These issues are on my mind after attending the 7^th Annual PopPov Conference on Population, Reproductive Health, and Economic Development, held last month in lovely (albeit frigid!) Oslo, Norway. The conference was a unique opportunity to hear new and in-progress research at the nexus of population, reproductive health, and economic development. But perhaps most importantly, it offered a much-needed venue for a parallel conversation about how to communicate those ideas – all with important policy implications – to the audiences who need to hear them.

Population policy presents a unique challenge in this respect, because it connects the most personal aspects of human behavior with potential macro-level consequences (i.e. demographic dividends, dependency ratios, and sustainable development). To paraphrase Hans Rosling (an invited speaker at the conference), population policy might be set at the Ministry of Health or Finance, but population decisions are ultimately happening in the bedroom.

When we talk about population, we are really talking about people, and the aggregate of the most important and intimate decisions in their lives. For example, will I have a child? Or two or three or four or more? And will I have one now, next year, or never? Will I use modern contraception to control my fertility? Will I marry, or divorce? Where will I choose to deliver my babies? Where will my family live? And am I empowered to make any of these decisions in the first place?

Perhaps for this reason, one recurring topic of discussion at PopPov concerned our population “glossary”, and whether it can appear insensitive to those intimate life choices described above, or at odds with the closely related (but often divergent) languages of women’s rights and maternal and child health. For example, it’s common in demography and economics to talk about the quantity-quality tradeoff for number of children – that is, the more children a woman has the more she will have to divide scarce resources (think healthcare, nutrition, and education) resulting in less human capital for each child. So – in demography terms – it makes perfect sense to promote birth spacing and voluntary contraception as one (of many) interventions to improve child health and welfare.

On the other hand, you can also imagine that women might respond poorly to being told they have “low-quality” children, or a policymaker to being told that his or her country needs “higher quality” people. Likewise, it’s hard to argue with policies which allow a woman to limit her fertility – but it’s no accident that women rarely report having “unwanted” children once they arrive. Rosling himself put forth perhaps the strongest critique of some population rhetoric, charging that terms like “population bomb” and “population explosion” were at once factually incorrect, dehumanizing, and often motivated by latent racism and prejudice.

These issues are not entirely semantic, nor are they new; indeed, there have been longstanding divides between those who see lower fertility as an end in itself (largely in the context of sustainable development), and those who see voluntary contraception as either a means to better health and development outcomes, or as a necessary component of women’s rights and empowerment via control of her desired fertility (or some combination of all three). These competing (though often complementary) agendas culminated in the 1994 “Cairo Consensus”, which, according to Cohen and Richards (1994), “placed the discussion of population firmly in a development context [and] identified women and their status as central to sustaining global development efforts…[In] the words of Chief Bisi Ogunley of Nigeria, ‘Our program is ‘allow people to count, do not count people.’’”

While the Cairo Consensus was thus a hugely important step in uniting the women’s rights, maternal health, population, and environmentalist communities, I worry that those divides are reemerging, at least linguistically. In the week prior to the PopPov conference, I attended the 2013 Global Maternal Health Conference (GMHC) in Arusha, Tanzania, hosted by the Maternal Health Task Force.  It was striking to see a discussion of many of the same issues – for example, access to maternal health services, contraceptive prevalence, and desired fertility – but communicated using a very different language. In Arusha, these issues were framed squarely within the context of women’s rights and health, respectful care and equity, with little discussion of macro level economic or population consequences. And while all PopPov discussions remained firmly within the “Cairo Consensus” framework of people-oriented population policy, the clear contrast in language was revealing – as were signs of frustration with the women’s rights community. (Notably, to the best of my knowledge, I was the only delegate to attend both conferences).

