WUNRN
The
Lancet, Volume
380, Issue 9837, Pages 142 - 148, 14 July 2012
Published
Online: 10 July 2012
GLOBAL POPULATION TRENDS &
POLICY OPTIONS - GENDER
Summary
Rapid
population growth is a threat to wellbeing in the poorest countries, whereas
very low fertility increasingly threatens the future welfare of many developed
countries. The mapping of global trends in population growth from 2005—10 shows
four distinct patterns. Most of the poorest countries, especially in
sub-Saharan Africa, are characterised by rapid growth of more than 2% per year.
Moderate annual growth of 1—2% is concentrated in large countries, such as
India and Indonesia, and across north Africa and western Latin America. Whereas
most advanced-economy countries and large middle-income countries, such as
China and Brazil, are characterised by low or no growth (0—1% per year), most
of eastern Europe, Japan, and a few western European countries are
characterised by population decline. Countries with rapid growth face adverse
social, economic, and environmental pressures, whereas those with low or
negative growth face rapid population ageing, unsustainable burdens on public
pensions and health-care systems, and slow economic growth. Countries with
rapid growth should consider the implementation of voluntary family planning
programmes as their main policy option to reduce the high unmet need for
contraception, unwanted pregnancies, and probirth reproductive norms. In
countries with low or negative growth, policies to address ageing and very low
fertility are still evolving. Further research into the potential effect of
demographic policies on other social systems, social groups, and fertility
decisions and trends is therefore recommended.
Introduction
After
more than a half century of unprecedented growth, the global population reached
7 billion individuals in 2011. This modern expansion of the human population
started at the onset of the industrial revolution in the late 18th century with
a decline in the death rate in Europe and the USA and Canada. In the 20th
century, reductions in death rates in Africa, Asia, and Latin America followed,
leading to a population explosion at the end of that century. Nowadays, growth
continues in most countries, but declines in birth rates are offsetting
declines in death rates and population size is expected to reach 10·1 billion
at the end of this century.1 If this projection holds, the
world's population will have grown by more than tenfold—from 0·8 to 10
billion—between 1800 and 2100.
In
this report, we summarise variations in growth and their consequences for
different regions of the world and then present policy options for addressing
undesirable population trends in developing and developed countries.
Global demographic
patterns in the past 50 years
In
the past five decades, demographic change has been more rapid and more
universal than in any other period of human history. As a result, the world is
now more diverse in birth, death, and growth rates than ever. Figure 1 shows this diversity by mapping global patterns of
population growth rates. Countries can be divided into groups depending on
their current population growth rate.
Rapid growth
(>2% per year)
This
group includes most of the poorest countries in the world: much of sub-Saharan
Africa, parts of south Asia (Pakistan and Afghanistan), the Arabian peninsula (which
also includes rich oil-producing countries with small populations), and a few
small countries in Latin America. These populations have relatively high
fertility compared with the rest of the world, and moderate to low mortality.
Population size in this group is expected to double by 2050.
In
sub-Saharan Africa, despite substantial mortality from AIDS, the population
growth rate is strongly positive and the UN expects no country in the continent
to have negative growth because of the epidemic.2
This is true even in South Africa where the epidemic is particularly severe and
fertility is lower than in the rest of the region. Consequently, the population
of sub-Saharan Africa is projected to more than double from 0·86 to 1·96
billion between 2010 and 2050 with some countries (eg, Niger) tripling in size.
Such rapid growth has several adverse consequences.
Key
messages
- Demographic change has been more rapid and more
universal in the past five decades than at any other period in human
history, with birth, death, and population growth rates varying widely
across world regions. Future trends, at least for the next four decades,
will also vary substantially.
- Fertility rates have declined to below three births per
woman in all regions of the world except for sub-Saharan Africa where
women, on average, still have more than five children.
- Whereas the population of Europe will decline marginally
during the next four decades, that of sub-Saharan Africa will more than
double in the same period.
