PRB

(April 2012) For some time now, Brazil, Russia, India, and China have been grouped together under the acronym BRIC. The BRICs are described as countries at the same stage of economic development, but not yet at the point where they would be considered more developed countries. The BRIC position argues that, since the four countries are “developing rapidly,” their combined economies could eclipse the collective economies of the current richest countries of the world by 2050.

The BRIC Economy

The combined 2010 gross national income of the BRICs was US$10.5 billion, 25 percent of the GNI of high-income countries (see table). In 2009, it was 15 percent of the world total. The BRICs rank quite high in terms of global GNIs and China has almost certainly overtaken Japan by now to claim the second spot.

Brazil, Russia, India, and China, Selected Indicators

* Atlas method.
Sources: Population Reference Bureau; United Nations Population Division; International Labour Organisation; National Statistical Offices; and World Bank.

The picture changes dramatically when we consider the countries’ rank on GNI per capita. The size of their economies is largely a result of population size.The BRICs are among the top 10 countries in the world in population.

Will the BRIC economies really eclipse the world’s wealthier countries? Table 1 offers one way to quantify that possibility. The high GNI growth rates of China and India are partly due to the still relatively small size of their economies. As economies grow, we can expect rates of growth to decrease simply because the denominator, GNI, will grow. Let’s assume that the BRICs will average a 4 percent GNI growth rate for the next 40 years and the high-income countries will average 2 percent. That latter assumption, of course, posits that the current recession will end at some point. And, an assumption of 4 percent growth for the BRICs over such a long period is rather generous. Under that scenario, the combined income of the BRICs would rise from 25 percent of the high-income countries’GNI in 2009 to 49 percent in 2050. Not exactly an eclipse but significant growth nonetheless.

Age Structure and Fertility

Age is all-important for its effect on the size of the labor force. India remains a rather young country with 33 percent of its population below age 15. Brazil is not far behind at 25 percent, while China and Russia, due to their very low birth rates, have only 17 and 15 percent, respectively.

The population pyramids (age and sex structure) of all four BRIC countries are quite different, primarily a result of their different birth histories. Brazil and China are somewhat similar, reflecting their transition to low birth rates. Brazil’s total fertility rate (the average number of children per woman) is now at a low, industrialized-country level of 1.9 children per woman. India has also made considerable progress in its fertility transition, but its TFR is still about 2.6.

Age and Sex Structure of Brazil (2010) and Russia (2010)

Sources: Brazil: United Nations; Russia: GOSKOMSTAT.

Age and Sex Structure of China (2010) and India (2011)

Sources: China: IDB; India: PRB/PFI projections.

China and Russia present two unusual age structures. China’s jagged pyramid results from a number of factors: mass deaths, social disruption, and the country’s “one-child” policy, all of which affected the population structure. In Russia, the economic disruption following the breakup of the USSR dropped the TFR below 1.2 in 1999, although it had risen to nearly 1.6 by 2010 (a rise that slowed in 2011). India is the “youngest” country of the group, and even by 2050, the 0-4 age group will be virtually equal to the 5-9 group.

Labor Force and Poverty

Both China and India still have substantial proportions of their labor force engaged in agriculture, but in India the proportion is a whopping two-thirds. In India, only about 7 million people work in the “organized” manufacturing sector (factories that register with the government and, supposedly, maintain records and pay workers required benefits). These workers, however, account for about two-thirds of manufacturing output while earning a comparatively high wage equivalent to US91 cents per hour in 2006.¹ The great majority of India’s labor force of 400 million work in the unorganized sector, where work varies from casual day labor to work in small shops and fabrication facilities and for which comparable labor force data are not available.

The large proportion of the population living in poverty—abject poverty—is often overlooked. The World Bank estimates that 76 percent of the population in India lives on less than US$2 per day, compared to 36 percent in China. Over 900 million people living in poverty in India, most with little effective education, are not likely to share in the prosperity enjoyed by a few and are not likely to form the basis for an exploding consumer market anytime soon. China’s future is difficult to foresee in that it now faces unaccustomed population aging should it not relax its stringent one-child policy. But China, unlike India, is one of the world’s largest exporters.

Of the four BRIC countries, Russia seems a true outlier. Despite an uptick in the birth rate, it still had 130,000 more deaths than births in 2011, primarily due to a decrease of 106,000 deaths in 2011 from the 2010 level. It had reported nearly 1 million more deaths than births in 2000. Childbearing among women ages 20 to 29 and the number of women moving into those ages will diminish sharply over the next 20 years, even with some offsetting effects of immigration.

Potential

Several things need to happen for the BRICs to reach their advertised potential. In India, a massive campaign to provide potential workers with education and training will be required. The government is trying to tackle this daunting task but provincial politics can be a major obstacle. As an official from the impoverished state of Bihar once commented to me regarding the demographic dividend in his state, “Having a huge amount of illiterate people is not an advantage!” Relaxed regulations in the early 1990s for foreign investments jump-started the Indian economy. Will China follow? China has a clearly disadvantageous demographic profile, and may need to alter it through immigration or by allowing the birth rate to rise? At the very least, Russia will likely have to rely on immigration to fill its labor force gaps. Finally, Brazil does have the appearance of a country whose economy has reached an advanced stage with a high per capita GNI. That said, the current world economic situation can too easily reshape the very different societies of the BRICs.

Carl Haub is a senior demographer at the Population Reference Bureau.

References

1. Jessica R. Sincavage, Carl Haub, and O.P. Sharma, “Labor Costs in India’s Organized Manufacturing Sector,” Monthly Labor Review 133, no. 5 (2010): 3-22.