All this to say that I don’t think there’s actually that much policy space between the women’s health and rights advocates and the population community – ultimately, both are interested in women’s empowerment, access to high-quality family planning and reproductive health services, and children’s health and welfare. But in the spirit of “policy communication,” I think that there’s work to be done in speaking each other’s languages, and thus realizing the natural alliance between their respective agendas. Language matters, particularly when you’re talking about the most intimate and personal choices in a woman’s life, and when you’re trying to convince policymakers of the relevance of your work. PopPov offered a wonderful opportunity to start that conversation – I hope others will work to continue it and move it forward.

Population and development in Western Africa are closely linked. At the heart of these issues lies the slow demographic transition of the region’s countries, which still experience some of the highest fertility rates in the world.

Last month the Center for Global Development hosted a meeting on the Role of Population and Development Research in Western Africa at our offices in Washington DC.   Over the daylong workshop, 17 participants with a diverse range of expertise and perspectives discussed the many pressing population and development issues in that part of the world. Participants came from organizations including USAID, the World Bank, IPAS, UC Berkeley, UNPFA, PRB, the Hewlett Foundation, and Cornell University. In their discussions, the group agreed that there remains a lack of clear policy recommendations or consensus on how to best address the population and development nexus, despite a renewed focus on the role of family planning, reproductive health, and demography as essential drivers of economic development.   In addition, a few common themes emerged and participants identified several research questions that will require closer attention over the coming years.

First, a major, multi-sectoral effort is needed to address the intermediate and direct determinants of high fertility. This could be framed as a priority effort for the Sahel region specifically, or be expanded more broadly. This effort would be greatly enhanced by building stronger networks in-country of people working on issues of population and reproductive health. In this respect, Parfait Eloundou-Enyegue from Cornell University (he attended the meeting at CGD), explained his work with IUSSP, which is aimed at strengthening demographic training in Francophone Africa.

Donor coordination is another area for improvement, particularly the coordination among key players such as USAID, DfID, the French Development Agency, the Bill & Melinda Gates Foundation, and the World Bank. A lot has been done already, as exemplified by the coordination that resulted in this summer’s successful London Family Planning Summit. Still, how can coordination efforts help make governments and agencies become more effective on the ground?

Reaching the highest level of leadership with policy recommendations on population and reproductive health is another major challenge. Population issues should be discussed and acknowledged by policymakers in Western African countries as well as their partner countries. This is urgently needed to address demographic challenges at the global and national level through country-level policies, partnerships, and funding opportunities. More needs to be done to make the results of population and demographic research both available and usable at the policy level.

Finally, women’s rights and family planning should be a key focus. The need here is to de-medicalize family planning and move away from family planning centers, ensuring that family planning is readily integrated at the community level. Since family planning should be delivered through a medical framework, it’s important to engage medical actors on these issues. A similar recommendation to focus on sexual and reproductive health and rights was a key aspect of CGD’s Focus UNFPA report, resulting from the CGD Working Group on UNFPA’s Leadership Transition.

Knowledge gaps in the region were also identified. While this may be a laundry list of sorts, key items included research on the political economy of change, the role of social media and technology, the role of the demographic dividend on economic policies and governance (including the rise of inequality in terms of fertility trends and contraceptive use), effectiveness of performance-based funding type mechanisms, service delivery options, possible roles for behavioral economics, linkages between environmental impacts and population growth, urbanization, and more.

A new area of concern (and potential opportunity) is how family planning and reproductive health will fare after the current set of Millennium Development Goals (MDGs) expire, and how that might affect policies and programs in Western Africa. While still two years away, much work has already been done to propose and refine possible new objectives. UNFPA has been holding thematic consultations on how population dynamics might feature into the post 2015 development agenda. There are several ways to participate at theworldwewant2015.org, including the opportunity to comment on background papers and submit content.

Follow up from the London Family Planning Summit also represents an opportunity to refocus current patterns of spending. New funds are being made available by DfID, the Bill & Melinda Gates Foundation, and UNFPA to increase access to family planning for 120 million women by 2020—Family Planning 2020. While funding streams and existing partnerships with donors are often less focused on Western and Central Africa, the new monies could have a significant impact in one of the regions of the world where total fertility rates of five or higher are not uncommon.

