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Updated 11 November 2004

Consequences Vol. 2, No. 2, 1996
 

 

 

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Population Policy: Consensus and Challenges

by Lori S. Ashford and Jeanne A. Noble

For better or worse, global population is increasing by about 1.5 percent per year, a growth rate--should it persist--that in less than half a century will double the number of people who live on the planet. Few will argue with the fact that for any nation--or the world as a whole--population growth is directly linked to both economic development and stresses on the natural environment. What is remarkable is the degree of agreement that exists today regarding not only the problem of rapid population growth, but also the kinds of investments that will be needed to bring about a more stable global population.

Current thinking regarding the causes and effects of population growth came to the light of world attention at the International Conference on Population and Development (ICPD), held in 1994 in Cairo. It was not the first time that world leaders had gathered to discuss the issue of global population growth (Table 1). But it was unique in paving the way for government and private actions that focus on fulfilling a wider range of women's needs, rather than giving top priority to reducing birth rates around the world. While the new perspective set forth at Cairo recognizes the importance of increased access to high quality family planning services, it highlights women's rights and reproductive health as critical elements of the population- development equation.

The ICPD attracted far greater attention from high-level policy makers, citizen activists, religious leaders, and the media than any of those that preceded it. The final document, entitled the Programme of Action, grew from a broad, participatory process that involved an unusual number of nongovernmental organizations (NGOs, such as the World Council of Churches, the International Planned Parenthood Federation, and grass roots women's and development organizations), as well as countless, interested individuals from around the globe. More than 1,500 NGOs were accredited to the ICPD, and approximately 1,200 of these were represented in Cairo. This participatory process resulted in a comprehensive conference document that encompassed economic, environmental, health, and social concerns. It was also potentially more legitimate, in coming from the hands of those who were closer in touch with local and cultural issues.

The conclusions of the Cairo conference were strengthened by two succeeding conferences that adopted similar recommendations. The 1995 World Summit on Social Development in Copenhagen and the 1995 Fourth World Conference on Women in Beijing each had a slightly different emphasis and outcome. But they reaffirmed the Cairo consensus that human development--and particularly, raising the status of women--would be key to solving some of the world's most critical problems.

The shift in thinking recognized at Cairo was in viewing population from a more humane and equitable perspective. The consensus document that was produced recognizes that consumption in wealthy countries and rapid population growth in poor countries put pressure on the natural environment, both locally and globally. Yet, rather than simply equating population policy with family planning, the new thinking is that population growth should be stabilized--and development enhanced--by attacking some of the roots of the problem: by improving women's access to education, health care, and economic and political decisions. Here we review how the consensus emerged, what it will cost to implement a world program of action, and the challenges that governments in rich and poor countries face in addressing these issues.

How Thinking Has Evolved

For nearly half a century, concerns about the effects of increasing numbers of people have spurred discussion on how best to stabilize population growth around the world--most of which occurs in the developing countries. In the 1960s, extensive international population aid programs were launched by the governments of the United States and Sweden and by the United Nations. Much of this activity followed predictions of a growing food crisis, and the emphasis was on birth control.

In 1974, when the UN sponsored its first intergovernmental conference on population, the U.S. was a leading advocate of measures to reduce population growth, and a principal donor for family planning programs in developing countries. The U.S. delegation, however, met with criticism from a number of developing countries, many of whom were recipients of population assistance. They argued that poorer countries needed economic development, not contraceptives.

Ten years later, in Mexico City, positions had nearly reversed, with governments of many developing countries now in favor of expanding family planning programs while the U.S. remained on the sidelines. In the 1980s, the position of the Reagan administration was that market forces were far more powerful engines of development than socially-driven investments.

A number of factors paved the way for a shift in the U.S. view, and the movement toward a broader international consensus on population. These included the end of the cold war; a wider recognition of an increasingly-interdependent world; the formulation of population policies in a growing number of developing countries; and the ascendancy of nongovernmental organizations, and particularly women's advocacy groups.

Today, more than half of all developing countries have national population policies, and about 130 national governments subsidize family planning services. When polled by the UN in 1994, 91 percent of the countries that lacked national population policies stated that they intended to formulate them in the near future, reflecting a rising global commitment to population-related concerns. But national policy statements do not necessarily translate into program implementation.

