The report also says that because fertility rates have declined significantly in most low-and middle-income, countries, outside of Africa, "… the priorities of donor countries and development agencies have shifted toward other issues, and global funds and initiatives have largely bypassed funding of family planning, with less attention being focused on the consequences of high fertility, even in those countries that are lagging in achieving sustainable population growth."
"Poor women endure a disproportionate burden of poor sexual and reproductive health because they run into financial or social barriers getting access to these basic but vital programs," says Joy Phumaphi, the World Bank’s Vice President for Human Development, a former WHO Assistant Director General, and a former Health Minister in Botswana, 1999-2003. "Their full and equal participation in development depends directly on accessing essential sexual and reproductive health care. The Bank is committed to helping these women, along with the UN Population Fund, WHO, and the technical health agencies, to make voluntary and informed decisions about fertility."
Phumaphi adds that falling birth rates cannot be achieved through better health programs alone. She says that improved education for girls, equal economic opportunities for women in society, and fewer households living below the poverty line, are also vital parts of a strategy to achieve sustainable reductions in birth rates.
Global population trends
The new report says the world is in the middle of major demographic changes. During recent decades, fertility levels have declined more rapidly—even in some of the poorest countries—than had been expected by most demographers. For example, in 1970, Bangladesh had some of the worst social indicators and lowest income of all countries, with a fertility rate of about seven children per woman; now that rate is about three. Similar declines in fertility can be found in countries in East Asia, Latin America, and the Middle East and North Africa. The widespread decline in fertility, coupled with reductions in mortality in most countries, have resulted in changes in the age structure and population growth rates that have far-reaching consequences for sectors such as health, education, labor markets, and social protection.
During the second half of the 20th century, world population more than doubled to reach six billion, an astonishing 3 billion increase in population in just 40 years. Although this rate has now slowed to 1.2 percent a year, an additional 75 million people are being added every year this decade. The world’s population is projected to reach 9.1 billion by 2050, with the majority likely to live in the world’s poorest countries.
The report says that the globe’s highest birth rates are found in Sub-Saharan Africa, where average fertility remains above five children per woman. While demographic patterns are converging in many regions, countries that are lagging in fertility decline and mortality reduction are increasingly different from the rest of the world.
"The longer it takes for countries to move to a low-fertility, low-mortality pattern, the greater the danger that high-birth rate countries will continue to experience greater inequalities in education, jobs, life expectancy, and adult prevalence of HIV/AIDS, than their wealthier counterparts," says Phumaphi.
Similarly, the report says that fertility can also affect women’s jobs in the workplace. One cross-national study has suggested that the percentage of women in the labor force is directly related to national birth rates and that, for example, in Bolivia, there were strong links between women using contraception and women jobs outside of the home. Again, in the Philippines, the average income growth for women with one to three pregnancies was twice that of women who had undergone more than seven pregnancies. Accordingly, the number of children a woman gives birth to affects her subsequent employment and income prospects, with the risk of further driving gender inequalities and perpetuating poverty.
What can the Bank do?
The World Bank continues to play a central role in ensuring access to all reproductive programs through policy advice and financial assistance. In its policy discussions with client countries, the Bank will continue to affirm: its long-standing and strong commitment to the Cairo Consensus, the landmark 1994 agreement on family planning and sexual and reproductive health; and to provide countries with whatever financial and technical help they request in this area. This commitment is a cornerstone of the World Bank’s new health, nutrition, and population strategy, which will help developing countries strengthen their health systems to improve the health and well-being of millions of the world’s poorest people, boost economic growth, reduce poverty caused by catastrophic illness, and provide the structural ‘glue’ that combines multiple health-related programs within client countries.
The new report argues that family planning is an integral part of reproductive healthcare, and it is now increasingly acknowledged that provision of such comprehensive programs serves as a proxy indicator of a functioning health system. Moreover, an effective health system also reduces child mortality, which in turn has been linked to declines in fertility levels. In addition, addressing "dual protection" (protection against sexually-transmitted infections (STIs) and HIV/AIDS, as well as unintended pregnancies), as well as offering family planning programs and HIV counseling in a synchronized manner is more likely through a well-functioning health system.
Family planning programs have been particularly susceptible to under-funding. Both governments and donors have not lived up to their financial commitments to support family planning and, as a result, shortfalls of contraceptive supplies pose a growing problem. The Bank, with its sector and fiscal analysis capacity, as well as engagement in policy dialogue with senior stakeholders, can help address this critical issue through donor harmonization, aid alignment, and mainstreaming family planning financing needs within a country’s national health plan.
Another factor limiting contraceptive supplies is the inadequate state of logistics in many poor countries. At the country level, a sound logistics system can distribute contraceptive commodities and other supplies smoothly and efficiently so that each clinic or pharmacy has enough stock on hand to meet clients' needs.
Changing household behaviors is also recognized as vital for increasing the use of family planning programs. Social and cultural factors such as disapproval by family and communities, and men’s roles in deciding family size, can deter women who might otherwise be interested in family planning help, while in some countries, providers and even programs may deny such care to vulnerable groups such as unmarried adolescents.
"The low status of women often poses a barrier because in many societies, women lack the power to make their own decisions about using contraceptives or using other reproductive healthcare," says the Bank’s Joy Phumaphi. "Educating girls, improving economic opportunities for women, while giving them control over the design, management, and oversight of reproductive health programs, are very important ways to encourage better access to these essential health programs."