In the coming weeks, keep an eye out on our Website for more on population and development in Western Africa. In addition, the Seventh Annual PopPov Conference on Population, Reproductive Health, and Economic Development is taking place this month in Oslo, Norway—updates from the meeting can be found here.

The country is in the midst of major transformations, not the least being a democratic transition.  And, coupled with this political evolution, future demographic trends will determine the prospects of Pakistan for sustainable development.  The acceleration of these demographic changes should help the democratic transition as the two would reinforce each other.  The implementation of sound population policies to achieve this demographic acceleration will call for strong leadership, far-reaching planning, and sound institutions.

Important demographic transformations are already underway in Pakistan – fertility is now below the threshold of 4 children per women – but the decline remains very slow compared to all countries in the region, except Afghanistan.  Pakistan’s mortality levels remain very high, especially infant mortality – 68 out of 1,000 children die in their first year of life.  And Pakistan also has the second highest rate of stillbirths in the world.  Contraceptive prevalence rates in Pakistan are low as well, as only 19 percent of Pakistani women use a modern method of family planning, and unmet demand for family planning services remains high.

Population growth is also bolstered by the young age structure, where large cohorts of young people are entering their reproductive years.  This creates a population momentum, which increases the already rapid natural growth.  At the same time, Pakistan must address the problem of its youth bulge, which occurs when the 15 to 29 year old age group represents more than 40 percent of all adults—the current proportion in Pakistan is a whopping 46.4 percent.  And this bulging youth group will require health care, education, and – above all – jobs.

Demographers and population specialists in Pakistan are most aware of these issues and challenges and are taking steps to address them.  I was privileged to witness their concern firsthand during the 13^th Annual Research Conference of the Population Association of Pakistan (PAP), which was held at the Institute of Business Administration (IBA) in Karachi in November 2012.   The Population Council in Islamabad is also leading a major effort around the demographic issues in the country and has prepared a landmark volume on the demographic dividend targeted specifically at Pakistani national leaders and policymakers.  And the new 18^th Constitution Amendment provides for the devolution to the regions of many prerogatives that were so far managed at the federal level, such as health and education services.  This will require a serious rethinking of the institutional framework needed to implement effective population policies (gated).

The challenge for Pakistan will be to manage all these transitions together – democratic, demographic, and institutional.  As the common saying goes, demography is not destiny.  But accelerating demographic changes and harnessing their socioeconomic benefits will definitely help shape the destiny of a great nation.

The author wants to thank all Pakistanis colleagues for their warm welcome in Pakistan, in particular Dr. Shahida Azfar, President of the Population Association of Pakistan (PAP) and Dr. Zeba Sathar, Director of the Population Council, Islamabad.  The author is also grateful to Jenny Ottenhoff and Catherine An, who provided most helpful comments on this blog.

Maybe you missed it–but this past Sunday, November 18, was African Statistics Day.

It’s the 12th celebration of the day, and a good time to note that substantial gaps remain in the availability and quality of data on basic indicators of human well-being such as income, poverty and cause of death in Africa.

In spite of a decade of historic levels of international and national spending on health, a 2009 study found that 3 out of 46 countries in the WHO/AFRO region had population-level data on cause of death. Even seemingly comprehensive and definitive statistical compilations, such as the recently released Atlas of African Health Statistics, readily concede that their data is entirely reliant on weak country-level data collection and variable tabulation. Similarly, the development of national administrative information systems, in health as well as other sectors, has been intermittent and slow to improve despite national and international efforts over the years (the challenges of planning based on estimates generated from limited data were pointed out by CGD research fellow Victoria Fan in a blog earlier this year).

While the results of weak national statistical systems are well-known and the subject of many aspirational declarations, we’re interested in African Statistics Day because we –CGD and African Population and Health Research Center (APHRC)–are joining forces on a working group to analyze the political economy challenges that underpin many countries’ notoriously low statistical coverage, quality and frequency.