The influence of women's groups

Many women's organizations began building active networks years in advance of the Cairo conference. During the 1980s and early 1990s, women's groups became increasingly critical of what they viewed as a "top down" approach to stabilizing population. They often asserted that in the quest for reaching global and national targets for reduced population growth, government-funded programs promoted contraceptives with little regard for the health of women who used them.

Women's groups have become increasingly prominent at UN- sponsored conferences. The Women's Caucus at the ICPD was said to comprise more than 400 organizations from sixty-two countries, and their pressure on national delegations was largely responsible for the strong language in the Cairo document that promoted women's health, rights, and opportunities.

The need for new investments

Women's groups are not alone in advocating improvements in the health and status of women. Most governments and major international development institutions (such as the World Bank) are increasing the resources they invest in women-centered programs, in that these activities contribute to economic development.

But unfortunately, the contributions of the donor community in the wake of the ICPD fall short of what is required. The goal set at Cairo was $17 billion in annual spending for family planning and reproductive health by the year 2000: one-third from international donors and the remainder from developing countries themselves. Since the ICPD, Japan and Germany have increased their population assistance budgets, but many other countries have made little or no change in their contributions. The U.S., which provides about 40 percent of international family planning assistance, reduced funding for these activities by nearly 90 percent in 1996. Given current trends, by the end of the century the world may have seen but a fourth of the recommended contributions, making it difficult to preserve present family planning programs, to say nothing of expanding into other much needed areas of reproductive health.

The Message From Cairo

Demographic trends

Population policies for the next century will need to address the concerns of both women and men during the largest increases in population that the world has ever seen. The "population explosion" written about in the 1970s is now a reality, and each year we add about 90 million people to the number who live on the planet. What remains to be seen is how soon, and at what level, the world's ever-increasing numbers will eventually stabilize.

Behind today's rapid growth are a number of changes that no one would have opposed. Since the 1950s, improvements in public health, increased food production, and the introduction of medical technology such as vaccines and antibiotics, have brought a sharp decline in death rates, particularly among infants and children. In developing countries, lower mortality, combined with high birth rates, have led to rapidly expanding populations. With larger numbers of people moving into their childbearing years than ever before, the total number of births continues to rise, even though individual couples have fewer children than did earlier generations--a demographic phenomenon that is known as population momentum.

Social and economic advances and family planning programs have contributed to fertility declines most markedly in Asia and Latin America. In both regions, women now bear about 3 children each--only half as many as was the case but thirty years ago. In the developing world, 53 percent of all couples currently use contraceptives.

Total fertility rates --the average number of children, based on current birth rates, that a woman will bear during her lifetime--have fallen from 6.1 in developing countries in the early 1960s to 3.4 in 1996. In the last three decades, fertility rates have declined substantially in every region except sub-Saharan Africa, where women still average 6.1 children each, the highest of any region in the world. The majority of African governments now believe their birth rates are too high, and have adopted population policies and have expanded their family planning services.

In spite of these advances, the world still has a long time to wait before the total population will stop growing. Since more people than ever before are entering the child-bearing age, global population is expected to increase well into the next century, with most of the expected increase--then as now--in the developing nations. Future growth thus seems inevitable, even with the widespread decline in fertility rates that the world is now experiencing. If fertility rates did not decline, a constant growth scenario would be even more alarming. In fact, very small changes in fertility can lead to a difference of billions of people 150 years from now (Fig. 1).

Population movements

Migration from one country to another is also at an all-time high: in the mid-1990s about 125 million people, most of them in developing countries, lived outside the country in which they were born. Examples are the large number of people, born in Burma, who now work or live in more prosperous Thailand and the large number of women from the Philippines employed as domestics in other Asian countries. The U.S., by way of reference, takes in only about 1 percent of the annual population growth of developing countries.

Rapid population growth has resulted in a large number of young people who now seek employment, often in adjoining lands. Although the countries that receive large numbers of migrants can benefit from an expanded labor pool, the influx of migrants--particularly the unskilled--is increasingly seen as a threat to the well- being of national residents, as one hears in the U.S. today. The countries from whom these workers come can benefit from wages sent home, but it is debatable whether the income can fully compensate for the loss of young, educated people who leave their native land.