(August 2011) Around the globe, family planning has been integrated with maternal and child health services for some years, even decades. In countries where integration is a key element of the health system, birth rates have fallen as more women have been able to avoid unintended pregnancies. As a result, population growth has slowed and certain countries have been able to accelerate economic progress and lift more people out of poverty. However, for women who are pregnant or have recently given birth, unmet need for family planning is still high. But a number of challenges face the integration of services, including resistance to change from government leaders and society in general.

In the case of Russia, John Snow, Inc. overcame such obstacles to implement a comprehensive family planning and maternal child health project, now managed by an autonomous nongovernmental organization, the Institute for Family Health. In a PRB Discuss Online, Natalia Vartapetova, chief of party, Institutionalizing Best Practices in Maternal and Child Health Project in the Russian Federation, JSI; and Asta-Maria Kenney, senior advisor, JSI, answered questions from participants about how JSI overcame resistance to family planning in Russia.

Aug. 25, 2011 NOON (EDT)

Transcript of Questions and Answers

Mia Foreman: The historical perspective of the JSI Russia case study is quite interesting! Thank you for sharing. It has been 4 years since the case study “Russia: Integrating Family Planning into the Health System” was published. Can you please update us on the current health status within the ten regions that are implementing or have implemented the Maternal and Child Health Initiative? What are the current abortion rates? What is the CPR? MMR and IMR? Have you seen a vast improvement in these regions since this case study was published?
Asta-Maria Kenney: Given the vast size of the Russian Federation and the urgent need to modernize FP/MCH practices across such a huge country, each new project takes us to new regions and we no longer maintain as close contact as we would wish with some of the pioneers—and do not collect data from them on a regular basis. We do, however, have some data about how five of the early oblasts (regions) are progressing at three points in time (2004, 2006, and 2009).

These data come from surveys of pregnant and postpartum women about their use of modern contraception before their pregnancy:

We also have official abortion rates (abortions/1,000 women aged 15-49) for the period 2003–2009 for 10 regions that participated in the first Maternal & Child Initiative (2003–2006). Please note, however, that these regions received minimal support from the project after 2006.

Both sets of data are encouraging and indicate that the project’s impact outlasted the project life! Data on maternal and infant mortality are considered highly sensitive in Russia, so they are hard to obtain and must be used with caution.

J Kishore: Family Planning and Maternal and Child health services are integrated for a long time in India. However, contraceptive use and use of permanent methods is not improved substantially. Male participation remains the lowest. Do you think that better strategic and innovative program are required to achieve goal for population control.
Asta-Maria Kenney: Not being familiar with the Indian context, it is hard for us to comment on your situation. In Russia, the concern is not population control but exactly the opposite: how to reverse the sharp population declines of the past couple of decades. The challenge in Russia is how to help the government—which has a strong pronatalist policy, including substantial payments for childbirth—recognize that most countries of the world support FP as an important health measure as well as because couples should be able to freely determine their family size. In fact, there is significant evidence that in developed countries where fertility is already low, improving/expanding FP encourages couples to switch from abortion to contraception, while having little or no impact on fertility.

Dramani Mahama: 1) Please how were you able to overcome resistance to family planning in Russia? 2) Who did you use to achieve the goal of overcoming resistance to family planning in Russia? 3) How much resources did you use for the integration of family planning and maternal/child health services in Russia?
Natalia Vartapetova: There were three key approaches to reduce resistance to family planning: (1) education of medical workers, primary OBGNs and midwives on the latest evidences and FP methods; (2) education of decision makers (government and community leaders) on the advantages of FP including church leaders on abortion prevention; (3) communication campaigns and information for women and men. Education activities do not cost much but unfortunately quite often neglected.

Issa Almasarweh: 1) Does a country with a negative population growth rate like Russia need to strengthen its family planning services? 2) Does Russia need a technical assistance from John Snow and funding from USAID?
Natalia Vartapetova: 1) Yes, Russia needs to strengthen FP services and programs as far as abortion rate and prevalence of STIs and HIV are still high as well as number of unwanted abandoned babies. 2) JSI and USAID-funded projects bring the latest knowledge and scientific evidence to Russian health care as well as modern training approaches and skills. Unfortunately currently Russian medical workers for various reasons have very limited opportunities to get new information and skills. USAID and JSI support is very important for improving quality of care for women and children in Russia.

Cecily Westermann: Some countries—including Russia—have attained the status of “negative population growth.” For many reasons, including conservation of resources, it would be best if other countries also achieved this status. How does one present “negative population growth” as an asset? Thank you.
Natalia Vartapetova: In Russia authorities are very concerned about a small size of the population taking into account Russia geographic territory. We cannot promote “negative population growth” as “an asset” but can explain this fact as a logical consequence of a new technological era that changing people’s lives, opportunities and priorities.

Laurentiu Stan: A reality of former Eastern Europe health system of Semashko type is that services are provided through parallel networks of providers. In your case, what were the MCH service delivery places were FP was most successfully integrated? Which were the key messages and approaches facilitating such integration?
Asta-Maria Kenney: Over the more than decade-long lifespan of the Russia projects, FP has been most successfully integrated into maternity hospitals and women’s consultations (outpatient clinics serving women), largely because most project interventions have been focused on these facilities. Other sites include pediatric polyclinics, HIV centers and STI dispensaries. Some partner oblasts (regions) have also had considerable success in integrating FP into rural health care: family doctors and general practitioners’ offices and FAPs (nurse practitioner/midwife points.) Family planning information has also been integrated on a small scale into pharmacies and into social services in a few oblasts. Given the sensitivities of FP in Russia, our core approach has been what we call “horizontal integration,” which refers to including FP into other health services, most significantly, maternal and child health care: antenatal care, breastfeeding and postpartum care (both in the hospital and at the later postpartum visit.) The most successful messages were: (1) For health workers: FP is an integral part of maternal and child health services, contributing to reduced maternal and infant mortality; (2) For health workers and the public: contraception is a better alternative to abortion; this addressed the widespread use of abortion as the main means of fertility control, despite most women’s profound dislike of obtaining repeat abortions; (3) For health workers and the public: modern contraception is safe and effective; this message addressed the deeply-held views, dating back to Soviet times, that contraception is dangerous to health and not very effective in preventing pregnancy.

