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Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary (2016)

Chapter: 5 Policy Options and Opportunities

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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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5

Policy Options and Opportunities

The workshop concluded with an opportunity for presenters and participants to share perspectives on policy options for the future. John May of the Population Reference Bureau discussed the politics of population and family planning policies and programs. Two groups of panelists provided the perspectives of donors and scientists on stalled fertility and its implications.

POLITICS OF FAMILY PLANNING POLICIES AND PROGRAMS

May brought 30 years of experience to bear on the subject of fertility in African countries, and he began with an overview of the current situation. First, there has been little change in the overall age structure of the population on the African continent since 1970. This means that there is still a long way to go in stabilizing the number of births so that the countries of Africa can experience a demographic dividend. The region’s total fertility rate of 5.1 children per woman is the highest in the world, and the rate of modern contraceptive use overall is 23 percent, May noted. The countries of the sub-Saharan region, with a current collective population of 920 million, are on track to reach 2.1 billion people by 2050.

May identified three primary causes of continuing population growth across the region: (1) a dramatic decline in mortality, especially among infants and children; (2) high fertility levels that have been slow to decline and often have stalled; and (3) an age structure that is very young in comparison with those of developed nations. These challenges, he added, will

Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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need to be pursued one country at a time because of the diversity of the region’s progress.

May also highlighted several aspects of the politics of family planning policy. First, there have been several traditional obstacles to family planning in the sub-Saharan region. Apart from the pro-natalist stance common in many countries and the fragility of life in the region, which have been discussed, he noted the prevalent idea that Africa is an empty continent that needs more people in order to have larger markets. The sub-Saharan region is five times the size of India but has a smaller total population—India’s is approximately 1.25 billion. Many African leaders, May added, have been worried about depopulation. Memories of the tragic history of slave trafficking are the backdrop for the decimation brought by the HIV/AIDS epidemic, he noted: both have threatened the survival of some ethnic populations. May said that he has often heard leaders argue that “it is people who are the wealth of the region” and that Africa’s young and growing population can help its countrie chart a course to prosperity like that of China.

A second issue is that some leaders have commented that they do not have the “policy space” to act to reduce fertility rates, May added. In some countries there are too few champions of family planning, or there may be active opposition to it. Other pressing problems, including HIV/AIDS, poverty, environmental degradation, and security issues, compete for the resources and attention that governments and leaders have and make it more difficult for them to devote attention to family planning issues.

The role of donors is another significant factor, May went on. During the past 30 to 40 years, donors have made many significant contributions in the region. Their role in supporting the collection of demographic data, including four rounds of census data that reflect a vast amount of work, has not been widely recognized, May pointed out. He particularly cited the Demographic and Health Surveys (DHS), on which many of the presenters drew in their research.1 Donors have introduced many family planning programs in the region, often in contexts that were not immediately receptive. Donors have also tried to influence policy, despite waxing and waning interest by many regional governments, and have supported active advocacy models, which have been beneficial in some countries. At the same time, he said, some governments have been suspicious of western organizations that promote family planning and have pushed back against some of these ideas.

Finally, May noted, the priorities of leaders and others in the sub-Saharan region have shifted over time. The focus of family planning advocacy in the 1960s and 1970s was on population control. Over time, the

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1See http://dhsprogram.com/What-We-Do/Survey-Types/DHS.cfm [August 2015].

Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

focus shifted to reproductive health. The HIV/AIDS crisis that began in the 1990s may have diverted some attention from family planning, however, and more recently the focus has shifted from reproductive health to the possibility of the economic growth that a demographic dividend—brought about by declining birth rates—could bring.

May also reviewed some key points about the effectiveness of family planning efforts. Overall, he suggested, such programs are believed to reduce fertility by 0.5 to 1.5 children per woman, though he believes the lower range of the estimate is closer to reality. Few family planning programs in the region have been studied using randomized controlled trials, though more such work is under way. However, some programs have been quite successful, May observed. Ethiopia, for example, has seen a dramatic decrease—by 3 children per woman—since 1990 as a result of increasing family planning coverage. This is a success story, he added, similar to what has occurred in many Asian countries. In Rwanda, there has also been a rapid increase in family planning coverage, linked to reforms in the health sector, political developments such as decentralization and finance reforms, and donor support.