A systematic shift from rural to urban living is another significant feature of increasing populations. Like migration, it is not necessarily a negative phenomenon. But problems arise when urbanization occurs so rapidly that local governments are unable to provide necessary public services, such as adequate housing and sanitation, and when there are not enough jobs to absorb all those who move to the cities. In 1994, 45 percent of the world's population lived in urban areas, up from 34 percent in 1960, and 19 percent in 1920. By 2005, more than half the world's population will reside in cities.

Gender equality

Development studies focus more and more on the quite different economic and social conditions faced by the world's women and men. Women around the world bear a disproportionate burden of poverty and ill-health, and have poorer access to education, jobs, and political power.

A growing body of scientific evidence supports the view that an improvement in the status of women pays dividends in any country: productivity increases as women's talents are added to the management and labor pool, and their greater participation in the work force is usually accompanied by a significant decline in fertility. Thus, policies aimed at lowering birth rates should include not only the distribution of contraceptives, but also expanded opportunities for women, allowing them to exercise greater control over their economic and reproductive lives. Providing women with a means to control their fertility, together with increased access to education, health care and remunerated employment, may be the most effective and socially acceptable means of moving toward a stable population, nationally and for the world as a whole.

Throughout the world, women are less educated than men: of the world's estimated 960 million illiterate adults, two-thirds are women, and 70 percent of the 130 million children not enrolled in primary school are girls. There is abundant evidence that more educated women tend to have fewer children (Fig. 2).

Education, by itself, does not directly lower fertility. Its influence on the number of births in any country is felt instead through related factors, such as a later age of marriage, improved opportunities for skilled employment, and postponement of a first child. In many countries, women with a secondary education have about half as many children as those with no education.

Education also increases women's access to employment opportunities. According to the national labor statistics compiled by the UN International Labour Organization, half the world's women are reported as "economically active," as compared with nine-tenths of all men. Moreover, women are often undercounted in national labor statistics, due to their higher level of participation in subsistence agriculture and other unremunerated family enterprises. In developing countries, official statistics place about a third of all women aged fifteen and older in the labor force, as compared with about 50 percent in developed countries. Still, variations between countries are great, even within regions (Fig. 3).

Throughout the world, but particularly in developing countries, women are less likely than men to be paid for their work. When they are, they earn less than men because they lack access to higher-paid jobs, such as managerial and supervisory positions, and because they receive lower compensation for comparable work.

If these inequities are ever to be righted, a much larger proportion of the foreign aid budget must be devoted to the health and education of women. Family planning, only one of many aspects of meeting women's needs, constitutes a very small part of development budgets, nationally or internationally, and the 1 to 2 percent of global foreign aid that is provided in this area is wholly inadequate for addressing the very real and urgent need to improve women's status. An attempt was made at Cairo to introduce the so- called 20/20 formula, whereby 20 percent of overseas aid and 20 percent of government expenditures in developing countries would be allocated for the social sector. Although the conference failed to make it part of its consensus recommendations, the formula stands as a compelling ideal.

The pivotal role of men

Men have a decisive role in eliminating gender disparities, since by tradition they most often hold the power to influence societal thinking in government and industry and in the home. There is growing recognition that population policies and programs should encourage men to take an active part in all aspects of family life: from attending to children's health needs to caring for their own and their partner's reproductive health. In recent world conferences, a general agreement has emerged that governments and private-sector entities should promote an equal partnership between men and women in all aspects of public and private life, by taking the following measures:

  • ensuring that women complete primary school and have greater access to secondary and higher education;

  • ensuring that women can own property equally with men, as well as obtain credit, negotiate contracts in their own names, and exercise their rights of inheritance;

  • eliminating gender discrimination in hiring, training, and wages;

  • enacting laws and implementing programs that enable both sexes to organize their work around their family responsibilities; and

  • eliminating exploitation, abuse, and violence against women.

Early in life, a traditional preference for boys encourages families to invest more in their sons than in their daughters, further perpetuating gender disparities. Thus, increasing awareness of the value of girls and investing early in girls' lives--with more education, better health care, and sufficient nutrition--are the first steps toward advancing women's status.

