POPULATION GROWTH, MILLENNIUM DEVELOPMENT GOALS
AND REPRODUCTIVE HEALTH
Department of Reproductive Health and Research
World Health Organization
March 2006
Paper submitted to the UK All Party Parliamentary Group on Population, Development
and Reproductive Health for the Parliamentary Hearings between May – July 2006 on
“Population Growth – Impact on the Millennium Development Goals"
1
The designations employed and the presentation of the material in this publication do not
imply the expression of any opinion whatsoever on the part of the World Health
Organization concerning the legal status of any country, territory, city or area or of its
authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on
maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply
that they are endorsed or recommended by the World Health Organization in preference
to others of a similar nature that are not mentioned. Errors and omissions excepted, the
names of proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by WHO to verify the information contained
in this publication. However, the published material is being distributed without warranty
of any kind, either express or implied. The responsibility for the interpretation and use of
the material lies with the reader. In no event shall the World Health Organization be
liable for damages arising from its use.
2
Introduction
The Millennium Development Goals (MDGs) aim to promote human
development by ensuring improvements in a range of areas including poverty alleviation,
education, health and environment (United Nations General Assembly 2000). All eight
goals are interlinked and closely related to population issues. Their achievement is
largely influenced by changes in population dynamics including population size.
This paper explores the potential impact of population growth on human
development and therefore, achieving the MDGs in broad terms. In this context,
population growth refers to “rapid” population growth defined as 2% or more annual
increase in the size of population. The focus is on the trends and consequences of
population growth at the societal level and its implications for human development based
on theoretical and empirical literature. The role of reproductive health in terms of both
the causes and consequences of population growth and the likely impact of reproductive
health care on achieving selected goals [goal 3 on women’s empowerment and gender
equality; goal 5 on improving maternal health; and the part of goal 6 on combating
human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)1] are
discussed.
Population growth
The rapid population growth from the 1950s until the present during which the
world’s population almost tripled to become its current level of 6.5 billions became a
concern of the international community from the late 1960s (Raleigh VS 1999; United
Nations Population Division 2005). This was centuries after Thomas Robert Malthus
wrote his “essay on population” where he discussed the possibility of future
“overpopulation” and the negative impact this would have on limited resources, in
particular food supplies. Malthus' suggested solution was “to proportion the population to
food, since the food could not be proportioned to population” (Malthus TR 1999).
Critiques of Malthus have opposed his theory arguing that he failed to foresee the
potential technological improvements that would increase food production (Sen A 1994).
Indeed, for example in India, empirical evidence showed that the growth rate of grain
production between 1951 and 1991 has kept up with population rates and even increased
1
The MDG 6 is to combat HIV/AIDS, malaria and other diseases.
3
with a small margin (Crook N 1996). However, in the late 1960s, alarmed by the high
population growth rates and research reporting substantial economic costs due to
continued high fertility, neo-Malthusian voices appeared expressing similar concerns and
proposing further policy actions to limit fertility in addition to the provision of family
planning alone (Davis K 1967; Ehrlich PR 1968).
According to the demographic transition theory, rapid population growth during a
certain period of time happens in all societies, because improvements in living conditions
and health care lead to reduced death rates first (Raleigh VS 1999). Declines in birth rates
(fertility) follow this after a certain lag period as the need for having "extra" children to
offset high child mortality decreases. In addition, as societies develop and socioeconomic development takes place, the need for more children as sources of labour and
carers of ageing parents becomes less (Kibirige JS 1997).
In more developed countries which already have completed their demographic
transitions, population sizes are now hardly changing. Developing countries, on the other
hand, are at different stages: rapid falls in mortality have been followed by declining birth
rates in some developing countries, such as India, Bangladesh and Thailand, but due to
the earlier levels of high fertility, their populations will continue growing for some time
(Raleigh VS 1999; United Nations Population Division 2005). In contrast, particularly
the group of 50 least-developed countries, most of which are located in Africa, are
characterized by continuing rapid population growth (United Nations Population Division
2005).