May closed with his thoughts about the path forward. First, he agreed with the “integrated view,” the notion that multiple developments are needed simultaneously: continued declines in child mortality, improvements in literacy among girls and women, increases in the number of adults who desire small family sizes, and increasing availability of effective family planning services. Those developments will require energetic, comprehensive, and sustained efforts, he noted. Efforts vigorously pursued in one decade and then allowed to languish are not effective, he explained. It is not clear, however, whether the “top-down” model that proved effective in many Asian countries or the more “bottom-up” approach of many Latin American countries is right for the sub-Saharan region, he noted. Most likely a hybrid of the two—impetus from the leadership together with grassroots and private sector efforts—may be the best model for African countries, he added. His parting message was that it is possible to intervene to change demographic trends with some degree of effectiveness, while still respecting human rights.

DONOR PERSPECTIVES

Three individuals who represent donors shared their perspectives on the issues. First, Sahlu Haile of the David and Lucile Packard Foundation described what the foundation has done to promote reproductive health and some of the lessons he draws from that experience. He is “very upbeat” about Eastern Africa, he began, despite the many problems the workshop presentations highlighted. Half a century after efforts

Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

to promote family planning began in the region, he said, the situation is changing for the better, and there are valuable lessons to be learned from the major successes. A close look at Nigeria, for example, reveals variation across the country. Contraceptive use has increased considerably in some regions of the country, and fertility rates have declined, even though other areas still have rapidly increasing populations.

In 2008, he noted, the Packard Foundation decided to expand beyond its work in Ethiopia and Nigeria. When staff began to explore fertility rates in Kenya, which they expected to find stalled, they found from new DHS data that in fact the decline had not stalled: fertility had declined to 3.9 births per woman. Efforts continue in that country, but the foundation then turned its attention to promoting family planning through a focus on the demographic dividend in Kenya. Haile suggested that this experience demonstrated the importance of focusing on what would be of most interest not to the international reproductive health community, but to national governments and local leaders. He agreed with May that many leaders are under pressure to pursue economic development and infrastructure improvements and that it is important for foundations to emphasize the ways in which the same factors that promote reductions in fertility—as well as the resulting slowing in population growth—also promote economic benefits such as industrialization and agricultural development.

He cited a transformation to the economic focus as a key factor in Ethiopia’s successes and noted that other African countries have begun to move in this direction. Recent gains shown in DHS data bear out his optimism, he added. Kenya, for example, has reduced its fertility rate from 6.1 in 1990 to 3.9 today. Haile said many countries in Southern Africa have shown such progress, though there is variation within countries and across the continent.

Tim Evans of the World Bank described the work of the Bank’s Health, Nutrition, and Population Global Practice, noting that the Bank views demography as central to development—to reducing poverty, improving equity, and promoting economic growth. The World Bank has articulated ambitious goals for ending extreme poverty and promoting shared prosperity among the poorest 40 percent of the world’s population, to be achieved by 2030. Health and population issues are an integral part of this agenda. Work on these two issues is complemented by programs focused on related topics, such as nutrition, health financing and delivery, and harnessing the private sector to support development.

The countries of Africa are at different stages in their demographic transition, as earlier presentations amply demonstrated, Evans commented. Figure 5-1 illustrates the distribution across countries of total fertility rates and life expectancy rates, and highlights the need for varied and flexible policy solutions, Evans explained. The lower-income nations

Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

images

FIGURE 5-1 Total fertility rates and life expectancy for high- and low-income nations, 2013.
NOTE: RMNCAH = Reproductive, Maternal, Newborn Child and Adolescent Health.
SOURCE: Evans (2015). Data from World Bank World Development Indicators 2015.

tend to fall in the upper left quadrant (higher fertility rates and lower life expectancy), while higher income nations tend to fall in the lower right quadrant (lower fertility rates and higher life expectancy). The Bank’s four main objectives related to reproductive health take this into account; they address supply and demand, as well as policy and measurement. The goals are to:

