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Demography, HIV/AIDS and Reproductive Health: Implications for the achievement of the MDGs: Roles of the West

Time (GMT +00) 13:00 14:15

Thoraya Obaid, Executive Director - UNFPA
John Cleland, Centre for Population Studies at the London School of Hygiene and Tropical Medicine

Neil Gerrard, MP

1. Thoraya Obaid started by stressing that demography, HIV/AIDS and reproductive health had to be more forcefully addressed if the world was to achieve the MDGs as these issues were central to their success.

2. Thoraya Obaid then went on to highlight the fact that the Millennium Project had recently launched a set of reports to propose the best strategies for meeting the MDGs. In terms of poverty, the Millennium Project concluded that there were strong links between rapid population growth, high fertility, ill-timed pregnancies and poverty which were summarised as 'a demographic-related poverty trap'. Thoraya Obaid highlighted that to break out of this trap one of the things the poor needed was reproductive health and rights, including voluntary family planning to enable birth spacing and increased investment in the health and education of each child in order to break the inter-generational state of poverty.

3. Another finding of the Millennium Project was that each region's prospects for progress towards the MDGs were affected by its demographic conditions and poorer countries were more likely to have demographic regimes marked by high fertility and high mortality, resulting in large youth populations with low adult ratios. She highlighted that these demographic profiles were associated with greater risks of conflict.

4. Thoraya Obaid also indicated that the Millennium Project team had also concluded that gender equality could not be achieved without guaranteeing women's and girl's reproductive rights and they stated that governments should incorporate universal access to reproductive and sexual health services and information as an integral part of their responses to AIDS.

5. Thoraya Obaid pointed out that all of the Millennium Project's findings reinforced the integrity and vision of the agreement that was reached ten years ago in Cairo at the International Conference on Population and Development and at the 1999 five year review at the General Assembly. Thoraya Obaid noted that while the Programme of Action adopted in Cairo recognised the right to sexual and reproductive health, and the empowerment of women and gender equality, and agreed on the need to ensure universal access to reproductive health services by 2015 (as decisive factors in the forces needed to facilitate development and reduce poverty), the relevance of reproductive health was not included as one of the eight MDGs or the targets set to achieve them.

6. This was recognised as a glaring omission amongst activists, journalists and policymakers and a missing link to development effectiveness especially as there was clear evidence that increasing access to reproductive health services, including family planning and sexual health, reduced poverty within families and nations. To illustrate, Thoraya Obaid pointed out that due to the spread of family planning programmes, women today in the developing world had an average of 4 children compared to 6 just 25 years ago. Furthermore, family planning in the developing world had increased from 38% of women in the 1970s to 52% presently. These factors had contributed to a revision down by 400 million of what the world's population would be by year 2050. The change in projections was due to two reasons. The first, the increasing impact of HIV/AIDS and rising death rates in some countries, particularly sub-Saharan Africa and the second, the increased use of family planning and fewer unwanted pregnancies.

7. Thoraya Obaid stressed however that while overall population growth was slowing, it was by no means over and between now and 2050, eight countries, namely India, Pakistan, Nigeria, the United States, China, Bangladesh, Ethiopia and the Democratic Republic of Congo were expected to account for half of the world's population increase. Moreover by far the highest growth rates were expected in the world's poorest nations where population would nearly triple in the next 45 years. This was a particular concern as these countries had the least access to information and services, the lowest use of family planning and the highest fertility and mortality rates.

8. Thoraya Obaid continued by stressing that despite the devastation caused by AIDS, most of the countries in Africa would continue to experience population growth in the coming decades due to high fertility levels with the exception of the hardest hit countries of Botswana, Lesotho, South Africa and Swaziland where outright reductions were projected.

9. Thoraya Obaid reiterated the need for quality reproductive health services because of the benefits of a potential 'demographic bonus' which was estimated to account for one third of the unprecedented economic growth of the East Asian economies between 1965 and 1990. Examples such as this illustrated that there were clear links between reproductive health and poverty reduction.

10. Thoraya Obaid then went on to illustrate how reproductive health and family planning also played a key role in another MDG, that of reducing child mortality especially as a leading cause of infant and child mortality was poor maternal health and death which accounted for nearly half of all infant deaths. In a similar vein, reproductive health was also essential for achieving the MDG on improving maternal health especially as currently; the highest proportion of women's ill health burden was related to their reproductive role.