Fertility is still high in most of the least-developed countries and, although it is
expected to decline, will remain higher than in the rest of the world for the coming
decades. It is predicted that the total population of the 50 least-developed countries will
more than double, passing from 0.8 billion in 2005 to 1.7 billion in 2050 (United Nations
Population Division 2005)2.
A possible explanation for the continuing high fertility and delay in completion of
demographic transition in certain countries is that the need for large families continues in
the context of stalling socio-economic development (Kibirige JS 1997). It can be
2
These estimates take into account the expected mortality due to HIV/AIDS in relevant settings.
4
concluded, therefore, that population growth needs attention in countries that are also a
long way off reaching the MDGs (Sahn DE & Stifel DC 2002).



World population almost tripled during the last half-a-century
Rapid falls in death rates in some developing countries have been followed by declines
in birth rates, but due to the earlier levels of high fertility, their populations will
continue growing
Fertility remains highest in the 50 least developed countries – their demographic
transition is delayed by slow economic growth and consequent low levels of investment
in human capital development
Consequences of population growth
Effects on economic growth
Although it is clear that populations with higher socio-economic development
have lower fertility levels, and thus stable population sizes, the evidence with respect to
the effect of population growth on the economic growth and development of populations
(and hence the likely impact of population growth on reaching the MDGs) is less
straightforward. Studies report conflicting results: either negative (Ahituv A 2001; Kelley
AC & Schmidt RM 1995) or positive (Crook N 1996) effects of population growth on
economic growth. The direction and size of the effect may vary from country to country
according to which stage of the demographic transition the country is at and its related
characteristics such as the political and economic context (Barlow R 1994; Kelley AC
1988). For example, an analysis of 45 countries found a greater positive effect of
declining fertility on economic growth for poorer countries and those with higher initial
fertility levels (Eastwood R & Lipton M 2001).

Declining fertility and population growth contribute to development as shown by their
positive influence on economic growth

Economic growth is mainly driven by accumulation of human capital
One recent analysis of 86 countries showed increased economic growth with
declining population growth, fertility and mortality. The only growth-inhibiting
population trend was the decline in the size of the working-age group, although this was
not universal across data sets (Kelley AC & Schmidt RM 2001). It appears that what
5
matters for economic growth is the accumulation of human capital (educated, skilled and
healthy population) (Barro RJ 2001; Orbeta AC 1992; Rosenzweig MR 1990; Strulik H
2005).
Human capital implications
Populations experiencing rapid growth demonstrate particular characteristics in
terms of composition. First, they have distinct age structures where approximately 40%
of the population is under 15 years of age. In the later stages of demographic transition,
the size of the working-age group increases (McNicoll G 1984). Changing age structure
has several implications for development of human capital at the population level. More
infrastructure and investment are needed for schooling needs of the increasing number of
young populations, their employment at a later stage and their sexual and reproductive
health needs throughout their reproductive age span. Indeed, a substantial number of
young people has entered their reproductive ages during the last two decades (United
Nations Population Division 2003). It is estimated that the size of young-age populations
will continue to increase in sub-Saharan Africa, South and West Asia and the Arab region
until 2015 (United Nations Population Division 2005).
Second, limited schooling and employment opportunities force migration and
change the size and composition of cities. Giant cities have appeared during the last twothree decades in many developing countries due to this effect. Rapid urbanisation without
planning puts greater financial and physical restraints on education, health and social
services if these services cannot keep pace with increasing demand (Vlahov D & Galea S
2002). Even in the developed-country cities, population growth has been reported to
increase costs of providing public services as well as to reduce service levels (Ladd HF
1992). In resource-poor settings where this increase cannot be fully accommodated, the
burden can be higher. For example, in United Republic of Tanzania, the change in
literacy rates from 90% in 1986 to 68% in 1995 was attributed to rising school fees due to
structural adjustments (Richey LA 2003).
Finally, rapid population growth increases existing socio-economic inequalities
within countries because poorer people tend to have more children. An analysis of 62
countries reported that this association is particularly stronger in middle-income countries
(Kremer M & Chen D 2002). Another study of 68 countries concluded that the large
6
fertility differentials within countries lower the growth rate of human capital and that it is
not the population growth but the distribution of fertility within the population which is
actually important for human development (De la Croix D & Doepke M 2002).