  1. Improve access to and quality of reproductive, maternal, neonatal, child, and adolescent health services.
  2. Increase women’s empowerment through girls’ education, life skills training for out-of-school girls and vulnerable women, and communication about social and behavioral change.
  3. Advise client countries of the benefits of accelerating fertility declines for human development and economic dividends—in comparison with the costs of inaction.
  4. Strengthen national civil registration and vital statistics systems in order to implement universal health coverage programs effectively and efficiently.
Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

The emphasis the Bank places on these objectives is reflected in a dramatic increase in lending for health, nutrition, and population programs and for reproductive health programs since 2010, as shown in Figure 5-2. Thirty countries in the sub-Saharan region currently receive World Bank support for reproductive health. The Bank has directed $2 billion in lending to African countries because it has recognized that funding that is substantial but falls short of the actual cost of a program is not likely to yield the desired results. At the same time, he added, the Bank is a minority financier, and its role as an institution is to bring together the necessary funding sources, including government and private-sector sources as well as other development partners, so that valuable programs have the resources they need to succeed.

The World Bank also has a growing analytic program whose mission is to help bridge the gap between research and policy documents and

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FIGURE 5-2 World Bank lending for programs related to health, nutrition, and population (HNP), and reproductive health (RH).
SOURCE: Evans (2015).

Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

effective implementation.2 Evans explained that the Bank is developing a formal approach to evaluating the work it funds to ensure that the strongest tools are used for diagnosing need, assessing the effectiveness of interventions, identifying optimal means of implementation, and conducting program evaluation.

One example that illustrates the approaches that Evans described is a six-country initiative to expedite the fertility transition in the Sahel.3 The World Bank has approved $205 million in financing for the Sahel Women’s Empowerment and Demographic Dividend project, which has two objectives:

  1. Increase women’s and adolescent girls’ empowerment and access to high-quality reproductive, child, and maternal health and nutrition services; and
  2. Improve regional knowledge generation and sharing as well as regional capacity and coordination.

Evans explained that the program applies three strategies: increasing the demand for reproductive health products and services, strengthening the capacity to supply products and personnel in rural areas, and strengthening the capacity and accountability of policy makers.

A second example is the World Bank’s support of a program called Every Woman Every Child, an initiative launched by United Nations (U.N.) Secretary General Ban Ki-Moon in 2010 to mobilize governments, the private sector, and others to address the health of women and children worldwide.4 In collaboration with the U.N., several nations, and other partners, the World Bank will collectively provide $12 billion in funding for investment plans to promote the health of women and children in Democratic Republic of the Congo, Ethiopia, Kenya, and Tanzania. The aim, Evans said, is to ensure that the funds are invested wisely in programs that can be fully funded and sustained long term. The hope is that these investments will catalyze other investment and development.

To conclude, Evans explained that the World Bank intends to sus-

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2Evans noted that examples of this work include The Demographic Transition in Africa: Dividend or Disaster (sub-Saharan region); Population and Development in the Sahel (8 countries); Demographic Change, HIV/AIDS and Jobs in Southern Africa (5 countries); The Demographic Transition in Mozambique; Adolescent SRH, Life Skills, Education and Job Skills in Zambia and Malawi; and Monitoring for Maternal and Reproductive Health Results: What Human Rights Can Offer.

3The Sahel is a semi-arid horizontal zone of Africa that lies between the Sahara desert and the savannah climate to its south.

4See http://www.everywomaneverychild.org/about/what-is-every-woman-every-child [August 2015].

Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

tain its focus on reproductive health and scale up its efforts to additional countries. In particular it will focus on “turning knowledge into action,” he added. It hopes to strengthen coordination and partnerships with local resources, to engage more effectively with the private sector, and to continue to anticipate such evolving developments as increasing urbanization.

Ellen Starbird of the U.S. Agency for International Development (USAID) described that agency’s work related to fertility and population growth. A primary USAID goal, she explained, is to end extreme poverty. Addressing high levels of fertility and population growth is key to economic growth, she noted, in part because of the cost of providing social services (e.g., health care and education) and social amenities (e.g., electricity and water) to rapidly growing populations.