Terry Hull: Integration of family planning with MCH would seem to be part of the issue, but what about the broader integration of reproductive and sexual health issues across the lifespan. Is Russia doing anything on these?
Natalia Vartapetova: We are working a lot now on integrating and incorporating reproductive and sexual health in healthy life context. Health promotion programs are very popular in Russia and get a significant attention and support from the Federal and regional governments. We use all available evidence to present and promote importance of reproductive and sexual health programs to decrease morbidity and mortality and improve quality of life.

Richard Cincotta: Among the U.S. public health community, many were surprised by the poor quality of health care and particularly MCH/FP services in Russia. Some argue that services declined in quality with the fall of communism. Others argue that these services improved very little since the early 1980s. How far back can one trace Russia’s MCH/FP problems? And how has this legacy affected your project?
Natalia Vartapetova: One can get trends of abortion, maternal and infant mortality rates back to 1970s. The most significant decrease has happened after 2000. You can check WHO Global Health Observatory to see the trends. In the project regions improvements have been more visible even initially they had higher rates than the Russia average.

Soumya: Social issues surrounding abortion, as well as penalties for abortion providers and women who undergo abortions, restrict access to PAC services even when legal. Whether such incidence are also common in Russia? If so, is Russia doing anything on these?
Asta-Maria Kenney: Abortion has been legal in Russia for many years. Along with IUDs, it was the the major method of fertility control. So abortion rates have traditionally been high and there is no stigma associated with abortion. Thus the obstacles you cite really haven’t been a big issue. Rather, the challenge is to integrate counseling and modern contraceptive care with abortion services, to help women avoid another unintended pregnancy.

Mia Foreman: After reading the JSI case study and learning more about this project, it is apparent to me that this is a well designed and excellent example of FP/MCH integration. We know it is difficult to replicate this exact model in other countries that work within different health systems and under different circumstances. At the same time, since we have a wide audience from across the globe participating in this forum, could you share with us key elements of the project that were needed to design and implement such a successful program that perhaps others can adapt?
Asta-Maria Kenney: Thank you for your kind comments! There were very many elements, but probably the most crucial ones were: (1) starting in pilot sites to fine-tune interventions and demonstrate results and, later, scaling up; (2) using Evidence-Based Medicine to convince health workers of the safety and efficacy of FP; (3) a highly participatory process that allowed counterparts to discuss evidence, ask questions, share concerns and adapt material to the Russian context; (4) working on policy at the same time as working to improve service delivery, since it is risky in Russia to practice in ways inconsistent with policy; (5) building cadres of leaders and advocates in each oblast (region) who expanded the reach of the project’s work; (6) educating and empowering the public at the same time as strengthening health services.

Karin Ringheim: Hello Asta-Maria and Natalia, thank you for providing your expertise on this topic. Knowing that integration of family planning and maternal and child health services was extensively researched in the late 1960s and early 1970s, and found to be successful in averting unwanted pregnancies, I’m interested in your views on why integrated services did not become the norm in the Soviet Union and much of the developing world? What factors stood in the way of what appears to be common sense? Thank you.
Natalia Vartapetova: The Soviet health care system was built on the approach that any health problem could be successfully solved only by a high specialized service. That is why it consisted of a number vertical medical professional services and experienced a significant lack of modern public health approach.

Cynthia Buckley: In March of this year, meetings were held with various religious leaders in the Russian Federation on population issues across the former Soviet Union and the problem of abortion. Led by officials of the Orthodox Church, the meetings generated a list of four recommendations to curb reliance upon abortion: 1) Public policies supporting motherhood and children, 2) Using traditional religions to raise public perceptions of the value of family, 3) Use of mass media to encourage marital fidelity and discourage abortions, and 4) Propaganda for healthy lifestyles, and creating a positive image for large families among youth. At no point in the records from the meeting (or in my research—dozens of other similar meetings) was the importance of family planning or reproductive health education mentioned for sustaining healthy families, or as a potentially effective means to decrease the demand for abortion. How has the religious community within the Russian Federation been integrated into the development and roll out of your comprehensive family planning and maternal child health program? What strategies proved most effective for engaging the religious community for either John Snow International or the Institute for Family Health? www.mospat.ru/en/2011/03/05/news37284/
Natalia Vartapetova: Russian Orthodox Church is often politically visible in Russia but is far from the real life in many regions. In some regions the Church was a good partner in developing reproductive health programs in the frame of the regional community committees. Russian is a multicultural and multiconfessional country and Muslim leaders have been quite supportive in promoting modern reproductive health in some regions as well.

Laurentiu Stan: Have you considered integrating FP into abortion departments? If yes, may you describe the process and which messages, materials, strategies, and methods you used? May you share any specific lessons learned that can be applied in other EE countries with similar health systems; e.g. Ukraine.
Natalia Vartapetova: The project actively worked with gynecological/abortion departments. The main strategies and lessons learned are: provide FP counseling after (not before) the abortion procedure; ensure good quality of the counseling; integrate FP into broader comprehensive post-abortion care messages; give women information materials to take home. Our data shows that repeated abortions rate in the project regions has fallen 1.7 times.