Nations with rapid population growth have high numbers of young age-groups that
place a heavy demand on schooling and employment opportunities
Failure to meet demands for employment of the working-age populations forces
migration – further stretching the capacities of public services needed to build human
capital
Rapid population growth increases existing socio-economic inequalities because poorer
people tend to have more children
The role of reproductive health
The evidence indicates that rapid population growth characterized by high fertility
in least-developed countries and unequal distribution of fertility due to differentials in
fertility rates between rich and poor in middle-income countries have significant
implications for the attainment of the MDGs in these countries. In addition, consequences
of population growth in terms of altered age-distribution, rapid urbanisation and
increased socio-economic inequalities have resource implications for both leastdeveloped and middle-income countries with respect to accumulation of the human
capital crucial for development.
A clear need to focus on reproductive health exists in all cases. In cases of
persisting high fertility, either at the overall population level or in certain segments of the
population, services should be able to respond both when high fertility is due to limited
availability of effective family planning methods - or information about them - or when
other interventions such as education or employment opportunities increase women’s
demand for family planning.
In the cases where composition of the population changes due to rapid growth, the
needs of an increasing number of people of reproductive age should be met to enhance
human potential. Programmatic responses in these circumstances include not only
meeting family planning needs but also addressing other reproductive health issues which
could pose a high burden on individuals, particularly women, if not appropriately dealt
with. For example, unsafe sex is the second leading risk factor to health (Ezzati M et al.
7
2002). More than half a million of women die each year due to pregnancy-related causes
(WHO 2004) and more than half of the nearly five million new HIV infections each year
occur among 15-24 year olds (UNAIDS 2005).
Access to reproductive health care for populations as defined at the International
Conference on Population and Development (ICPD) in 1994 is therefore a key
intervention to address the causes as well as consequences of population growth. It
facilitates reduction of high fertility levels in populations ready for the second stage of
demographic transition as well as strengthens human capital by reducing the burden due
to high fertility, unplanned fertility, complications of pregnancies and childbirth, and
sexually transmitted infections including HIV. Addressing these conditions has important
implications for development by enhancing human potential. Increased focus on
reproductive health therefore will accelerate achievement of all MDGs as also suggested
earlier (Sachs & McArthur 2005).


Both causes (high fertility) and consequences (restraints in building human
capital) of rapid population growth need to be addressed through increased
attention to sexual and reproductive health, in particular family planning
By meeting family planning and sexual and reproductive health needs of
individuals, societies are better able to build human capital, hence socio-economic
development
It should be noted that improving other aspects of human capital, for example, in
terms of education, women’s status or environmental sustainability would also contribute
to overcome some of the problems of population growth. Indeed, the MDGs aim to
promote improvements in each of these areas. Efforts to achieve all MDGs (and to
increase attention to sexual and reproductive health) would assist building human capital
as well as translating it into sustainable human development. This means distribution of
human capabilities both to the future generations (e.g., the influence of maternal
education and health on the well-being of the next generation, environmental
sustainability) and to the poor and disadvantaged segments of the population (e.g.,
addressing health inequalities, policies to improve the status of women) (Anand S & Sen
A 2000).
8
These complex and inter-related linkages between population issues and the
MDGs will not be detailed here, but highlights will be given below on how attention to
reproductive health could contribute to achievement of goal 3 (women’s empowerment
and gender equality), goal 5 (improving maternal health), and the part of goal 6 on
combating HIV/AIDS.
Reproductive health and achieving selected MDGs
Although women's ability to control their fertility is by itself not sufficient to
gaining their full empowerment and achieving gender equality, it is the first and the most
important step (Oppenheim K 2005). Women who are able to control their fertility are
more likely to be educated and work outside the home. In addition, in the long run, this
could help changing the traditional roles that cultures currently assign to women, such as
looking after the children and the household, leaving more power-bearing activities to
men. In certain settings, high fertility was shown to be related to assigning lower
household resources for girls (Anand S & Morduch J 1996). Decreased fertility could
partly reverse these trends, thus helping populations to move towards the achievement of
goal 3.
