13 March 2006
Ann Mette Kjaerby,
Parliamentary and Policy Adviser APPG
Room 563 Portcullis house,
House of Commons
Westminster SW1A 2LW
Dear Ms Kjaerby,
I am enclosing an evidence submission for the All-Parliamentary Group on Population,
Development and Reproductive Health from members of the IDS. This has not been written
jointly but different individuals have contributed and I have brought them together into one
submission.
The focus areas addressed are 1. The importance of sexual and reproductive health and rights
to meeting the MDGs in poverty, gender equality and maternal and child health, and 2.
Population growth and water ‘crises’
The Institute of Development Studies is an international centre for research, post graduate
teaching, and training on development issues particularly as they affect low, middle income
and transition countries.
Contributing researchers are:
Susan Jolly – Gender, sexuality and development
Lyla Mehta – Development and environment with particular reference to water management
Hilary Standing – Gender, reproductive health and development
Yours sincerely
Dr Hilary Standing
Fellow, Knowledge, Technology and Society Team
The following submissions address aspects of the MDGs in health, poverty and gender
equality and in environmental sustainability. The first set of comments concerns the pressing
need to improve the sexual and reproductive health (SRH) of poor populations so as to
address the MDGs more broadly. The second set draws attention to the contribution of
sexuality and sexual rights in meeting the MDGs and frames the question of rights in the
context of the current debate about population growth. The third set examines the question of
water scarcity and raises doubts about the centrality of population growth as determining
factor.
We are aware of a renewed concern about demographic projections, particularly in relation to
sub-Saharan Africa. We do not hold a collective view on this. Some colleagues are very
concerned at what they see as a rising neo-Malthusianism in debates about population growth
particularly given the history of population control policies in some parts of the world. Others
question whether aggregate “numbers” tell us anything about global developmental
trajectories. We do share a concern that this should be an open, informed and democractic
debate, bringing in the voices of all stakeholders, including those of civil society in the
countries most affected.
Importance of improving SRH to meet the MDGs
Improvements in SRH will serve to increase the likelihood of meeting several MDGs in the
following ways:
 By reducing the wholly disproportionate burden of disease from easily treatable or
avoidable SRH related conditions
 By contributing to poverty reduction through multiple pathways, including reducing the
impoverishing impacts of poor reproductive health and of maternal deaths
 By contributing to improving gender equality by enabling women and men to make
choices about their reproductive lives and sexual wellbeing
There are extremely strong links between good SRH, reduced fertility and poverty reduction.
For example, failure to deal with obstetric complications, unsafe abortion, low birth weight
and early childbearing result in life-long morbidities such as fistula which affect individual
and household productivity and welfare. Longer birth intervals decrease child mortality.
Lower numbers of births decrease the risk of maternal mortality and morbidity. Lower
fertility is generally associated with reduced poverty at household and national levels.
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SRH health burden
(Taken from “Bringing Population dynamics and SRH into Development Policy Debates, presentation by Dr
Jaques Baudouy, AFD-DFID Workshop on Demography, Reproductive Health, and Sustainable Economic
Growth in Africa, Paris, 1-3 March)
However, millions of poor people lack access to decent services and the technologies which
could transform their SRH. Of greatest concern is the level of inequality in access to and
utilisation of services by the poorest quintiles where there are disproportionately worse sexual
and reproductive health outcomes. For example, use of skilled birth attendants in the lowest
quintile of the population in Bangladesh is 4% against 42% for the highest quintile (itself an
unsatisfactory figure). The same pattern of inequality holds across all SRH services. Yet most
SRH interventions that can make a difference are well tried and tested and relatively lost cost.
The universal availability of comprehensive essential obstretric care would avert 40% of
maternal deaths. UNFPA’s Global Survey of 2003 shows an unmet need for contraceptives of
29% among women in the south. This unmet need is also demonstrated by the estimated
68,000 women risking death through unsafe abortion (almost certainly an underestimate).