11. Thoryra Obaid then presented a depressing statistic that a woman in sub-Saharan Africa faced a 1 in 16 chance of dying during pregnancy and childbirth as compared to 1 in 2800 in developed countries. There was thus an urgent need to close this gap and prevent these needless deaths which required a) family planning, b) antenatal and postnatal care c) skilled attendants at birth and d) emergency obstetric care.

12. Thoraya Obaid then stressed that access to reproductive health services was also important to achieving the MDG on combating HIV/AIDS. The face of HIV/AIDS was increasingly that of heterosexual, young females who were often married. With over 75% of HIV cases due to sexual transmission, sexual and reproductive health care was a strategic entry point for maximising the impact of HIV/AIDS (and other sexually transmitted diseases) prevention efforts and ensure women's human rights.

13. After outlining some of the reasons why population and demographics and reproductive health needed to be addressed in order the achieve the MDGs, Thoraya Obaid turned to consider what was necessary to ensure that these issues were addressed and given the priority they deserved. Essentially this involved the UNFPA and its partners in government and civil society expending all efforts to ensure that issues of population and reproductive health and rights were given prominence in all the various reports and declarations that were forthcoming as part of the 2005 processes. Thoraya Obaid stressed that his was extremely important because at this point, population and reproductive health and rights were nowhere to be found in the actual Millennium Declaration and the MDGs, and this was a serious omission that caused these issues to be marginalised at the very time that they should have been made a priority.

14. Thoraya Obaid finished her presentation by quoting the UN Secretary General Kofi Annan who stated "The Millennium Development Goals, particularly the eradication of extreme poverty and hunger, cannot be achieved if questions of population and reproductive health are not squarely addressed. And that means stronger efforts to promote women's rights, and greater investment in education and health, including reproductive health and family planning". Thoraya Obaid pointed out that this was the challenge for 2005.

15. The floor then passed to John Cleland who echoed Thoraya Obaid's opening statement and concurred that addressing population, reproductive health and HIV/AIDS were necessary for the achievement of the MDGs and unless they were addressed, the targets would be missed. The focus of his session however was mainly on population issues.

16. John Cleland noted that the focus of the UNFPA on voluntary family planning to manage population growth had been successful beyond the expectations of many, particularly in Asia and Latin America where the end of the era of population growth was in sight. The biggest lesson from the past 40 years of experience was that even in the poorest countries such as Bangladesh and Nepal, family planning was possible. He noted that initially the rationale for investment in family planning had been largely economic (that rapid economic growth hindered social and economic progress) although paradoxically, in the hey days of family planning programmes in the 1980s and early 1990s, most economists had been sceptical or unconvinced because of the lack of sound empirical evidence. It was only in the last 10 years that there had been new evidence that allowed much more confident conclusions to be drawn about the influence of demographic trends on economic progress. This realisation was largely due to the work of a group of US economists, and summarised in a book 'Population Matters'.

17. John Cleland posited that the crucial shift in the evidence base was due to two factors. The first was the longer time series to look at the complex inter-relationships between population movements and economic growth. The second, and perhaps even more crucially, was the decomposition of population growth as a unitary concept into its components (mortality decline, fertility decline and changes in the age structure). The results of this new consensus amongst economists he summarised as a better understanding that:

a) Mortality decline had a beneficial effect on human progress as it allowed greater investment in human capital and was associated with better health

b) Fertility decline had several beneficial effects on economic progress: a rapid one because of the fall in child dependency burdens, a culture specific one of allowing women to enter into the labour force and a longer term one, and probably the most important, that of the effect on the age structure. Some 20 years after fertility began to decline, countries entered the 'Golden Era' in which the labour force grew relatively much faster than the dependant populations. This onetime bonus lasted for 25-50 years after which the stage of population ageing was reached as it had done in many developed countries and increasingly in East Asia.

18. John Cleland noted too that it was now widely accepted that approximately 1/3 of the increase in per capita income in East Asia in the 1980s and most of the 1990s was due to earlier sharp decline in fertility and a favourable age structure. Economists argued however that this benefit was not automatic and required an enabling policy framework, such as a supportive fiscal and trade policy regime. He argued that this was the likely reason why Latin America did not benefit from its window of opportunity in the same way as East Asia.

