Explore case studies across a range of digital health technologies.
Explore PRB and PACE’s work at the intersection of digital health technologies and family planning programming.
Digital health is an umbrella term that encompasses an array of information and communications technologies used in health care, including mobile health (mHealth), telehealth/telemedicine, eHealth, health information technology (IT), health management information systems, use of blockchain technology, and artificial intelligence. These digital health technologies can support individuals, health providers, and health systems managers to make informed decisions and engage individuals to improve demand, access, coverage, quality, and affordability of health care for everyone.
As low- and middle-income countries transition from paper to digital systems, family planning programs can benefit from unprecedented opportunities to improve services. Investments in digital health tools have expanded exponentially, but information on what works—and what does not— remains limited and scattered. As investments have increased, digital applications and data fragmentation have proliferated, but stakeholders are moving toward more coordinated efforts to scale digital health solutions, support countries’ digital health infrastructure, and share evidence-based learnings.
Digital Health Compendium
The interactive Digital Health Compendium, launched by PACE in 2020, features case studies across a range of digital health technologies used to enhance the impact and efficiency of family planning programs. In 2021, PACE transitioned leadership of the Compendium to The Medical Concierge Group (TMCG), a digital health and telemedicine company based in Uganda.
This Digital Health Compendium enables users to explore case studies across a range of digital health technologies used to enhance family planning programs mainly in sub-Saharan Africa, but also in other regions of the world. Digital health applications in family planning programs can be broadly classified as those affecting demand generation, service delivery, supply chain management, and the policy and enabling environment. In many low- and middle-income countries, digital health innovations were adopted earlier in other health sectors, including HIV/AIDS, maternal and child health, and noncommunicable disease prevention and response. As a result, much of the impact evidence is restricted to those sectors. To advance greater adoption of digital technology in family planning programs, more data and information on the challenges, opportunities, scalability, and results are needed. This compendium aims to consolidate emerging information and data on applications of digital technology in family planning programs to inform adoption and scale-up of successful approaches.
Webinar: Designing or Implementing a Family Planning Program? How To Introduce Digital Solutions Sustainably and at Scale
PRB alongside The Medical Concierge Group, Knowledge Success, and Maternal & Infant Health Consulting hosted a webinar during Transform Digital Health Week 2021 titled “Designing or Implementing a Family Planning Program? How To Introduce Digital Solutions Sustainably and at Scale.” Four projects featured in the Digital Health Compendium highlighted trusted and innovative lessons on scaling and sustaining family planning and reproductive health initiatives through leveraging digital health solutions. The panel of national and international experts discussed broader implementation topics including involvement of government counterparts, partnerships, and revenue models. Technology-specific lessons included adaptability, integration, flexibility, and uptake. Recordings available below.
Dialogue politique entre jeunes leaders et décideurs politiques sur le maintien de l'utilisation de la contraception chez les jeunes en Afrique de l'Ouest
PACE s'efforce également de mettre en relation les journalistes, les décideurs et les jeunes leaders présents au webinaire, afin de promouvoir des reportages de qualité sur l'utilisation durable de la contraception.
Dans de nombreux pays, les jeunes âgées de 15 à 24 ans présentent des taux d’abandon de la contraception plus élevés que les femmes plus âgées. Afin d’en discuter les causes et d’identifier des solutions au niveau politique, PACE a organisé, le 26 mai, un dialogue politique virtuel de deux heures sur l’abandon de la contraception chez les jeunes en Afrique de l’Ouest, en collaboration avec le Réseau des femmes sénégalaises pour la promotion de la planification familiale et Knowledge SUCCESS. L’événement visait à renforcer l’engagement des décideurs politiques régionaux pour traiter les obstacles à l’utilisation durable de la contraception chez les jeunes et à créer des opportunités de collaboration entre les organisations dirigées par des jeunes, les journalistes et les jeunes chercheurs.
Ce dialogue politique innovant a permis de tirer trois grandes leçons sur l’engagement significatif des jeunes dans les politiques et les programmes de planification familiale :
- Bien que les organisations dirigées par des jeunes offrent des idées novatrices sur la prise de décision en matière de planification familiale, leur rôle dans l’amélioration de l’utilisation des contraceptifs par les jeunes est souvent limité à la sensibilisation. Les jeunes doivent être inclus dans le processus d’élaboration des politiques et des programmes.