Access to safe abortion would save up to 15% of maternal deaths.
There are grounds for serious concern that – despite the international endorsement of the
Cairo Agenda, SRH has fallen between the cracks of successive international initiatives on
global health, particularly the increasingly verticalised global disease programmes, including
HIV and AIDS. Despite commitments, resources have been declining (see below). This trend
must be urgently reversed if the MDGs which are influenced by SRH are to be met. It
requires renewed international and bilateral commitment to support national, nongovernmental and civil society efforts to create an enabling environment for meeting SRH
needs. Donors also need to look closely at the kinds of aid instruments they are increasingly
favouring, such as direct budget support, to see whether they are contributing to or detracting
from an enabling environment for SRH.
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Declining resources for family
planning and basic reproductive
health services
Source: UNFPA.
2003. Financial
Resource Flows for
Population Activities
in 2001. New York:
UNFPA; and
UNFPA/NIDI
Resource Flows
project database; as
cited in United
Nations. 2004. Report
of the SecretaryGeneral to the 37th
Session of the
Commission on
Population and
Development
(E/CN.9/2004/4). New
York; United Nations.
Note: Data for 2002
are provisional; data
for 2003 are
estimates.
(Taken from “Bringing Population dynamics and SRH into Development Policy Debates, presentation by Dr
Jaques Baudouy, AFD-DFID Workshop on Demography, Reproductive Health, and Sustainable Economic
Growth in Africa, Paris, 1-3 March)
Population impacts on MDGs: Connections with sexuality and rights
Before the International Conference on Population and Development (ICPD) held in Cairo in
1994, discussions around population focussed almost exclusively on demographic and macroeconomic aspects, with a virtual silence around gender and sexuality - even though sex is still
the main way through which people get pregnant, and gendered access to health services, as
well as heterosexual gender dynamics have huge implications for decision-making on, and
impacts of fertility.
At Cairo, a breakthrough was achieved with sexuality and gender making it onto the agenda,
and a broader understanding of population issues asserted, including the agreement in the
Cairo Convention of 1994 which understands reproductive health to include that ‘people are
able to have a satisfying and safe sex life’. The following year, gender and sexuality were
again part of the discussion at the Fourth World Conference on Women at Beijing, and the
Platform for Action was agreed which asserts women’s rights to ‘have control over and
decide freely and responsibly on matters related to their sexuality’ (paragraph 96). These
agreements were achieved due to both government and activist mobilisation around sexual
and reproductive health and rights, and strengthened the foundations for further application of
rights based approaches to sexuality and reproduction.
Development has largely dealt with sexuality in limited or negative ways, for example in
relation to family planning, ill-health and violence. But development needs to engage with
sexuality far more broadly. The connections between sexuality and poverty are extensive, as
shown by the application of Robert Chambers ‘Web of Poverty’s Disadvantages’ to the issue
of sexuality in a recent IDs Policy Brief on sexuality and development. The importance of
sexuality for human well-being and fulfilment, and as a determinant of inequalities and
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poverty must be acknowledged, and an analysis of the connections with sexuality
incorporated into all policies and programmes tackling poverty. Sexual rights frameworks
provide a promising entry point for development to engage with sexuality. However to date
these frameworks have focused largely on negative rights - to freedom from discrimination,
violence and ill-health. Sexual rights frameworks need to go further and also recognise the
positive aspects of sexuality, including rights to sexual fulfilment, well-being and pleasure.
SRHR, including improved access to sexual and reproductive health services, and sex
education, and the contribution all these make to reducing poverty, will contribute to slowing
population growth. There have been positive examples of population reduction through
improved sexual and reproductive health services, and increased female literacy – for
example, Amartya Sen argued that Kerala’s population reduction strategy contrasted
favourably with China’s top-down population control approaches of the early ‘90s. Kerala’s
policies were both more empowering and more effective.
