PRB

While we have much to learn yet about the novel coronavirus SARS-CoV2, and the COVID-19 disease it causes, evidence to date suggests that deaths among people who have tested positive for the coronavirus are highest at older ages and near zero for young children. Higher mortality rates at older ages may be associated with the increased prevalence of chronic conditions at older ages, such as cardiovascular diseases, diabetes, and chronic respiratory diseases. These chronic conditions appear to be associated with more severe illness and worse patient outcomes. The age pattern of mortality means that areas with higher proportions of older adults are likely at risk of higher rates of severe illness or death than those with younger populations.

Many factors may affect the intensity of a COVID-19 outbreak in a given country, including underlying health conditions in the population, the effectiveness of government response, and the availability of health care resources. Age structure (the share of the total population in each age group) alone cannot tell us which countries will be hardest hit in the pandemic but can provide important context in understanding and responding to the crisis. If two countries have the same age-specific mortality rates from COVID-19, the country with an older population would have more deaths per 1,000 people—a higher crude death rate—from the disease than the country with the younger population.

For example, social distancing measures in Italy may have helped that country reduce transmission of the disease, but its high proportion of older adults, in combination with high case fatality rates (proportion of the confirmed cases with COVID-19 that were fatal) at older ages has contributed to a large number of COVID-19-related deaths. In 2020, Italy was one of the oldest countries in the world; nearly 30% of Italy’s population is ages 60 and older and nearly 4% is ages 85 and older (see table). In contrast, China—where the virus started and the number infected spiraled until recently—has 17% of population ages 60 and older and less than 1% ages 85 and older. With the death rate from the disease reported to be six times higher among those above age 80 compared with the rate overall, the number of COVID-19-related deaths could have been much higher if China had an older age structure.1

Click on the table and interactive figure to compare age structures across countries.

Table. Comparing Age Structures Across Countries, 2020

Figure. Population by Age Group, 2020

Click on image to view interactive.

This article was originally posted on New Security Beat. It is reposted here with their permission.

Featured side by side at the top of The New York Times home page recently were two stories: one on the United States and China, the world’s largest producers of carbon emissions, committing to a global climate agreement, another on how rising seas are already affecting coastal communities in the United States.

The stories reflected the immediacy of global environmental challenges – climate change being the predominant one among many. These challenges were the impetus for the Population Reference Bureau (PRB) to focus on “human needs and sustainable resources” in this year’s World Population Data Sheet, a widely used print and digital resource for the latest demographic, health, and environment data from around the world. As in years past, the Data Sheet features our latest global population projections, but there are additional indicators in the 2016 edition that underline the challenge of balancing sustainability with a growing population.

New Demographic Projections

First, the population picture: Despite an overall decline in fertility rates, our projections this year point to a world with 9.9 billion people at mid-century, about one third more than we have today. Devotees of our annual Data Sheet may notice that our 2050 forecast has been inching up over recent years. The principal reason has been slower than anticipated rates of fertility decline in many sub-Saharan African countries. The top 10 country fertility rates in the world are all in Africa, led by Niger with an average of 7.6 lifetime births per woman. Niger’s population is on track to more than triple by 2050.

Drilling down, population trends vary widely by region. Under our assumptions, Africa’s population will more than double by mid-century, gaining 1.3 billion people. Compare this to a projected gain of nearly 900 million in Asia, by far the most populous region today, and only 223 million in the Americas. Europe (including all of Russia) is actually expected to decline by 12 million people. Africa alone will account for more than half (54 percent) of the total projected population increase by 2050, while Asia will kick in 34 percent. The combined population of the 48 “least developed countries” as defined by the United Nations will double.

The global population increase is likely to come despite lower fertility rates on the whole. Rapid increases in world population over the last several decades have yielded a large number of people of childbearing age, creating what’s called “population momentum.” Most countries will continue to grow for many years even though their fertility has declined or is in the process of doing so. Thus, barring a dramatic and unprecedented decrease in fertility rates in the next few decades – particularly in Africa – the world will inevitably have billions more people.

Regional population growth disparities also relate to the global immigration challenge that is currently roiling Europe (though it is by no means confined to that part of the world). The combination of growing population and environmental pressures as well as political upheaval in certain countries and regions will inevitably prompt more people to seek better lives elsewhere. Migration statistics are notoriously unreliable, given the difficulties of tracking undocumented movements and variations in what defines a migrant. However, this year’s Data Sheet indicates that Africa has the most out-migration in relation to the size of its population, while Europe is absorbing the most migrants proportionately.

Future migration patterns may also play an important role in determining prospective population sizes of both sending and receiving countries and regions. Germany, for example, experienced the highest net migration of foreigners in its post-war history last year, at slightly more than 1 million people. For the first time, migrants from outside Europe made up the majority of Germany’s immigrants. While the region is projected to start losing population in coming decades, migration could be a significant wild card in this outcome.

Environmental and Health Dimensions

From an environmental and resource perspective, the world also faces stark regional differences. In the Data Sheet, we focused on presenting indicators with reliable data that give a broad view of how population, health, and environmental factors interact.

Generally speaking, reliable environmental and resource data are hard to obtain, often because collecting such data has been a lower priority for many countries that already have data collection challenges, or because such data transcend borders and regions, requiring a more global collection approach. In some cases, such as measuring net changes in tree cover, technical obstacles preclude accurate counts for a sufficient number of countries for inclusion in the Data Sheet.

Global carbon emissions figures, compiled by the Oak Ridge National Laboratory, were up 60 percent between 1992 and 2013 (the latest year for which reliable data are available), to 9.8 billion metric tons. A large chunk of that increase came from less developed countries, particularly China, whose total emissions rose nearly fourfold to 2.8 billion metric tons. India’s total emissions increased nearly 300 percent to 555 million metric tons.