- L’environnement juridique et politique est généralement évalué sur l’existence de textes et de documents. Or il convient d’accorder une plus grande attention à l’application des lois et des politiques et à leur effet sur les utilisateurs.
- La poursuite de la contraception doit être prise en compte en même temps que l’accès en tant que tel afin d’optimiser le retour sur investissement des efforts déployés par les gouvernements pour élargir l’accès aux informations et aux services de planification familiale volontaire.
Fatou Diop (Alliance nationale des jeunes pour la santé de la reproduction et la planification familiale – Sénégal) et Rachid Awal (African Youth and Adolescents Network – Niger) – représentant des organisations de jeunes – ont présenté des résultats clés sur l’abandon de la contraception par les jeunes, en s’appuyant sur une note de politique de PACE. Ils ont souligné, entre autres, que les jeunes peuvent être particulièrement sensibles aux effets secondaires et qu’ils sont confrontés à des obstacles importants, tels que les préjugés des prestataires, pour accéder à des services de planification familiale de qualité. Ils ont exposé sept recommandations politiques pour surmonter ces obstacles, telles qu’un counseling de qualité incluant des mécanismes de suivi actif entre les rendez-vous et l’accès effectif à la gamme complète des méthodes contraceptives.
Hervé Bassinga (Institut supérieur des sciences de la population), a présenté les résultats d’une analyse par les étudiants du premier programme de communication pour les politiques de PACE en Afrique de l’Ouest, sur l’ouverture des contextes et des programmes nationaux pour l’utilisation durable de la contraception chez les jeunes au Bénin, au Burkina Faso, en Guinée, au Mali et au Togo. Sa présentation a montré que plusieurs bonnes pratiques de soutien à l’utilisation durable de la contraception chez les jeunes ne sont actuellement pas reflétées dans les politiques des pays et qu’une attention accrue est nécessaire, au niveau politique, pour soutenir la continuation contraceptive. Par exemple, quatre de ces cinq pays n’ont ni loi ou politique favorisant l’accès des jeunes aux soins de planification familiale sans le consentement des deux parents ou du conjoint.
Au cours d’une table ronde animée par les jeunes leaders, plusieurs décideurs politiques de haut niveau, dont l’Honorable Assoupi Amèle Adjeh, parlementaire togolaise, le Dr Siré Camara, fonctionnaire du Ministère de la Santé de Guinée Conakry, Fatimata Sanou Touré, magistrate burkinabè, et Angelo Évariste Ahouandjinou, maire de la plus grande commune du Bénin, ont approuvé les recommandations de la note de politique. Ils ont insisté sur l’importance d’impliquer les jeunes dans les discussions, depuis le niveau communautaire jusqu’au niveau national, sur la manière de soutenir la poursuite de la contraception chez les jeunes. Fatou Diop a insisté sur le fait que les jeunes ne doivent pas être vus comme de simples bénéficiaires de services à informer, mais être considérés comme des égaux ayant des idées novatrices sur la manière d’améliorer la continuation contraceptive.
Fatimata Sanou Toure et l’Honorable Assoupi Amèle Adjeh ont établi le lien entre l’abandon de la contraception chez les jeunes et la question des grossesses non désirées chez les jeunes scolarisées. Le Dr Siré Camara a indiqué qu’en Guinée, les infirmeries des écoles et des universités sont en mesure d’offrir des services de planification familiale.
Fatimata Sanou Touré et le Dr Siré Camara ont également souligné que, même lorsque de bonnes politiques sont en place, leur mise en œuvre demeure problématique. Par exemple, alors que les contraceptifs sont gratuits dans le secteur public dans de nombreux pays, les jeunes préfèrent souvent se les procurer dans le secteur privé. L’Honorable Assoupi Amèle Adjeh a suggéré que les prestataires refusant de fournir des services aux jeunes devraient en supporter les conséquences juridiques. Angelo Évariste Ahouandjinou a également indiqué qu’une ligne budgétaire pour les contraceptifs existe dans sa municipalité et que des informations sur la planification familiale sont disponibles pour les jeunes.
