Parliamentary and Policy Adviser APPG

13 March 2006

Ann Mette Kjaerby,

Room 563 Portcullis house,

House of Commons

Westminster SW1A 2LW

Dear Ms Kjaerby,

I am enclosing an evidence submission for the All-Parliamentary Group on Population, Development and Reproductive Health from members of the IDS. This has not been written jointly but different individuals have contributed and I have brought them together into one submission.

The focus areas addressed are 1. The importance of sexual and reproductive health and rights to meeting the MDGs in poverty, gender equality and maternal and child health, and 2. Population growth and water ‘crises’

The Institute of Development Studies is an international centre for research, post graduate teaching, and training on development issues particularly as they affect low, middle income and transition countries.

Contributing researchers are:

Susan Jolly – Gender, sexuality and development

Lyla Mehta – Development and environment with particular reference to water management

Hilary Standing – Gender, reproductive health and development

Yours sincerely

Dr Hilary Standing

Fellow, Knowledge, Technology and Society Team

The following submissions address aspects of the MDGs in health, poverty and gender equality and in environmental sustainability. The first set of comments concerns the pressing need to improve the sexual and reproductive health (SRH) of poor populations so as to address the MDGs more broadly. The second set draws attention to the contribution of sexuality and sexual rights in meeting the MDGs and frames the question of rights in the context of the current debate about population growth. The third set examines the question of water scarcity and raises doubts about the centrality of population growth as determining factor.

We are aware of a renewed concern about demographic projections, particularly in relation to sub-Saharan Africa. We do not hold a collective view on this. Some colleagues are very concerned at what they see as a rising neo-Malthusianism in debates about population growth particularly given the history of population control policies in some parts of the world. Others question whether aggregate “numbers” tell us anything about global developmental trajectories. We do share a concern that this should be an open, informed and democractic debate, bringing in the voices of all stakeholders, including those of civil society in the countries most affected.

Importance of improving SRH to meet the MDGs

Improvements in SRH will serve to increase the likelihood of meeting several MDGs in the following ways:

· By reducing the wholly disproportionate burden of disease from easily treatable or avoidable SRH related conditions

· By contributing to poverty reduction through multiple pathways, including reducing the impoverishing impacts of poor reproductive health and of maternal deaths

· By contributing to improving gender equality by enabling women and men to make choices about their reproductive lives and sexual wellbeing

There are extremely strong links between good SRH, reduced fertility and poverty reduction. For example, failure to deal with obstetric complications, unsafe abortion, low birth weight and early childbearing result in life-long morbidities such as fistula which affect individual and household productivity and welfare. Longer birth intervals decrease child mortality. Lower numbers of births decrease the risk of maternal mortality and morbidity. Lower fertility is generally associated with reduced poverty at household and national levels.

(Taken from “Bringing Population dynamics and SRH into Development Policy Debates, presentation by Dr Jaques Baudouy, AFD-DFID Workshop on Demography, Reproductive Health, and Sustainable Economic Growth in Africa, Paris, 1-3 March)

However, millions of poor people lack access to decent services and the technologies which could transform their SRH. Of greatest concern is the level of inequality in access to and utilisation of services by the poorest quintiles where there are disproportionately worse sexual and reproductive health outcomes. For example, use of skilled birth attendants in the lowest quintile of the population in Bangladesh is 4% against 42% for the highest quintile (itself an unsatisfactory figure). The same pattern of inequality holds across all SRH services. Yet most SRH interventions that can make a difference are well tried and tested and relatively lost cost. The universal availability of comprehensive essential obstretric care would avert 40% of maternal deaths. UNFPA’s Global Survey of 2003 shows an unmet need for contraceptives of 29% among women in the south. This unmet need is also demonstrated by the estimated 68,000 women risking death through unsafe abortion (almost certainly an underestimate). Access to safe abortion would save up to 15% of maternal deaths.