Statistical system weaknesses stem, in part, from limitations in capacity, technical know-how and qualified human resources.  Limited financial resources also have something to do with weak systems, but the explosion of data collection efforts in the region suggests this is not the main obstacle (see: Case Study Kenya). Our working group has identified a third, relatively unaddressed, obstacle to statistics development: misaligned political and institutional incentives within governments and created by donor assistance policies and practices (for example, here and here).

Examples of misaligned incentives abound.  National statistics offices may collect and analyze data for a consumer price index, for example, but be barred from reporting accurate results for political reasons.   Budget formulas or results-based funding systems can unintentionally create incentives to “beef up” numbers, as in systems where schools are paid per pupil enrolled and administrative information systems grossly over-report the number of students. Even when data has been collected by national statistics offices, many times with donor money, data sets are inaccessible to policymakers, researchers and civil society. Working Group member Gabriel Demombynes notes in a recent blog that in spite of technical and financial support from DfID, USAID, EU, DANIDA, the World Bank, and UNDP for the Integrated Household Budget Survey in Kenya, only a small group of researchers have access to the raw data.  Further down the line but equally important are challenges related to ensuring that the data is useful for policy and decision makers as well as civil society.

We need to better understand the political economy challenges of data issues in Africa in order to develop more practical strategies to strengthen national statistical systems. The APHRC-CGD Working Group aims to better understand the relationship between the institutional arrangements governing national statistics systems and how they affect rigorous, efficient and timely production of relevant data for decision-making. The extent of national statistics offices’ autonomy and accountability is a major area for investigation (related issues are discussed in a recent blog by Francis Fukuyama). The second challenge the new group hopes to tackle is how to address the problem of limited accessibility to and use of data that is already being produced. Innovative open data systems (for example the Kenya Open Data Portal) provide a good starting point for this research.

This African Statistics Day—although we don’t think we are ready to celebrate yet—we would like to acknowledge past efforts to improve data collection, emphasize the connection between quality data and progressive African development—and finally urge donors and international institutions to continue to  focus on improving data quality and access.

Between 1970 and 2010, most emerging countries achieved impressive gains in contraceptive coverage.  As a result, their fertility has declined, their population growth rate has slowed down, and many of these countries have been able to capture the economic benefits of the demographic dividend, which occurs when the labor force becomes relatively larger in the total population thanks to lower fertility levels.  In addition, the fertility decline improves the dependency ratios and reduces the burden of youth on working adults.

By contrast, many sub-Saharan African (SSA) countries (which can be seen at bottom of the graph) have started their contraceptive revolution very late and progress to date has been minimal.  Today, SSA countries have among the lowest contraceptive prevalence rates in the world.  Even Kenya, which had once shown promising downward fertility trends, has been affected by the poor performance of its family planning program between 1995 and 2005. By and large, the lack of progress in contraceptive coverage has precluded significant decreases in fertility in the region.

The widespread belief in SSA that “development was the best contraceptive” has been the major reason why countries did not launch organized family planning programs.  More recently, the promise of rapid economic growth has enticed African leaders and donors to believe that fertility would eventually decline on its own.  With the benefit of hindsight, this appears to have been wishful thinking.  In any case, this view is not supported by data from emerging countries.

The sluggish decline in fertility in SSA has had far-reaching economic consequences, not to mention the plight on the health of women and their children.  Since the independences in the 1960s, economic growth in SSA has been counteracted by fast population growth.  The end result has been a paltry increase of the GDP per capita of about 50% on average.  In fact, several SSA countries have a GDP per capita that is lower today than what it was 50 years ago.  Whereas most SSA countries have seen their economies grow at 4 to 6% per year since 1995, their populations have increased at a rapid pace of around 3% per year.  At these rates, most SSA countries would need between 25 and 70 years just to double their (already low) current GDP per capita.  Because of the very slow decline of their fertility levels, many SSA countries might not be able to capture the demographic dividend either.

