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USAID’s New Global Health Framework and Delivering Equity in Health Interventions
›USAID’s new Global Health Strategic Framework, Better Health for Development, lays out the agency’s major health priorities for the next five years. “Core global health priorities” include reducing maternal mortality, ensuring child survival and nutrition, fostering an “AIDS free generation,” and fighting infectious diseases. Family planning and reproductive health is listed as a key area for bilateral engagement. In particular, the strategy hopes to continue to “graduate” countries from the agency’s family planning program, which since the 1980s has transitioned 21 countries into local ownership of family planning support. The strategy also takes stock of the shifting global health environment, noting the rise of the “BRICS” countries as new donors and the need to strengthen public health systems in developing countries. “Already, private payments account for 50-80 percent of total health spending in Africa and Asia, leading to system inefficiencies, inequitable access, and health costs that prove catastrophic to individuals and families,” the report reads. In order to achieve its priorities within this context, the document sets out a number of strategies, including a focus on program sustainability, the empowerment of women, and integrated approaches to development. Health, it says, “cannot be isolated from other development challenges.”
Speaking of health interventions, a team of researchers led by Aluisio Barros of the Federal University of Pelotas, Brazil, recently compared coverage data from more than 50 countries against an index of household wealth to estimate the most and least equitable interventions. The study, “Equity in Maternal, Newborn, and Child Health Interventions in Countdown to 2015: A Retrospective Review of Survey Data From 54 Countries,” published in The Lancet, found that “interventions with similar levels of overall coverage often have very different degrees of inequality.” According to the data, “the most inequitable indicator was skilled birth attendant, followed by four or more antenatal care visits, whereas the most equitable was early initiation of breastfeeding.” For example, though the average for attendance by a skilled birth attendant was 53.6 percent across the entire sample, the wealthiest fifth had an 84.4 percent coverage rate and the poorest stood at 32.3 percent. “Interventions that are usually delivered in fixed health facilities…tend to be the most inequitably distributed,” write the authors, with geographical access, financial barriers, and discrimination appearing as likely obstacles for the poor. The authors conclude that, although “concern about inequalities in maternal and child health in poor countries was conspicuously absent from the global agenda in the past,” the availability of new, intervention-specific data provides a means of targeting equity issues in health delivery more successfully. -
Comparing Urban Governance and Citizen Rights in China and India
›Today, according to Xuefei Ren, 129 cities in China and 45 in India have populations of over a million people. Such large-scale urbanization has created major governance challenges. Speaking at a May 23 Asia Program event co-sponsored with the Kissinger Institute on China, United States Studies, and the Comparative Urban Studies Project, Ren, a Wilson Center Fellow, examined two case studies of urbanization-driven governance in China and India and their effect on citizen rights.
Her first case study involved housing demolitions and urban re-development in Shanghai and Mumbai. In Shanghai, nearly a million households were relocated between 1995 and 2008 to make way for hotels, airports, and luxury apartments. City regulations in 1991 and 2001 legalized forced demolitions, and no prior consent from residents was needed.
However, Ren noted that displaced residents “are not quite powerless.” She highlighted the case of a woman who sued the city government after being relocated and was eventually granted the compensation she had requested. In 2003, China’s central government ordered a freeze on large-scale demolitions. Several years later, it passed a “landmark” property rights law.
Meanwhile, in Mumbai, local officials in the early 2000s had their own re-development plans. The Indian city is rife with overcrowded, low-income housing; slums are populated by seven million citizens (40 percent of the city’s total population), and comprise up to 10 percent of Mumbai’s total land area.
In 2004, aware that most of the slums were located in desirable areas – near airports or in central business districts – city planners recognized a major development opportunity. Over the next two years, officials launched a demolition campaign that left 400,000 people homeless. According to Ren, certain categories of residents were theoretically entitled to compensation, but with “legal protections carrying little weight,” most of them received nothing.
Yet, as in Shanghai, Mumbai’s city dwellers successfully fought back. Housing activists staged acts of “direct agitation,” including a series of street protests and road blockages. Such tactics, said Ren, were “disruptive but effective.” The Mumbai courts sided against the activists in 2006, but India’s Supreme Court later issued a ruling in their favor.
Fighting Land Acquisitions: A Comparison
Ren’s second case study compared land acquisition efforts outside the slums.