Europe’s total emissions actually decreased over this period by 17 percent to 1.56 billion metric tons, while emissions in Canada and the United States only rose about 5 percent to 1.54 billion metric tons. Overall, 43 countries were estimated to have reduced their carbon emissions from 1992 to 2013, including notable reductions in high-income countries such as Germany and the United Kingdom. These trends and the global climate deal bring reasons for optimism about lowering future emissions levels.

Energy use is a key component of carbon emissions, and we figured that the share of energy consumption from renewable resources would help gauge how close the globe is to reducing dependency on heavily polluting fossil fuels. Note that “renewables” is a nuanced category; while it includes things like solar and wind power, it also includes hydropower, which is sometimes linked to serious environmental issues, and solid biofuels, which can include pretty much anything people burn for fuel, such as trees and bushes. As a result, many low-income countries have high renewable shares, such as Sierra Leone at 80 percent, while industrialized countries come in on the low side (eight percent for the United States). Worldwide, renewables account for 18 percent of energy consumption, according to data compiled from the International Energy Agency and World Bank.

In our rapidly urbanizing world, we also thought it was important to highlight trends related to resource use that affect public health. In the Insights section of our digital Data Sheet, we show how increasing urbanization and industrialization in developing countries has led to higher concentrations of fine particulate matter that can lodge in people’s lungs and cause asthma and other serious health problems. Middle-income countries face the biggest challenge as their industrialization process moves more quickly than their ability to manage pollution.

The global income divide comes to the fore again in a great set of data on municipal waste volumes compiled by a dedicated team of researchers running the Wasteaware data project. Municipal waste is a massive and growing public health and environmental problem, particularly in low-income countries where toxins from large numbers of uncontrolled dumpsites end up in water tables and in the air through unsorted refuse burning. While waste volumes (measured in kilograms per capita per year) tend to rise in tandem with national incomes, wealthier cities logically have more resources to devote to controlled disposal and household waste collection.

The municipal waste data underline that population numbers are not the whole issue when it comes to resource use and sustainability. In principle, having more people means resources must be managed more soundly, and funds made available to do so. Even so, many more billions of people will surely strain the planet’s ability to sustain us.

The mid-century population projection is by no means certain, but it is a warning that needs to be heeded. Is it possible to support a population of 10 billion? We hope to be prepared to answer that question.

Explore the digital 2016 World Population Data Sheet for access to more maps, data, and insights, or download the PDF.

Sources: International Energy Agency, The New York Times, Oak Ridge National Laboratory, Population Reference Bureau, Wasteaware, World Bank.

(July 2015) PRB welcomes 10 Policy Communication Fellows from around the world to our Washington office for the summer workshop, kicking off the year-long program. This year’s Fellows come from 10 countries: Bangladesh, Burkina Faso, Ethiopia, Ghana, India, Malawi, Nigeria, Pakistan, South Africa, and Tanzania. Following training by PRB staff and guests and visits to USAID and the World Bank, the workshop will close with each fellow delivering a policy presentation they have developed from their research.

PRB started the Policy Communication Fellows program to bridge the gap that often exists between the research and policy environments. Research often has profound implications for policy, but without proper communication between the research community and policy audiences, the significance of research findings may be lost. The responsibility to address this gap lies with both policymakers and researchers. The main objective of the program is to train future researchers (current Ph.D. students) from developing countries who are involved in health and population issues to:

• Understand the process by which research informs the policy environment;
• Identify and communicate the policy implications of their research; and
• Learn various ways to communicate findings to policy audiences.

Participants begin the fellowship year with a two-week workshop, during which they learn the skills necessary to effectively communicate their research to policy audiences. During the course of the fellowship year, participants apply those skills through several written assignments. The program year concludes with a short workshop prior to the Population Association of America Annual Meeting, during which the Fellows make formal policy presentations on the results and recommendations of their research.

The Policy Communication Fellows program began in 1987. The program has changed over time, but a few core pieces remain the same: The program has always begun with a two-week program during the summer; a shorter one-day or two-day workshop in conjunction with the Population Association of America annual meeting in the spring; mentorship from PRB staff through the year; and a strong focus on writing for policy audiences.

(February 2015) Less than a generation after the genocide in Rwanda that claimed 1 million lives, left 2 million displaced, and destroyed health systems, Rwanda today has been hailed as one of the few countries on a fast track to reducing child and maternal mortality—thus meeting two of the United Nations Millennium Development Goals in 2015.

Rwanda’s maternal mortality ratio decreased by 77 percent between 2000 and 2013 and currently stands at 320 deaths per 100,000 live births.¹ Under-5 child mortality has been reduced by more than 70 percent and is well on the way to meet the goal of 54 deaths per 1,000 live births.²

Many factors created this success story. The increase in skilled providers during childbirth over a decade has been especially important for women; and for children, improvements in immunization coverage and exclusive breastfeeding are important factors.

Maternal Health a Priority in Postwar Rebuilding

After the genocide, Rwanda faced a severe health worker shortage, as well as limited health infrastructure and high rates of maternal and child mortality. The government prioritized reproductive, maternal, newborn, and child health as a way to rebuild basic systems and services through several complementary policies:

• Health workforce and infrastructure development.
• Strong community involvement.
• A comprehensive community-based health insurance scheme.
• System strengthening through innovative data collection tools.