What happens (or doesn’t happen) today in many SSA countries will also impact the total population of the planet.  A delay of a rapid fertility decline in, say, Nigeria, will eventually increase global population figures.  At the end of this century, the population numbers might be vastly bigger from what they are anticipated today—an effect that should be attributed to slow fertility transitions in many SSA countries.

In fact, SSA countries and the African women need a true game changer, and this is rapid fertility decline.  For too long, one the main policy levers at hand to achieve this, namely the expansion of contraceptive coverage, was absent from the development debate.  In this respect, the London Summit on Family Planning was a clarion call.  What is most needed now is a swift implementation of the Summit’s resolutions to serve an additional 130 million women among the 222 million that still need family planning services.  For this to be achieved within eight years at a price tag or about 4 billion, governments and donors alike will need to maintain momentum around their recently renewed commitments.

The authors would like to thank Kate McQueston for her great contributions to this blog.

The University of California Berkeley organized a one-day international meeting of experts under the OASIS initiative: Organizing to Advance Solutions in the Sahel to discuss this issue.  The meeting combined specialists from all spectrums of sciences, and all aspects of Sahelian studies, namely climate, demography, agriculture, environment, governance, women’s rights, and role of civil society.  From this one-day meeting emerged several key themes:

1. The effects of poverty are already substantial in the Sahel—the Guardian blog reports that as many as 18 million people (one-fifth of the population of the region) are at risk from hunger.  The effects of this poverty has had a disproportionate impact on women, with the negative consequences of early marriage, high fertility, and repeated unwanted pregnancies
2. These development issues are unlikely to be addressed absent a real sense of urgency.  In particular, the plight of the Sahel must become visible on the global development agenda.  The FAO has been supporting a campaign to support awareness of hunger in the region, spurred by drought and high food prices, and the London Summit on Family Planning also brought about renewed interest in family planning.
3. Rapid demographic growth is one of the most pressing challenges in the Sahel.  The total population is poised to double over the next 20 years or so, adding further pressure to an already fragile ecosystem.  However, demography is not destiny and policies and programs to trigger the decline of fertility and mitigate rapid population growth have been implemented successfully in many other parts of the world.  Such policies ought to be pursued also in the Sahel.

Nonetheless, despite a global renewal of support for family planning, expansion of contraceptive coverage has been woefully lagging in the region.  Family planning will not only bring health benefits, especially for women and children, but it will help accelerate the decline of fertility.  In turn, the latter could potentially spur economic development because the fertility decline increases the relative size of the labor force while improving dependency ratios and reducing the burden of youth on working adults (a phenomenon known as the “demographic dividend”).  Family planning, however, must be combined with other interventions such as afforestation, enhanced agricultural production, women’s empowerment, and improved governance.  Single solutions will not work, but ignoring one of these solutions will not work either.  The time to act decisively in the Sahel is today, not tomorrow.

 The author would like to thank Kate McQueston for her contributions to this blog. 

We all know poverty is undesirable.  Not only because of its effects on quality of life, but poverty also has intergenerational impacts and leads to negative health outcomes.  In general, the poor’s demographic characteristics can vary quite significantly from the wealthy—including shorter life expectancies, higher rates of infant and child mortality, reduced educational and human capital attainment levels, and a higher burden of disease.  Higher incomes, on the contrary, have been associated with positive improvements in health, increased female labor force participation, and better educational outcomes for children.

Reduced fertility has often been seen as a mechanism for increased economic productivity.  As fewer children are born, more of the population participates in the work force, thus increasing per capita income.  Youth dependency ratios (the number of children under the age of 15 per adult) also become more favorable, enabling adults to invest more on their children (e.g., in education and health). This benefit has been coined the “demographic dividend” and is often used to prod developing countries in investing more in family planning and reproductive health.

