Showing posts from category Pakistan.
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Afghanistan and Pakistan: Demographic Siblings? [Part Two]
›February 15, 2012 // By Elizabeth Leahy MadsenLate last year, Afghanistan’s first-ever nationally representative survey of demographic and health issues was published, providing estimates of indicators that had previously been modeled or inferred from smaller samples. My first post on the survey focused on the methodology and results, which found that Afghanistan is not as much of a demographic outlier as many observers had assumed. But perhaps the most surprising finding is how the results compare to those of Afghanistan’s neighbor, Pakistan.
The political future of each country depends largely on the other and, with Afghanistan making progress on reproductive health issues that remain stalled in Pakistan, their demographic trajectories are heading toward closer synchronization as well. In one key measure – use of contraception among married women – Afghanistan is almost identical to Pakistan. The modern contraceptive prevalence rate is 19.9 percent, slightly lower than the rate of 21.7 percent in Pakistan.
While Pakistan faces its own serious political instability, it is widely regarded as more developed than its neighbor. Afghanistan is included in the UN’s grouping of least developed countries, and Pakistan is not. Pakistan’s GDP per capita is almost twice as high. On the surface, this should suggest lower fertility. There is a general negative relationship between economic development and fertility, though demographers are quick to point out its complexities, and David Shapiro and colleagues have found that countries with larger increases in GDP actually experience slower fertility declines.
Pakistan’s fertility rate of 4.1 children per woman is in fact 20 percent lower than Afghanistan’s, but the similarities in contraceptive use, which is one of the direct determinants of fertility, suggest that this gap could be shrinking. If Afghanistan’s median age at marriage (18 compared to 20 in Pakistan) was higher and more women were educated (76 percent of women have never been to school compared to 65 percent in Pakistan), the two fertility rates might be closer.
Pakistan’s Entrenched Challenge
Why are these indicators closer than might be expected? Relative to the other countries in South Asia, Pakistan has had considerably less success in promoting family planning use. Bangladesh has a per capita income about half that of India and one-quarter that of Sri Lanka, yet the three countries’ fertility rates are identical. Nepal has the lowest income in the region – even slightly below Afghanistan – yet more than 40 percent of married women use modern contraception and fertility is three children per woman. And then there is Pakistan. Despite a per capita income 90 percent that of India, only 22 percent of married women use modern contraception and fertility remains persistently high at over four children per woman.
The weaknesses of Pakistan’s family planning program have been well-documented. Government commitment has been lacking and cultural expectations and gender inequities are a powerful force to promote large family size. The country’s most recent DHS report cited disengagement with the program among local agencies, low levels of outreach into communities, and weak health sector support as likely causes for the stagnation of contraceptive use. In summer 2011, the Pakistani government abolished the federal Ministry of Health and empowered provincial governments with all responsibilities for health services. This transfer of authority could pay dividends by increasing local ownership of health care, but some in and outside Pakistan have raised concerns about the loss of regulatory oversight and information sharing entailed in total decentralization.
Compared to the Afghanistan survey, the most recent Pakistan Demographic and Health Survey provides more detail on women’s motivations and preferences regarding fertility and family planning. Overall, 55 percent of married women in Pakistan have a “demand” for family planning; that is, they wish to avoid pregnancy or report that their most recent pregnancy or birth was mistimed or unwanted. More than half of these women are using family planning, while the remaining 25 percent of married women have an “unmet need.”
Unintended pregnancies and births play a major role in shaping Pakistan’s demographic trajectory. The DHS survey finds that 24 percent of births occur earlier than women would like or were not wanted at all. If unwanted births were prevented, Pakistan’s fertility rate would be 3.1 children per woman rather than 4.1. Yet 30 percent of married women are using no contraceptive method and do not intend to in the future. The most common reasons for not intending to use family planning are that fertility is “up to God” and that the woman or her husband is opposed to it.
Linked Destinies
Just as Afghanistan and Pakistan’s political circumstances have become more entwined, their demographic paths are more closely in parallel than we might have expected. For Afghanistan, given the myriad challenges in the socioeconomic, political, cultural, and geographic environments, this is good news; for Pakistan, where efforts to meet family planning needs have fallen short of capacity, it is not. While Afghanistan is doing better than expected, Pakistan should be doing better.
Regardless, both countries are at an important juncture. With very young age structures and the attendant pressures on employment and government stability, each government must reduce unmet need for family planning or face mounting difficulties to providing for their populations in the future. In addition to rolling out health services, turning the share of women without education from a majority into zero would be an excellent way to start.
Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.
Sources: Afghanistan Ministry of Public Health, Bongaarts (2008, 1978), Cincotta (2009), Embassy of Afghanistan, Haub (2009), International Monetary Fund, MEASURE DHS, Nishtar (2011), Population Action International, Savedoff (2011), Shapiro et al. (2011), UN-OHRLLS, UN Population Division, U.S. Census Bureau, The Washington Post.
Image Credit: Chart arranged by Elizabeth Leahy Madsen, data from MEASURE DHS. -
Afghanistan’s First Demographic and Health Survey Reveals Surprises [Part One]
›February 14, 2012 // By Elizabeth Leahy MadsenLate last year, Afghanistan’s first-ever nationally representative survey of demographic and health issues was published, providing estimates of indicators that had previously been modeled or inferred from smaller samples. It shows that Afghan women have an average of five children each, lower than most experts had anticipated, and that their rate of modern contraceptive use is just slightly lower than that of women in neighboring Pakistan.
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Water and Population: Limits to Growth?
›February 3, 2012 // By Laurie MazurWater – essential, finite, and increasingly scarce – has been dubbed “the new oil.” Experts debate whether human societies are approaching “peak water,” beyond which lies a bleak future of diminishing supplies and soaring demand. Others observe that, for many, the water crisis has already arrived.
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Is Foreign Aid Worth the Cost?
›“Is foreign aid worth the cost? That’s not really the question unless you’re Ron Paul,” quipped Carol J. Lancaster, dean of the School of Foreign Service at Georgetown University, at the Wilson Center on January 23. “The real questions are: What do we want to accomplish with our foreign aid? Where should it go? And in what form?” [Video Below]
Lancaster noted that following World War II, foreign aid became “a two-pronged instrument – one as an instrument of the Cold War and the other as an extension of American values.” It has been a very “intense marriage” between the two, he said, “with one side up and the other side down at different times, as any marriage tends to be.” Truman convinced Congress to provide aid to Greece and Turkey in 1948 to combat communism, and he was able to gain approval for the Marshall Plan by “scaring the wits out of Congress” about the communist threat.
Aid Under Fire
Congressman Donald Payne (N.J.), who is the ranking Democrat on the House Foreign Affairs Committee’s Subcommittee on Africa, agreed that the Cold War was the principal reason for our foreign aid programs after World War II, as we provided hundreds of billions of dollars in aid to our supporters around the world. But, “It’s different today,” he added. “Since the end of the Cold War, more funds are going for humanitarian and development assistance, but it is still directly linked to our national interests. One in five American jobs are tied to U.S. trade, and the growth of our trading partners is our growth as well.”
Payne cautioned that there is “a new group in the House of Representatives who think we should step out of the world. They’ve told their constituents they are going to cut the budget, and foreign aid is an easy target.” Payne noted that polls show the American people think one-quarter or more of the federal budget goes to foreign aid when it is little more than one percent.
Nevertheless, there has been bipartisan support for former President Bush’s HIV/AIDS initiative in Africa which is showing remarkable results in reducing deaths from the disease. Payne added that aid to Africa is showing results in the number of economies that are doing well despite the global economic downturn.
Payne expressed frustration with the inability to enact a foreign aid authorization bill in the last several Congresses because the measures became weighted down with all manner of policy riders that were both partisan and controversial. Consequently, our foreign relations operations are solely dependent on the annual appropriations bills which tend to become encumbered as well with troublesome riders.
The Dangers of “Nation Building”
Charles O. Flickner, Jr., a 28-year Republican staff member on the Senate Budget Committee and then the Foreign Operations Appropriations Subcommittee in the House, presented a more skeptical view, saying foreign aid is not worth the $35 billion it is costing us each year, even though some of the programs have been successful and should be continued. The biggest problem in recent years, he said, has been the amount of money wasted on projects in Iraq and Afghanistan without adequate planning or execution. Money was being virtually shoveled out the door in amounts the host countries did not have the capacity to absorb, said Flickner, and as a consequence we have witnessed a lot of failed projects and corruption.
Smaller projects, which the U.S. government and private aid donors are better at, have a greater chance for success because they do not overwhelm the capacities of host countries. He cited some of the scholarships and technical training programs available for foreign nationals as being among the most worthwhile in building internal leadership capacity for the future in developing countries.