Declines in maternal mortality are linked to skilled birth attendance and improvements in the contraceptive coverage rate. Rwanda bolstered its workforce to address maternal and child mortality. By 2012, there was one doctor per 16,000 people and one nurse per 1,300 people. Before 1997, Rwanda had no trained midwives, but now there are around 1,000.³ Rwanda established new standards for quality of care, and in 2010, delivery by a skilled provider was at 69 percent, as was delivery in a health facility (see figure).

The government decentralized the health sector to strengthen community involvement and trained 45,000 community health workers to provide primary health services at the village level. Elected by their community, these workers connect communities to health services, especially in remote areas, and monitor health at the village level. Each village elects three volunteers who are trained by the Ministry of Health: a male and a female, who are in charge of integrated case management of childhood illness and family planning; and a female who is in charge of maternal and newborn care. They all play a key role in expanding the coverage of family planning, antenatal care, and childhood immunization, and they also provide services for malaria, pneumonia, and diarrheal diseases.

Rwanda’s national performance-based financing system rewards community health workers according to selected indicators, including the proportion of women delivering at health facilities and the percentage of children receiving a full course of basic immunizations. Such incentives have helped boost the use of maternal and child health services, according to Paul Farmer, a U.S. physician living in Rwanda, known for his work with underserved populations.⁴

Maternal and Child Health Core of Community-Based Health Insurance

Rwanda’s government is committed to providing universal health care as part of its Vision 2020 Strategy. Since 2000, the core of this commitment has been its community-based health insurance scheme known as Mutuelle de Santé. The system lowers catastrophic out-of-pocket payments and ensures access for vulnerable populations, focusing on maternal and child health services.

Community committees are responsible for mobilizing and registering members, collecting fees, and clearing bills from health facilities. Annual premiums are based on wealth categories. Ambulance transport is also covered, thus reducing a significant barrier to emergency care for pregnant women who have complications.⁵ With specially programmed mobile phones, community health workers can contact health facilities for referrals.

From 2000 to 2007, growth in use of health services was greatest among the poorest people. Health insurance was made compulsory in 2008 and by 2012, 90 percent of the population had enrolled.⁶

Hand-in-hand with its comprehensive insurance program, Rwanda has adopted a number of innovative tools to strengthen its health systems. All maternal and child health services are integrated under one national monitoring and evaluation framework to improve priority setting, planning, and resource allocation. Rwanda has developed a web-based Health Management Information System to collect data from a variety of sources and has scaled up maternal death reviews as part of their efforts to strengthen data collection.⁷

Family Planning Key to Sustained Success in Maternal Health

The success story in maternal health is also a story about increased family planning coverage. Modern contraceptive prevalence increased in Rwanda from 4 percent to 45 percent in 10 years. Research shows that family planning can prevent as many as one in three maternal deaths by allowing women to delay motherhood, space births, avoid unintended pregnancies, and stop childbearing when they have reached their desired family size.

Rwanda’s total fertility rate decreased from 6.2 children per woman in 1992 to 4.0 in 2013.⁸ Community health workers have much to do with these successes. They can provide condoms, pills, injectables, and cycle beads. The fast-improving uptake of maternal health services has been linked to a strong positive response to community health workers; the push to subscribe to the community-based insurance scheme; and an effective public education campaign that reached three-quarters of women, supported by a system of fines imposed on those who fail to attend antenatal care and deliver in health care centers.⁹

Challenges Remain

Rwanda still faces challenges. The country needs 586 more midwives to reach 95 percent skilled birth attendance.¹⁰ Rural areas are still underserved: Forty percent of women live more than an hour away from a health facility. Even with the increase in family planning and decline in the total fertility rate, contraception remains unavailable to or underused by many Rwandans. And nearly one in every two children under 5 are stunted.

In 1995, most development agencies were ready to give up on Rwanda, then one of the poorest and most vulnerable countries in the world. But now, Rwanda is one of the few countries on track in 2015 to meet the Millennium Development Goals for reducing child and maternal health.

References

1. World Health Organization, Trends in Maternal Mortality: 1990 to 2013 (Geneva: WHO, 2014).
2. Rwanda Ministry of Health et al., Success Factors for Women’s and Children’s Health: Rwanda (Geneva: Partnership for Maternal, Newborn, & Child Health and World Health Organization, 2014).
3. Rwanda Ministry of Health et al., Success Factors for Women’s and Children’s Health.
4. Paul Farmer et al., “Reduced Premature Mortality in Rwanda: Lessons From Success,” British Medical Journal 346, no. f65 (2013), accessed at www.bmj.com/content/346/bmj.f65.full.pdf+html, on Jan. 12, 2015.
5. Overseas Development Institute, Delivering Maternal Health: Why Is Rwanda Doing Better Than Malawi, Niger, and Uganda? (London: Overseas Development Institute, 2012).
6. Farmer et al., “Reduced Premature Mortality in Rwanda.”
7. Daphrose Nyirasafali, Maternal Mortality Reduction Programme in Rwanda (Kigali, Rwanda: UNFPA, 2010).
8. Carl Haub and Toshiko Kaneda, 2014 World Population Data Sheet (Washington, DC: Population Reference Bureau, 2014).
9. Overseas Development Institute, Delivering Maternal Health.
10. Rwanda Ministry of Health et al., Success Factors for Women’s and Children’s Health.

Globally, an estimated one in four children under age 5 suffer from stunting, a form of malnutrition in which children are shorter than normal for their age.¹ In India, almost 62 million children (48 percent) across all income groups are stunted (see figure). Stunting, or chronic malnutrition, is accompanied by a host of problems—weak immune systems, risk of sickness and disease, arrested cognitive and physical development, and a greater risk of dying before age 5.

