diminish the importance of Oportunidades to say that this is not the only program Mexico needs. Mexico desperately needs jobs. (Mexicans don’t come to the U.S. for free stuff. They come to work.) One of the fears of Santiago Levy, the program’s pioneer, is that without more job creation, Oportunidades could simply be producing a better-educated workforce for the United States.
The American Question
The column on Tuesday was not about the United States. But the vast majority of the comments focused on the questions of whether a conditional cash transfer program could work in the United States, and how this idea compares to welfare. Welfare (the version that gets people’s hackles up) used to be unlimited and not conditioned — the so-called nanny state. But this was abolished by President Clinton, who changed it to Temporary Assistance for Needy Families. As the name says, TANF is temporary, and is conditioned on working. It is an example of tough love, the “daddy state” — government as lifestyle supervisor and enforcer of civic responsibilities for those considered to be in need of such supervision. Conditional cash transfers are another version of the daddy state, only the conditions are different: give your children a better start so they may be less poor tomorrow.
It is not clear whether a conditional cash transfer program could work in the United States. The pilot of Opportunity NYC was not a huge success — it is still being evaluated, so it’s probably too soon to tell. It may be that certain aspects of the program work well, and could be refined and tested again in another pilot. There are precedents for the success of similar ideas. According to Gordon Berlin, the president of the social research organization MDRC, programs in Wisconsin, Minnesota and two provinces of Canada that gave the poor extra money for working were effective. All brought increases in work and earnings as well as benefits to the schooling of the participants’ young children.
Poverty in the United States is not the same as poverty in Mexico, and the reasons people are poor are different. The U.S. already does have many anti-poverty programs, although some don’t work very well or are deliberately designed to be hard to access. There is plenty of hunger in America — let’s not minimize people’s suffering or buy the argument from several commenters that the well-off have a monopoly on hard work or virtue. Among the comments were several that betrayed a profound lack of knowledge and interest about what it’s like to be poor.
Most poor people are desperately trying to do the best for their kids with the hand they’ve been dealt. A lot of people hold down several jobs at once and are still poor. As Ann from Milwaukee, reminds us, earning $10 an hour, which is more than the minimum wage, means your yearly salary is about $24,000. “Try to pay rent, transportation, utilities, daycare, food for a family on that.”
But the fact is that the poor here are, by global standards, not so poor. The very poor in other countries build their own houses of mud or logs and oilcloth, live on dirt floors and sleep on straw, own a single sari or one pair of pants and eat only tortillas and beans or only rice and chiles. They must struggle against their circumstances to acquire the basics of survival and human dignity. These are the people that conditional cash transfer programs are designed to help. And they are helping them by the millions.

Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and now a contributing writer for the paper’s Sunday magazine. Her new book, “Join the Club: How Peer Pressure Can Transform the World,” is forthcoming from W.W. Norton.
http://opinionator.blogs.nytimes.com/2011/01/07/helping-the-worlds-poorest-for-a-change/

POVERTY: PHILIPPINES: Family planning "urgently needed"

  Photo: Ana Santos/IRIN:  A 16-year-old sits beside her newborn baby. This is her second child.

2 December 2010 (IRIN) - Population and sustainable development experts warn that the Philippine population could reach levels that will prevent the country from ever breaking free from a cycle of poverty.
"We need to lower birth rates to 2.2 percent, which is just the sustainable replacement rate," Malcolm Potts from the Bixby Center for Population, Health and Sustainability, told IRIN, warning that at current fertility rates of 3.03 percent, the Philippine population of 94 million could reach 150 million in just 10 years.
Citing Department of Health studies indicating that women in the poorest quintile have 5.9 children while those in the richest quintile have 1.9 children, Potts said, "It's very simple; poor people cannot separate sex from child-bearing. We must give the poor access to family planning and contraception to give them choices."
The Guttmacher Institute, a US-based reproductive health think-tank, released a study in 2009 showing that 35 percent of poor Filipino women aged 15-49 accounted for 53 percent of the unmet need for contraception.
Highest unemployment rate
The Philippines has the highest unemployment rate in the Southeast Asian region at 8 percent compared with Indonesia at 7.9 percent, Vietnam at 4.6 percent, Malaysia at 3.7 percent and Thailand at 1.5 percent.
According to the World Bank, poverty incidence rose from 30 percent in 2003 to 32.9 percent in 2006.
"Having fewer children will allow the poor to invest more in education and health for their children to improve their lives when they grow up," Ernesto Pernia, a professor at the University of the Philippines School of Economics said, citing the correlation between family size and poverty incidence.
Urgent need for legislation
There is no national legislation on the standardization of budgets for family planning and reproductive healthcare services for the poor.
The Reproductive Health Bill aims to address this by providing a full range of contraceptive options, including the pill and condoms, as well as natural birth-control methods.
However, the bill is staunchly opposed by the influential Catholic Church that only approves of natural family planning methods requiring periodic abstinence.
The Bill has been wildly debated for the past 15 years.
"Natural family planning, also known as the rhythm method, has never played a role in fertility decline in any country, whether Catholic or not," Potts said.
Martha Campbell, president of Ventures Strategies for Health and Development, which studies reproductive healthcare strategies for developing countries said, "Other Catholic countries like Mexico and Brazil have already decided that the Vatican doesn't need to step into their reproductive lives. The Philippines is the only remaining country where the Catholic Church has a stranglehold on women's health."
"Population growth is a public welfare issue that affects the poorest of the poor. Other poverty containment efforts will never be sufficient until we can curb population growth," said Congresswoman Kaka Bag-ao of the Akbayan Citizen's Action Party, which is pushing for the passage of the Bill.
On 8 December, the UN Population Fund and the International Council on Management of Population Programmes (ICOMP) will hold a regional consultation on family planning in Bangkok.
The goal of the three-day meeting is to gain support from governments and civil societies to prioritize family planning programmes and increase investments in family planning to help achieve the Millennium Development Goals, and particularly, universal access to reproductive health.
http://www.irinnews.org/report.aspx?ReportID=91261