STABILIZING WORLD POPULATION GROWTH
AND PROTECTING HUMAN HEALTH:
USAID'S STRATEGY
The Challenge
Certain factors play a critical role in keeping nations poor:
a lack of resources; limited educational opportunities; a dearth of
skills; and economic, social, and political systems that impede
broad-based growth. Rapid population growth and poor health are
inextricably linked, and they make every one of these conditions
worse.
Poor health conditions and rapid population growth are closely
associated with low status and limited rights for women. Moreover,
the lack of basic rights, high rates of unintended pregnancy, and
lack of access to basic health and family planning services
threaten the health of both women and children. Conversely, the
expectation of infant and child mortality encourages people to have
numerous children in order to ensure that a few survive. When
access to information about nutrition and sanitation is poor and
health care and family planning services are inadequate, the result
is increased mortality that contributes to high rates of fertility.
Poor health conditions and rapid population growth obstruct
rational planning by forcing the national discourse to focus on
day-to-day survival. No other factors so limit the options and
flexibility of developing nations. Rapid population growth renders
inadequate any investment in schools, housing, food production
capacity, and infrastructure. It challenges the ability of
governments to provide even the most basic health and social
services. When people are undernourished and disease-prone, they
cannot contribute to their own development.
As expanding populations demand an ever greater number of
jobs, a climate is created where workers, especially women and
minorities, are oppressed. The educational and economic framework
gradually collapses from supporting too many people with too few
resources.
The problems of population and health in the developing world
are being aggravated by the spread of HIV/AIDS. This health crisis
threatens to overwhelm already limited health facilities and
consume resources needed for long-term investments, both human and
financial.
By their nature and consequences, population and health are
global issues. Population pressure puts increasing stress on the
Earth's already fragile environment. The world's population will
grow by almost 1 billion people over the next 10 years, despite the
fact that fertility and growth rates have begun to drop in many
countries due to efforts made over the past three decades. This
translates into a net increase of more than 270,000 people every
day -- 95 percent of them in the developing world.
Actions taken this decade -- especially the expansion of
reproductive choice -- will determine when the world's population
will stabilize. What is done, or not done, in the next decade will
determine the economic, social, and political prospects for much of
the world for the next century.
The high fertility rates associated with poverty and rapid
population growth have implications for the individual and the
family. Very early, multiple, closely spaced pregnancies
drastically increase the health risks to women and their children,
limit opportunities for women, and diminish the ability of families
to invest in their children's education and health. Millions of
unwanted births and the prevalence of abortion are evidence that
many women lack adequate access to reproductive health services.
More than 500,000 women die each year because of preventable
complications from pregnancy, abortion, and childbirth; over 35,000
children die each day, mostly from preventable causes, and mostly
in the developing world. The HIV/AIDS epidemic continues to spread
at the rate of approximately 5,000 new infections per day. These
conditions impede sustainable development and are tragedies for
individuals, families, communities, and nations.
Yet the population and health problems in the developing world
can be addressed. With better access to family planning and health
services, individuals can enhance their ability to affect and
improve their own lives and the lives of their children. Moreover,
by slowing the rate of population increase, societies can give
themselves more time and better options.
Progress has been made. The delivery of child survival
technologies, notably immunizations and oral rehydration therapy,
has led to markedly lower child mortality. At the same time,
fertility rates in most countries have been brought down by the
increased use of contraception, decreased child mortality, expanded
education (especially among females), and economic growth.
USAID-supported population and health programs, conducted in close
cooperation with concerned national governments, local and
international private voluntary organizations (PVOs), other donors,
and indigenous non-governmental organization (NGO) partners, have
contributed significantly to this progress.
Strategic Goals and Areas of Concentration
USAID's population and health goals are mutually reinforcing.
Specifically, USAID will contribute to a cooperative global effort
to stabilize world population growth and support women's
reproductive rights. Consistent with U.N. projections, this effort
should result in a total world population between 8 billion and 9
billion by the year 2025, and less than 10 billion by the year
2050, with very low growth thereafter. Over this decade, USAID
also will contribute to a global health goal of halving current
maternal mortality rates, reducing child mortality rates by
one-third, and decreasing the rate of new HIV infections by 15
percent.