Rajiv Chandrasekaran agreed on the amount of wasted aid dollars being spent in Iraq and Afghanistan, which he has covered as a foreign correspondent for The Washington Post. He told the story of a small, dirt-poor town in Afghanistan he visited in where the bazaar was bustling with new shops and goods, and people were freely spending money on modern electronics, motor bikes, and clothes. The town was the beneficiary of a massive U.S. aid program that provided seed money for farmers to grow crops and created day labor jobs for the residents of the area. A contractor was authorized to spend $30 million on the economic development of the town during the U.S. counterinsurgency surge and that came to roughly $300 per person. It was clear to the USAID official on the ground and to the reporter that the experiment would not be sustainable over the long-term, even though there was a temporary sense of economic activity and prosperity.
Future Vulnerabilities
The panel seemed to agree that it was unfair to blame USAID for these failures since they were thrown into situations overnight they were not prepared to manage in countries that were not capable of absorbing the assistance being directed at them – all in the midst of ongoing conflict. The real test of whether the new directions being charted by the Obama Administration will work will be on the smaller, more manageable projects in which the host countries have a greater role in shaping and implementing.
Lancaster listed four vulnerabilities in the future course of U.S. foreign aid that should be avoided, including trying to merge our various interests through the State and Defense Departments with our aid programs in countries like Pakistan, where the institutions are weak and corrupt; the danger of creating an entitlement dependency through funding of HIV/AIDS drugs, where we will be guilty of causing deaths if we reduce funding; the danger of attempting to undertake too many initiatives at once, such as food aid, global health, climate change, and science and technology innovations, while simultaneously trying to reform the infrastructure of USAID; and trying too hard to demonstrate results from aid given the difficulty of disentangling causes and effects and gauging success over too short a time frame.
Event Resources:
Don Wolfensberger is director of the Congress Project at the Wilson Center. -
Engaging Faith-Based Organizations on Maternal Health
›“Faith-inspired organizations have many different opportunities [than non-faith-based NGOs]. The point that is often reiterated is that religions are sustainable. They will be there before the NGOs get there and will be there long after,” said Katherine Marshall, executive director of the World Faiths Development Dialogue at the Wilson Center on November 16. Marshall noted in her opening remarks that maternal health should be an easy issue for all groups, regardless of religious tradition, to stand behind. Yet, in reality, maternal health is a topic that “very swiftly takes you into complex issues, like reproductive health, abortion, and family planning,” she said.
As part of the Advancing Dialogue on Maternal Health series, the Woodrow Wilson International Center for Scholars’ Global Health Initiative collaborated with the World Faiths Development Dialogue and Christian Connections for International Health to convene a small technical meeting on November 15 with 30 maternal health and religious experts to discuss case studies involving faith-based organizations in Bangladesh, Nigeria, Pakistan, and Yemen. The country case studies served as a springboard for group discussion and offered a number of recommendations for increasing the capacity of faith-based organizations (FBOs) working on maternal health issues.
Engaging Religious Leaders in Pakistan
“When working with religious leaders to improve maternal health there are some do’s and don’ts,” said Nabeela Ali, chief of party with the Pakistan Initiative for Mothers and Newborns (PAIMAN). Ali described a PAIMAN project that worked with 800 ulamas (religious leaders) to increase awareness about pregnancy and promote positive behavior change among men.
One of the “do’s” highlighted by Ali was the need to build arguments for maternal health based on the Quran and to tailor terminology according to the ulamas preferences. The ulamas who worked with PAIMAN did not want to utilize the word “training,” so instead they called their education programming “consultative meetings.” More than 200,000 men and women were reached during the sermons and the strategy was been picked up by the government as one of the best practices written into in the Karachi Declaration, signed by the secretaries of health and population in 2009.
Despite the successes of the program, Ali warned against having unrealistic expectations for religious leaders interfacing with maternal health. She stressed the importance for having a long-term “program” approach to the issue, as opposed to a short-term “project” framework.
Behavior Change in Yemen
“Religion is a main factor in decisions Yemeni people make about most issues in their lives and religious leaders can play a major role in behavior change,” said Jamila AlSharie a community mobilizer for Pathfinder International.
Eighty-two percent of Yemeni women say the husband decides if they should receive family planning and 22 percent say they do not take contraception because they belief it is against their religion and fertility is the will of God, said AlSharie. Therefore, the adoption of healthy behavior change requires the involvement of key opinion leaders and the alignment of messages set in religious values. Trainings with religious leaders included family planning from an Islamic perspective, risks associated with early pregnancy, nutrition, education, and healthcare as a human right.