Cletus Tindana: For some countries, family planning and maternal/child health services have always been together and the advantages cannot be over emphasized as compared to running a parallel system. Why has it taken Russia all these years to start integrating these services? What are some of the advantages derived in the parallel system?
Asta-Maria Kenney: The Soviet health system was always very vertical and specialized. Consequently, when FP was introduced, a separate, but very tiny FP system was established. Probably partly because it wasn’t very well integrated with MCH (or other) services, and for a variety of political reasons, it didn’t “take off.” What our projects did was “mainstream” FP into MCH care—and to some extent into AIDS services and pediatric care—which put them into an appropriate context. The results are encouraging—if not yet everything we might have hoped for!

Lena Kolyada: Have you engaged private sector (private doctors, pharma, etc.) in the integration process. If yes, could you please share how?
Natalia Vartapetova: There are still quite a few private health care providers in Russia. People mostly use public services. We involved pharmaceutical producers in promotion of family planning. There were three directions where this collaboration was especially successful: training of health providers, printing and dissemination of education materials for providers and printing and dissemination information materials for clients.

Yuba Raj Tripathi: What kind of population policy is applied in Russia at present for the better MCH? How?
Natalia Vartapetova: The government tries to stimulate fertility through various incentives like a 3-year maternal leave and so called maternal capital for child education or housing. The government also put significant amount of resources into development of modern perinatal services across Russia to make maternal care safer and more attractive for clients.

Laurentiu Stan: Is very well known that Russia and other countries in Eastern Europe displays a relatively high rate of abortions. Do you have any results showing how and why the integration of FP with MCH services contributed to reduction of unwanted pregnancies and abortions?
Natalia Vartapetova: In the project regions percent of antenatal clients who reported that pregnancy was not planned decreased from 33 percent in 2004 to 22 percent in 2009.

Asta-Maria Kenney: Please see our response to Mia Foreman’s question concerning CPR and abortion rates. We have data from other project sites, but they cover short time periods, while the data above look at trends beyond the life of the project, so they are particularly compelling. Unfortunately, we did not collect data on unwanted pregnancies.

Priyanka Dixit: 1) In developing countries, is the relation between utilization of antenatal care and institutional delivery and further institutional delivery and child immunization services causal? 2) Do women who receive maternal care services have improved adoption of contraceptive use, in terms of duration and type of method?
Asta-Maria Kenney: Use of antenatal care and hospital deliveries are virtually universal in the Russian Federation. Childhood immunization and the schedule for infant care is well integrated into the woman’s postpartum visits as well as into home visits afterwards. As for the second question, there is very limited data available about contraceptive use in Russia as a whole. However, at the sites where the project has worked, postpartum contraceptive use has improved and women get better counseling about their contraceptive options.

Linda Ippolito: Congratulations Asta and Natalia for very informative session, and all the best with the continuation of these important initiatives.

(June 2011) For years, family planning (FP) has been integrated with maternal and child health services (MCH) in countries such as Colombia, Indonesia, Mexico, the Philippines, and Thailand. Birth rates have fallen in these countries as more women have been able to avoid unintended pregnancies. As a result, population growth has slowed and the countries have been able to speed economic progress and lift more people out of poverty. But in many countries, women who are pregnant or have recently given birth are still not informed about FP or offered a contraceptive method to prevent another pregnancy as part of their MCH services, even though the majority of them do not want another birth within two years. Integrating FP and MCH services can better meet the needs of these women, while also offering opportunities to strengthen health systems.

MCH services are a logical and strategic entry point for FP because they reach a “captive audience” of women who are at high risk of a subsequent pregnancy and strongly motivated to prevent another immediate pregnancy. Integration of FP and MCH has been shown to increase women’s use of contraception, which leads to better birth spacing and improves the health of women and their infants. Integration is also cost-effective, can save the health system money, and responds to the multiple demands on women’s time that often leads them to neglect their own health.

But there are challenges, including resistance within the often separate government health units responsible for FP and MCH services, weak health systems, and clinic- or community-based workers who are not trained to provide both services.¹ While the challenges can be daunting, many programs have successfully addressed barriers to integration.

Integrating Services in a Health System Resistant to Change: John Snow Inc. (JSI), Russia

Integrating services requires political, administrative, and technical changes that may generate resistance among health workers and managers, or prompt fears of losing prioritization and resources.² In Russia, FP is a highly sensitive political issue because of population decline in recent decades and religious opposition. In the early to mid-1990s, international evidence-based standards for contraception were not widely known or practiced, hormonal methods were viewed as harmful to health, and frequent unintended pregnancies led women to have repeat abortions.

In 1999, recognizing the need to integrate FP into maternal and child health services, USAID/Russia supported JSI in implementing a new pilot project—the Women and Infant’s Health (WIN) project—in two regions. The project was designed to integrate FP as a key element of improved MCH services. A variety of stakeholders collaborated in designing and implementing the program, building commitment and shared ownership. A technical working group of policymakers from various sectors willing to implement innovative practices reviewed the evidence on contraceptive safety and the benefits of offering FP within a MCH continuum of care. The group also included health personnel and medical school faculty who were trained to provide new contraceptive methods according to international standards for client-centered care, and the pharmaceutical industry who were engaged to expand the limited method mix.

The new client-focused system addressed a broad spectrum of reproductive health services including antenatal, maternity, and newborn care; exclusive breastfeeding support; and FP counseling and services, especially for postpartum and post-abortion clients. The WIN project’s national media campaign promoted the new services through television and radio spots, brochures, posters, and local promotional activities.