This underlines the importance of maintaining a strong focus on rights in the field of
population health and of keeping the reminder of historical experience in this area. In respect
of history - the assertion of the rights of individuals to reproductive choice (which also
includes the right not to have children - an important but neglected point given the strong
pressures in many societies for natalism)was strongly argued as the basis for the Cairo
consensus. This was both in the context of a broader concern about gender empowerment,
and due to concerns in developing countries from the 1970s over population control policies
which encouraged coercive practices (particularly where incentive based family planning
programmes operated). In a number of contexts (e.g. India in the late 70s and through the
80s) these were something of an "own goal" in public health terms as well as a rights
infringement. So any debate about rights in the area of fertility choice has to be sensitive to
this history, including the danger of instrumentalist arguments of ends justifying means.
In the international human rights framework the key actors are individuals (who have rights)
and nation states (which are the duty bearers in safeguarding those rights). Arguably, this is
not the most nuanced way of thinking about rights in an arena which straddles many interests
"beyond the individual." But the concept of the "rights of the state" in a strong sense to
determine the reproductive behaviour of individuals potentially conflicts with the state’s role
as a duty bearer to safeguard citizens from abuse or coercion. However, states certainly can,
and arguably have a duty to, advocate for behaviours or actions that are considered to be in
the broader public interest. The more important question is therefore who/which groups
decide on the nature of the public interest and on the basis of what evidence? The need is
therefore for an informed debate involving all voices and enabling all parties to have access
to high quality evidence and argument.
Environmental sustainability: Scarcity, water ‘crises’ and the ghosts of Malthus
On the eve of the Fourth World Water Forum, there is again much talk about future ‘water
crises’ due to growing water scarcity and population growth. The problems are well known.
Globally, 1.1 billion people lack access to drinking water and 2.6 billion lack adequate
sanitation facilities. Clearly, the lack of access to safe water and sanitation is one of the most
pressing problems confronting humankind’s survival and it is shocking that in the new
century millions of women and young girls still have to walk miles and miles for a small pot
of water in different parts of the world.
But is population growth the cause of these woes? Many conventional analyses tend to think
so. Projections of water supply and population growth rates predict a dark scenario of the
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future: while the average per capita supply of water will decrease by one third by 2025, water
use will increase by about 50 percent during the same period. As a consequence, half of the
world’s population will live under conditions of ‘severe water stress’, with Africa, the Middle
East and South Asia being most affected.
Largely even though Malthusian mathematics may no longer be adhered to, neo-Malthusians
tend to focus on human numbers as the cause of current scarcity to population growth as the
cause of absolute scarcity in the future. Thus volumetric quantities and projection of future
demand for water against population growth are common instruments used. Population
growth, mismanagement and the lack of supply are seen as the main reasons for water
‘crises.’
Several flaws exist in these dominant perceptions of resource ‘crises’ and population
growth. For instance, by focusing only on aggregate figures of water supply versus water
demand relative to population rates the distribution of existing water resources is ignored.
From Amartya Sen we know that some people’s lack of water does not necessarily imply
that water is scarce. Instead, it may mean that certain sections of the population are unable
to gain access to water for a range of reasons: be it that water is too highly priced; due to
the lack of infrastructure, or due to social exclusion. Thus the aggregate water availability
in a region or the average water per capita tells us little about the distribution of water
within the society as a whole. Power relations, such as who has control over and access to
water, rather than absolute scarcity are usually the underlying factors causing the water
crises. IDS research, for example, by drawing on detailed anthropological and
sociological research has demonstrated water ‘crises’ are usually the result of struggles
over access to, and control over water resources. Moreover, scarcity is often politicised to
legitimise controversial schemes that do not end up benefiting the water-poor and those
currently lacking access to water.
Scarcity and population growth are also linked with future resource conflicts. NeoMalthusian thinkers such as Homer- Dixon and Clare have claimed that population growth
especially in water stressed areas can lead to violent conflict. But this thinking is flawed
because resource scarcity is seen to play an independent role in causing conflict and other
factors such as ideology, power relations, unequal property rights are seen as subordinate.