However, although reducing population growth is important, USAID focuses not on reducing fertility rates but on meeting unmet demand for contraception and promoting informed choice, she said. The agency’s view is that the contraceptive prevalence rate is a key determinant of fertility and that effective family planning prevents unintended pregnancies, reduces abortion rates, and helps women achieve the spacing of births that they desire. Accordingly, the key indicators USAID tracks are

  • modern contraceptive rate,
  • unmet need or percentage of demand for contraceptives that is satisfied,
  • birth spacing (proportion spaced at least two years apart), and
  • birth rate among adolescents.

USAID uses a model to track growth along the indicators, Starbird said. Once a country reaches a fertility level of 3 births per woman and a contraceptive prevalence rate of 50 percent, the agency begins graduation planning, which can take as long as 10 years, to ensure that the systems are in place to sustain the progress. USAID classifies countries into four groups, she added: those where change is happening quickly, those that are encouraging change, those where change is slow, and those where no change—or even backwards movement—is evident. USAID has identified 24 priority countries where unmet need as well as fertility rates and maternal and child mortality are high. An additional 14 countries receive some support (9 through membership in a family planning partnership, the Ouagadougou Partnership5), and 24 countries have graduated from USAID support because of progress made. The countries are listed in

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5See http://www.prb.org/Publications/Reports/2012/ouagadougou-partnership-en.aspx [August 2015].

Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

Box 5-1. Figures 5-3 and 5-4 show how the priority countries fared for two indicators, modern contraceptive use and met demand for family planning, between the two most recent DHS.

USAID also identified a single indicator that would provide a useful snapshot of progress: the rate at which the demand for modern contraceptives is satisfied. That indicator measures the proportion of women who want to avoid pregnancy who are using modern contraception to do that. One advantage of this indicator, Starbird explained, is that it allows

BOX 5-1
Countries Supported or Assisted by USAID,
or Graduated from Support

Priority Countries

Afghanistan

Bangladesh

Democratic Republic of the Congo

Ethiopia

Ghana

Haiti

India

Kenya

Liberia

Madagascar

Malawi

Mali

Mozambique

Nepal

Nigeria

Pakistan

Philippines

Rwanda

Senegal

South Sudan

Tanzania

Uganda

Yemen

Zambia

Other Countries that Receive Assistance or Support

Angola

Benin

Burkina Faso

Cambodia

Côte d’Ivoire

Guinea

Mauritania

Niger

Timor Leste

Togo

Ukraine

Zimbabwe

Graduated Countries

Dominican Republic

Ecuador

Egypt

El Salvador

Honduras

Indonesia

Jamaica

Nicaragua

Paraguay

Peru

Russia

South Africa

SOURCE: Starbird (2015).

Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

images

FIGURE 5-3 Progress of USAID priority countries in modern contraceptive use. *Indicates Ouagadougou Partnership countries.
NOTES: Trend data were not available for Afghanistan and South Sudan. Rates of change are calculated from the last two survey data points from the Demographic and Health Surveys, Multiple Indicator Cluster Surveys, Reproductive Health Surveys, and Performance Monitoring and Accountability 2020 Surveys. This analysis is based on the 24 USAID’s Office of Population and Reproductive Health priority countries and the Ouagadougou Partnership countries and data from January 2015.
SOURCE: Starbird (2015).

USAID to track countries’ progress from wherever they began, rather than establishing a fixed rate they should meet. Modern contraceptive prevalence is important because it is the most effective means of preventing pregnancy, she explained. There has been a general increase in met demand, and in the prevalence of modern contraceptive use, she noted.

USAID’s portfolio includes projects that address all essential elements of effective family planning, in Starbird’s view, and the agency uses what it learns from these programs and from the indicators it tracks to identify problems, engage policy makers, and scale up practices that prove effective.

National Academies of Sciences, Engineering, and Medicine staff member Tom Plewes offered a few comments on the work of the Bill & Melinda Gates Foundation on behalf of panelist Win Brown, an official of the foundation, who was unable to attend the workshop. The foundation has a deep commitment to fertility and population issues, Plewes reported. It has focused in particular on using the tools of demographic analysis, the importance of the demographic dividend, and the relation-

Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

images

FIGURE 5-4 Progress of USAID priority countries in meeting demand for family planning.
*Indicates Ouagadougou Partnership countries.
NOTE: Rates of change are calculated from the last two survey data points from the Demographic and Health Surveys, Multiple Indicator Cluster Surveys, and Reproductive Health Surveys. This analysis is based on the 24 USAID’s Office of Population and Reproductive Health priority countries and the Ouagadougou Partnership countries and data from January 2015.
SOURCE: Starbird (2015).

ship between family planning and population growth. The foundation has also been very supportive of international population goals. It aims to provide services to 120 million more women and girls by 2020 and to increase its focus on communicating what works around the world.