Family planning

During the last three decades, the developing world has experienced what might be called a reproductive revolution. In this short span of time the percentage of couples using contraceptives has increased fivefold, from less than 10 percent in the 1960s to more than 50 percent in the 1990s. A landmark study published in 1990 indicated that family planning programs were responsible for averting over 400 million births. As shown in Figure 4, however, family planning practices vary considerably from country to country. In many developed countries, contraceptive prevalence exceeds 70 percent, while in some developing regions, such as sub-Saharan Africa, it remains below 15 percent. Regional variation in contraceptive use reflects fundamental differences in religious views, desired family size, women's status, their knowledge of contraceptives, and the strength of organized family planning programs.

Extensive country-level surveys show that many women say they would like to delay or limit future births but are not now using contraception. Demographers describe these women as having an "unmet need" for family planning. In some countries (Fig. 5), unmet need is as high as 36 percent of all married women. It is estimated that up to 120 million women of reproductive age have an unmet need for family planning in the developing regions of the world. These estimates do not include sexually-active adolescents and unmarried women--groups that have been excluded from surveys that inquire about reproductive health and family planning. Meeting the remaining unmet need for contraception may be difficult, especially if the "easiest" groups of women have already been served--namely those who were already inclined to use contraceptives, and who enjoyed relatively easy access to organized programs.

It should also be kept in mind that this demand is unlikely to be met by the free market, given that the price of modern contraception is often beyond the reach of the world's poor. If all women who wish to postpone or avoid future childbirths are to have access to modern contraception, governments or the international community will have to make up this difference through subsidized services.

Reproductive health

Since the mid-1980s, advocates of women's health have become increasingly concerned that population policies and programs are focused too narrowly on contraception. In the most extreme cases, women's rights have been compromised by targets and quotas imposed by overzealous officials. This has happened in China, for example, in connection with its enforced policy of a one-child family, and was the case in India in the 1970s, where ambitious family planning targets led to unethical practices promoting vasectomy. In many other cases, the limited resources available for family planning services do not allow attention to the broader health concerns of contraceptive users.

According to the World Bank, about one-third of the "disease burden" (ill health and premature death) faced by women is linked to pregnancy, childbirth, abortion, human immunodeficiency virus (HIV), and other sexually transmitted diseases. By the first decade of the next millennium, fully as many people will be infected with HIV as died as combatants and civilians during World War II. Women acquire the infection more easily than men, and at a younger age, and pregnant women can also pass HIV on to their unborn children. Millions of children die of AIDS and millions will be orphaned. To date, large-scale efforts to slow the spread of HIV have been disappointing. To be successful, programs must combine efforts to change sexual behavior with easy access to condoms, and early detection and treatment of sexually-transmitted diseases.

The Cairo document defines reproductive health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes." The challenge for policy makers, and ultimately for health-care providers, is to identify those people most at risk of a debilitating or life-threatening reproductive health problem, and the most cost- effective ways of addressing it.

Maternal mortality

An estimated 585,000 women die each year from causes that are related to pregnancy, and 99 percent of these largely unnecessary deaths occur in developing countries. According to the United Nations Children's Fund (UNICEF), one in thirteen women in sub-Saharan Africa and one in thirty- five in South Asia dies from pregnancy-related causes, compared with one in about 3,200 in Europe and the U.S. The marked difference is partly explained by the fact that, in developing countries, fewer women receive prenatal care and fewer births are attended by trained health personnel.

In 1987, an international conference in Nairobi produced the "Safe Motherhood Initiative" as a policy response to the problem of high maternal mortality in developing countries. Its primary goal is to reduce reproductive- related morbidity and mortality by 50 percent by the year 2000, through increasing access to family planning services, improving community- based maternity care, and providing adequate emergency obstetric care. Since that time, a growing number of organizations in more than 100 countries have undertaken activities that contribute to this goal. But in many countries, high rates of maternal mortality have shown no significant decline in the nine years since the Safe Motherhood Initiative was adopted.