- Implementation of voluntary family planning programmes
has been the main policy response to high fertility and rapid population
growth. A well-organised family planning programme can reduce fertility by
about 1·5 births per woman. The effect on future population can be very
large. For example, the difference in fertility rates assumed for the low
and high variants in the UN population projections is only one birth per
woman but it yields a difference of 2·6 billion people in sub-Saharan
Africa by 2100.
- Delay in the implementation of voluntary family
planning programmes in settings with rapidly growing populations has huge
implications for future demographic trends and socioeconomic development.
- Below-replacement fertility in economically advanced
countries is a major threat to wellbeing. The rapid ageing of the
population in these countries poses substantial challenges to public
pensions and health-care systems and could lead to slower growth in income
per head than is currently achieved.
- Supporting efforts to reduce high fertility in
developing countries while advocating probirth policies in developed
countries seems contradictory and is a challenge to the global development
agenda; but it is sound policy aimed at improving human welfare in both
settings.
Rapid
population growth puts pressure on public services and infrastructure.
Low-income countries tend to have limited public services (ie, health care,
education, municipal), an insufficiently trained labour force, and weak
infrastructure (eg, roads, water supply, electricity). Governments' attempts to
overcome these problems are made more difficult by the rapidly growing number
of people that need to be served. New services, new school graduates, and new
infrastructure have to be created at a rate of 2—4% per year simply to maintain
conditions without deterioration.
A
rapidly growing population can result in reduced economic growth because it
leads to a high ratio of young to working age people, thus reducing income per
head and contributing to low savings.3
Poor health can likewise result from rapid population increases. Low income
countries do not have the private and public resources to ensure adequate
health care, and available health-care facilities are often unable to serve
adequately the ever increasing needs of the population. Additionally, high
birth rates, childbearing at very young and at advanced ages, and short birth
intervals increase maternal and child mortality.4
Another
result of rapid population growth is stress on the environment.
Expanding
populations and rising consumption contribute to several worrying environmental
trends: shortages of fresh water; depletion of soils; pollution of air, water,
and soil; rising food and energy costs; deforestation; and loss of
biodiversity. Prospects are worst for the poorest countries (most of them in
sub-Saharan Africa) which have very rapid population growth and limited
agricultural resources such as water and arable land.5
For example, Niger's population is projected to more than triple (from 16 to 55
million) between 2010 and 2050. Whether this growth is feasible is not clear,
since available arable land is very limited and threatened by desertification,
and much of the present population lives on the edge of famine.
Moderate growth
(1—2% per year)
This
group includes large countries such as India and Indonesia, and north Africa
and western Latin America. Most have relatively low death rates compared with
the rest of the world, and fertility that has been declining for some time. In
these populations the adverse consequences of very rapid growth are being
reduced. In particular, the decline in fertility has several benefits with
time: stresses on public services and infrastructure become less acute,
maternal and infant mortality benefit from the widespread use of contraception,
the economy receives a boost (the so-called demographic dividend) as the labour
force grows more rapidly than the young and old dependent population, and women
can start working for wages outside the household instead of devoting most of
their time to childrearing.6,
7
Low or no growth
(<1% year)
This
group includes the most advanced-economy countries (eg, the USA and Canada and
much of Europe) and several large middle-income countries (eg, China and
Brazil) which have completed their transitions to low fertility and have near
zero growth rates. Although the stresses of rapid population growth no longer
exist in these countries, they have high consumption levels and hence are major
contributors to global environmental problems such as climate change. Additionally,
these countries now face a new demographic challenge—population ageing. Ageing
has been underway for several decades and is expected to continue at a rapid
pace for the foreseeable future. For example, between 2010 and 2050 the
proportion of elderly people (aged more than 65 years) is projected to rise
from 16·3 to 27·4% in Europe, from 13·1 to 22·0% in the USA and Canada, from
22·6 to 37·8% in Japan, and from 8·2 to 23·3% in China.1 These trends have major
implications for the welfare of elderly people and for the economy. In rapidly
developing countries (eg, China) support has traditionally been provided by
families, but this support is under threat because parents have fewer children
than in the past and children increasingly move away from home. Unfortunately,
few developing countries have created formal institutions to take over this
care. By contrast, in developed countries much of the support for elderly
people is now provided by public pensions and health-care programmes. These
programmes are popular and have successfully reduced poverty for elderly
people, but their sustainability is being threatened as their costs become
increasingly burdensome to tax payers. Developed countries with ageing
populations are now struggling to address the fiscal stresses in these systems
because failure to do so could have severe economic consequences.