19. John Cleland then went on to consider Africa, the one region where the end of population growth was not yet in sight and HIV/AIDS was most entrenched which vastly complicated the demographic future. He illustrated that even in the medium population projections in Africa by the UN Population Prospects in 2002, Africa's population was expected to increase by 20 million people per year and by the middle of the century, to represent 20% of the world's population compared to 13% today. John Cleland stressed however that such regional generalisations masked huge variability within the continent.

a) In a small group of Southern African countries, largely because of their very severe HIV/AIDS epidemics and prior fertility declines, population growth rates were projected to shudder to a halt and possibly turn negative. In these countries, 100 years of progress on life expectancies would be lost.

b) In an even smaller group of countries, with moderate HIV/AIDS epidemics such as Kenya and Tanzania as well as considerable past fertility decline, populations were expected to grow modestly over the next 45 years.

c) In a larger group of countries, populations were expected to double in the next 45 years for example in Nigeria from 130million to 258million in Sudan from 35million to 60million, in Malawi from 12million to 25million and in Rwanda from 6.8million to 17million. John Cleland noted that Malawi and Rwanda had had relatively high HIV/AIDS prevalence rates which underscored Thoraya Obaid's point that where fertility was high and remained high, HIV/AIDS did not arrest future population growth unless it reached the astronomical levels reported in Botswana and South Africa.

d) In a substantial group of African countries, fertility levels remained very high and projected growth to 2050 was expected to be well in excess of a doubling for example in Ethiopia from 74million to 171million in Uganda from 28million to 103 million, in Mali from 13million to 46million, in Niger from 13million to 53million, and Somalia from 10.7million to 40million.

e) All of these statistics represented the medium level population projections of the UN population division

20. John Cleland indicated that the validity of these future demographic scenarios depended on 2 factors - 1) what would happen to fertility levels and 2) what would happen to HIV prevalence rates and associated mortality. Here he referred to past and projected fertility rates for Regions of Sub-Saharan under which Southern Africa (dominated numerically by South Africa) stood significantly apart from the other African regions because fertility has already reduced substantively. In the other three sub-regions of Africa the picture was different. In Central Africa (of which little was known because it was dominated numerically by the DRC where demographic research has been impractical) a significant decline had not been noted but was projected to start. In East and West Africa, there had been a gentle decline from about 7 births per woman to 6 and the UN expected that decline to continue in a linear fashion to reach a little above 2 births per woman by the middle of the century.

21. John Cleland then examined what had happened to contraception in East and Southern Africa over the last 30 years where substantial increases had occurred in some but not all. He noted that the level of contraception amongst married couples was critical as it was the main dynamo behind fertility decline in Asia, Latin America and the Arab States. In West and Central Africa however, a very different and worrying picture could be seen. Here the use of modern contraceptives had only crept up in the past 25 years. At the same time as this desired family sizes were coming down and was typically close to 5 in East and Southern. In West and Central Africa, desired family sizes were still very high at between 7 and 8 per woman although moving in the right direction even though there was a prevailing pro-natalism in this part of Africa. In comparison, desired family sizes in Asia and Latin America had always been between 3 and 4 in 1960s and 70s suggesting that it might be harder to achieve fertility decline in Africa than in other regions in the world. The desired family size of men in much of Africa was similar to that of women with the exception of West Africa where polygamous households were more common. John Cleland also pointed out that approval of family planning in Africa was still low at less than 50% and that unmet need for family planning stood at about 24% and was not growing rapidly. In drawing a conclusion from this John Cleland argued that the future of fertility in Africa was uncertain and it was unwise to assume that Africa's decline would be as rapid and ubiquitous as in other world regions. In order to achieve the UN projections a massive promotion of family planning would be required. This was more than an issue of access to services but was also about making the idea of smaller families and family planning socially and morally legitimate which largely rested at the door of political will.

22. John Cleland then turned to HIV/AIDS and its implications on the achievement of the MDGs. He noted that HIV prevalence projections were very difficult to make especially as there were huge uncertainties concerning disease transmission. According to one attempt to project the future of national HIV epidemics, published in the 2000 UN Population Prospects, it was thought that the peak in new HIV infections had probably passed in most countries but HIV/AIDS prevalence rates would continue to increase in 11 of the 35 most affected African countries. Under the UN's 2000 projections 13 countries would see prevalence rates in excess of 10%, with 11 of these 13 countries having already reached this point, 7 counties would have prevalence rates between 5-9% and in the remaining countries prevalence rates would remain below 5%. These statistics made no allowance for drug therapies but nevertheless seemed to be an optimistic case scenario.