From 2003 to 2006, with JSI’s continued technical assistance, WIN was further scaled up through the Maternal and Child Health Initiative (MCHI). WIN/MCHI’s innovative design helped regional and municipal government-supported health facilities adopt internationally recognized, client-centered, evidence-based MCH standards and practices. By 2006, the new protocols had been embraced and activities scaled up in 16 of Russia’s 89 regions. In the last two years of the project alone, contraceptive prevalence for reversible methods increased from 41 percent to nearly 58 percent, and the abortion rate fell from 49 to 43 per 1,000 women ages 15 to 44.³

These successes were instrumental in enabling JSI’s project office in Russia to become an autonomous NGO, the Institute for Family Health, in 2007. The institute continues to implement the MCHI project and others with USAID support, fostering the sustainability and further scale-up of integration activities, including in rural regions with high abortion rates. By 2009, for the 10 regions involved in the MCHI project, official statistics showed that abortions had further fallen to 31 per 1,000.⁴

Integrating Services in a Post-Conflict Setting: Health Alliance International, Timor-Leste

After decades of conflict that extensively damaged the health system, Timor-Leste became an independent nation in 2002. As in other post-conflict environments, there was an urgent need for reproductive health and FP services. Health Alliance International (HAI), a Ministry of Health partner providing maternal and newborn care, began to integrate FP services into its existing program in 2006. First, HAI clarified for the government the link between closely spaced births and high mortality and morbidity among infants and mothers. HAI then encouraged Ministry of Health officials and health workers to integrate education about child spacing and FP into basic maternal care. It also built the capacity of the Ministry of Health’s midwives to deliver FP information and services. Offering FP services during MCH home and facility visits contributed to an increase in the contraceptive prevalence rate from 8 percent in 2003 to 26 percent in 2008.⁵

Providing Integrated FP and MCH Services Where Demand Is Low: ACCESS/Nigeria

In predominately Muslim northern Nigeria, religious and cultural resistance contributes to low use of FP. In addition, a poor public-sector health system deters clients from seeking reproductive health services. In 2006, as part of its mandate to broaden access to FP for postpartum women, ACCESS/Nigeria initiated a program in Kano State that aimed to increase the use of emergency obstetric and newborn care services and FP. The first six months of the project focused on emergency obstetric and newborn care training in facilities. Providers were then trained in postpartum family planning with an emphasis on birth spacing. FP messages were integrated into care during pregnancy, after delivery, and during postnatal care. In 2008, providers were trained to insert contraceptive implants and IUDs. All trainings have been followed up by supportive supervision activities. At the community level, selected female community counselors were trained to provide basic maternal and newborn health messages for pregnant women and those who had recently given birth, including FP information.

ACCESS FP discovered that providing FP did not negatively affect the use of MCH services. In fact, client satisfaction with both services increased. Providers considered integrating FP with MCH in this conservative society a good approach, especially through educating women and couples about the importance of birth spacing for child health. One provider noted: “In our setting here, most of the time they don’t come for FP. So only when we catch them during antenatal care or labor and delivery, we can use the opportunity to talk with them.”

While the program had positive results, challenges included provider and community attitudes, and inadequate staff time to address both MNCH and FP needs. The following elements were considered important to the success of this program:

• Training providers to give FP messages beginning in the antenatal period and continuing to reinforce these messages throughout the postpartum period and beyond.
• Attending to community linkages and contextual considerations, such as the role of husbands.
• Providing support materials such as job aids at the facility and posters in the community.

Despite challenges, organizations and partners are finding solutions to integrate FP and MCH services. It takes creativity, political, financial, and managerial commitment and the willingness to address barriers from the national to community level to make sure that women receive the health care they demand and need to live healthy and productive lives. These programs have shown it is worth the effort.

Mia Foreman is a policy analyst at the Population Reference Bureau.

References

1. Kate J. Kerber et al., “Continuum of Care For Maternal, Newborn, and Child Health: From Slogan to Service Delivery,”The Lancet 370, no. 9595 (2007): 1358-69.
2. WHO, “Integrated Health Services—What and Why?”Technical Brief no. 1 (Geneva: WHO, 2008).
3. Laurel Cappa and Natalia Varapetova,TASC Russia Maternal and Child Health Initiative (MCHI), Final Technical Report (Arlington, VA: JSI, 2007).
4. JSI, personal communication, 2011.
5. Susan Thompson and Mary Anne Mercer, “Integrating Child Spacing and Maternal Care in Timor-Leste,” Health Alliance International Flexible Fund Case Study, accessed at www.flexfund.org, on May 2, 2011

How long one lives depends on gender and context, among other factors.

Gender differences in mortality and life expectancy vary by country. But in most countries, men live shorter lives than women (see figure). In Russia, for instance, the difference between male and female life expectancy is 13 years (59 vs. 72). In other countries, such as the United States, the male disadvantage is smaller: 5 years (75 vs. 80). And in some countries, such as Afghanistan, there is little or no male disadvantage (42 vs. 42).¹

Life Expectancy at Birth by Sex, 2007

 

Source: C. Haub, 2007 World Population Data Sheet.

The Life Expectancy Gap

What’s behind the male/female gap in life expectancy? Factors that influence gender differences in mortality include biological factors such as hormonal influences on physiology and behavior, and environmental factors, such as cultural influences on gender differences in health behaviors.