Population decline
(<0% per year)
A
small but growing number of countries have defied earlier projections and are
now declining in size. Japan, Germany, Russia, and much of eastern Europe had
negative growth in 2005—10. By 2050, Russia is projected to have 17% fewer
people than in 2010 and Japan 20%. Additionally, these countries will have the
greatest ageing, with the proportion of people aged older than 65 years
reaching more than 30% by 2050.8
The
key demographic cause of negative growth is fertility below the replacement
level of 2·1 births per woman. With such low fertility each generation of women
is smaller than the previous one thus leading to population decline. Two fifths
of the world's population now lives in countries with fertility below
replacement (eg, Europe's 1·5 and China's 1·6 births per woman). However, three
offsetting demographic factors can keep below-replacement countries temporarily
growing: rising life expectancy, because the longer people live the more people
are alive; immigration; and population momentum, which refers to the boost in
growth produced by a young population age structure. Together these factors
explain why the number of countries with below-replacement fertility nowadays
is much larger than the number of countries that have negative growth. However,
the UN expects the list of countries with negative growth to increase as the
role of the offsetting factors diminishes with time.
Future population
trends 2010—50
Figure 2 shows trends in projected global population to 2050 based
on the low, medium, and high variants of the UN projections.1 These variants differ only in the
assumptions regarding the future path of fertility. For the medium variant
projection, fertility trends are based on a new probabilistic method that uses
empirical fertility trends estimated for all countries of the world for the
period 1950 to 2010. The low and high variant projections assume fertility will
remain half a birth lower or higher, respectively, than the medium variant rate
for the projection period. As shown in Figure 2,
a slight change in assumed fertility leads to a substantially different
population trajectory. In the high variant assumption, population size in 2050
is 1·3 billion people higher than in the medium variant and the low variant is
1·2 billion lower.
The table1 summarises the UN medium variant
population projections from 2010 to 2050 for major regions of the world. The
population of sub-Saharan Africa is expected to more than double by 2050,
making it by far the most rapidly growing region. Asia, Latin America, and the
USA and Canada are projected to add about a quarter more to their present
populations. Europe is the only region where a decline is anticipated (mostly
in eastern Europe).
Population
projections (2010—50), by region, UN medium variant
By
2010, fertility had declined to below three births per woman in all but one
region. The important exception is sub-Saharan Africa where fertility is still
greater than five births per woman. In future decades, fertility declines are
projected in all developing regions with the largest decline assumed in sub-Saharan
Africa (from 5·1 in 2005—10 to 2·5 in 2045—50). Whether such a rapid decline
can be achieved is debatable and, as noted, even a modestly higher fertility
trajectory will lead to much higher population in 2050.
Fertility
declines are achieved by expanding the use of contraception among women of
reproductive age. In developing countries as a whole, contraceptive prevalence
rose from a few percent in the 1950s to 61% in 2010, with very large increases
in Asia and Latin America. Unfortunately, sub-Saharan Africa still lags behind
in contraceptive uptake. The region witnessed some improvement in use between
1990 and 2000 (from 13 to 20%), but contraceptive use seems to have stagnated
in the past decade.9 Should this trend continue, the
population of sub-Saharan Africa will be well beyond the projected 2 billion
mark in 2050. For many developing countries and particularly sub-Saharan
Africa, achieving contraceptive prevalence consistent with the projected medium
variant population growth will require substantial investment to meet the unmet
need for family planning.