23. Some justification for this optimism comes from UNAIDS's estimation of trends in Southern, Eastern and Western African countries' median HIV prevalence rates among women attending antenatal care clinics between 1997 to 2002. In Southern Africa (data based on 8 countries), a dismal picture of increasing prevalence rates could be seen. In east Africa (data based on 5 countries) there was a decline in prevalence, largely due to the contribution of Uganda, Burundi and Kenya. In the 6 West African countries, a relatively low level epidemic could be seen with prevalence rates having remained low and the epidemic not having shifted much in the last 7 or so years. John Cleland noted that the question then became why there had been an explosive epidemic in Southern, and to a lesser extent Eastern Africa, and not in Western Africa. Essentially, the answer to this question was not known but could have been something to do with different HIV sub-types, male circumcision or co-infection with other sexually transmitted infections, particularly Herpes Simplex virus type II.

24. While the huge uncertainty of the future course of HIV in Africa needed to be stressed, it remained quite possible that the majority of countries would never experience HIV prevalence above 5%. He then examined the implications of a 5% prevalence rate which he summarised as leading to a reduction of life expectancy by 6 years, although (i.e. between ages 15 and 50) overall life expectancy would continue to increase; a lifetime risk of infection of 18% and huge potential pressure on health services. There would not however be a catastrophic economic disaster, and a 5% HIV/AIDS prevalence rate would have a limited effect on population growth.

25. In concluding, John Cleland noted that there was a clear need to continue HIV/AIDS prevention efforts throughout Africa. He stressed however that the real disaster was within the context of marriage because there was limited evidence of increasing use of condoms amongst married and co-habiting couples. Given that over half of women between the ages of 15-24 in Africa were already married and that in mature epidemics over half of all infections occur to married people, the MDGs would not be achieved without adequately addressing contraception and reproductive health needs within marriage. It was here that holistic integrated reproductive health services could do most.

26. On population growth John Cleland concluded that in many but not all African countries, continued high fertility and population growth rates were a bigger threat to economic growth and poverty reduction than HIV/AIDS and therefore there was a need for family planning to remain high on the agenda. John Cleland also concluded that there need not be any contradiction between vigorous promotion of family planning to reduce fertility, a commitment to a holistic approach to reproductive health and continued action to address HIV/AIDS, and that all should be advocated in concert and with equal force.

27. In the discussion that followed, many interesting points were addressed.

a) It was argued that the issue of an ageing population was always presented as a problem. Given that two thirds of people over the age of 60 lived in developing countries, a statistic that was projected to double over the next century, there was a need to focus on the poverty of the elderly whereas the MDG targets were predominantly youth focused.

b) The issue of raising funds and political commitment for UNFPA and others working on reproductive health issues was frustrated by not achieving the target. While agreement had been reached in Cairo in 1994 to raise US$17billion by 2000, 1/3 from donors and 2/3 from developing countries, to date, donors had only reached 50% of their pledged amounts and developing countries 80%.

c) Microbicides presented an interesting and potentially valuable way which issues of HIV infection within marriage or within the Abstinence Be Faithful Condom framework, could be addressed as a female controlled method.

d) In conflict situations, there was a vital need to educate the judiciary and police sectors to ensure the punishment of perpetrators of rape, especially as 1/3 of women that were raped during the Rwandan genocide are dying of AIDS.

e) An interesting outcome of the World Faith Development Dialogue recently held in Ireland, at which faith based organisations examined their role in the MDGs, was that an article had been published on the 31st of January which stated that the Vatican Pope's theologian has indicated that it is legitimate to use condoms in 'extreme cases' of which HIV/AIDS was one. This was because HIV/AIDS caused death which was a contradiction of the commandment 'that shall not kill'.

Nambusi Kyegombe

February 2005


This session examines the implications of using goals and targets as proxies for wider poverty reduction and development processes. Population issues have been largely excluded from the MDGs, with no discussion of demography or why population issues matter to the achievement of the MDGs.

This session uses demography, HIV/AIDS and poor reproductive health as themes to allow the exploration of how specific targets may exclude other important issues which impact on well-being, productivity, investments in human capital and the achievement of the MDGs.

Committee Room 9