Often crises occur because powerful actors get away with resource appropriation and thus
enhance environmental degradation Moreover, examples where, despite scarcity,
cooperation rather than conflict occurred are largely ignored. From common property
theorists such as Elinor Ostorm we know that institutions matter and that local people, as
well as governments, can successfully manage resources through property regimes varying
in scale and space. They have also succeeded in directing attention away from simplistic
neo-Malthusian equations concerning population, resource availability and environmental
degradation. Thus Hobbesian notions of anarchy—where states, regions, and people
engage in noncooperative strategies and fight over scarce resources—may not be an
accurate or predictable scenario. Thus, seeing people and ‘nature’ as contradictory and
human action as inherently bad for the environment ignores how people manage
environmental resources in a positive and sustainable way., has demonstrated at a recent
workshop on scarcity at IDS how underlying neo- Malthusian assumptions and narratives
on scarcity influence policy decisions in different areas such as population control and
environment.
Unfortunately, policy interventions by different actors in the development field are still
heavily influenced by neo-Malthusian thinking. This leads to policy interventions that are
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blind to dimensions of access and power relations (e.g. the debate on water privatisation).
Furthermore, policy interventions in developing countries still focus on supply solutions for
dealing with increased water demand. Other critical issues such as improving existing
infrastructure, using demand management options, promoting just decision making processes,
and curtailing those who exercise power over the weak and marginalised are often ignored.
Sources: SRH and sexuality
Family Care International briefing cards on the Millenium Development Goals and Sexual
and Reproductive Health , 2005 http://www.familycareintl.org/pubs/PDF/SRH13E.pdf).
Jolly, S., March 2006, ‘Sexuality and Development’, IDS Policy Briefing
Jolly, S., and Correa, S., 2006, Sexuality, Development, and Human Rights, Paper
commissioned by the Swedish Ministry of Foreign Affairs for Workshop to launch new
policy on Sexual and Reproductive Health and Rights, April 6th, Stockholm
Sen, Amartya 1994, Population, Delusion and Reality. Cairo Lecture, 22 September 1994
http://mthwww.uwc.edu/wwwmahes/courses/geog/malthus/sen_NYR.htm
See also analyses of population growth trajectories by DAWN, ‘Development Alternatives
With Women for a New Era’) www.dawnorg.org
Sources: Water crises
Hartmann, B.: Ghosts of Malthus: Narratives and Mobilizations of Scarcity in the U.S.
Political Context. IDS/ESRC workshop on ‘Scarcity and the Politics of Allocation’, 6-7 June
2005, University of Sussex, Brighton, UK.
www.ids.ac.uk/ids/KNOTS/Projects/Scarcity.html)
Hilyard, N. “Scarcity” as Political Strategy: Reflections on Three Hanging Children. Scarcity
workshop. (www.ids.ac.uk/ids/KNOTS/Projects/Scarcity.html) see above).
Mehta, L. Scarcity and the politics of allocation. Workshop report.
(www.ids.ac.uk/ids/KNOTS/Projects/Scarcity.html)
Mehta, L.: The politics and poetics of water: naturalising scarcity in western India. Orient
Longman: New Delhi.
World Water Assessment Programme: Water for People, Water for Life. The United Nations
World Water Development Report 2003.
http://www.unesco.org/water/wwap/wwdr/index.shtml
World Bank, Water Resources Sector Strategy: Concept Note for Discussion with CODE,
Sept. 7, 2001
United Nations Population Fund/ The Population Institute: Population Awareness Week
2003, Water- The 21st Century Crisis, 2003.
http://population.newc.com/teampublish/uploads/2003wpawmanual.pdf#search='Population
%20Awareness%20Week%202003,%20Water%20The%2021st%20Century%20Crisis'
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