Stunting happens over time and can be caused by inadequate maternal nutrition, poor feeding practices, or substandard food quality as well as frequent infections. The high rate of stunting in India is surprising given its economic growth, especially in contrast to sub-Saharan Africa where GDP is lower.

Sanitation a Potential Contributor to Malnutrition

A recent story in the New York Times explored the link between high rates of child malnutrition in India and the country’s poor sanitation, shedding light on a potential cause of a protracted problem. For India, the issue is not a lack of food, but rather a lack of toilets for its population—one-half of India’s population, at least 620 million people, defecates outside.

The interaction between diarrheal disease and malnutrition is well established. Diarrhea is often caused by a lack of clean water for proper hand-washing. A lack of toilets further exacerbates the problem as feces on the ground contribute to contaminated drinking water and water resources in general.

The World Health Organization estimates that 50 percent of malnutrition is associated with repeated diarrhea or intestinal worm infections from unsafe water or poor sanitation or hygiene.²

Stunting can stem from enteropathy, a chronic illness caused by inflammation that keeps the body from absorbing calories and nutrients. Children who are exposed to open defecation or who don’t have a clean water supply may ingest bacteria, viruses, fungi, or parasites that cause intestinal infection; chronic inflammation in a child’s gastrointestinal track is linked to stunting and anemia, and puts children at risk for poor early childhood development.³

Many organizations have adopted an integrated approach to improve water, sanitation, and hygiene, known as WASH programs. One of the United Nation’s Millennium Development Goals is to halve by 2015 the proportion of the population without sustainable access to safe drinking water and basic sanitation. However, despite progress, 2.5 billion people in developing countries still lack access to improved sanitation facilities.⁴

Women’s Roles Affect Children’s Nutrition

“The story is not so simple,” says Rhonda Smith, associate vice president for International Programs at the Population Reference Bureau (PRB), who leads PRB’s efforts to reduce malnutrition in pregnant women and children under the RENEW project. According to Smith, several factors contribute to stunting. “Women’s low status in many segments of Indian society can have a significant effect on children’s nutrition. Limited decisionmaking authority means less control over food purchases and less ability to control how food is distributed among family members.”

Indeed, researchers have found that women’s relative bargaining power within the household determined how resources are directed to support feeding practices, prenatal and birthing care, and treatment for illness and immunizations.⁵ In India, studies found that a higher share of children whose mothers had below primary education or were younger than 20 were stunted, but that children living in female-headed households were less stunted, and that reduced stunting was associated with whether women were able to make decisions to travel outside the home and whether they were able to make decisions about household purchases.⁶

The Challenges Ahead for India

Diarrhea prevalence drops substantially only if open defecation is completely eliminated.⁷ Narendra Modi, India’s prime minister, pledged to add 5 million toilets by the end of September of this year.⁸

Unfortunately, the toilets that have been built in India have sometimes gone unused or have been used to store tools, grain, or building materials.⁹ Changes in social norms and behaviors must change too. According to Unicef, India has revamped its national sanitation program to focus less on subsidized toilet construction and more on helping the population understand the benefits of toilets. Dean Spears, an economist and visiting researcher at the Delhi School of Economics, writes, “Open defecation is everybody’s problem. It is the quintessential ‘public bad’ with negative spillover effects even on households that do not practice it.”

References

1. Unicef, Improving Child Nutrition: The Achievable Imperative for Global Progress (New York: Unicef, 2013).
2. World Health Organization, Safer Water, Better Health: Costs, Benefits, and Sustainability of Interventions to Protect and Promote Health (Geneva: WHO, 2008).
3. Francis M. Ngure et al., “Water, Sanitation, and Hygiene (WASH), Environmental Enteropathy, Nutrition, and Early Childhood Development: Making the Links,” Annals of the New York Academy of Sciences 1308 (2014): 118-28.
4. United Nations, “We Can End Poverty: Millennium Development Goals and Beyond 2015,” accessed at www.un.org/millenniumgoals/environ.shtml, on July 29, 2014.
5. Unicef, Gender Influences on Child Survival, Health, and Nutrition: A Narrative Review (New York: Unicef, 2011).
6. Monal Shroff et al., “Maternal Autonomy Is Inversely Related to Child Stunting in Andhra Pradesh, India,” Maternal and Child Nutrition 5, no. 1 (2009): 64-74; and Diane Dancer and Ramu Rammohan, “Maternal Autonomy and Child Nutrition: Evidence From Rural Nepal,” Indian Growth and Development Review 2, no. 1 (2009): 18-38.
7. Unicef, Water, Sanitation, and Hygiene: 2012 Annual Report (New York: Unicef, 2013).
8. “Sanitation in India: The Final Frontier,” The Economist, July 19, 2014.
9. Dean Spears, “Child Stunting and Open Defecation: How Much of the South Asian Height ‘Enigma’ Is a Toilet Gap?” (February 2013), accessed at www.ideasforindia.in/article.aspx?article_id=108, on July 30, 2014.

Jeremy Shiffman is a Visiting Scholar at PRB, and professor of public administration and policy at American University in Washington, D.C. A political scientist by training, he researches the politics of health policy and administration in low-income countries, with a particular interest in health agenda-setting: why some issues receive priority while others are neglected. He has investigated maternal survival, newborn survival, family planning, donor funding for health, and health systems reform, among other issues. His research has been funded by the Gates, MacArthur, and Rockefeller foundations. His work has appeared in The Lancet, Population and Development Review, The American Journal of Public Health, Social Science and Medicine, Health Policy and Planning, The British Journal of Obstetrics and Gynaecology, and The Bulletin of the World Health Organization. Heidi Worley, senior writer/editor at PRB, spoke with Shiffman about his current research on global health networks.