SCIENTIFIC PERSPECTIVES

The final discussion was an opportunity to hear scientific perspectives on stalled fertility declines in the sub-Saharan region.

Julia DaVanzo of the RAND Corporation brought the perspective of a nonspecialist in fertility issues in Africa. She outlined the research opportunities discussed at the workshop that seemed most promising to her:

  • Examine the success stories. The presentations clearly identified many examples of places and approaches that have been effective in reducing fertility rates, DaVanzo noted, but more could be done to identify the factors that contributed to those successes and
Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×
  • how they might apply elsewhere. Regions that have low reported contraceptive usage rates but still sustain fertility declines, for example, may have lessons for others. To benefit from those lessons, she said, it is important to understand whether the apparent discrepancy is the result of under-reporting of contraceptive use, use of traditional methods or emergency contraceptives or abortion, or other factors.

  • Explore the diversity of the region. Cross-country studies are helpful, she added, but the sub-Saharan countries vary dramatically in size, so weighting some of the analyses to avoid over-generalizing from small and possibly anomalous populations, would be useful. More disaggregation of data will also be important in helping to parse out differences across the region, she added. Examining sub-regions systematically and assessing the extent to which lessons learned in one place apply to another would also be useful.
  • Explore the extent to which fertility declines have stalled. The presentations suggest stalls in some places and not others, DaVanzo noted, and she added that the definition of a stall is not entirely precise. She suggested that this is another reason to look even more closely at the variation across the region and at the role of factors, such as breastfeeding and traditional methods of contraception, men’s attitudes about fertility, and preventable contraceptive failure, which may vary significantly from place to place.
  • Address difficulties in collecting needed data. Presenters noted problems with data collection and quality in many areas, DaVanzo said. Improvements in data quality and the measurement of important factors, such as fertility desires, preferences, and norms, will aid researchers and policy makers. Qualitative methods could be valuable in filling some of the gaps, she added, and in filling in the picture of differences across age spans and other dimensions.
  • Take a more careful look at the role of recent economic and other developments. More systematic understanding of changes in spending levels and funding and governing structures, and other nondemographic factors, could help to illuminate some of the reasons why sub-Saharan African countries have had different experiences and trajectories than developing countries in other regions. Better data on policies and spending and how they relate to demographic developments in the region will be useful, she said. Economic issues, such as employment prospects for women—and how compatible the jobs accessible to women are with pregnancy
Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

and childbearing—may shed light on changing patterns of contraceptive use and fertility, for example, DaVanzo noted.

Alex Ezeh of the African Population and Health Research Center referred to an earlier discussion of the issue of African exceptionalism with respect to the fertility stall. He noted that there is not a clear threshold rate of change in fertility over time that marks a country as experiencing a stall. Much of the evidence supporting the idea that fertility declines have stalled in much of the sub-Saharan region comes from DHS, he noted, but data for many individual countries and regions show that fertility has continued to decline since the mid-1990s. “What is incontrovertible is that the pace of decline has been painfully slow” for many African countries he added, but he distinguished between a slow pace and a stall, noting that the program and policy implications may be different for the two circumstances.

Ezeh highlighted issues raised by the slow pace of fertility decline. Fertility rates have a direct relationship to population projections, he noted: A change of even 0.5 or 1.0 children per woman will have a very large effect on long-term population projections. The slow pace limits possibilities for a demographic dividend in the region. The sub-Saharan region’s population will continue growing, given the current pace of fertility declines, until after 2100, he explained, so the advantageous peak in dependency ratio necessary for a dividend will not occur.

The drivers of high fertility in the region need greater attention, in Ezeh’s view. In particular, he noted, early childbearing has not been effectively addressed by programs or policies. Ethiopia, which addressed the problem by raising the legal age for marriage, is an exception, but other countries need to address the cultural reasons why girls tend to marry and bear children so young. Raising the average age at first birth from 15 to 20 could translate into a 25 percent smaller population in 60 years, he suggested.

