Globally, the demographic transition from high to low fertility and mortality has improved quality of life for billions of people over the past several decades. The average number of children born per woman worldwide decreased from nearly 5 in 1950 to 2.47 by 2020. Improvements in infant and child mortality boosted life expectancy at birth from a global average of 47 years in 1950 to over 72 years today. These gains in fertility and mortality were a result of rising incomes and significant investments and improvements in public health, education, and family planning access—18 months into a global pandemic, it’s becoming increasingly apparent that COVID-19 has disrupted these gains, slowing progress along the demographic transition for those countries in the earliest stages. This World Population Day is therefore an important opportunity to recommit to investments in health and education and resume our progress in improving lives for the world’s poorest and most vulnerable.

Because of COVID-19, years-to-decades of development were reversed, slowing global gains in mortality and morbidity

Hunger and poverty increased during the pandemic as COVID-19 disrupted markets and limited access to food, leading to a rise in prices that devastated those with little money to spare. The World Bank expects food insecurity to continue or increase into 2022 as the pandemic rages in low-income countries. This is not just a short-term problem: reduced calorie intake can impair cognitive development and harm earning potential throughout the life course. Sadly, extreme climate events and conflict had already been leading to a rise in hunger prior to COVID-19, with an increase in the number of undernourished from 624 million people in 2014 to 688 million in 2019. From 2000 to 2020 the number of children under 5 years suffering from stunting—impaired growth and development that children experience from poor nutrition, repeated infection, and inadequate psychosocial stimulation—dropped from 33 percent to 22 percent, but it will take a dedicated effort to preserve those gains as food insecurity rises and COVID-19 disruptions continue. Already, since the outbreak of COVID-19, over 100 million people have been pushed back into extreme poverty and chronic hunger. 

COVID-19 has also disrupted supply chains for essential health tests and medications. According to the World Health Organization, lockdowns and suspension of trade, among other factors, led to decreased supplies of essential malaria commodities, such as long-lasting insecticidal nets, rapid diagnostic tests, and antimalarial medicines. Children under age 5 accounted for 67 percent (274,000) of all malaria deaths worldwide in 2019; those in Africa are particularly vulnerable, as the region was home to 94 percent of malaria cases and deaths that same year. Given that life expectancy gains are driven by improvements in infant and child mortality in the early stages of the demographic transition, these worsening health outcomes are further evidence of lost headway. 

Progress in further reducing mortality has been stalled as COVID-19 competes with other health priorities. Prevention and treatment for non-communicable diseases (NCDs) have been particularly crowded out. Early evidence showed that Africans living with NCDs like hypertension and diabetes were more likely to suffer severe cases of, and die from, COVID-19. But the link between NCDs and COVID-19 aren’t just a problem in Africa. A study of COVID-19 fatalities in Italy found that 98.8 percent of deceased patients had at least one comorbidity, and 48.6 percent had at least three comorbidities.

NCDs were on the rise prior to the pandemic, and cardiovascular diseases are the number one cause of death globally. And while that means that communicable diseases are no longer the top killer (a good thing), it also means that people are dying prematurely of NCDs when proper interventions could prolong their lives. The majority of people living with diabetes are in low- or middle-income countries but they don’t receive the care they need for proper management. The World Health Organization (WHO) expects a long-term upsurge in deaths from NCDs as a result of the pandemic because of problems like closures of population-level screening programs and government or public transport lockdowns hindering access to the health facilities. In a May 2020 WHO survey, responses from 163 Ministries of Health showed that over 40 percent of countries surveyed experienced disruptions to cancer treatment and almost 30 percent experienced disrupted services for cardiovascular emergencies (including heart attack and stroke).

Education and family planning losses led to unwanted pregnancies and setbacks in reproductive health

Women’s education and family planning programs are the primary drivers of fertility decline—the other key ingredient in the demographic transition. Education suffered across the board as a result of COVID-19 lockdowns, but those children in poorer families suffered most. Globally, 94 percent of students, 1.6 billion children, were out of school at the peak of school closures in April 2020. As of early this year, around 700 million students worldwide were still expected to learn from homes that often lack electricity or caregivers with the time or skill set to guide their children’s education. Girls’ education is at even greater risk, as girls are more likely to drop out of school.