Cet événement a réuni plus de 85 participants, dont plusieurs journalistes ouest-africains. PACE soutient la participation d’organisations de jeunes pour traduire les recommandations en actions politiques: une table ronde sur l’utilisation des données mettra en relation les jeunes leaders et des jeunes chercheurs formé en communication pour les politiques; une formation sur mesure sera mise en œuvre pour renforcer les capacités de communication stratégique des organisations de jeunes afin de soutenir leur implication croissante pour une redevabilité quant à la mise en œuvre des engagements politiques dans leurs pays respectifs. PACE s’efforce également de mettre en relation les journalistes, les décideurs et les jeunes leaders présents au webinaire, afin de promouvoir des reportages de qualité sur l’utilisation durable de la contraception.
July 13, 2021
In many countries, youth ages 15 to 24 have higher rates of contraceptive discontinuation than older women. To explore the factors behind this challenge and identify policy solutions, PACE convened a two-hour virtual policy dialogue on youth contraceptive discontinuation in West Africa on May 26, in collaboration with the Réseau des Femmes Sénégalaises pour la Promotion de la Planification Familiale and Knowledge SUCCESS. The event aimed to increase regional policymakers’ commitment to addressing the barriers to sustained contraceptive use among youth and forge collaboration opportunities for youth-led organizations, journalists, and young researchers.
This innovative policy dialogue provided three major lessons about meaningful youth engagement in family planning policies and programs:
- While youth-led organizations offer innovative insights about family planning decision-making, their role in enhancing youth contraceptive use tends to be limited to youth sensitization. Youth should be included in the policymaking and program design process.
- The legal and policy environment is generally assessed based on the existence of texts and documents, and greater consideration needs to be given to how laws and policies are applied and experienced by users.
- Contraceptive continuation must be considered alongside contraceptive access in order to optimize the return on investment of governments’ efforts to expand access to voluntary family planning information and services.
Fatou Diop (Alliance Nationale des Jeunes pour la Santé de la Reproduction et la Planification Familiale – Senegal) and Rachid Awal (African Youth and Adolescents Network – Niger), representing youth-led organizations, presented key findings about youth contraceptive discontinuation, drawing on a PACE policy brief. They highlighted that youth may be particularly sensitive to side effects and face significant barriers, including provider bias, to accessing quality family planning services. They outlined seven policy recommendations to address these obstacles, such as providing high-quality counseling, including active follow up mechanisms between appointments, and ensuring access to the full range of contraceptive methods.
Hervé Bassinga (Institut Supérieur des Sciences de la Population), alumnus of PACE’s inaugural policy fellows program in West Africa, presented results of the alumni’s analysis of the favorability of national country and program contexts for sustaining youth contraceptive use in Benin, Burkina Faso, Guinea, Mali, and Togo. His presentation revealed that many best practices for sustaining youth contraceptive use are not currently reflected in countries’ policies, and that more attention is needed at the policy level to sustain youth contraceptive use. Of the five countries, four do not have a law or policy that supports youth access to family planning care without consent from both parents and spouses.
During a moderated panel discussion featuring youth leaders, several high-level policymakers, including Honorable Assoupi Amèle Adjeh, a parliamentarian from Togo, Dr. Siré Camara, an official from the Ministry of Health of Guinea Conakry, Fatimata Sanou Toure, a magistrate from Burkina Faso, and Angelo Evariste Ahouandjinou, the mayor of the largest municipality of Benin, endorsed the policy brief recommendations. They emphasized the importance of involving young people in discussions, from the community to the national level, about how to support contraceptive continuation among youth. Fatou Diop emphasized that young people shouldn’t just be considered as recipients of services who need to be reached with information but should be seen as equals who have innovative ideas about how to enhance contraceptive continuation among young people.
Fatimata Sanou Toure and Honorable Assoupi Amèle Adjeh linked youth contraceptive discontinuation to the issue of unintended pregnancies among youth who are in school. Dr. Siré Camara mentioned that in Guinea, nurses’ offices in schools and universities are able to offer family planning services.
Fatimata Sanou Toure and Dr. Siré Camara also emphasized that even when good policies are in place, implementation issues occur. For example, while contraceptives are free in the public sector in many countries, youth often prefer to access contraceptives in the private sector. Honorable Assoupi Amèle Adjeh suggested that providers who refuse to provide services to young people should face legal consequences. Angelo Evariste Ahouandjinou noted that a budget line item for contraceptives is in place for his municipality and that information about family planning is available to youth.