To achieve this, USAID will concentrate its population and
health programs on two types of countries:
Countries that contribute the most to global population and
health problems. Such countries have the following
characteristics: childbearing by large numbers of very young and
older women; many closely spaced births; high numbers of infant,
child, and maternal deaths; high female illiteracy; large numbers
of women with an articulated but unmet need for family planning
services; and large numbers of persons infected with HIV, or
growing rates of HIV infection.
Countries where population and health conditions impede
sustainable development. Relevant characteristics of these
countries include fertility and population growth rates that
outstrip the country's ability to provide adequate food and social
services; growth rates that threaten the environment; significant
reproductive health problems due to heavy reliance on unsafe
abortions; health conditions that impede the ability of children to
learn and the ability of adults to produce and participate; growing
rates of HIV infection; and significant gender gaps in education.
Operational Approaches
At the program level, USAID's operational approach will be
founded on these principles and objectives:
* Promoting the rights of couples and individuals to
determine freely and responsibly the number and spacing of their
children.
* Improving individual health, with special attention to the
reproductive health needs of women and adolescents and the general
health needs of infants and children.
* Reducing population growth rates to levels consistent with
sustainable development.
* Making programs responsive and accountable to the end-user.
USAID will collaborate with other donors, host country
governments, development agencies, universities and academic
organizations, the private sector, PVOs, and NGOs. Where
appropriate, USAID will pursue and practice joint planning and
allocation of resources, sharing of methods, and pooling of
technical resources. This will extend from the institutional level
to the field.
Working closely with host country governments and local
communities, USAID will construct country strategies that address
the core elements of sustainable development. The population and
health component of the country strategy will take into account the
activities of other donors, development efforts in other sectors,
and every element of USAID's population and health assistance in
that country. These population and health strategy components will
address how population growth problems can be solved in that
country, how the country can acquire the independent ability to
cope with its population and health problems, and how USAID's
programs will help the country graduate from foreign assistance.
These plans must take into account the quality and strength of the
health infrastructure; the true access that citizens, especially
women, have to health and family planning services; the situation
regarding HIV/AIDS and sexually transmitted diseases; and the
employment, education, and empowerment of women.
We will help the United States expand its leadership in the
field of population and health. The United States already
possesses an extensive network of specialized programs,
institutions, and technical experts. USAID will rely on these
resources and encourage their expanded use by the donor community
and developing nations.
The Agency will operate both bilaterally and multilaterally.
It will continue to work with and support the United Nations
Population Fund (UNFPA), the International Planned Parenthood
Federation (IPPF/London), the World Health Organization (WHO), the
United Nations Development Program (UNDP), the United Nations
Children's Fund (UNICEF), and the World Bank and other
international financial institutions and their global population,
health, research, and information activities. This will enhance
USAID's ability to deal with the transnational effect of population
and health problems while enabling USAID to share its resources
with virtually all developing countries.
Population and health programs will be responsive to needs and
problems as they are defined locally. They will actively involve
women clients, providers, and indigenous experts in the conception,
design, operation, evolution, and evaluation of population and
health programs. To be effective, programs must encourage the
development and involvement of indigenous PVOs and NGOs.
We will emphasize the use of integrated approaches to expand
reproductive choice and rights, help slow population growth,
decrease maternal and child mortality, and reduce the spread of
HIV/AIDS and other sexually transmitted diseases.
By "integrated approaches," USAID means that population
programs should seek to provide individuals with access to a range
of family planning methods; should integrate family planning
programs, as appropriate, with services that enhance women's health
and child well-being and survival, in order to enhance both the
effectiveness and the acceptance of family planning services;
should utilize family planning systems, as appropriate, to provide
information and services that limit the spread of sexually
transmitted diseases; and should emphasize the importance of
providing education for girls and women. By addressing co-factors,
and by implementing related programs at the same place and time,
integrated approaches increase the impact and sustainability of
population programs.
Integrated approaches can save resources. They also are
important in addressing HIV/AIDS because this disease particularly
afflicts the very people who are in their most economically
productive years and who should be most active in the development
process: the young, the well-educated, and people in urban centers.
Care and treatment consume ever-larger portions of national
resources. The progress of the disease destroys family structure
and increases infant mortality and the failure of children to
thrive. Limiting the spread of HIV/AIDS thus is an economical and
essential investment in sustainable development.