For goal 5 and HIV/AIDS section of goal 6, reproductive health care is crucial.
For example, an analysis of 79 less developed countries demonstrated that the presence of
health attendants at birth, contraceptive prevalence, age at marriage and total fertility
were among the significant predictors of maternal mortality (Shen & Williamson 1999).
The use of modern family planning methods has been shown to prevent unintended
pregnancies and, therefore, their possible complications (Chiou Chiun F et al. 2003;
Cleland J & Ali MM 2004; Gallo MF et al. 2005; Peterson HB et al. 1996;
UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and
Research Training in Human Reproduction 1997; Angeles G et al. 2004). It is estimated
that at least a quarter of maternal deaths would be avoided if women were able to avoid
unplanned pregnancies (Freedman et al. 2005). A range of other elements of reproductive
health care such as antenatal, delivery and postnatal care, prevention of complications of
unsafe abortion, prevention and treatment of sexually transmitted infections including
HIV, have direct impact on improved maternal health.
9
The effective prevention and treatment of sexually transmitted infections,
including HIV, is an integral component of sexual and reproductive health services.
There is a strong association between sexually transmitted infections and HIV infection
(Cameron DW et al. 1989; Laga M et al. 1993) and there is biological evidence that the
presence of a sexually transmitted infection increases (and treatment of an existing
sexually transmitted infection reduces) acquisition of HIV (Cohen MS et al. 1997;
Robinson NJ et al. 1997). The family planning component of reproductive health services
is also crucial in reducing the number of new HIV cases among women and children.
Recently, an in-depth analysis from eight African countries with severe epidemics
demonstrated that for prevention of HIV in infants, the current focus on prevention of
transmission of the virus from mothers to infants using antiretroviral drugs is less
effective than achieving small reductions in maternal HIV prevalence or in unintended
pregnancy among women with HIV (Sweat MD 2004). Indeed, family planning services
in sub-Saharan Africa may be preventing more HIV infections than the provision of
antiretroviral drugs does (Reynolds HW et al. 2005).
Providing universal access to effective reproductive health care is therefore,
essential for improving maternal health (reach goal 5) and tackling HIV/AIDS (reach
goal 6). It should be noted that better care for women during pregnancy and at the time of
delivery will also have a positive impact on newborn health and thus contribute to the
achievement of goal 4 on reducing child mortality (Darmstadt GL et al. 2005; Feresu S et
al. 2005).



Increased focus and investment in sexual and reproductive health will accelerate
achievement of all MDGs
Women's ability to control their fertility is the first and the most important step for their
empowerment, therefore achievement of goal 3
Universal access to effective reproductive health care is fundamental to improving
maternal health (reach goal 5) and tackling HIV/AIDS (reach goal 6) and will also
contribute to reducing newborn and hence child mortality (reach goal 4)
Conclusion
Population growth is still a problem in countries where socio-economic
development is also far from the desired level. The cause in most of the least-developed
countries is persisting high fertility. Despite having lowered their fertility levels, middle-
10
income countries demonstrate unequal distribution of fertility with higher fertility in
poorer segments of the population, which increases socio-economic inequalities.
Consequences of population growth can potentially restrain investments in human capital,
such as the education, the creation of employment opportunities and the provision of
sexual and reproductive health care services that are crucial to fulfilment of all MDGs.
Increased focus on provision of sexual and reproductive health care is needed to address
both the underlying causes in least-developed and middle-income countries and the
dynamics of the consequences of population growth if human well-being and
development (and MDGs) are to be reached.
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The designations employed and the presentation of the material in this publication do not
imply the expression of any opinion whatsoever on the part of the World Health
Organization concerning the legal status of any country, territory, city or area or of its
authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on
maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply
that they are endorsed or recommended by the World Health Organization in preference
to others of a similar nature that are not mentioned. Errors and omissions excepted, the
names of proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by WHO to verify the information contained
in this publication. However, the published material is being distributed without warranty
of any kind, either express or implied. The responsibility for the interpretation and use of
the material lies with the reader. In no event shall the World Health Organization be
liable for damages arising from its use.
15