A recent paper from the Harvard School of Public Health examines the effect of reduced fertility at the household level—asking if declines in the number of children per household benefit different socioeconomic groups in similar ways.  The study takes into account data from 60 low- and middle-income countries, finding that while all socio-economic groups benefited over time from lower youth dependency ratios, the highest income groups benefited from the fastest declines.  Another interesting pattern emerges from this research—in all four regions examined (Sub-Saharan Africa, South-East Asia, Latin America, and “Other”)—the total number of children was largest in the 2nd quintile and decreased only among the higher three quintiles; while the youth dependency ratio more directly followed the wealth gradient.  This finding suggests that higher numbers of children even in “less poor” families may continue to foster inequality over time as high income families reduce fertility at faster rates.  The study’s results agree with previous work, which found that inequality persisted after fertility declines, and that the demographic dividend was primarily to the benefit of already higher income families.  A similar finding from a 2008 study found that as national fertility fell, inequality increased.

A recent article in The Economist discusses this phenomenon, pulling away two main implications. First, inequality is expected to increasein the majority of low-and middle-income countries over the next decades, with demographic changes as a significant contributor. Second, working to reduce the fertility across all socio-economic status will not, on its own, be sufficient to reduce inequality.

To these two excellent points, we add a third—that inequity should be increasingly considered within population policies and programs (which has been discussed in John’s recent book, World Population Policies).  Most importantly, the demographic dividend isn’t a catch-all boon for development.  As some portions of society reap the benefits of lower fertility levels, policy makers will need to be conscious to providing continued support and opportunity to the poorest segments in society.

Despite major fertility declines that have taken place in recent decades almost all over the world, population growth is far from over.  As Ken Weiss points out in a recent five-part series in the Los Angeles Times, the adverse effects of population growth are well documented and wide ranging.  But population reduction through fertility declines may also have unintended consequences if proper policies aren’t in place early on.

The world today must accommodate the largest cohort ever in human history of young people within reproductive age. According to UN data, the percentage of population under 25 years of age in less developed countries represent over 60 percent of their total population. The phenomena has been termed the “youth bulge”, and the trend has been correlated with factors such as unemployment, social unrest, and civil conflict—particularly in countries with weak governance structures.  Approximately 80% of the world’s conflicts, since 1970, have occurred in nations with high fertility rates.  In these cases, economic growth is absolutely necessary to create employment for youth under the auspices of national security.  Youth will also need marketable skills, hence the huge efforts that will be required to build human capital.

Population growth may also imply tremendous tensions on food prices and could increase the global burden of hunger. One doesn’t have to look far for such an example.  The United States is currently suffering from one of the most severe droughts in nearly  50 years—over half the country is stricken by moderate drought or worse.  Last week, the UN food agency released findings that the overall food price index increased by 6% in July, directly correlating the prices of food commodities with drought conditions.  In populations living in extreme poverty, such as the 400 million people living in Africa on less than $1.25 a day, even small increases of food prices can have devastating effects.

Reducing population growth through fertility reduction, although beneficial in many respects, might also have unintended consequences.  As many countries reach lower fertility rates, investments in material capital and economic production also increase. For instance, China’s rapid industrialization still relies heavily on coal to supply its growing energy needs and has caused significant environmental degradation.  CGD fellow David Wheeler’s research shows that population interventions, including family planning and female education, can be more cost-effective than many environmental interventions, including solar, wind, and nuclear power, second-generation biofuels, and carbon capture and storage—and on par with forest conservation.  Kate McQueston reviews the two sides to sustainable development as it relates to fertility here.  One way to avoid the debate is to understand that fertility reduction isn’t the only answer to environmental conservation.  Economic development should also coincide with changes in traditional consumption patterns.  I argued previously that policy changes to reduce material consumption, improve education, and the implementation of natural assets accounting would develop new systems that are not necessarily dependent on material consumption.