Male Participation a Key Strategy
“As a faith-based organization we believe it is a God-given right to safe health care and delivery so we mobilize communities to support pregnant women to address their needs, educate families about referrals and existing services in the community,” said Elidon Bardhi, country director for the Bangladesh arm of the Adventist Development and Relief Agency (ADRA).
Through female-run community organizations, ADRA educates men and women about the danger signs of labor and when to seek care. For example, many men in Bangladesh hold the belief that women should eat less during pregnancy to ensure a smaller baby is born, thereby making delivery easier, said Bardhi. ADRA addressed such misconceptions through a human rights-based approach and emphasized male participation as a key strategy, ensuring there were seven male participants for every one female.
A Culturally Nuanced Approach in Nigeria
The Nigerian Urban Reproductive Health Initiative (NURHI) is a public-private partnership that identifies and creates strategies for integrating family planning with maternal health. According to Kabir Abduallahi, team leader of NURHI, “family planning” is not as acceptable a term as “safe birth spacing” in Nigeria, so the project highlighted how family planning can help space births and save lives.
Religion and culture play an important role in the behavior of any community. The introduction of a controversial healthcare intervention (such as family planning) in a religiously conservative community requires careful assessment of the environment and careful planning for its introduction, said Abduallahi. Baseline surveys and formative research data helped NURHI understand the social context and refine intervention strategies.
Ten Ways to Increase the Capacity of FBOs
Faith-based organizations’ close links to communities provide them with an opportunity to promote behavior change and address other cultural factors contributing to maternal mortality rates such as early marriage and family planning.
Working in collaboration with FBOs and other stakeholders is critical to promoting demand for maternal and reproductive health services; however, there is limited knowledge about faith-based maternal healthcare and FBOs are often left off the global health agenda. In conclusion, Marshall noted 10 areas the group identified as areas to focus on:- Move projects to programs: Projects are often donor driven and limited in scope and duration. Donors and policymakers should move from project-oriented activities to local, regional, and national-level advocacy programs to build sustainable change.
- Coordinate, coordinate, coordinate: Significant resources are wasted due to a lack of coordination between FBOs and development agencies. A country-level coordinating mechanism should be developed to streamline efforts not only between agencies but also across faiths.
- Context, context, context: A thorough understanding of the local culture and social norms is imperative to successful program implementation.
- Terminology is important: In Pakistan, religious leaders redefined sensitization meetings around family planning and maternal and child health as “consultative meetings” not “trainings.” In Nigeria, the culture prefers “child birth spacing” over “family planning.” In Yemen, it’s “safe age of marriage” instead of “early childhood marriage.”
- Most religious leaders are open and with adequate information can produce behavior and value changes. Utilizing the Quran, Hadith, and Bible can support arguments and emphasize the issue of health and gender equity.
- Relationship building: Winning the trust of religious leaders can be difficult and time-consuming but is necessary for opening doors to patriarchal societies.
- Rights-based approach: A human rights-based approach can be a very powerful agent of change for addressing negative social structures such as violence against women, but it can also create controversy. In Bangladesh, ADRA utilized the approach to educate men about nutrition, dowry and child marriage, and education of women.
- Networks: There is a significant need to create forums that bring together the various FBO and global development communities in order to share knowledge and enhance advocacy messages. Networks are needed to streamline resources and inventory existing research, projects, and faith-based models that work.
- Monitoring and evaluation systems: There is a striking lack of data about the impact and outcomes of FBOs. Increasing the monitoring and evaluation skills of FBO workers can improve evaluation systems and meet the demand for new data.
- There needs to be greater political will for engaging the faith-inspired community.
Event ResourcesPhoto Credit: David Hawxhurst/Wilson Center. -
Michael Kugelman, Ahmad Rafay Alam, and Gitanjali Bakshi for Foreign Policy
Why South Asia Needs a Kabul Water Treaty
›December 12, 2011 // By Wilson Center StaffPakistan is once again accusing India of water hegemony. This time, however, the accusation refers not to Indian damming of the Western Rivers in the disputed regions of Jammu and Kashmir, but to Indian support for Afghan development projects along the Kabul River. This accusation indulges in conspiratorial thinking, and distracts from a factual understanding of the water issues between the two countries.
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Reducing Urban Poverty: A New Generation of Ideas
›Download Reducing Urban Poverty: A New Generation of Ideas from the Wilson Center.