Family planning and reproductive health has also been harmed. Clinics were closed and supply chains for contraceptives—many of which are manufactured in Asia—were disrupted. Limited access to family planning and reproductive health led to 1.4 million unintended pregnancies, more medically-unattended births, and an increase in unsafe abortions. Though much of that is back online now, the consequences of those disruptions will reverberate for a lifetime for those who experienced them firsthand. And the problem continues: 44 percent of countries have reported pandemic-related disruptions to family-planning and contraception services in 2021.

Economic hits to developed countries hamper family planning and reproductive health in poorer countries. The United Kingdom has been the largest funder to the UNFPA, and their decision to cut 85 percent of their funds to the UNFPA flagship program for family planning in 2021 shows just how fragile the current global funding structures are. According to Dr. Natalia Kanem, Executive Director of the UNFPA, the $180 million withdrawn by the UK could have been used in 2021 to “prevent around 250,000 maternal and child deaths, 14.6 million unintended pregnancies, and 4.3 million unsafe abortions.” 

From crisis comes opportunity

The extent to which the demographic transition will be stalled by COVID-19 will be determined by how well we bounce back from the pandemic, and how we use the pandemic as opportunity to shape more effective and empowering interventions. While global fertility is lower today than ever, it has only decreased by half a child per woman on average since the early 1990s. That trend is partly driven by slower fertility declines in sub-Saharan Africa over the past two decades compared with earlier, rapid declines in East Asia and Latin America. Kanem recommends that the global community “scale up investments in these services by making them an integral part of national recovery plans. In countries with limited fiscal space, the international community must lend more support through debt relief so that governments do not have to divert funds from health care to pay off creditors.”

We must also invest in technology and innovation. One area is in supply chain resilience. USAID’s Global Health Supply Chain Program-Procurement and Supply Management project has been working with country partners for the past five years to strengthen their public health supply chain. The nearly $10 billion project has delivered “enough artemisinin-based combination therapies to treat about 320.3 million malaria infections and more than 12.5 million patient years of antiretrovirals to treat HIV.”

Educational innovation and resources are also sorely needed. Education in rural parts of low-income countries is weak; even when school enrollments are high, students may lack literacy and numeracy. Columbia economist Alex Eble and colleagues conducted aggressive and sustained education interventions that combined assistant teachers delivering after-school supplementary classes, scripted lesson plans, and frequent monitoring focusing on improving teacher practice (coaching). Their study found that such interventions are effective in addressing inequities. In Guinea Bissau, for example, children receiving the intervention scored 58.1 percentage points better than controls on early grade reading and math tests. Eble and colleagues estimate that effective interventions in the Gambia cost $242 per child per year and in Guinea Bissau cost $425 per child per year—a bargain in some respects, but prohibitive in the sense that both funds and political willingness are needed to support such sustained interventions.

Resuming and even accelerating progress along the demographic transition for those countries at the earliest stages can set the populations on a path to reap significant economic benefits from a more mature age structure. Countries with older age structures—fewer child dependents and a larger working-age population—can reap a demographic dividend of accelerated economic growth, with benefits to health, education, the economy, and political stability, as Kaitlyn Patierno, Elizabeth Leahy Madsen, and Smita Gaith describe in their chapter in my forthcoming edited volume. While the demographic dividend is not automatic and requires a broad set of policies such as investment in human capital and an open macroeconomic climate, the foundation is demographic change, which COVID-19 has affected.

Investing in good health for all even when there’s no pandemic would mean better outcomes when pandemics occur. As health scholar Jeremy Youde has said, “The COVID-19 pandemic is exposing the differences in pandemic preparednessamong different states, questions about which groups in society get access to testing and treatment, and the weaknesses in our global institutions due to under-funding and restricted organizational agency.” These differences extend well beyond COVID-19 to other health issues and need our attention now.