WORLEY: How do you define a “global health network?
SHIFFMAN: Global health networks are cross-national webs of individuals and organizations linked by a common concern about a particular global health problem. They now exist for nearly all high-burden health conditions in low-income countries. These networks connect various types of institutions—United Nations agencies, donors and foundations, national governments, nongovernmental organizations (NGOs), medical associations, research institutions, and think tanks. Some network members produce knowledge; others advocate; still others provide funds, develop policy ideas, or implement programs. Among their activities, global health networks exchange information on promising new interventions, debate how best to address conditions at global conferences, organize campaigns, and press governments and donors to provide resources.

WORLEY: Can you give us some examples?
SHIFFMAN: For some health conditions one can identify a specific institution that facilitates collective action, for example, the Roll Back Malaria Partnership. For other conditions, multiple institutions bring together individuals and organizations in networks: For instance, for HIV/AIDS there are biennial international conferences, civil society coalitions, a formal UN body (UNAIDS), a financing mechanism (the Global Fund to Fight AIDS, Tuberculosis and Malaria), and a large bilateral program (the U.S. President’s Emergency Plan for AIDS Relief). For still other conditions—mental health, for example—institutions are weak, making informal ties crucial for network formation and spurring collective action.

WORLEY: Why is it important to study global health networks?
SHIFFMAN: In the past three decades, the global health landscape has shifted dramatically with the proliferation of global health networks. Thirty years ago, international health looked considerably different—strong networks of individuals and organizations existed for a few conditions: malaria, smallpox, polio, and several other vaccine-preventable childhood diseases. For most conditions, however, if a global effort existed at all, it was largely housed in an international organization, usually the World Health Organization, that worked bilaterally with national governments rather than through a global network. Yet despite their growth, health policy scholars have given global health networks little attention. As a result, we don’t know much about why they have emerged, what effects they produce, and what roles they play in the global governance of health.

WORLEY: Which networks are you examining in your research program?
SHIFFMAN: Our research program considers six global health networks addressing high-burden conditions in low- and middle-income countries to learn more about how networks emerge and what effects they have. Our case studies include networks that address tuberculosis, pneumonia, tobacco use, alcohol control, newborn mortality, and maternal death in childbirth. These studies are part of the Global Health Advocacy and Policy Project, a research initiative funded by the Bill & Melinda Gates Foundation that groups 14 investigators from North America, South America, and Europe.

WORLEY: What outcomes are you studying?
SHIFFMAN: Two questions ground this project.

• Effectiveness: Why are some networks better able than others to assert influence in the direction of their preferences?
• Emergence: Why do networks more easily crystallize around some global health issues than others, and once formed, why do some flourish while others stagnate?

Effectiveness refers to the extent to which networks are able to change the world to meet their members’ perceptions of what reality should look like.¹ We examine effectiveness by considering outputs, policy consequences, and impact. Outputs are the immediate products of network activity, such as guidance on intervention strategy, research, and international meetings. Policy consequences pertain to the global policy process, including international resolutions, funding, national policy adoption, and the scale-up of interventions. Impact refers to the ultimate goal of improvement in population health.

By emergence we mean both the formation and the evolution of networks. Global networks materialize around some issues but not others. And among those that form, only some flourish. Understanding whether and how they emerge is crucial if we wish to understand their role, particularly since early decisions on matters such as governance, membership, and focus may have lasting consequences.²

While our focus is explaining the emergence and effectiveness of networks, we also consider their legitimacy, that is, whether they have a right to exert power, and why they differ in the degree to which they are perceived to have this right.

WORLEY: How will you examine the effectiveness and emergence of global health networks?
SHIFFMAN: Emergence and effectiveness of global health networks are best understood by looking at the interaction among three categories of factors.

Features of networks themselves and the actors in them: leadership, governance, composition, and framing strategies.

Features of their policy environments: allies and opponents, funding, and global norms.

And particular characteristics of the issues they address.³ Especially important are:

• Severity of the problem: Robust networks are more likely to emerge when problems lead, or are perceived to lead, to high mortality and morbidity, economic damage, or social disruption.
• Tractability of the problem: Networks are more likely to form and be effective on problems perceived to be solvable.⁴
• Nature of the affected populations: Populations that inspire sympathy, especially those understood not to be responsible for acquiring the condition—children affected by HIV/AIDS, for instance—are more likely to inspire network mobilization.⁵ Also, positive network results are more likely if affected populations are able to mobilize on their own behalf. People living with HIV/AIDS, for instance, have been a backbone for a global AIDS movement, facilitating its growth, effectiveness, and perceived legitimacy.

This research program on global health networks will conclude at the end of 2014 and will culminate in a series of articles based on the findings. Collectively, these papers will represent the first comparative research effort on the emergence and effectiveness of global health networks.

References

1. Kathryn Sikkink, “The Power of Networks in International Politics,” in Networked Politics: Agency, Power, and Governance, ed. Miles Kahler (Ithaca, NY: Cornell University Press, 2009).
2. Paul Pierson, “Path Dependence, Increasing Returns, and the Study of Politics,” American Political Science Review 94, no. 2 (2000): 251-67.
3. Margaret E. Keck and Kathryn Sikkink, Activists Beyond Borders: Advocacy Networks in International Politics (Ithaca, NY: Cornell University Press, 1998); and Deborah A. Stone, “Causal Stories and the Formation of Policy Agendas,” Political Science Quarterly 104, no. 2 (1989): 281-300.
4. Stone, “Causal Stories and the Formation of Policy Agendas.”
5. Stone, “Causal Stories and the Formation of Policy Agendas”; and Anne Schneider and Helen Ingram, “Social Construction of Target Populations: Implications for Politics and Policy,” American Political Science Review 87, no. 2 (1993): 334-47.