Last year, residents in Wukan, a village along China’s southeast coast in the province of Guangdong, launched a protest movement against land seizures. They alleged that government officials had sold their land to developers and failed to provide residents with appropriate compensation. The protestors made two demands: the return of their land and the holding of local elections.
Notably, Ren said, protestors in Wukan affirmed their support for the Communist Party, and never framed their movement as an anti-government effort. In March 2012, local elections were in fact held, with two leaders of the protest movement voted into office (one as village chief, the other as his deputy).
Ren also discussed an attempt by India’s Tata Motors corporation to acquire land in Singur, a village about 100 miles from Calcutta in the state of West Bengal. The company wanted to use this land to construct a factory for the Nano, a small, cheap car marketed to India’s urban middle class. In 2005, the West Bengal government, which had been controlled by the Communist Party of India-Marxist (CPI-M) for nearly 30 years, actively wooed the firm. State authorities “went overboard” in offering Tata Motors subsidies and highly fertile land, said Ren. Small landowners were obliged to surrender their plots at low prices, and in 2006 the corporation formally took over the land (nearly 1,000 acres altogether), despite heavy opposition from peasants.
However, violent protests continued and after several months, Tata Motors was forced to pull out of West Bengal. Then, in a state election in May 2011, the Trinomool Congress Party, led by the populist leader Mamata Banerjee, swept the CPI-M from power. Banerjee had run her campaign on a promise to restore the land to Singur’s farmers.
Just weeks after the new government assumed power, West Bengal passed a law that would allow for about 400 acres from the Tata Motors project to be returned to farmers who had refused government compensation for their land.
Ren acknowledged that in both countries, citizenship rights are not enjoyed by all and tend to be unevenly distributed across social groups. Still, she concluded, Chinese and Indian cities “have become strategic sites for reassembling citizen rights.” By asserting their land and housing rights, city denizens “are becoming active citizens.”
Michael Kugelman is a program associate with the Wilson Center’s Asia Program. He can be reached at michael.kugelman@wilsoncenter.org and on Twitter @michaelkugelman.
Photo Credit: Mumbai pipes, courtesy of flickr user lenskap. -
Poor Land Tenure: A Key Component to Why Nations Fail
›The murder of five land rights campaigners during the last two months – one in Colombia, three in Brazil, and one in Cambodia – have not captured many headlines, but they are a reminder of the central role land tenure plays not just in rural economic development but also in sparking broadly distributed economic gains throughout a society.
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Philippines’ Bohol Island Demonstrates Benefits of Integrated Conservation and Health Development
›In March 2012, I participated in a study tour to the island of Bohol, near the unique Danajon double barrier reef ecosystem – the only one of its kind in the Philippines and one of only three in the Indian and Pacific Oceans. Nowhere is the connection between population dynamics and biodiversity more evident than in the Philippines, one of the most densely-populated countries on the planet, with more than 300 people per square kilometer. Nearly every major species of fish in the region shows signs of overfishing, according to the World Bank.
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Uganda’s Demographic and Health Challenges Put Into Perspective With Newfound Oil Discoveries [Part One]
›April 26, 2012 // By Kate DiamondUganda’s population is the second youngest in the world, with half of the country younger than 15.7 years old (just older than Niger’s median age of 15.5 years). In the past 10 years, the country – about half the size of France in land area – has added 10 million people, growing from 24 to 34 million. That growth, paired with other factors like poor governance and long-standing insecurity, has made providing basic services a difficult task for a government that is one of Africa’s most aid-dependent.
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Megacities, Global Security, and the Map of the Future
›“We’re in an urban century, there is no doubt,” said Peter H. Liotta, visiting scholar at the U.S. Military Academy West Point and co-author of The Real Population Bomb: Megacities, Global Security, and the Map of the Future, during a March 20 event at the Wilson Center. Liotta’s book focuses on the geopolitical impacts of poorly managed urbanization on the most vulnerable as well as the security issues such urbanization might create. He was joined by Jaana Remes of the McKinsey Global Institute, who painted a more promising picture of a globally rising, economically prosperous urban middle class, and Stimson Center visiting fellow Peter Engelke, who grappled with the contradictions between these alternative urban realities. [Video Below]
“Urbanization is key to economic development, but it has been, is now, and will continue to be into the future beset by a very large shadow side, wherein the marginalized face grinding poverty, squalor, and despair,” explained Engelke.