Population policy
options in developing countries
Since
the 1960s, alongside efforts to increase levels of education and to improve
health, the main policy response to high fertility and rapid population growth
has been implementation of voluntary family planning programmes that provide
information about, and access to, contraceptives. This policy has permitted
women and men to control their reproductive lives and avoid unwanted
childbearing. The choice of voluntary family planning programmes as the main
policy instrument to reduce fertility has been based largely on the
documentation of a substantial rate of unwanted childbearing and an unsatisfied
demand for contraception. When questioned in surveys such as the Demographic
and Health Surveys or World Fertility Surveys, large proportions of married
women in developing countries report that they do not want a pregnancy soon. A
substantial proportion of these women (more than half in some countries) are
not protected from the risk of pregnancy by practising effective contraception
and, as a result, unintended pregnancies are common.10 Family planning programmes
provide a win-win solution; the welfare of individual women and children is
improved, and the national economy and environment benefit. The present
international consensus around this issue is shown in the Millennium
Development Goals, specifically in target 5B—to provide universal access to
reproductive health by 2015 and to reduce the unmet need for family planning.
Figure 3 presents estimates of unmet need for contraception for
major regions of the world between 1990 and 2009. In sub-Saharan Africa, a
quarter of women have an unmet need for family planning, which is twice as high
as in any other region. Additionally, the extent of unmet need for family
planning in the region has remained almost unchanged since 1990 and trends in
the past decade suggest a possible increase.
Figure
3 - Percentage of married women with unmet need for contraception by region,
1990—95, 2000—05, and 2009
Data
from UN world contraceptive use, 2010.9
LAC=Latin America and Caribbean. N=North. S=southern. SSA=sub-Saharan Africa.
According
to Singh and colleagues,10
meeting the contraceptive needs of 215 million women with unmet need for modern
contraception would reduce unintended pregnancies by more than two thirds,
avert 70% of maternal deaths, 44% of newborn deaths, and 73% of unsafe
abortions, and reduce by 76% the number of women needing medical care for
complications related to unsafe abortion. In addition to these health benefits,
the resulting reduction in fertility and population growth would bring
substantial socioeconomic and environmental benefits.
Effect of voluntary
family planning programmes on fertility
The
substantial shifts in reproductive behaviour in the developing world during the
past 50 years are well established, but debate about the causes of this change
continues. Whereas conventional demographic and economic theories emphasise the
demand-driven nature of reproductive change,11
revisions and elaborations of these theories assign crucial roles to changes in
the cost of birth control and to ideational shifts such as changing attitudes
to birth control and diffusion mechanisms.12—15 Family planning programmes can contribute
substantially to accelerate fertility transitions by reducing the various costs
(broadly defined to include health, social, and psychological obstacles to use
of contraception and abortion) and by providing information that can affect
parent's assessments of the costs and benefits of children.
Measurement
of this fertility effect of family planning programmes is not straightforward
since it requires the estimation of an unobservable quantity—ie, the level of
fertility that would have occurred in a population if the family planning
programme had never been implemented. The best available evidence of the
effects of such programmes comes from both controlled and natural experiments.
The
largest and most influential controlled experiment in the discipline of family
planning is the Family Planning and Health Services Project that started in the
late 1970s in Matlab, a rural district of Bangladesh.12, 16,
17Figure 4
summarises the effect of the programme on fertility. Within 2 years of the
start of the intervention, the proportion of women using contraception in the
intervention area increased from less than 5 to 32%. By contrast, very little
change occurred in the control area and in the rest of Bangladesh during the
first years of the experiment. The rise in contraceptive prevalence in the
intervention area led to a decline in fertility of about 1·5 births per woman
below that in the control area. The success of this intervention led to the
adoption of the Matlab model by the Bangladesh government as its national
family planning strategy.
Figure
4 Full-size image (34K) Download
to PowerPoint
Bangladesh
also presents a natural experiment in comparison to Pakistan. The two countries
were united from 1947 until Bangladesh was created after the civil war in 1971.
As a result, these two populations still have much in common and levels of
development are broadly similar, even though Pakistan scores slightly higher on
several development indicators. Figure 5
shows the trends in fertility in the two countries from 1975 to 2010. In
1975—80, the two countries had nearly the same very high fertility of 6·6
births per woman, but trends diverged in subsequent decades. By the late 1990s,
Bangladesh's fertility had declined to 3·4 births per woman while in Pakistan,
fertility remained at 5·0.