The World Health Organization (WHO) estimates that illegal--and thus often unsafe--abortion is one of the leading causes of maternal mortality and may be responsible for an estimated 75,000 deaths each year, and as many as one in four maternal deaths in some countries. In contrast, abortion provided under legal, regulated conditions leads to less than 1 death per 100,000 procedures in countries like the U.S. and Denmark.

Abortion is a hot-button issue that inevitably arises in policy discussions regarding population and reproductive health. Putting aside the strong personal and religious feelings that certainly pertain, the experiences of both developed and developing countries have shown that maternal mortality is likely to remain high when women are denied access to early and safe abortion services. But it is also true, based on twenty-five years of family planning programs, that ready access to affordable and effective contraception will substantially reduce the number of abortions.

The compromise language of the ICPD states that "In circumstances in which abortion is not against the law, such abortion should be safe. In all cases women should have access to quality services for the management of complications arising from abortion." The recognition of unsafe abortion as a women's health concern was a first for an international forum of this size.

Infant and child mortality

Promoting family planning is a sure way to reduce unsafe abortions; it is also a way to reduce maternal, infant, and child mortality. Governments and international donor agencies have given a high priority to infant mortality--both because of the high rates that exist in developing countries, and because of the connection between infant mortality and fertility. In 1996, the average infant mortality rate for developing countries is 68 deaths per 1,000 live births, compared with 9 in developed nations. Improvements have been slowest in sub-Saharan Africa, where nearly 1 of every 10 children will die before her or his first birthday.

Infant and child mortality rates are strongly correlated with fertility rates and can be mutually reinforcing. High infant and child mortality can prompt women to bear more children to ensure that some will survive as adults. Yet giving birth to more children, particularly when they are closely spaced, brings greater health risks to the mother. Conversely, greater use of contraception is associated with lower child mortality (Fig. 6).

Family planning lowers child mortality by reducing the number of high-risk births. In addition, if every woman who wished to delay or limit births made use of effective contraception, maternal mortality would drop, worldwide, by an estimated 17 to 35 percent. Combining broader reproductive health services with family planning is thus a potentially efficient use of resources, because many preventive measures can be provided by the same health personnel. Integration of services also benefits women by providing convenient and more comprehensive care.

Armed with these facts, government delegations to the ICPD called for comprehensive reproductive health services to be made available to all by the year 2015. These services should include: family planning; prenatal and post-partum care; safe pregnancy and delivery services; prevention and treatment of sexually transmitted diseases; and a broad range of counseling and information services to encourage responsible sexuality and parenthood.

Population and poverty

For decades, experts have debated whether poverty is a cause or an effect of population growth. Recent studies underscore the complexity of the issue, and suggest that both statements are true: high fertility is a symptom as well as a cause of poverty. Studies within particular countries indicate that rapid population growth inhibits efforts to raise incomes in poor countries that have high birth rates and a youthful age structure. In other words, in countries that are already poor, rapid population growth only makes matters worse. Rather than debating whether rapid population growth is a cause of under-development, the governments meeting in Cairo agreed that both issues are of concern, and that improvements in women's status and the health of a population would promote positive change in both areas.

The Link Between Population And Environment

In 1994, the U.S. National Resources Defense Council reported that developed nations, with only 22 percent of the world's population, account for two-thirds of all natural resources consumed, worldwide, and three- quarters of all pollutants and wastes produced. Some economists see the disparity as no cause for alarm: if free markets function well, a scarcity of resources will trigger higher prices, which will in turn encourage measures to conserve them. Most environmentalists are less optimistic about the ability of free markets to regulate resources that are commonly-owned, such as ocean fisheries or rain forests, and prefer to err on the side of caution. Thus, they call for measures to slow population growth in order to reduce the overall rate of consumption.

Environmental activists are not alone in calling for reduced population growth. In 1991 and 1992, the Royal Society of London, the U.S. National Academy of Sciences, and the Royal Swedish Academy of Sciences published joint statements concluding that "if current predictions of population growth prove accurate and patterns of human activity on the planet remain unchanged, science and technology may not be able to prevent irreversible degradation of the natural environment and continued poverty for much of the world." In 1993, representatives of national academies of science from around the world met in New Delhi, India for a "Science Summit" on world population. As a result, fifty-eight countries issued a joint statement expressing concern about the intertwined problems of rapid population growth, environmental degradation, and poverty. "The academies believe that ultimate success in dealing with global social, economic, and environmental problems cannot be achieved without a stable world population. The goal should be to reach zero population growth within the lifetime of our children."