This event included more than 85 participants, including several West African journalists. PACE is supporting the participation of youth-led organizations to translate recommendations into policy action, through connecting youth leaders and policy fellow alumni for a roundtable discussion about data utilization and provide a bespoke policy communication training to the youth-led organizations to support their increased involvement in ensuring accountability for implementation of policy commitments in their respective countries. PACE is also working to connect journalists who attended the webinar with participating decisionmakers and youth leaders, to promote high-quality reporting on sustained contraceptive use.
July 8, 2021
Population age structure—or the relative size of a population across age groups—is important for national policy agendas and resource allocation. Although mortality and migration play a role, a country’s age structure is primarily driven by its past fertility trends, which have important economic, social, and political implications. Whereas countries with sustained, low fertility of less than two children per woman typically experience a relatively large share of middle-aged and older adults, countries with high fertility generally have a large share of children and, to develop, must invest sufficient resources to adequately address their health and educational needs.
As fertility declines from high to low levels, the share of its young dependent population declines relative to those in the working-ages. With a higher proportion of wage earners and fewer dependents to support, a country has a window of opportunity for sustained economic growth—or a demographic dividend—when complementary investments in health, education, and infrastructure are maintained, and policies encourage an open and stable economy.1 The window is time-limited, however, eventually closing as the age structure matures and older adults account for a greater share of the population. Our analysis explores the timing and duration of countries’ window of opportunity in the 24 USAID family planning priority countries (see annex) under different future fertility scenarios.
Countries With Moderate Child Dependency Have Economically Favorable Age Structures
Demographers use a variety of measures to assess the age structure of a population. One such measure is the dependency ratio, or the number of people in the dependent age groups per 100 working-age people. The two principal dependency ratios are the child dependency ratio and the old-age dependency ratio:
Child dependency ratio: Number of children (ages 0 to 14) per 100 working-age adults (ages 15 to 64).
Old-age dependency ratio: Number of older adults (ages 65 and over) per 100 working-age adults (ages 15 to 64).
In practice, not all individuals ages 15 and 64 are working, nor is everyone less than age 15 or 65 and older dependent, economically or otherwise. Nonetheless, these categories help assess the potential burden age structure places on a country and help classify countries in a way that sheds light on the potential challenges and opportunities they face with any given age structure.
Using these two dependency ratios, we developed a typology of age structures consisting of six summary categories defined as follows:
- High child dependency: Countries with a high child dependency ratio (≥45) and low old-age dependency ratio (<15).
- Moderate child dependency: Countries with a moderate child dependency ratio (≥25 and <45) and low old-age dependency ratio (<15).
- Double dependency: Countries with a moderate child dependency ratio (≥25 and <45) and high old-age dependency ratio (≥15).
- High old-age dependency: Countries with a low child dependency ratio (<25) and high old-age dependency ratio (≥15).
- Low overall dependency: Countries with both a low child dependency ratio (<25) and low old-age dependency ratio (<15).2
- High overall dependency: Countries with both a high child dependency ratio (≥45) and high old-age dependency (≥15).
The timing and pace of a country’s age structure shifts depend on the timing and speed at which its fertility rate changes. This article presents future country-level trajectories for age structural transitions under three fertility scenarios—high, medium, and low fertility—between 2020 and 2100 in the 24 countries. Population projections are generated using assumptions about the future and therefore always include an element of uncertainty and variability that should inform their interpretation. This note of caution is particularly relevant for projections looking far into the future. Even in view of these important limitations, comparing the projected trajectories over the next eight decades across three fertility scenarios enables us to highlight the impact that differences in fertility levels can have on age structure changes over time.3
Our analysis explores when and for how long countries are projected to be classified in the moderate child dependency category under each fertility scenario. Based on the few available definitions of the demographic window of opportunity, the moderate child dependency category is the age structure category that is most aligned with the existing definitions.4
Countries in the moderate child dependency category have experienced a decline in child dependency from a high level (45 or more children less than age 15 per 100 people ages 15 to 64) to a moderate level (between 25 and 44 children less than age 15 per 100 people ages 15 to 64), yet old-age dependency still remains low (less than 15 older adults ages 65 and over per 100 people ages 15 to 64). In this category, working-age adults comprise a larger share of the population than any other age group. Assuming the growing working-age population can find gainful employment in the labor markets, savings, production, and income grow, increasing countries’ capacity to invest in social and economic infrastructure and boost sustainable development. When the old-age dependency ratio reaches higher levels, countries increasingly experience pressure to divert resources towards supporting the older population, for example through pensions and long-term care services. This pressure can exist in both double-dependency and high-old age dependency countries. In countries with a limited pension system, working-age adults still provide a source of informal support to older family members. While the low overall dependency category (where both child and old-age dependencies are low) is also an optimal time for investments that boost economic growth, it is common only in a limited number of countries, typically with sustained immigration of working-age adults.