There are grounds for serious concern that – despite the international endorsement of the Cairo Agenda, SRH has fallen between the cracks of successive international initiatives on global health, particularly the increasingly verticalised global disease programmes, including HIV and AIDS. Despite commitments, resources have been declining (see below). This trend must be urgently reversed if the MDGs which are influenced by SRH are to be met. It requires renewed international and bilateral commitment to support national, non-governmental and civil society efforts to create an enabling environment for meeting SRH needs. Donors also need to look closely at the kinds of aid instruments they are increasingly favouring, such as direct budget support, to see whether they are contributing to or detracting from an enabling environment for SRH.

Population impacts on MDGs: Connections with sexuality and rights

Before the International Conference on Population and Development (ICPD) held in Cairo in 1994, discussions around population focussed almost exclusively on demographic and macro-economic aspects, with a virtual silence around gender and sexuality - even though sex is still the main way through which people get pregnant, and gendered access to health services, as well as heterosexual gender dynamics have huge implications for decision-making on, and impacts of fertility.

At Cairo, a breakthrough was achieved with sexuality and gender making it onto the agenda, and a broader understanding of population issues asserted, including the agreement in the Cairo Convention of 1994 which understands reproductive health to include that ‘people are able to have a satisfying and safe sex life’. The following year, gender and sexuality were again part of the discussion at the Fourth World Conference on Women at Beijing, and the Platform for Action was agreed which asserts women’s rights to ‘have control over and decide freely and responsibly on matters related to their sexuality’ (paragraph 96). These agreements were achieved due to both government and activist mobilisation around sexual and reproductive health and rights, and strengthened the foundations for further application of rights based approaches to sexuality and reproduction.

Development has largely dealt with sexuality in limited or negative ways, for example in relation to family planning, ill-health and violence. But development needs to engage with sexuality far more broadly. The connections between sexuality and poverty are extensive, as shown by the application of Robert Chambers ‘Web of Poverty’s Disadvantages’ to the issue of sexuality in a recent IDs Policy Brief on sexuality and development. The importance of sexuality for human well-being and fulfilment, and as a determinant of inequalities and poverty must be acknowledged, and an analysis of the connections with sexuality incorporated into all policies and programmes tackling poverty. Sexual rights frameworks provide a promising entry point for development to engage with sexuality. However to date these frameworks have focused largely on negative rights - to freedom from discrimination, violence and ill-health. Sexual rights frameworks need to go further and also recognise the positive aspects of sexuality, including rights to sexual fulfilment, well-being and pleasure.

SRHR, including improved access to sexual and reproductive health services, and sex education, and the contribution all these make to reducing poverty, will contribute to slowing population growth. There have been positive examples of population reduction through improved sexual and reproductive health services, and increased female literacy – for example, Amartya Sen argued that Kerala’s population reduction strategy contrasted favourably with China’s top-down population control approaches of the early ‘90s. Kerala’s policies were both more empowering and more effective.

This underlines the importance of maintaining a strong focus on rights in the field of population health and of keeping the reminder of historical experience in this area. In respect of history - the assertion of the rights of individuals to reproductive choice (which also includes the right not to have children - an important but neglected point given the strong pressures in many societies for natalism)was strongly argued as the basis for the Cairo consensus. This was both in the context of a broader concern about gender empowerment, and due to concerns in developing countries from the 1970s over population control policies which encouraged coercive practices (particularly where incentive based family planning programmes operated). In a number of contexts (e.g. India in the late 70s and through the 80s) these were something of an "own goal" in public health terms as well as a rights infringement. So any debate about rights in the area of fertility choice has to be sensitive to this history, including the danger of instrumentalist arguments of ends justifying means.
In the international human rights framework the key actors are individuals (who have rights) and nation states (which are the duty bearers in safeguarding those rights). Arguably, this is not the most nuanced way of thinking about rights in an arena which straddles many interests "beyond the individual." But the concept of the "rights of the state" in a strong sense to determine the reproductive behaviour of individuals potentially conflicts with the state’s role as a duty bearer to safeguard citizens from abuse or coercion. However, states certainly can, and arguably have a duty to, advocate for behaviours or actions that are considered to be in the broader public interest. The more important question is therefore who/which groups decide on the nature of the public interest and on the basis of what evidence? The need is therefore for an informed debate involving all voices and enabling all parties to have access to high quality evidence and argument.