Twenty years after its civil war ended in 1992, Mozambique has made significant progress. Economic growth has remained steady for over a decade. Malaria prevalence in children has declined and households are more protected by insecticide-treated nets or indoor spraying. More than one-half of all childbirths occur in health facilities. And early childhood mortality is declining dramatically, with half as many deaths among children under 5, compared to 14 years ago (see figure).

Early Childhood Mortality Is on the Decline in Mozambique. 

Note: MDHS refers to the Mozambique Demographic and Health Survey; MICS refers to the Multiple Indicator Cluster Survey.
Sources: Instituto Nacional de Estatística, Ministério da Saúde, Maputo, Moçambique, and ICF International, Mozambique Demographic and Health Survey 2011 (Calverton, MD: ICF International, 2013); United Nations Children’s Fund (UNICEF) and Instituto Nacional de Estatística, Maputo, Moçambique, Mozambique Multiple Indicator Cluster Survey 2008-2009 (New York: United Nations Children’s Fund (UNICEF), 2009); Instituto Nacional de Estatistica, Ministerio da Saude, Maputo, Moçambique and ORC Macro, Mozambique Demographic and Health Survey 2003 (Calverton, MD: ORC Macro, 2005); andManuel da Costa Gaspar et al., Instituto Nacional de Estatística, Maputo, Moçambique, and Macro International, Mozambique Demographic and Health Survey 1997 (Calverton, MD: Macro International Inc., 1998).

The country recently released a final report from its 2011 Mozambique Demographic and Health Survey (MDHS), lending evidence to this progress but highlighting areas where gaps remain. Fertility rates are still high (average of 5.9 children per woman), and in fact have risen slightly since the last MDHS in 2003 (5.5 children per woman). Fertility is lower for better-educated and wealthier women, and those living in urban areas.¹

Knowledge of modern contraceptive methods is common, yet contraceptive use remains low, and unmet need for family planning is generally high across women of all backgrounds, with one in four married women expressing an unmet need for family planning (meaning they do not want to become pregnant for two years or more but are not using a modern contraceptive method). Mozambique continues to have a high level of early childbearing, affecting over one-third of women ages 15 to 19, although as education levels increase, teen pregnancy is less common. This group has the highest unmet need for family planning: While one quarter use modern contraception, over half still express the desire to limit births. And maternal mortality remains high at 408 deaths per 100,000 live births.²

Getting the Word Out

To help inform decisionmakers about these gaps, PRB was asked, through its IDEA project, to develop a policy communications strategy to disseminate the 2011 MDHS to refocus attention on population, family planning, and health policies and programs. IDEA (Informing Decisionmakers to Act) provides information about family planning and reproductive health to policy audiences around the world. IDEA received support from USAID/Mozambique to partner with the Mozambican Instituto Nacional de Estatistics (INE) that conducted the 2011 survey.

IDEA staff collaborated with the staff from INE and the Mozambique Ministry of Health to develop a set of publications in Portuguese and English for provincial policymakers and other decisionmakers, educators, and journalists. (Several of the publications, in Portuguese, are online and linked below.) These included:

• Mozambique Population Data Sheet with a data table and illustrative graphics on select MDHS findings: fertility and family planning, child health and education, household conditions, malaria, HIV/AIDS knowledge and testing, and gender-based violence.
• Regional brochures for the northern, central, and southern regions with key MDHS findings and trends.
• Thematic brochures on fertility and family planning, maternal and child health, gender, HIV/AIDS, and malaria.
• Teacher’s guide with instructions on interpreting and using the Data Sheet in the classroom to increase statistical literacy.
• Journalist’s guide on using MDHS, adapted from the MEASURE DHS Journalists’ Guide to the Demographic and Health Surveys.

Demand for Materials Is High

On May 2, 2013, the national MDHS launched its findings. Following the launch, the IDEA products were disseminated during provincial-level meetings, sectoral meetings, and one-day media training workshops in 10 provinces and Maputo. At these meetings, INE used the products to raise awareness of areas requiring further attention and investment from local leaders. Toshiko Kaneda, the project leader and a senior research associate at PRB, said of PRB’s role in this process, “A huge amount of effort goes into collecting data, but they (INE) don’t feel like the data get enough use. That’s why a project like ours that tries to promote the use of the data by making the results accessible to policymakers, other decisionmakers, and nontechnical audiences is so important. “

Feedback from these meetings was positive. At least 30 percent of participants gave comments that reflected their intention to further use the data in their work: Requests came for access to more data, district-level disaggregation, and future coverage or content improvements. Kaneda reported, “INE was excited about the excellent feedback they were getting from all the print publications. They said they will be very beneficial as they promote the use of the MDHS results in policy planning, which they are trying to improve at the provincial-level.” Project consultant Marjorie Macieira noted that “INE expressed how helpful to them it was to have PRB participate in the selection and definition of key indicators, and with the actual design and development of the thematic brochures.”

Multiple Uses for MDHS Data

Data from the MDHS, made accessible by PRB, can help decisionmakers and program planners to address health problems. Mozambique is located in southern Africa, the region with the highest prevalence of HIV in the world. More than 10 percent of adults ages 15 to 49 in Mozambique are living with HIV.³ According to the MDHS, neither women nor men have a comprehensive knowledge of HIV/AIDS and its prevention. Three-quarters of men know ways to prevent HIV, such as condom use and limiting sex to one uninfected partner, but only half of women share this knowledge. Risky sexual behavior is common (30 percent of men had two or more sexual partners in the last year before the survey) but few have undergone testing. Young people are a priority group for HIV-prevention activities throughout the region, especially given that early initiation of sexual activity is common: More than three-quarters of women ages 20 to 24 were sexually active before age 18, compared to two-thirds of men.⁴ The MDHS data can help health educators craft evidence-based programs to address these pressing problems, such as delaying the age of sexual activity initiation as a strategy to reduce the risk of HIV infection among youth.