Figure
5 Full-size image (26K) Download
to PowerPoint
Fertility
trends in Pakistan and Bangladesh, 1975—05
Data
from UN world population prospects: the 2010 revision.1
Much
of the contrasting fertility trends in these two countries can plausibly be
attributed to differences in family planning programmes. Pakistan's programme
has been weak and ineffective and has lacked government funds and commitment.
By contrast, Bangladesh has implemented one of the world's most effective
voluntary family planning programmes, using the experience and lessons from the
Matlab experiment. A unique feature of the programme is its cadre of literate
female workers who counsel women and distribute supplies at the doorstep, thus
overcoming the barriers posed by the purdah system (ie, the practice of
concealing women from men).20
Bongaarts21
has described other such natural experiments comparing Kenya and Uganda,
Indonesia and the Philippines, and Iran and Jordan. In all these comparisons,
fertility was substantially lower in the countries with strong programmes
(Kenya, Indonesia, and Iran) than in the corresponding countries with weak
programmes (Uganda, the Philippines, and Jordan). These findings from both
controlled and natural experiments support the conclusion that a well-organised
family planning programme with a substantial
information—education—communication component can reduce fertility by about 1·5
births per woman.
The
effect of such a reduction in fertility on population size can be very large.
For instance, the difference in fertility rates between the low and high
variant of the UN projections for sub-Saharan Africa is one child per woman. By
2050, that difference will result in a difference of half a billion people in
the population of that region, depending on whether actual fertility follows
the path of the low or high variant projection. In the absence of substantial
investments in family planning programmes in the region, the high variant could
well become a reality, especially in view of the slow pace of fertility change
in the region. However, with substantial new investments in family planning in
sub-Saharan Africa, the low variant could probably be achieved. The timing of
fertility decline is also a crucial determinant of future population growth.
For example, Pakistan's failure to promote family planning in the 1970s and
1980s led to much more rapid population growth than in Bangladesh. In 1980,
Pakistan's population (80·5 million) was slightly smaller than Bangladesh's
(80·6 million), but by 2050 its population is projected to be 41% larger than
Bangladesh's (275 vs 194 million).1
When populations are growing rapidly, a delay in the implementation of family
planning programmes and the fertility decline associated with them have major
implications for future demographic trends.
Policy options in
countries with low fertility
Although
much attention of policy makers and researchers has justifiably focused on high
fertility in the developing countries of sub-Saharan Africa and southeast Asia,
concerns about the adverse effects of below-replacement fertility in
economically advanced countries are rising rapidly. Policy makers have, until
recently, been reluctant to support probirth measures and action. Several
factors explain this reluctance: a disinclination to interfere with personal
decision making about family size, the apparent inconsistency of advocating probirth
policies at home while supporting efforts to reduce fertility in developing
countries, the hope that fertility will soon increase again without
intervention, and the high cost of intervention.22, 23
However this reluctance has now largely disappeared as the cost of inaction
becomes increasingly evident and efforts to reform pension policies and
health-care systems have proven difficult and unpopular. Moreover, if fertility
remains very low then reform alone will be inadequate to address the problems.
Various measures have been implemented or are being considered, including birth
bonuses, family support measures (eg, subsidised childcare, reduced taxes for
families with children), paid parental leave, and even a dating service (in
Singapore). Such measures can be expected to raise fertility because on average
in most developed countries, actual fertility is lower than desired family size
and reductions in the cost of childbearing will make it easier for women to
combine a career with the preferred level of childbearing. Reviews of the past
effect of such measures conclude that they can indeed raise fertility but the
effect is modest. 22—25
Country studies in the past 10 years in Japan, Italy, and Spain, among others,
confirm this conclusion and show that probirth policy measures can have
different effects in different institutional, cultural, or economic
environments.24—28
Another
important policy option linked to addressing low fertility in economically
advanced countries is immigration. However, some researchers estimate that
hundreds of millions of immigrants will be needed to keep the ratio of working
age people to dependants constant in the many countries with low fertility.29
Despite increasing approaches to limiting the migration of unskilled people,
policies in high-income countries with low fertility are converging on the need
to attract increasing numbers of highly skilled workers and this objective is
being realised through regular immigration programmes in countries such as
Canada, Australia, the USA, France, Germany, and the UK.30
The effect of this pattern of migration on development in the countries of
origin of the immigrants is not clear and the traditional debates around
so-called brain drain (and more recently on brain gain) are dominant themes in
discussion of international migration and development.