Environmental sustainability: Scarcity, water ‘crises’ and the ghosts of Malthus

On the eve of the Fourth World Water Forum, there is again much talk about future ‘water crises’ due to growing water scarcity and population growth. The problems are well known. Globally, 1.1 billion people lack access to drinking water and 2.6 billion lack adequate sanitation facilities. Clearly, the lack of access to safe water and sanitation is one of the most pressing problems confronting humankind’s survival and it is shocking that in the new century millions of women and young girls still have to walk miles and miles for a small pot of water in different parts of the world.

But is population growth the cause of these woes? Many conventional analyses tend to think so. Projections of water supply and population growth rates predict a dark scenario of the future: while the average per capita supply of water will decrease by one third by 2025, water use will increase by about 50 percent during the same period. As a consequence, half of the world’s population will live under conditions of ‘severe water stress’, with Africa, the Middle East and South Asia being most affected.

Largely even though Malthusian mathematics may no longer be adhered to, neo-Malthusians tend to focus on human numbers as the cause of current scarcity to population growth as the cause of absolute scarcity in the future. Thus volumetric quantities and projection of future demand for water against population growth are common instruments used. Population growth, mismanagement and the lack of supply are seen as the main reasons for water ‘crises.’

Several flaws exist in these dominant perceptions of resource ‘crises’ and population growth. For instance, by focusing only on aggregate figures of water supply versus water demand relative to population rates the distribution of existing water resources is ignored. From Amartya Sen we know that some people’s lack of water does not necessarily imply that water is scarce. Instead, it may mean that certain sections of the population are unable to gain access to water for a range of reasons: be it that water is too highly priced; due to the lack of infrastructure, or due to social exclusion. Thus the aggregate water availability in a region or the average water per capita tells us little about the distribution of water within the society as a whole. Power relations, such as who has control over and access to water, rather than absolute scarcity are usually the underlying factors causing the water crises. IDS research, for example, by drawing on detailed anthropological and sociological research has demonstrated water ‘crises’ are usually the result of struggles over access to, and control over water resources. Moreover, scarcity is often politicised to legitimise controversial schemes that do not end up benefiting the water-poor and those currently lacking access to water.

Scarcity and population growth are also linked with future resource conflicts. Neo- Malthusian thinkers such as Homer- Dixon and Clare have claimed that population growth especially in water stressed areas can lead to violent conflict. But this thinking is flawed because resource scarcity is seen to play an independent role in causing conflict and other factors such as ideology, power relations, unequal property rights are seen as subordinate. Often crises occur because powerful actors get away with resource appropriation and thus enhance environmental degradation Moreover, examples where, despite scarcity, cooperation rather than conflict occurred are largely ignored. From common property theorists such as Elinor Ostorm we know that institutions matter and that local people, as well as governments, can successfully manage resources through property regimes varying in scale and space. They have also succeeded in directing attention away from simplistic neo-Malthusian equations concerning population, resource availability and environmental degradation. Thus Hobbesian notions of anarchy—where states, regions, and people engage in noncooperative strategies and fight over scarce resources—may not be an accurate or predictable scenario. Thus, seeing people and ‘nature’ as contradictory and human action as inherently bad for the environment ignores how people manage environmental resources in a positive and sustainable way., has demonstrated at a recent workshop on scarcity at IDS how underlying neo- Malthusian assumptions and narratives on scarcity influence policy decisions in different areas such as population control and environment.