Journalists, especially those who undergo media training, can use the MDHS data to make the numbers come alive in their stories. Macieira shared, “Another challenge was getting the media’s attention focused on disseminating the 2011 MDHS findings because of the generally less appealing interest of ‘statistical information.’ The media is more likely to cover breaking political developments and will need additional training to get them educated on maximizing use of the MDHS findings in their daily news coverage,” a plan, she noted, that INE already has in process.

References

1. Instituto Nacional de Estatística, Ministério da Saúde, Maputo, Moçambique, and ICF International, Mozambique Demographic and Health Survey 2011 (Calverton, MD: ICF International, 2013).
2. Instituto Nacional de Estatística, Ministério da Saúde, Maputo, Moçambique, and ICF International, Mozambique Demographic and Health Survey 2011.
3. UNAIDS, “HIV and AIDS Estimates 2012 Mozambique,” accessed at www.unaids.org/en/regionscountries/countries/mozambique/, on Oct. 17, 2013.
4. Instituto Nacional de Estatística, Ministério da Saúde, Maputo, Moçambique, and ICF International, Mozambique Demographic and Health Survey 2011.

(April 2013) Muslims account for around one-fifth of the world’s population—or about 1.6 billion people. They represent the majority population in about 50 countries and territories clustered in Asia and Africa (see Table 1).¹ Muslims are diverse, varying by race, language, and the degree of their religious conservatism. Some Muslims live in countries where the government is influenced or ruled by Islamic law (such as Saudi Arabia and Iran), while others live in countries with secular governments (such as Tunisia and Bangladesh).

Table 1
Countries With More Than 50 Percent Muslim Population

Notes: Palestine includes the Arab Population of Gaza and the West Bank. The populations of Bahrain, Kuwait, Oman, Qatar, and the United Arab Emirates include non-nationals living in these countries.
Source: Pew Forum on Religious & Public Life, The Future of the Global Muslim Population, Projections for 2010-2030 (Washington, DC: Pew Research Center’s Forum on Religion and Public Life, 2011).

Indonesia has the largest Muslim population of any country—212 million of its 241 million people (88 percent). India’s 184 million Muslims represent almost 15 percent of the country’s population. In Europe, Kosovo and Albania are the only two Muslim-majority countries. France has the largest Muslim population in western Europe (8 percent). Muslims are almost 5 percent of the United Kingdom’s population and less than 1 percent of the U.S. population. About 18 percent of Israel’s population is Muslim.

It is often stated that Islam is the fastest-growing religion in the world—a statement that may well be true because of the pace of the demographic transition in the Muslim-majority countries relative to the rest of the world. The process of demographic transition has three stages:

• In the first stage, both mortality and fertility rates are high, and as a result population growth is low.
• In the second stage, mortality declines and fertility decreases later, with a time lag resulting in rapid population growth.
• In the third and last stage of the transition, both mortality and fertility levels are low, and once again population growth is low.

Putting the population growth of Muslim-majority countries in a global perspective, the Middle East and North Africa (MENA) region has the largest concentration of countries with populations that are more than 90 percent Muslim. The region experienced rapid mortality decline during the second half of the 20th century, while fertility remained relatively high. As a result, between 1950 and 2000, the MENA region experienced the fastest population growth among the world’s major regions. MENA’s population growth reached a peak of 3 percent per year around 1980, while the growth rate for the world reached its peak of 2 percent annual growth more than a decade earlier.²

Today, Iran, Lebanon, Tunisia, and Turkey (all in the MENA region) have completed their demographic transition, reaching total fertility rates (TFR, the average number of children per woman) at or below 2.1 children per woman (“replacement level”). Indonesia and Morocco are almost there as well. But because of past high fertility rates, these countries have a “young” age structure, and their populations will continue to grow. For example, between 2012 and 2050, Iran’s population is expected to grow from 79 million to 100 million and Indonesia’s from 241 million to more than 300 million. In each case, the population will grow by around 25 percent.

The speed of population growth will be faster in countries that are in the early or middle stage of their demographic transition, most notably for those countries in sub-Saharan Africa. Niger’s TFR of 7.1 will cause a tripling of the population to 54 million by 2050. Similarly, Mali’s TFR of 6.3 will expand its population from 16 million in 2012 to 45 million in 2050. The population of Nigeria—Africa’s most-populated country—is expected to more than double by 2050, reaching more than 400 million. Today, almost half (48 percent) of Nigeria’s population is Muslim, according to estimates from the Pew Forum on Religion and Public Life, but in a couple of decades Muslims are expected to become a majority there as well. Table 2 shows two important demographic transition indicators, life expectancy at birth and TFR, for countries that are home to the 10-largest Muslim populations.

Table 2
The 10 Largest Muslim Populations

Sources: Muslim population (estimates) and percent Muslim come from Pew Forum on Religion & Public Life, The Future of the Global Muslim Population. Projections for 2010-2030 (Washington, DC: Pew Research Center’s Forum on Religion and Public Life, 2011); total population, life expectancy at birth, and total fertility rate come from Population Reference Bureau, 2012 World Population Data Sheet (Washington, DC: Population Reference Bureau, 2012).