The Cairo Program Of Action

Specific goals

At the Cairo conference, the international policy community concluded that stabilizing the world's population will require efforts to reduce poverty, improve health, and raise the status of women, in connection with more conventional programs to bring down fertility. The Program of Action, endorsed by 179 nations, calls for a comprehensive set of actions by both governments and the private sector. Among the more significant are to:

  • bring about more equitable relationships between men and women, enabling women to participate more fully in development;

  • reduce and eliminate unsustainable patterns of production and consumption;

  • formulate and implement population policies as part of social and economic development;

  • provide universal access to family planning services and reproductive health care;

  • improve the health of infants and children;

  • increase access to education, especially for girls; and

  • involve men in child-rearing responsibilities and family planning.

Five quantifiable goals were set for the twenty-year period between 1995 and 2015:

  • universal access to family planning and reproductive health services;

  • reduced infant and child mortality;

  • reduced maternal mortality;

  • increased life expectancy at birth; and

  • universal access to and completion of primary education, with particular emphasis on girls.

In all, the Cairo Program of Action contains about 240 recommended actions to be carried out by public and private entities in both poor and wealthy countries.

The challenge of implementation

Recommendations drawn up at international conferences--no matter how long the list of those who endorse them (Table 2)--are, like New Year's Resolutions, of little value if they are not acted upon. What is more, when we review the long lists of well-intended recommendations from recent United Nations conferences--such as Cairo, Copenhagen, and Beijing--one can rightly wonder whether governments will be able to accomplish all of the tasks that they have now endorsed. The array of interventions called for to achieve social and demographic change is daunting, even for nations that are better off economically. What is more, many of those concerned with slowing population growth worry about the overall effect of the broadened recommendations endorsed at Cairo, given shrinking resources in the U.S. and the high levels of unmet need for contraception that already exist in many developing countries.

For a number of reasons, changes in population trends, however much desired, can come about only slowly.

First, demographic change is of necessity a gradual process, that operates not on time scales of months or years, but of generations. In a world where policy makers are faced with short-term crises that demand immediate responses, tackling the thorny issues of population can seldom seem the first order of business, or even the second or third. Nor does population growth generate the continuous news coverage that might attract wider public attention.

Second, the fundamental issues that are involved are personal and often socially controversial. International meetings on population and women's issues have met with religious opposition--most notably, at Cairo, from the Vatican and some Muslim clergy. Political and religious groups within many countries may block the implementation of publicly- supported programs that they see as eroding morals or promoting promiscuity. Portions of the consensus language agreed to in Cairo and subsequent conferences are fragile at best--particularly in areas dealing with women's sexual and reproductive rights.

Third, tensions will inevitably arise over resource allocation, because the new strategy for addressing population concerns calls for simultaneous investments in health, education, and the empowerment of women, in addition to contraceptive and reproductive health services. Some social scientists have expressed disappointment that the new focus on human development downplays the importance of lowering fertility. The broadening and consequent dilution of program efforts, they argue, could make it difficult to achieve measurable results in any one sector.

Lastly, U.S. leadership on population issues has been inconsistent and divided. The U.S. is the largest single donor of population assistance and made the greatest increases in dollar commitments between 1993 and 1995, largely due to the renewed interest of the Clinton administration in world population issues. This country's leadership was cited as an important factor in the success of recent world conferences, and particularly at Cairo. In the face of opposition from religious and other groups, U.S. policy officials held fast in the effort to convince other governments of the importance of population, environment, and women's reproductive health issues. Whether this will continue is now in question. The 1995-1996 Congress has been far less supportive of international population programs, curtailing a more active role and sharply reducing financial commitments. It remains to be seen whether the increased commitment of other developed and developing countries will offset the turn-about in U.S. support.