Conclusions
Rapid
population growth and high fertility are a threat to the wellbeing of
individuals and societies in the poorest developing countries. The choice of
voluntary family planning programmes as the main policy instrument is based
largely on evidence of a substantial unsatisfied demand for contraception.
Family planning programmes aim to reduce the various social, economic, and
health obstacles to the use of contraception, thus reducing unwanted fertility.
Additionally, information—education—communication messages can contribute to
declines in desired family size.
The
very low fertility now prevailing in many developed countries is increasingly
also regarded as a threat to the future welfare of these societies. Rapid
population ageing is leading to an unsustainable burden on public pensions and
health-care systems. Additionally, ageing and population declines are expected
to lead to slower growth in income per head than is currently achieved.
Unfortunately, an understanding of the linkages between policies, social and
economic conditions, and fertility remains limited, thus making it more
difficult to consider action. Further research is needed to elucidate the
potential effect of various family policies on childbearing decision-making; on
the role of the welfare state and its cultural underpinnings in determining
long-term fertility trends; on the interaction of demographic policies with
other social systems, such as gender and the family; and on the effects of
policies on different social groups.28
The
need for further research should not prevent policy makers from taking action
now based on present knowledge and experience to address the challenges of high
and low fertility regimes and to reduce their adverse effects on the wellbeing
of families and societies.
Search strategy and
selection criteria
For
this report, we started with brainstorming sessions to define our priorities
and focus and then identified key relevant published work and data sources on
the basis of the extensive collection of published and grey literature
available to us through many years of working on related topics. We also
searched databases including Popline and Medline, with the terms “population
growth”, “population trends”, “policy options high fertility countries”,
“policy options low fertility countries”, “family planning”, “unmet need”,
“future population trends”, “population ageing”, “HIV/AIDS and population
growth”, and “demographic transition”. We used the principle of intensity
sampling to select items that would best clarify the nature of the topic of
interest.
For
the secondary data analysis, we searched databases and websites for secondary
datasets, including the UN Department of Economic and Social Affairs/Population
Division for data on world contraceptive use 2010 and unmet need for family
planning; population projections to 2100; WHO Department of Family and
Community Health, Regional Office for South-East Asia, New Delhi, India; and
the World Bank country poverty data for data on family planning, and about
Bangladesh and Pakistan. For these secondary data sources, we applied the
principle of reputational case selection, in which instances are chosen on the
recommendation of an expert or key informant, to identify secondary data
sources relevant to addressing global population trends and to shaping ideas
for programme and policy priorities. These searches were done several times
from October, 2010, to March, 2012.
Contributors
ACE
led the entire process of writing this report, beginning with conceptualisation
in consultation with coauthors. He drafted the outline, and guided the review
of relevant published work and analysis of secondary data. He wrote the
introduction and conclusion of the paper. JB contributed to conceptualising and
shaping the report. He wrote the section about demographic patterns in 2010 and
guided on inputs relating to the demographic effect of the AIDS epidemic. BM
wrote the sections about future population trends, 2010—50, and population
policy options in developing countries and low fertility countires. All authors
read and approved the final version of the report.
Conflicts
of interest
We
declare that we have no conflicts of interest.
Acknowledgments
We
thank the Hewlett Foundation for their general support to the African
Population and Health Research Center, which supported the writing time of ACE
and BM. We also thank Remare Ettarh for assistance in generating Figure 1.
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