In 2008 the global population reached a remarkable turning point; for the first time in history, more than half of the world’s people were living in cities. Moving forward into the 21st century, the world faces an unprecedented urban expansion with projections for the global urban population to reach nearly five billion by the year 2030. Virtually all of this growth will occur in the developing world where cities gain an average of five million residents every month, overwhelming ecosystems and placing tremendous pressure on the capacity of local governments to provide necessary infrastructure and services. Failure to incorporate urban priorities into the global development agenda carries serious implications for human security, global security, and environmental sustainability.
Recognizing a need to develop and strengthen urban-focused practitioner and policymaking ties with academia, and disseminate evidence-based development programming, the Wilson Center’s Comparative Urban Studies Project, USAID’s Urban Programs Team, the International Housing Coalition, the World Bank, and Cities Alliance teamed up to co-sponsor an academic paper competition for graduate students studying urban issues. The first competition took place in the months leading up to the 5th World Urban Forum, held in Rio de Janeiro in March 2010.
This publication, Reducing Urban Poverty: A New Generation of Ideas, marks the second annual academic paper competition. “Reducing urban poverty” was chosen as the theme with each author focusing on one of three topics: land markets and security of tenure; health; and, livelihoods. A panel of urban experts representing the sponsoring institutions reviewed 70 submitted abstracts, from which 16 were invited to write full length papers. Of these, six were selected for this publication. We congratulate the graduate students who participated in this competition for their contribution to our understanding of the complex relationship between urbanization and poverty.
These papers highlight the new research and innovative thinking of the next generation of urban planners, practitioners, and policymakers. It is our hope that by infusing the dialogue on these issues between the academic and policy worlds with fresh perspectives, we will foster new and innovative strategies to reduce global urban poverty.
Sources: UNFPA, UN-HABITAT. -
Michael Kugelman for Seminar
Safeguarding South Asia’s Water Security
›November 4, 2011 // By Wilson Center StaffThe original version of this article, by Michael Kugelman, appeared in the public policy journal Seminar.
In today’s era of globalization, the line between critic and hypocrite is increasingly becoming blurred. Single out a problem in a region or country other than one’s own, and risk triggering an immediate, yet understandable, response: Why criticize the problem here, when you face the same one back home?
Such a response is particularly justified in the context of water insecurity, a dilemma that afflicts scores of countries, including the author’s United States. In the parched American West, New Mexico has only 10 years-worth of drinking water remaining, while Arizona already imports every drop. Less arid areas of the country are increasingly water-stressed as well. Rivers in South Carolina and Massachusetts, lakes in Florida and Georgia, and even the mighty Lake Superior (the world’s largest fresh-water lake) are all running dry. According to the U.S. Environmental Protection Agency, if American water consumption habits continue unchecked, as many as 36 states will face water shortages within the next few years. Also notable is the fact that America’s waterways are choked with pollution, and that nearly twenty million Americans may fall ill each year from contaminated water. Not to mention that more than thirty U.S. states are fighting with their neighbors over water.
Such a narrative is a familiar one, because it also applies to South Asia. However, in South Asia, the narrative is considerably more urgent. The region houses a quarter of the world’s population, yet contains less than five percent of its annual renewable water resources. With the exception of Bhutan and Nepal, South Asia’s per capita water availability falls below the world average. Annual water availability has plummeted by nearly 70 percent since 1950, and from around 21,000 cubic meters in the 1960s to approximately 8,000 in 2005. If such patterns continue, the region could face “widespread water scarcity” (that is, per capita water availability under 1,000 cubic meters) by 2025. Furthermore, the United Nations, based on a variety of measures – including ecological insecurity, water management problems and resource stress – characterizes two key water basins of South Asia (the Helmand and Indus) as “highly vulnerable.”
These findings are not surprising, given that the region suffers from many drivers of water insecurity: high population growth, vulnerability to climate change, arid weather, agriculture dependent economies, and political tensions. This is not to say that South Asia is devoid of water security stabilizers; indeed, its various trans-national arrangements, to differing degrees, help the region manage its water constraints and tensions. This paper argues that such arrangements are vital, yet also incapable of safeguarding regional water security on their own. It asserts that more attention to demand-side water management within individual countries is as crucial for South Asian water security as are trans-national water mechanisms.
Continue reading on Seminar.
Michael Kugelman is a program associate for the Asia Program at the Woodrow Wilson Center.
Sources: The American Prospect, Jaitly (2009), The New York Times, UNEP, UN Population Division, Washington Post.
Video Credit: “Groundwater depletion in India revealed by GRACE,” courtesy of flickr user NASA Goddard Photo and Video. For more on the visualization, see the story on NASA’s Looking at Earth.