It is difficult to predict the pace of a country’s demographic transition. Iran surprised the world when its TFR dropped from 5.6 in 1985 to 2.0 in 2000—the fastest decline ever recorded.³ On the other hand, fertility declines were underway in Egypt and Jordan, but are stalled now; Egypt’s TFR is 2.9 and Jordan’s 3.8, still far from replacement level.

During the demographic transition, countries experience transformations of their age structure and face a phenomenon known as the “youth bulge”—when youth constitute a significant portion of the population that maintains the momentum for population growth. Today, almost a third of Egypt’s and Pakistan’s populations are between the ages of 15 and 29.

Considering where most Muslim-majority countries are in their demographic transition—most Muslim-majority countries (plus Nigeria) still have fertility rates above the world average of 2.4 children per woman. Islam may indeed remain the fastest-growing religion in the world for the foreseeable future.

Farzaneh Roudi-Fahimi is program director, Middle East and North Africa Program, at the Population Reference Bureau. John F. May is a PRB Visiting Scholar. Allyson C. Lynch is a PRB intern.

References

1. Carl Haub and Toshiko Kaneda, 2012 World Population Data Sheet (Washington, DC: Population Reference Bureau, 2012); UN Population Division, World Population Prospects: The 2010 Revision (New York: UN Population Division, 2011); and Pew Forum on Religion & Public Life, The Future of the Global Muslim Population, Projections for 2010-2030 (Washington, DC: Pew Research Center’s Forum on Religion and Public Life, 2011). See also Hans Groth and Alfonso Sousa-Poza, eds., Population Dynamics in Muslim Countries: Assembling the Jigsaw (New York: Springer, 2012).
2. Farzaneh Roudi-Fahimi, Population Trends and Challenges in the Middle East and North Africa (Washington, DC: Population Reference Bureau, 2001).
3. Farzaneh Roudi-Fahimi, Iran’s Family Planning Program: Responding to a Nation’s Needs (Washington, DC: Population Reference Bureau, 2002).

• • This datasheet also in French and Spanish.

Girls and boys in developing countries are enrolling in secondary school in greater numbers than ever before, giving them knowledge and skills for healthy, productive lives. While this is good news, many young people still face challenges to employment, and they must also navigate serious risks to their health, such as smoking, early marriage and childbearing, or having unprotected sex.

The World’s Youth 2013 Data Sheet provides a comprehensive portrait of the well-being of youth ages 10 to 24 across the globe, including such indicators as the current and projected size of youth populations, educational enrollments, labor force participation, marriage and fertility, and health risks and behaviors.

Key findings include:

Teenage Pregnancy and Childbearing

Around the world, many women ages 15 to 19 are currently pregnant or have already given birth. This scenario is especially true in rural areas, where girls are married young and pressured to start having children immediately. In Zimbabwe, Senegal, and Colombia, more than one in five teenagers from rural areas have begun childbearing. And teenagers from the poorest households are more likely to become pregnant or give birth than those from the wealthiest households. In Zimbabwe, Senegal, Colombia, and Peru, more than one-quarter of teens ages 15 to 19 from the poorest 20 percent of households have begun childbearing. In Peru, the rate of early childbearing is nearly six times greater among those from the poorest households compared to the wealthiest.

Prevalence of Child Marriage

Child marriage, defined as marriage before age 18, is practiced in all regions of the world. This harmful traditional practice not only violates the human rights of girls and young women, but also threatens their health and well-being. Nearly half of all women ages 20 to 24 in South Central Asia and Western Africa were married by age 18, putting them at a higher risk for early pregnancy and maternal disability and death, and limiting their access to education and employment. Although the prevalence of child marriage is lower in other regions, such as Southeast Asia and Western Asia, nearly one in five girls in those two regions was married by age 18. And in the poorest regions of the world—particularly Eastern Africa, Western Africa, and South Central Asia—more than one in 10 girls were married by age 15.

Adolescent Fertility Rates Worldwide

The adolescent fertility rate measures the number of births per 1,000 women ages 15 to 19. Although the number of births among adolescent girls is declining around the world, adolescent childbearing remains common in many countries, particularly in sub-Saharan Africa. Early childbearing poses serious consequences to the health and development of young girls. The risk of maternal death and disability is higher for adolescents than for women in their 20s. At the same time, early childbearing often limits girls’ opportunities for education, training, and livelihood development. Adolescent childbearing is more common in developing countries, where nearly 10 percent of adolescent girls give birth each year, compared to less than 2 percent in developed countries.

Progression to Secondary School

While many countries around the world have seen rapid progress toward universal primary education, ensuring that adolescents start and complete secondary education is crucial to their acquiring the knowledge and skills needed for healthy, productive lives. Progression to secondary school measures the likelihood that children who finish primary school will start their first year of secondary school. In the Philippines, nearly all children progress from primary school to secondary school. In Senegal and Lesotho, fewer than three-quarters of all students start secondary school, with girls less likely to progress compared to boys. While this transition may be more challenging for females than males, young men are also at-risk of leaving school too early. In the Dominican Republic and Mozambique, boys are less likely than girls to start secondary school.

Young People Without Jobs, Education, or Training

Many countries around the world are concerned about young people who are not in education, employment, or training (NEET). While unemployed youth who are in school or receiving training are investing in their future employment prospects and earning potential, NEETs are unemployed and not engaged in education opportunities. When young people are not in contact with the education system or the labor market, they cannot develop key skills for meaningful employment. Across countries with available data, more young women than young men are classified as NEETs. This situation is particularly pronounced in countries like Niger and Pakistan, where more than two of every three young women are NEETs.