With these issues as a backdrop, Ezeh concluded with a few more general observations. Projections indicate that there will be 2 billion people in the sub-Saharan region by 2050, maybe as many as 4.5 billion by 2100, he noted. The question is, he wondered, “why is this a problem?” Earlier presenters had noted that many parts of the region are not densely populated and that some leaders and others view increasing populations as a positive development. For Ezeh, the problem is not the numbers themselves but the quality of life. The slow pace of decline will affect many other aspects of life, including the quality of access to and quality of education, health care, and employment opportunities for generations to come. The capacity of countries to invest in the infrastructure and services

Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

that people need—in dense urban areas as well as rural ones—is stretched by population growth, he observed. Using this lens to focus attention on the risks of rapid growth may be more effective than focusing just on population levels. Increasingly, he added, the sub-Saharan region will contribute to the global workforce. This means that the rest of the world has an interest in whether African countries have the resources to train this global workforce.

Ezeh also agreed with many previous speakers in highlighting the importance of attention to the diversity within regions and within countries in sub-Saharan Africa. While some issues are shared across the region, many others are specific to certain areas. In many cases, researchers and policy makers do not have adequate evidence to understand the obstacles to service delivery, he noted.

Finally, Ezeh observed, “many times we start well but we don’t see it through.” Funders that have supported many programs in the region often shift their priorities over time, he explained, which has made it difficult for many countries to sustain the traction those funders’ programs had generated. Much of the fertility-related programming is funded externally, he noted, but it is not always coordinated to a degree that will ensure that “investments being made today yield intended results 20 years down the road.”

James Phillips of Columbia University focused on the role of programs and whether they have contributed to stalls in fertility decline in the region. To address this question, he drew on theories that have been proposed for how programs work to develop a model for “programmatic transition.” By this he meant the pathway that the effective implementation of a program should follow in bringing about change, for example by making services more accessible and convenient and better meeting the needs of the target population; this idea is illustrated in Figure 5-5.

Phillips conducted a “bibliometric review” of approximately 20,000 articles about family planning and reproductive health published between 1994 and 2014 to assess the state of the research base. He used the Scopus database of peer-reviewed research literature6 to search for a set of 10 keywords associated with fertility rates. He plotted the results in a graphic that converted the data into pixels to show the density of coverage of these key topics; see Figure 5-6. The topics on the edges were those less well represented or investigated, but Phillips also identified what he called “black holes,” or topics that he expected would be well represented, but were not. He also identified some changes across the 20-year span, including that research on unintended pregnancy and fertility, abortion, and legal issues had become increasingly peripheral.

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6See http://www.elsevier.com/solutions/scopus [August 2015].

Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

images

FIGURE 5-5 Model of how fertility programs bring about change.
SOURCE: Phillips (2015). This work was supported by Grants to Columbia University by the Doris Duke Charitable Foundation Africa Health Initiative.

Phillips drew a few conclusions from additional analyses, noting, for example, that the research tended not to explore links between programmatic and policy indicators and topics such as adolescence, and that HIV research was separate from and peripheral to programmatic research related to family planning. HIV has grown from a peripheral topic to one that is closely linked with reproductive health, though not to family planning. He had expected to see an increasing focus on human rights and on programs and policies, but he did not find that.

Phillips also reported that investment in family planning programs has deteriorated in comparison with other health investments in sub-Saharan Africa during the time he examined. For example, family planning accounts for less than 3 percent of total health expenditures in four sub-Saharan countries: Benin (0.2 percent), Burkina Faso (1.1 percent), Liberia (2.3 percent), and Tanzania (0.9 percent).

Phillips expressed concern that the region may be drifting away from investment and programmatic research. Programmatic learning may be stalling, he suggested, because research has become less focused on family planning program implementation and systems issues, and less connected

Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

images

FIGURE 5-6 Graphic representation of density of coverage of family planning and reproductive health topics.
SOURCE: Phillips (2015). This work was supported by Grants to Columbia University by the Doris Duke Charitable Foundation Africa Health Initiative.

with socio-demographic research. This stalling, he fears, may be contributing to the stalling in fertility declines.