Although Liotta and Remes laid out very different “maps of the future,” Engelke suggested three commonalities. First, they both highlight the “unprecedented scale and speed of global change.” Second, they acknowledge that “a global demographic shift is well underway, and has been for some time.” And third, they accept that we have yet to fully integrate cities into the physical and mental maps by which we navigate the world, he said. Despite the economic dynamism of cities, “we live in a world that, I submit, has not yet grasped this reality even in conceptual terms, much less political and policy ones.”
The City as a Source of Vulnerability
People come to megacities “because there’s a chance,” said Liotta. “It looks like a nightmare to us, but people come because they’re waiting for a future.” This chance, however, is often slim, according to Liotta.
The sheer scale of modern urbanization (approximately 200,000 people move every day from rural to urban areas) produces myriad sources of vulnerability for the poorest and most marginalized, said Liotta. “World population growth will occur in the poorest, youngest, and often heavily Muslim states, which lack education, capital, and employment. And for the first time in history the world will be primarily urbanized, with most megacities in the poor states where you don’t have policing, sanitation, and health care.”
This urban shift concentrates young populations presumed to be unstable, exacerbates the risk of disease and climate change, and increases the threat of declining resource availability and food production, Liotta said. In states where “the lights are out” – that is, where urbanization is not met with sufficient economic development – our new urban century may feature significant security challenges, he argued. “Every single security problem we have today, and in the future – whether it’s human security, environmental security, or national security – is [in] the places where the lights are out.”
In The Real Population Bomb, Liotta links these sorts of security issues to what he terms “entangled vulnerability scenarios,” such as scarcity of water for drinking and irrigation, outbreak and rapid spread of disease, or lack of sufficient warning systems for natural disasters or environmental impacts. These scenarios, he argues, deserve a greater showing next to the traditional focus on hard security “threats.”
Fertility rates are generally declining, which will eventually dissipate the youth bulges being experienced by many countries, but the challenge is how to “manage that glide path,” said Liotta. It is about “doing it well collectively, because we are not thinking collectively well about how to do this and places in the world are in serious trouble.”
The City as a Center of Growth
Jaana Remes presented both a broader scale of analysis and a more positive outlook. Urbanization is “the most powerful positive economic force in today’s environment,” she asserted, drawing on the McKinsey Global Institute report, Urban World: Mapping the Economic Power of Cities.
Compared to the historical experiences of the Western world, change in the most rapidly urbanizing of today’s developing states is occurring at “100 times the scale, in one tenth of the time,” said Remes. This change is fundamentally shifting the economic profiles of states such as India and China, which are projected to account for approximately one third of global GDP by 2050.
This growth in economic prominence can be accounted for by the rise of urban populations of middle class consumers not just in megacities, but also in the rapidly growing “middleweight” cities (from 200,000 to 10 million people) explained Remes. The path that these cities take will be “very significant for…how our world is going to look like in the next few decades,” she said. They are where “the lion’s share of global investment is going to be made.”
Engaging Global Urbanization
“That we are seeing cities rise in their profile is nothing new in history,” said Remes, “in fact you can argue that cities are actually some of the longest-lasting assets in the world.” Today, 600 urban centers generate more than 60 percent of global GDP; 400 of these are in emerging markets. So, “even though the scale of the change we expect to see is very dramatic, from the cities perspective, it is probably going to be more evolution than revolution.”
Taking advantage of this growth will require some significant global re-posturing. In terms of commercial diplomacy for instance, most nations continue to distribute their people more according to the “geopolitical power of the 20th century than the economic opportunity of the 21st,” said Remes. She points out, for example, that the city of Wuhan in China is expected to generate 10 times the GDP growth of Auckland, New Zealand, yet the number of foreign service officials stationed in each city is in the opposite proportion.
Policymakers looking to adapt should also look more closely at opportunities to re-develop existing, or “brownfield,” infrastructure. The challenge of accommodating the tremendous pace of urbanization may be great, she said, but “we have not yet seen one piece of infrastructure where you can’t make substantial improvements.”