Where appropriate, USAID will seek to integrate family
planning programs with programs that enhance public health. For
instance, barrier contraceptive methods, particularly condoms, are
the most effective means of preventing the spread of AIDS and other
sexually transmitted diseases. Similarly, mothers taking their
children for immunizations may also wish to take advantage of
family planning services.
Finally, USAID will emphasize the quality, continuity,
availability, and technical standards of services. We will build
on existing health and family planning programs, assets, and
investments.
Programs and Methods
The types of programs USAID supports will vary with the
particular needs of the individual country and the kind of
approaches that local communities initiate and support. However,
most of USAID's resources will be directed to the following areas:
Support for voluntary family planning systems, including
facilities and institutions that provide information on family
planning methods and distribute contraceptives. Self-sustaining
family planning systems and services will remain the core of
USAID's population programs. Over 100 million women in the
developing world have an articulated but unmet need for family
planning. Moreover, millions of young people will reach
reproductive age in the near future, creating even greater demand
for family planning services and imposing additional burdens on
existing family planning systems. Providing information about and
access to a wide range of appropriate family planning methods not
only remains the most effective means of reducing population growth
rates to levels consistent with sustainable development but also
significantly improves the health of women and children.
Building the local capacity of self-sustaining family planning
systems and services also requires support for training (including
clinical training), management, logistics, other support systems,
and access to technical information and technology. Programs
designed to affect popular attitudes toward family planning should
address the needs and attitudes of men as well as women, emphasize
free and informed choice, and assess the reasons why people
participate or do not participate in programs. Targets or quotas
for the recruitment of clients should not be imposed on family
planning providers; over the long term, meeting the unmet need for
information and services is the best way to achieve national
demographic goals.
Reproductive health care, including prevention and control of
sexually transmitted diseases, especially HIV/AIDS, and improved
prenatal and delivery services. Contraception is but one element
of reproductive health, and to be effective, population and health
policies must address women's reproductive health needs throughout
their lives.
The particular needs of adolescents and young adults,
including easily accessible information, counseling, and services
dealing with early sexual activity, the health and economic
consequences of early childbearing and unsafe abortions, and
prevention of sexually transmitted diseases, including HIV/AIDS.
Enhancing the ability and freedom of adolescents and young adults
to make informed choices about contraception and health is
especially critical.
Infant and child health, particularly immunizations, diarrheal
and respiratory disease control, and nutrition. Complete
immunization coverage and good nutrition are among the most
cost-effective preventive health strategies.
Education for girls and women, particularly at the primary and
secondary school levels, and basic literacy for adolescents and
young women. This also correlates strongly with lower birth rates,
improved child survival, and smaller desired family size.
USAID, its indigenous partners, contractors, and grantees will
design programs with certain critical standards in mind to maximize
their impact and to ensure the greatest return from the development
funds invested:
Does the program contribute to achieving population growth
rates that are in balance with available resources as measured at
the global and national levels?
Does the program contribute to measurable improvements in
immunization coverage; reductions in infant, child, and maternal
mortality; and reductions in new HIV infections at the global and
country levels?
Does the program address the attitudes as well as practices of
both men and women? Does it enhance the capacity of local
institutions, communities, and individuals to identify and solve
health and family planning problems? Do programs and projects
address issues of sustainability, especially the technical and
managerial aspects?
Does the program take into account links between population
and environment, health, working conditions, social mobility, and
democratic governance?
Does the program contribute to greater participation by women
in the work force? Does it address issues of increased empowerment
of women?
Measuring Results
To measure progress toward its goals and the effectiveness of
its population and health programs, USAID will evaluate results in
terms of the following measures: reduced fertility; reduced infant
and child mortality; reduced high-risk births; reduced maternal
mortality; and slower growth (and eventual reduction) in the number
of new AIDS cases.
Measures of success at the country level will vary. There
will be many intermediate signs of progress, such as expanded
access to, increased use of, and improved quality of family
planning and reproductive health services; increased contraceptive
prevalence and continuation; improved women's reproductive health;
expanded immunization coverage; decreases in the incidence and
severity of communicable diseases among children; lower
malnutrition rates; equal access to health care by gender; and
higher school enrollment ratios for girls.
Ultimately, the success of USAID's population and health
strategy will be measured in terms of its contribution to expanding
reproductive choice and rights, improving the health of women and
children, reducing the spread of HIV/AIDS, and stabilizing world
population at a level consistent with sustainable development.