The Significance Of World Conferences

The agreements reached at UN conferences, although they are not binding, can serve several important purposes. As an expression of worldwide consensus, they give legitimacy to a framework of thinking about what needs to be done to address critical global issues, and provide guidance to policy makers and program planners. Internationally-endorsed documents can also influence government policies through the international "peer pressure" that is a part of the document-drafting process. In addition, the agreements can be used by NGOs and activists to hold governments accountable for agreed-upon changes in policies and national programs. Finally, the documents can serve as a device for pressuring donors, as well as national governments, to increase funding for population-related activities.

In the U.S., as well as in developing countries, the role of NGOs will be critical in expanding family planning and reproductive health services and investing in women, because these organizations, by definition, are more insulated from the shifting winds that blow through the political world. Community groups, nonprofit organizations, and commercial ventures can all complement the work of government agencies, due to their greater freedom and flexibility and their years of experience in population- related fields. The increased involvement of NGOs in the ICPD and other world conferences may be the single most important guarantee that words will be translated into action.

From Cairo To The Next Century

Developing countries--where the need is greatest and the resources are least--will be challenged to find the right mix of policies and programs to bring about progress in improving individual well-being, reducing fertility, and pursuing sustainable development strategies. Neither donors nor host governments will be able to make all the needed investments at once. For this reason the governments of developing nations will need to consider a phased approach, and for providing key services at the appropriate stages of their national development. In some countries, investments in primary education and the expansion of basic maternal and child health services, including family planning, are most needed. In others, a more appropriate focus may be to improve the quality of existing services and to expand economic opportunities for women.

The clear message from Cairo is that no single activity will bring the societal changes needed to slow the current expansion of world population and mitigate the negative impacts of rapid growth. Governments and population experts now recognize that a number of social interventions--when combined and sustained over a period of time--will bring about lower birth rates, lower death rates, and ultimately, a stable population. The policies to be pursued include sustainable development, education and empowerment of women, increased availability of contraceptives, and high-quality health care, especially in the area of reproductive health.

Any one of these interventions would bring significant benefits to a country, whether or not there were a global population problem, and all have dedicated proponents. The remarkable feature of the Cairo process was bringing together a wide range of interests and proposed solutions, and unifying rather than dividing proponents of various courses of action.

It may be too early to gauge the effects of this most recent population conference on national policies and actions, but at least in the U.S., there is little cause for optimism. In the two years since Cairo, the largest contributor to international family planning assistance has dramatically decreased its funding, leading some programs to cancel plans for expansion and others to close their doors entirely. Fluctuations in international assistance may alone determine whether the actions recommended at Cairo will become a reality.

The Program of Action adopted by the international community at Cairo is broad and multi-faceted. In focusing on rapid population growth it addresses a major cause of today's environmental problems, and many of the economic, social, and political concerns of tomorrow. It remains to be seen whether there is sufficient resolve, both locally and nationally, to move forward with implementation.

Reviewed by Malcolm Potts and Amy Ong Tsui


For Further Reading

Beyond the Numbers: A Reader on Population, Consumption, and the Environment. Edited by Laurie Ann Mazur, Island Press, 444 pp, Washington, D.C., 1994.

"Global and U.S. National Population Trends," by Carl Haub. Consequences, Vol 1, No 2, pp 3-11, 1995.

New Perspectives on Population: Lessons from Cairo, by Lori S. Ashford. Population Bulletin, Vol 50, No 1. Population Reference Bureau, Inc., Washington, D.C., 1995.

Population Policy: A New Consensus, by Robert Cassen and Lisa Bates. Overseas Development Council, Washington, D.C., 1994.

Population: The Complex Reality. Edited by Sir Francis Graham- Smith. The Royal Society, London, 1993. Summary of the Programme of Action of the International Conference on Population and Development. United Nations, New York, 1995.


Reviewers

Dr. Malcolm Potts is Bixby Professor of Population and Family Planning in the School of Public Health at the University of California, Berkeley. He is a member of the National Academy of Sciences.

Dr. Amy Ong Tsui is an Associate Professor of Maternal and Child Health at the University of North Carolina in Chapel Hill, where she also directs the EVALUATION Project at the Carolina Population Center. Her research interests are in health and family planning in developing countries, and the evaluation of programs that address these concerns.

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