The importance of specific factors may reflect the environmental context. How developed a country is can affect or shape the most important influences on gender differences in mortality.²

Men’s Behavior and Women’s Childbearing

In developed countries, men’s more risky unhealthy behaviors are a major reason they die younger. Their higher rates of cigarette smoking, heavy drinking, gun use, employment in hazardous occupations, and risk taking in recreation and driving are responsible for males’ higher death rate due to lung cancer, accidents, suicide, and homicide.³

Risky male behavior may be fueled by biology and culture. Research suggests that testosterone contributes to males’ greater physical activity and aggressiveness; this “domino effect” leads to their higher death rate due to accidents and homicide. But when looking at gender disparities in health and mortality, it can be hard to get at biological differences. “You can’t tease out the societal differences from the biology,” says Ingrid Waldron, a professor of biology at the University of Pennsylvania. “They come as a package.”

Men’s risky behaviors also contribute to their having higher mortality rates in developing countries, but in developing countries the gender gap in mortality has been smaller than in developed countries. Environmental factors such as unsafe water and inadequate nutrition increase the death rate due to infectious diseases for both sexes. Women, however, face additional risks associated with childbirth. Maternal mortality is high in sub-Saharan Africa, and there are higher suicide rates for women than men in China.

Another reason the gender gap in mortality is smaller in developing countries is because in many of these countries, women have much lower social status than men. As women’s status catches up with men’s in these countries, the gender gap is expected to increase in the developing nations. But in developed countries, the gender gap is expected to decrease as women adopt unhealthy behaviors similar to men’s—drinking and smoking more, experiencing more job-related stress.

How Work Factors In

Differences in what is expected of men and women and how they are taught to behave also contribute to variation in health-related behaviors. For example, many cultures encourage or condone men’s heavy drinking, but discourage it in women. Also, in many cultures, women are not expected to work outside the home in the cash economy while men are expected to be part of the labor force.

Because women are less likely to be part of the work force than men, they suffer less from the ravages of work. As a result, their health deteriorates less quickly.⁴

Low-paid or manual work seems to take a toll in terms of health. People in the bottom income group tend to have both worse health and more rapidly deteriorating health while they are working. Yet, while manual workers are typically less healthy on average, the differences among male and female workers in this occupational group are much smaller than differences across occupations.⁵

Changes in Smoking Patterns and Their Effect on the Mortality Gap

Changes over time can affect the gap in life expectancies. In most developed countries, men’s widespread adoption of cigarette smoking during the first half of the 20th century was a major factor behind males’ widening mortality disadvantage. Later, in the United States, the mortality gap narrowed as women began to smoke more and men smoked less than before. The difference in male and female life expectancy has narrowed in recent years, from at least 7.7 years from 1972-1979 to 5.2 years in 2004, according to the U.S. National Center for Health Statistics. Changes in smoking patterns tend to affect men more than women, because more men have smoked and because smoking has elevated death rates more for men than for women.⁶ As smoking becomes even less common, mortality rates will probably decline further.⁷

The Female Paradox

While women rate their health worse than men and visit the hospital more often than men from early adolescence to late middle age, they are less likely to die at each age. This paradox can be explained at least in part by differences in the prevalence of chronic conditions men and women face.⁸

Women experience higher rates of pain (headache, arthritis), and some respiratory conditions, including bronchitis, asthma, and lung problems not related to cancer. They are also much more likely to suffer from reproductive cancers, hypertension, vision problems, and depression. Men are more likely to suffer from hearing loss; smoking-related ailments, such as emphysema and respiratory cancer; and circulatory problems including cardiovascular disease and diabetes.

However, women and men with the same chronic conditions have the same self-rated health. Yet men with respiratory cancer, cardiovascular disease, and bronchitis are more likely to die than women with these conditions. This implies that men may experience more severe forms of these conditions.

Researchers have found that conditions associated with excess male hospitalizations and deaths tend to be smoking-related. Indeed, men with smoking-related conditions are significantly more likely to die in two years than women with the same conditions. This may be the case, because typically, men are exposed to smoking for a longer time on average than women.⁹

Making a Difference

Public campaigns have helped decrease deaths related to unhealthy behaviors, particularly those associated with male deaths. These efforts may well help narrow the male-female mortality gap in the United States. The 40-year-old antismoking campaign has led to a drop in lung cancer death rates for men. And the efforts to reduce drunk driving have been effective, Waldron notes. Pointing to public concerns about secondhand smoke and the efforts of Mothers Against Drunk Driving to alert the public of the risks of drunk driving, Waldron says that the grassroots support made it easier to push through policy change. “In this country [the United States], movements that have had big benefits had citizens’ support,” she says. “Leadership was important, but not everything.”

References

1. Carl Haub, 2007 World Population Data Sheet (Washington, DC: Population Reference Bureau, 2007).
2. Ingrid Waldron, “Gender Differences in Mortality—Causes and Variation in Different Societies,” in The Sociology of Health and Illness: Critical Perspectives, 7th ed., ed. Peter Conrad (New York: Worth-St. Martin’s Press, 2005).
3. Waldron, “Gender Differences in Mortality.”
4. Anne Case and Angus Deaton, “Broken Down by Work and Sex: How Our Health Declines,” NBER Working Paper No. 9821 (2003), accessed online at www.nber.org, on Oct. 10, 2007.
5. Case and Deaton, “Broken Down.”
6. Samuel H. Preston and Haidong Wang, “Sex Mortality Differentials in the United States: The Role of Cohort Smoking Patterns,” paper delivered at the 2006 annual meeting of the Population Association of America, April 2006, Los Angeles.
7. Preston and Wang, “Sex Mortality Differentials in the United States.”
8. Anne Case and Christina Paxson, “Sex Differences in Morbidity and Mortality,” Demography 42, no. 2 (2005): 189-214. An earlier version published as a working paper may be accessed online at www.nber.org.
9. Case and Paxson, “Sex Differences in Morbidity and Mortality.”