Summing up the need to work on what he argued has been a shortfall in policy engagement, Engelke concluded that, “we are indeed quite a ways from acknowledging the enormous challenges, but also the opportunities, that global urbanization presents to us.”
Event ResourcesSources: UN Population Division.
Photo Credit: David Hawxhurst/Wilson Center. -
Mia Foreman, Behind the Numbers
Serving the Reproductive Health Needs of Urban Communities in Nairobi
›The original version of this article, by Mia Foreman, appeared on the Population Reference Bureau’s Behind the Numbers blog.
Kenya’s population is growing rapidly, more than tripling from 10.9 million people in 1969 to 38.6 million in 2009. According to the United Nations, the annual population growth rate between 2010 and 2015 is 2.7 percent with 22.5 percent of the population residing in urban areas in 2011.
One area that has seen tremendous growth is Nairobi’s largest slum, Kibera. While experts have given estimates ranging from 270,000 to 2,000,000 residents, Kibera is a large area of informal settlements plagued by challenges such as the lack of electricity, job opportunities, and high levels of violence.
While it may be easier to focus on what is lacking in Kibera, there are also many services being provided in the community including affordable and quality reproductive health care by organizations such as Marie Stopes Kenya.
Marie Stopes Kenya was established in Kenya in 1985 as a locally registered nongovernmental organization. It is Kenya’s largest and most specialized sexual reproductive health and family planning organization and is known for providing a wide range of high-quality, affordable, and client-centered services to men, women, and youth throughout Kenya. In 1997, Marie Stopes Kenya opened its first clinic in Kibera and began offering reproductive health services at an affordable rate for residents.
Continue reading on Behind the Numbers.
Sources: UN Population Division.
Photo Credit: “The Kibera ‘river’,” courtesy of Dara Lipton and flickr user The Advocacy Project. -
Taking Stock of Past and Current Demographic Trends
›March 29, 2012 // By Kayly OberECSP is at London’s 2012 Planet Under Pressure conference following all of the most pertinent population, health, and security events.
“Demography is a science of assumptions,” said Sarah Harper, a demographer at the University Oxford, during a panel at the Planet Under Pressure conference. Thirty years ago, she said, demographers believed the world would reach 24 billion by 2050, now the latest UN median projections predict 10 billion. That means a lot of progress has been made for families and development as a whole, but there are some obstacles yet.
Harper stressed that the development community should focus on parts of the world with stubbornly high fertility rates, particularly sub-Saharan Africa. If total fertility rates came down there by 2050, below the expected four children per woman, the region could be home to as many as a billion fewer people than current projections. The earlier we acknowledge this growth, the easier it will be to offer interventions like family planning and reproductive health to hedge it, she said.
Additionally, demographers need worry about important changes in modern population and environment dynamics.
As Harper notes in an interview with ECSP (video below):There has been so much hype around population growth that I think we’ve ignored the other characteristics of population…that it’s changing in its density – we’re all becoming more urban; it’s changing in its distribution – we’re becoming more mobile; and it’s also changing in its composition – the world is getting older.
Sir John Sulston of the Royal Society agreed: population is a more-nuanced subject than many can digest. “Population has been much too ignored because it’s difficult,” he said.
I think it’s very clear that these changes are going to interact with the environment and be affected by environmental change but are also going to impact upon future environmental change.
Sulston urged us to look not just at the diversity of the world, but also the inequity. Today, there is “inequity in countries, between countries, and between generations.”
There is no silver bullet – the international community need to look at three components in concert if we want to make a difference, he said: first, bring down infant mortality; second, invest in family planning; and third, emphasize education for women.
“It’s not about surviving, it’s about flourishing,” Sulston said.
When the ECSP delegation isn’t attending plenary and breakout sessions here at the conference, we’re manning our Wilson Center information booth. And over the last few days, we’ve had the pleasure of introducing our work to a number of new faces, including curious faculty, energetic students, and hopeful doctoral candidates. If you’re attending please feel free to stop by.
Expect more updates from East London, including more short video interviews, in the next three days as ECSP highlights the unique perspectives coming out of the Planet Under Pressure conference.
Pictures from the event are available on our Facebook and Flickr pages, and you can join the conversation on Twitter (#Planet2012) or watch the livestream here.
Photo Credit: Sean Peoples/Woodrow Wilson Center,
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