To identify when and for how long countries are projected to be in the moderate child dependency category under each fertility scenario, our analysis identifies which age structure category the countries are projected to occupy for each five-year period between 2020 and 2100 per scenario. We use population projections produced by the United Nations Population Division (UNPD) based on the high-, medium-, and low-fertility scenarios.5 The assumptions in the three fertility scenarios differ by a half-child per woman; that is, compared to the average woman under the medium-fertility scenario, a woman has a half-child fewer under the low-fertility scenario and a half-child more under the high-fertility scenario. The differences in the age structure trajectories across different scenarios therefore reflect the impact of having a half-child more or a half-child less than the medium fertility assumptions made by the UNPD.
Most Priority Countries Will Retain High Child Dependency for Decades
If fertility decline follows the medium fertility scenario—a pattern similar to past transitions—only half of the USAID family planning priority countries will enter the moderate child dependency category by 2050.
Almost all of the countries analyzed—21 out of 24, with Bangladesh, India, and Nepal as the exceptions—were in the high child dependency category in 2020 (see the 2020 map in Figure 1). Under the medium-fertility assumptions, seven of those 21 countries are projected to make the transition from high child dependency to moderate child dependency between 2020 and 2050.6 Twelve more countries are projected to make the transition between 2050 and 2075, and the last two countries, Mozambique and Zambia, are projected to do so between 2075 and 2100. For countries with late transitions, the time spent in the moderate child dependency category is projected to be brief: By 2100, all 24 countries are projected to have transitioned out of the moderate child dependency category and be in the double dependency or high old-age dependency categories.
The projected timing of the transition from high to moderate child dependency varies substantially across and within regions. Some countries in South Asia have already made the transition and the rest are expected to do so by 2045. The transition is projected to take place between 2050 and 2080 for the 10 countries in East Africa and between 2055 and 2075 for the five countries in West Africa according to the medium-fertility scenario.
Figure 1. Age Structure Categories for the 24 USAID Family Planning Priority Countries (Medium Fertility Scenario): 2020, 2050, 2075, and 2100
Variations in the pace of fertility decline can accelerate or stall age structural transitions by over two decades.
The timing of country transitions across each age structure category and each country’s duration within each category also vary substantially under different future fertility scenarios. Under the high-fertility scenario, in which fertility declines slowly, countries are projected to make the transition into the moderate child dependency category 10 to 25 years later compared to the medium-fertility scenario. In contrast, countries could make the transition five to 20 years earlier under the low-fertility scenario with accelerated fertility decline. Youthful, high-fertility countries, such as those in sub-Saharan Africa, are also projected to spend five to 20 years longer in the moderate child dependency category under the low-fertility scenario compared to the medium-fertility scenario. Extending the duration spent in the moderate child dependency category would give countries more time to invest in the health and education of children and young people and to implement policies for economic growth that are key ingredients for attaining a demographic dividend.
Kenya provides an example of the range of possible transitions from high child dependency to moderate child dependency: Kenya could enter the moderate child dependency category around 2035, 2050, or 2065 under the low-, medium-, and high-fertility scenarios, respectively (see Figure 2). Likewise, Kenya could remain in the moderate child dependency category for as long as 25 years in the low-fertility scenario, compared to just five years in the high-fertility scenario. Our analysis indicates that by accelerating the pace of fertility decline, Kenya could enter the optimal moderate child dependency category 15 years earlier and stay in the category for a decade longer. On the other hand, if fertility declines more slowly than assumed in the medium-fertility scenario, Kenya is projected to enter the moderate child dependency category around 15 years later and spend approximately 10 fewer years in the category.