(June 2002) Recently released population estimates for Russia confirm the accelerating population decline that has been underway since the breakup of the Soviet Union more than a decade ago. The Russian population stood at 144 million on January 1, 2002, down 4.3 million from its peak at the beginning of 1992. The pace of natural decrease (the surplus of deaths over births) and slowing migration appears to have intensified since 1998. In each of the last three years, the natural decrease of the population was over 900,000. In 2001, net immigration offset natural decrease by 8 percent, which meant the population fell by 820,000.

Net Migration and Natural Increase in Russia, 1980–2001

Source: State Committee of the Russian Federation on Statistics, Goskomstat Rossii, accessed at www.gks.ru, on June 6, 2002.

Slowing migration fails to compensate for the surplus of deaths over births.

Until 1998, migration into the country compensated for over half of natural decrease, but the flow of returning Russians and Russian speakers appears to be petering out. The recently released population estimates will likely be the last before Russia conducts its first post-Soviet population census in October this year. The results of the census are eagerly anticipated, given Russia’s size and dramatic demographic upheavals over the last decade. Russia will be one of the last countries of the former Soviet Union and Eastern Europe to conduct a post-breakup census.

A combination of pronatalist policies and the anti-alcohol campaign of the 1980s combined to produce a natural increase in the population of nearly one million annually during 1986-87. Since 1987, however, the number of deaths has increased by 720,000 annually, while the number of births has declined by close to 1.2 million.

While the high increases in deaths among middle-aged men from cardiovascular disease and such external causes as murder, suicide, accidents, and poisoning has received the greatest attention, it is actually the decline in the birth rate that has had the greatest impact on population size.

Undoubtedly, the “mortality crisis” among Russian males requires attention. If the goal were simply to stem the population decline, however, it would be prudent to focus on measures to influence fertility. Analysts looking at the intersection of Russian birth and death rates often note that the situation started around the time of Russia’s independence in 1992 and refer to the situation as the “Russian cross.” While coincidental, the rising death rates and falling birth rates are not correlated, and the natural decrease is partly attributable to the aging of the Russian population and the peculiarities in the country’s age structure.

Of the decline in the number of births from 1989 to 1999, about 9 percent can be attributed to decreases in the number of women of prime childbearing age and the remainder to real declines in childbearing. The 1986-88 period was the last time the Russian total fertility rate (TFR) was above 2.1 children per woman — the rate at which couples “replace” themselves in the population. At that time, the birth rate was somewhat artificially stimulated by various pronatalist measures that caused women to accelerate rather than increase their fertility. These measures included extended and paid maternity leave and easier qualification for housing and other benefits. After peaking at 2.19 children per woman in 1987, the TFR fell by more than a child per woman to 1.17 in 1999.

If there is any bright spot in the Russian demographic picture — and there are few — it is that the TFR increased slightly in 2000 to 1.21, the largest such increase since the decline started in the late 1980s. While still far below replacement level, this increase may be an indication that Russian women and couples are adjusting to the “new normal” and feel confident enough about the future to increase childbearing.

With regard to mortality, about 60 percent of the increase in the number of deaths from 1989 to 1999 could be attributed to a growth in the number of older people in the population and the rest to a real increase in mortality that is not age related. For males, only 30 percent of the increase in deaths relate to age.

The persistent male-female life expectancy gap in Russia has been well chronicled. The male-female gap was at its lowest in 1987 at 9.6 years. By 1994, male life expectancy had fallen by 7.3 years, while female life expectancy had declined by less than half of that (3.4 years). At that time, the gap was 13.6 years.

By 1998, life expectancy for both sexes had recovered about half of the decline, and the gap had narrowed to 11.6 years before falling again following the 1998 collapse of the Russian ruble. By 2000, male life expectancy had fallen to 59.0 years and female life expectancy to 72.2 years, with the gap increasing to 13.2 years, nearly back to the level at the depth of the Russian mortality crisis. Thus, it appears that males in Russia are far more susceptible to economic and social dislocations than are females.

While HIV/AIDS has so far not had a dramatic impact on the burden of disease or mortality levels in the country, the officially registered number of HIV/AIDS cases appears to be increasing at an exponential rate, with 100,000 of the 180,000 cases occurring in 2001 alone. Unofficial estimates place these numbers at only one-fifth to one-tenth of the actual figures.

Though a portion of Russia’s demographic crisis should be attributed to the effects of an aging population, the ratio of deaths to births is far higher in Russia than in other countries. In Russia, there are about 1.7 deaths for each birth, while in such aging, low-fertility European countries as Germany, Italy, and Spain, the number of deaths barely exceeds the number of births.

President Vladimir Putin and others are pinning their hopes of stemming Russia’s population decline on increased migration into Russia. More specifically, they would like to see the legal, regulated migration of well educated Russians and Russian-speakers from other former Soviet states to regions in Russia where they are most needed. The return migration of the 25.2 million Russians living “near abroad” has plummeted from its post-breakup peak. In 2001, there was return migration to Russia of only 72,300, less than 10 percent of the 1994 peak when there was a net immigration to Russia of over 800,000 persons. From 1990 to 1999, emigration from Russia to areas beyond the former Soviet states averaged about 100,000 annually. By 2001, this exodus of mostly skilled, educated peoples had fallen by half to 51,400. The net migration exchange with former Soviet countries has had the largest impact on overall migration levels. In the peak year of 1994, 1.1 million people immigrated to Russia from the other former Soviet states. In 2001, this figure had fallen to just 186,200.

Table 1
Demographic Trends in Russia, 1985–2001

Source: Goskomstat Rossii, State Committee on Statistics of the Russian Federation.