The interconnectedness of population with a variety of issues, from environmental conservation to national security, means improving population policies would create positive externalities for a wide range of other sectors. But improving population outcomes means overcoming barriers—including funding and access to contraception, improved education and employment, environmentally friendly consumption patterns and effective national policies. Finally, let us face it: some religious and political attitudes remain a hindrance to fertility reduction efforts.  In the case of the Philippines, the Catholic Church still opposes open access to family planning, which has fostered high levels of induced abortions (almost half a million per year).  Individuals need to be able to decide for themselves on matters of reproduction, through systems free of heavy influence from social conservatives and religious institutions.

The bottom line: population growth will continue in the next decades, with major consequences for employment and food security.  And even when fertility comes down rapidly, as in China, the environmental footprint might be huge if environmentally-friendly consumption patterns are not put in place as well.

Family planning is back with a bang, thanks to this week’s London Summit. The event, several months in the making, was the brainchild of the UK government and the Bill & Melinda Gates Foundation, in partnership with the UNFPA. According to early reports, the Summit was a resounding success, raising $4.6 billion in commitments from government donors, NGOs, and international foundations. With these funds, donors have pledged to provide access to contraceptives for an additional 120 million women and girls, which they believe could prevent 200,000 maternal deaths, and stop 3 million infants from dying in their first year of life.

Access to contraception is undoubtedly a good thing; as a matter of human rights, women should be empowered to exercise control of their bodies and lives, including the timing and number of their pregnancies. I applaud the summit organizers, and Melinda Gates in particular, for their “no controversy” stance on women’s access. That said, I worry that the summit’s relatively narrow goal – more women using modern family planning – might oversimplify the underlying causes of high fertility and low contraceptive uptake. Women’s lives and choices are complex and varied – religion, norms, personal preferences, education, wealth, and family dynamics all play a role in their demand for children and contraception alike. In contrast, the common rhetorical arithmetic is too neat: family planning = contraception; contraception = fewer children; more donor money = greater access.

To be fair, the simple rhetoric is targeted toward advocacy and promotional purposes, and may not fully represent the attitudes of summit organizers. Still, questions remain. Can donor money counter strong religious convictions about contraceptive use, or cultural norms that encourage large families? Money can bridge financial barriers to contraception, but is that really what’s impeding access? For example, a recent paper suggests showed that contraceptive access alone did not reduce unwanted births unless policies or technologies were also introduced that shifted control of fertility from men to women. And while the concept of “unmet need” is central to family planning advocacy, some public health experts and economists continue to debate whether estimates of “unmet need” are greatly inflated, or whether the definition of “unmet need” is even a useful construct given the many complexities of individual fertility demand.

At CGD, we’ve had a longstanding interest in population and development, and we’ve thought carefully about some of these issues. Earlier this year, we released  a working paper with Kate McQueston on the causes and consequences of adolescent fertility in the developing world. After conducting a systematic review of existing empirical literature and analyzing the results, our findings challenged the conventional wisdom about fertility behavior. Contraceptive access programs sometimes increased on contraceptive use, but results varied from study to study; even the strongest results, while statistically significant, showed a relationship of relatively limited magnitude, and a highly questionable connection to actual fertility rates. What’s more, we found that adolescent fertility was more the consequence than cause of negative socioeconomic outcomes, particularly school dropout. Surprised? This finding holds equally true in rich countries: teen moms are not poor “because they have babies. They have babies because [they are] poor.” While we should be careful to overgeneralize, or to conflate adolescents with women more generally, this does suggest that the proximate causes of fertility – sexual activity and contraceptive use – may mask the deeper forces driving fertility behavior, at least among girls.

What does this mean for donors as they make good on their pledges of support to family planning? There are a couple of takeaways. First, have limited expectations. Increasing contraceptive access and uptake may not, on its own, be sufficient to change fertility trends. Nor will it, on its own, be sufficient to empower women who are otherwise oppressed, disenfranchised, or abused; indeed, it is unlikely to reach them at all. Second, think about the big picture. What are the barriers to family planning in the first place? Lack of financial resources? Geographic remoteness? Few opportunities for women outside the home, such that having more children is the most rewarding option? Of these barriers, which are donors prepared to address, and with which strategies? A greater supply of contraception may help, but empirical studies show that conditional cash transfers or scholarships to encourage school continuation or return may be even more effective, both at lowering fertility rates and increasing women’s empowerment.