Figure 2. Age Structure Trajectories for 2020-2100 Under High-, Medium-, and Low-Fertility Scenarios for the 24 USAID Family Planning Priority Countries
Nigeria, which has a higher current fertility rate than Kenya, is projected to enter the moderate child dependency category around 2075 under the medium-fertility scenario but would not reach this category until around 2095 under the high-fertility scenario (see the Nigeria graph in Figure 2). In the low-fertility scenario, Nigeria would enter the moderate child dependency category much earlier, around 2060. Nigeria’s time in the optimal moderate child dependency category could be as short as around 10 years under the high-fertility scenario, or as long as around 30 years under the low-fertility scenario. By accelerating fertility decline to the low-fertility scenario level, Nigeria could enter the moderate child dependency category 15 years earlier and spend five additional years in the category compared to the medium-fertility scenario.
Sound Policy Investments Can Extend the Window of Opportunity
Our findings underscore the need for countries to intentionally plan and allocate resources based on the realities of age structure in their contexts and when they will enter the window of opportunity. Forward-looking planning is essential given the time-limited nature of the window of opportunity. Further, our analysis shows that high-fertility countries that experience faster fertility decline will benefit from a longer-lasting favorable age structure, while slow and gradual fertility decline will compress the window of opportunity and hasten the transition to double dependency burden. As countries anticipate the window of opportunity, the likely duration of that window could influence their policy choices and help policymakers prioritize certain investments.
Countries with a youthful age structure, where a large share of the population is under age 15, should prioritize efforts to expand access to and use of voluntary family planning and reproductive health services. In addition to the benefits of family planning to women and couples, these investments may accelerate the pace of fertility decline and entry into the moderate child dependency category. Investments in family planning programs, as well as efforts to create an enabling environment for young entrepreneurs and job-seekers and ensure an open and stable economy—such as building reliable financial and legal institutions—should continue during the window of opportunity.7 These efforts should go hand-in-hand with investing in developing youth’s human capital, addressing barriers to women’s participation in the formal labor force, and ensuring services and opportunities reach vulnerable, neglected populations. Finally, countries should prepare for the transition to the doubled dependency and high old-age dependency age structures by addressing the spectrum of gender, cultural, and economic barriers that lead to tradeoffs between women’s workforce participation and attaining their desired family size. Further research is warranted on policy priorities that may have the greatest impact in countries projected to experience a comparatively short window of opportunity.
These findings demonstrate how current and future trends in fertility can significantly shift the opening of demographic window of opportunity. The pace of fertility decline in a high-fertility country can impact not only the timing of when the window of opportunity opens, but also the duration the window will stay open. With investments that increase access to and use of voluntary family planning and improve educational attainment for women and girls, countries may be able to open the demographic window of opportunity earlier than projected and have more time to position themselves to achieve the greatest possible benefits from the demographic dividend.
Annex: USAID Family Planning Priority Countries
USAID currently prioritizes 24 countries across Africa, Asia, and Latin America and the Caribbean with support for voluntary family planning and related health services to enable women and couples to have the number of children they want when they want them.
Democratic Republic of Congo
Latin America and the Caribbean
PRB would like to acknowledge Automata Studios for their development of the charts and visuals in this web article.
- Kaitlyn Patierno, Smita Gaith, and Elizabeth Leahy Madsen, “Which Policies Promote a Demographic Dividend? An Evidence Review,” 2019, www.prb.org/resources/which-policies-promote-a-demographic-dividend-an-evidence-review/.
- Both the low overall dependency and high overall dependency categories are rare and occur more often in countries with unique fertility and migration patterns.
- The impact of any errors in the assumptions underlying population projections compounds over time, so the longer the projection period, the greater the chance the projection results will not hold. However, the long-term projections up to 2100 allows us to explore how different fertility scenarios result in remarkably different age structures for countries.
- United Nations (UN), Department of Economic and Social Affairs, World Population to 2300 (New York: UN, 2004); Richard Cincotta, “Opening the Demographic Window: Age Structure in Sub-Saharan Africa,” New Security Beat, 2017, www.newsecuritybeat.org/2017/10/opening-demographic-window-age-structure-sub-saharan-africa/.
- UN, Department of Economic and Social Affairs, World Population Prospects: The 2019 Revision (New York: UN, 2019).
- We assume age structure transitions take place in the middle of the given five-year period.
- Patierno, Gaith, and Madsen, “Which Policies Promote a Demographic Dividend?”