These trends could be rather easily explained by the decline in Russia’s gross domestic product following the 1998 ruble crisis, a development that made Russia less attractive to migrants. Combined with uncertain levels of illegal migration, however, these trends paint a rather complex and murky picture. Figures for the number of illegal migrants in Russia range from 700,000 to an implausible 15 million.

Regardless of the exact numbers, it appears that Russia is becoming at least a migration magnet within the region. Like other migration magnet countries, Russia is encouraging the legal migration of certain groups while discouraging the entry of others and failing miserably at this balancing act. Anecdotal information indicates that most migrants enter Russia legally and stay beyond their allotted time. Most are from the other former Soviet states, but there are also large numbers from Southeast Asia.

In the October 2002 census, a special effort will be made to enumerate the size of this illegal population, their ages, sex, countries of citizenship, and reasons for being in Russia. While the extent of criminality often attributed to groups of illegal immigrants in Russia may be overstated, it is likely that they are living on the fringes of Russian society. If it is the case that many are from outside the former Soviet states and lack Russian language skills, then their incorporation into Russian society may be more problematic. That hardly appears to be what Russia desires.

Timothy Heleniak is research fellow at the Kennan Institute, Woodrow Wilson International Center for Scholars and adjunct professor, Georgetown University.

(April 2000) There is good news and bad news for Russian men. The shocking increase in the mortality of Russian men has reversed in the last few years. But Russia would need years to catch up to levels of life expectancy that prevailed in that country in the early 1960s, let alone to reach the levels found in other industrialized countries now.

Male Life Expectancy at Birth.

Sources: State Committee of the Russian Federation on Statistics (Goskomstat) and the U.S. National Center for Health Statistics.

The increase in Russian death rates during the 1990s captured public attention. Nicholas Eberstadt, a scholar with the American Enterprise Institute, called it a “catastrophe of historic proportions,” involving far more premature deaths than were suffered by the Russian army in World War I. Life expectancy for men fell abruptly from a high of 65 years in 1987 to a low of 57 years in 1994, then rebounded to 61 years in 1998.

Most commentators have put the decline in the context of the economic and social turmoil following the breakup of the Soviet Union in 1989. But a team of Russian and French demographers collected several decades of time-series mortality data for the former Soviet Union and dated the decline to the early 1960s, long before the breakup.

For the first 40 or so years of its existence, the USSR enjoyed a remarkable improvement in health conditions, despite civil wars, internal repression, and world war. By the early 1960s, life expectancy had caught up with that in the United States. During the 1960s, though, life expectancy in the United States rose rapidly, while life expect-ancy in the Russian republic faltered and began to decline. The gap between East and West in life expectancy, like the gap in economic performance, grew steadily wider.

This trend was already apparent by the early 1980s. In a 1982 Population Bulletin published by PRB, Murray Feshbach, former chief of the U.S. Census Bureau’s research unit on the USSR’s population, noted “the mortality rise of the last decade and a half” and cautioned that “[I]f the health sector is neglected, the adverse mortality trend which has resulted in a major reduction in the life expectancy of Soviet males may persist.”

The story within the story came in the late 1980s, when then-President Mikhail Gorbachev instituted a vigorous antialcohol campaign as part of a wider effort to rescue Russian society, and the Soviet state, from self-destruction. The draconian, unpopular, and probably unsustainable campaign produced a sharp but temporary improvement in mortality rates. The collapse of the public health campaign, the collapse of the Gorbachev government, and the breakup of the Soviet Union nearly coincided in 1988 and 1989. The progress quickly made since the mid-1980s was just as quickly lost, and the long-term decline continued until the mid-1990s.

Cause-of-death data are difficult to use for comparisons over long periods or across countries with very different medical and statistical systems, but several independent analyses have come to the same conclusion: The decline in life expectancy and the gap between levels in Russia and the rest of Europe can be attributed mainly to abnormally high rates of cardiovascular disease and injury, for both of which abuse of alcohol was a major risk factor.

But limiting the comparison to the last 10 or 12 years is misleading. Comparing the unusually good years of 1986 and 1987, when the antialcohol campaign was most effective, with the lowest points of the mid-1990s exaggerates the speed of decline. Any other choice of start and end dates would produce a more characteristic picture of steady, long-term decline.

This is not just a historian’s quibble, since such comparisons have political meaning in Russia today. Dating every bad trend from 1989 fits in with revisionist nostalgia for the old days under communism. It also fits with the arguments made about giving foreign aid and policy advice to Russia: The catastrophe shows either the need for more aid and advice or the mess that comes of accepting either, depending on one’s point of view. Perhaps worst of all, the exclusive focus on the post-Soviet period obscures the achievement of the mid-1980s, which must rank as one of the most dramatic improvements in life expectancy ever induced by public policy. Surely there are some lessons from that experience, and an example of real accomplishment amidst the turmoil of the last days of the Soviet Empire, that could help Russians continue their recovery from their current troubles.

John Haaga is director of Domestic Programs at the Population Reference Bureau.

References

Vladimir Shkolnikov, France Meslé, and Jacques Vallin, “Health Crisis in Russia,” Population: An English Selection 8 (1996).

Alexandre Avdeev and Alain Blum, “La population russe : des raisons d’espérer ?” (‘The Russian Population: Reasons for Hope?’) Population & Sociétés 351 (November 1999). Available in French on the INED website: www.ined.fr/publications/.

Nicholas Eberstadt, “Russia: Too Sick to Matter?” Policy Review, no. 95 (June and July 1999): 3-26.

José Luis Bobadilla, Christine A. Costello, and Faith Mitchell, eds., Premature Death in the New Independent States (Washington, DC: National Academy Press, 1997).