In this era of shrinking global health budgets, I urge donors to remember that while contraceptive access is necessary for women’s rights, health and empowerment, it is not, on its own, sufficient to achieve any of those goals.

This is the sensible thing to do and at the right time.  In recent history, family planning programs have been woefully underfunded.  Today, 215 million women lack desired access to family planning services, and too often resort to abortion when these services are not available.  Many women still are not able to attain the family planning method of their choice, and commodities stock-outs remain far too frequent.  Greater access to family planning is not only an issue of public health but also a matter of human rights and long-run, sustainable economic growth.

Of course, social conservatives and die-hard opponents to family planning will strike back at this argument.  They will bring to the discussion canned ideology, moral arguments, and anathema.  But this discourse is grounded on an insufficient evidence-base by any scientific standard, and happily most people now see through this flawed argumentation.  On matters of reproduction, people in developed countries now decide for themselves despite the opinions of political or religious “pundits”.  Yet many people in poor countries are still unable to make decisions in the same way.

So how will the global health community move forward following the London Summit?  While principles and commitments are necessary, the primary challenge will be in the implementation.  Without going into the details of whom, or which agencies are going to implement the goals of the Summit, I would like to highlight four crucial elements for the renewed efforts on family planning to succeed.

First, there must be a sense of urgency.  The 16 percent or so of the world population that lives in countries where fertility is still above 4 children per woman need rapid access to contraception.  Most of the 49 least developed countries fall in this category, and their population is expected to more than triple during this century.  Among the least developed countries (LCDs), Bangladesh managed to reduce its fertility levels through strong leadership and door-to-door family planning programs.  But most LDCs with very high fertility, in particular those in the Sahel, need action immediately as they face formidable developmental and environmental challenges.

Second, family planning must remain voluntary – everywhere and for everybody.  Since the 1994 International Conference on Population and Development held in Cairo, family planning programs adhere closely to this commitment.  They strive to provide high-quality services, with the proper counseling and methods of choice at affordable prices.  Nonetheless, there is much room for improvement.  Supply-side approaches must be combined with demand-creation efforts.  Moreover, synergies between HIV/AIDS and family planning programs should also be explored.

Third, the renewed focus on family planning will be successful only if broader development goals are also taken into account.  Gender sensitive policies, including universal female education as well as women’s labor force participation and legal autonomy, are also necessary.  Much more needs to be done to combine family planning programs with conditional or unconditional cash transfers and income generating activities.  And it’s critically important to eliminate child marriage: doing so is a sine qua non for rapid fertility declines.  New mechanisms for services provision must also be tried.  The result-based financing system, in which providers are incentivized to provide good services, has proven very effective in Rwanda and other countries.  Such new approaches should to be scaled up.

Fourth, policymakers must keep aware of macro-demographic considerations, and the linkages between population growth and the other development sectors.  In particular, they need to realize that capturing the potential benefits of a demographic dividend will require a rapid acceleration of the fertility transition.  Population policies and programs also need to better define their contribution to global public goods.  To achieve this, more evidence-based policies are required.  The last few decades have brought a new wealth of information on population policies and programs.  Still, much of this research has yet to be translated into actionable policies.

The London Summit finally brings back to the development agenda an issue that has been for too long neglected and obscured by ideology.  The task ahead is huge, urgent and achievable.  Let us always keep in mind that the lack of information on and free access to family planning services deprives the poorest of the poor from exerting their basic right to a better life.

The author thanks Amanda Glassman, Victoria Fan, Lawrence MacDonald, Kate McQueston, Catherine An, and Jenny Ottenhoff for their helpful comments.