“How fast should we expect African fertility to decline?” was the primary question for Eliya Zulu of the Africa Population Health Research Center, given the nature of the challenges facing sub-Saharan African countries. Kenya went from 8.4 children per woman in 1978 to 3.9 today, but other countries have had a much more difficult time, he noted. East Asian countries showed the fastest declines, and that comparison has received a lot of emphasis. He agreed that a lot can be learned from other regions, but the goal of fertility decline in and of itself may be less compelling to leaders in African countries at this stage, in his view.

The population growth projected for much of sub-Saharan Africa will be difficult to slow, and it will have dramatic implications for food security and many other social and economic problems, as many of the presentations detailed, Zulu noted. These issues may be more pressing for decision makers in the region, he added, than the possibility of a

Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
×

demographic dividend. In particular, he noted, arguments focusing on the potential benefits of combining a focus on family planning with other aspects of a long-term growth and development agenda, such as those noted in many Asian countries, will be more useful to leaders of African countries than a focus on the negative consequences of growing populations. In Uganda, for example, Zulu explained, there is nothing that can be done to prevent the country from reaching a population of at least 80 million. He argued that instead of focusing on population growth as a dire outcome, leaders should work on ways to make sure this population is the source of human capital with the skills and knowledge to help the country develop.

Zulu acknowledged that the sub-Saharan region faces unique challenges in trying to follow the long-term developments pathways that have been successful in Asia and elsewhere. Compared with other regions, sub-Saharan Africa was the furthest behind in terms of education, child mortality, teen pregnancy and marriage, and other factors as its countries began the fertility transition, Zulu noted. There is economic growth, but it is not benefiting all sectors of the population in many countries. “The big elephant in the room,” he suggested, is the question of whether the region’s countries will be able to transform their economies to provide the growth that their growing populations will require.

The answer, in his view, lies in governance. There is a need, he suggested, for governments to strengthen accountability, reduce corruption, and improve efficiency. Policy makers, in his experience, are beginning to ask useful questions about what they can do to adapt and intervene, and what the best targets for investment are. He charged the group to continue thinking about the best kinds of evidence to put before the leaders to support progress in family planning and its role in economic development.

Jotham Musinguzi of Partners in Population and Development provided closing thoughts about the panel discussions. Leaders, he noted, are increasingly focused on regional integration and on providing and improving infrastructure to reduce the cost of doing business and to create jobs. Many leaders approach donors with requests for help with infrastructure that will provide jobs and make it easier to do business in the region, but they have paid less attention to population issues. In his view, the advocacy and data provided by donors are very important in helping to persuade leaders of the importance of population issues. He expressed the concern that despite the many gains that have been made in reducing fertility and slowing population growth, “we could still lose out if we don’t continue with sustained advocacy, using opportunities like linking African development with the democratic dividend concept, as the Asian tigers did.”

Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Suggested Citation:"5 Policy Options and Opportunities." National Academies of Sciences, Engineering, and Medicine. 2016. Recent Fertility Trends in Sub-Saharan Africa: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21857.
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Fertility rates and population growth influence economic development. The marked declines in fertility seen in some developing nations have been accompanied by slowing population growth, which in turn provided a window of opportunity for rapid economic growth. For many sub-Saharan African nations, this window has not yet opened because fertility rates have not declined as rapidly there as elsewhere.

Fertility rates in many sub-Saharan African countries are high: the total rate for the region is estimated to be 5.1 births per woman, and rates that had begun to decline in many countries in the region have stalled. High rates of fertility in these countries are likely to contribute to continued rapid population growth: the United Nations projects that the region's population will increase by 1.2 billion by 2050, the highest growth among the regions for which there are projections.

In June 2015, the Committee on Population organized a workshop to explore fertility trends and the factors that have influenced them. The workshop committee was asked to explore history and trends related to fertility, proximate determinants and other influences, the status and impact of family planning programs, and prospects for further reducing fertility rates. This study will help donors, researchers, and policy makers better understand the factors that may explain the slow pace of fertility decline in this region, and develop methods to improve family planning in sub-Saharan Africa.

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