Population, Health Care, Welfare and Pension Systems Ryuzaburo Sato National Institute of Population and Social Security Research 7
Dr. Ryuzaburo Sato is Director of Department of Information Collection and Analysis, National Institute of Population and Social Security Research, Tokyo, Japan. 8
Table of Contents Table of Contents 9 List of Tables 10 List of Figures 11 Abbreviations 12 Executive Summary 13 1 Introduction Relationship between Development Issues and Population Issues in Less Developed Regions 16 2 Demographic Trends in Less Developed Regions 16 2.1 Trends in Population Size 17 2.2 Demographic Transition 19 2.3 Mortality Trends 22 2.4 Fertility Trends 24 2.5 Trends in Sex/Age Structure 27 2.6 Changes in Families 29 2.7 Urbanization and Internal Migration 30 2.8 International Migration 31 3 Factors in Demographic Changes in Less Developed Regions 31 3.1 Approaches for Research on Fertility Determinants 31 3.1.1 Proximate Determinants Approach 31 3.1.2 Economic Rationality Approach 33 3.1.3 Cultural Norms Approach 33 3.2 Policy Intervention in Fertility 34 3.3 Spread and Limitations of Family Planning Programs 34 4 Impacts of Demographic Changes in Less Developed Regions 36 4.1 Impacts of Rapid Population Growth 36 4.2 Impacts of Population Aging 38 5 Policy Measures 39 5.1 Population Policies and Debates 39 5.2 Integrated Approach to Problems on Population, Development and Environment 40 5.3 Empowerment of Women 41 9
5.4 Reproductive Health and Rights 42 5.4.1 Definition and Philosophy 42 5.4.2 Background to the Rise of Reproductive Health and Rights 43 5.4.3 Significance and Problems of Reproductive Health and Rights 43 5.4.4 Reproductive Health and Rights and the Future of Fertility Transition 44 5.5 Diffusion of Family Planning and Problems 44 5.5.1 Unmet Need and Satisfaction of It 44 5.5.2 Service Quality and Informed Choice 45 5.5.3 Roles of Family Planning Programs 45 5.6 Improvement in Health Care and Problems 46 5.7 Establishment of Social Welfare and Social Security Systems(Especially Pension Systems) and Problems 46 6 Conclusion Outlook and Suggestions 47 6.1 Outlook Importance of Population and Development Issues 47 6.1.1 Expansion of Population Size 47 6.1.2 Importance of Resources and Environment Issues 48 6.1.3 Regional Gaps in Demographic Transition 48 6.1.4 Improvement of Quality of Life and Increase in Choices 48 6.1.5 Potential Impact of Migration 48 6.1.6 Perspective of the Population System Based on Relationships among the People and between People and the Environment 49 6.1.7 Reconstruction of Population and Development Policies 49 6.2 Some Suggestions 49 6.2.1 Action to Prevent Population Increase 49 6.2.2 Emphasis on Gender Perspective 50 6.2.3 Appeals to Young People 50 6.2.4 Regional Gaps in Demographic Transition 51 6.2.5 Improvement in Health and Welfare 51 6.2.6 For Construction of Social Security Systems 51 6.2.7 Comprehensive Approach 52 6.2.8 Promotion of Research 52 References 53 List of Tables Table 2.1 Populous Countries, 1950, 2000 and 2050 19 Table 2.2 Total Fertility Rate for the World, Major Development Groups and Major Areas, 1950-2000 25 10
Table 3.1 Percentage of Married Women of Reproductive Age Currently Using Contraceptive Methods for the World, Major Development Groups and Major Areas 33 List of Figures Figure 2.1 Population of Major Development Groups, 1950, 2000 and 2050 17 Figure 2.2 Population of Major Areas, 1950, 2000 and 2050 18 Figure 2.3 Pattern of Demographic Transition 20 Figure 2.4 Estimated and Projected Population of the World According to the Different Projection Variants, 1950-2050 22 Figure 2.5 Expectation of Life at Birth for Less Developed Regions by Sex, 1950-55, 1995-2000 and 2045-2050 23 Figure 2.6 Estimated and Projected Total Fertility Rate for the World and Major Development Groups, 1950-2050 25 Figure 2.7 Median Age for the World and Major Development Groups, 1950, 2000 and 2050 29 Figure 2.8 Median Age for Major Areas, 1950, 2000 and 2050 29 Figure 2.9 Percentage Urban for Major Development Groups, 1950, 2000 and 2030 30 11
Abbreviations DHS FGM ICPD IEC IPPF IUD TFR UNCED Demographic Health Surveys Female Genital Mutilation (UN) International Conference on Population and Development Information, Education and Communitaion International Planned Parenthood Federation Intrauterine Device Total Fertility Rate United Nations Conference on Environment and Development 12
Population, Health Care, Welfare and Pension Systems Executive Summary Population is an essential factor in the formulation of development assistance strategies in the 21st century, given the focus on sustainable development in developing regions and on global issues. These areas are expected to see substantial demographic changes in the 21st century. They will inevitably have a massive impact on society, the economy and the environment of the regions in question, and adversely, changes in social, economic and environmental conditions will affect the magnitude and direction of demographic changes. After some historical development, the debates on the population and development issue in developing regions are now based on the agreement in United Nations conferences in 1990s including the International Conference on Population and Development in Cairo in 1994. Central principles of the agreement included demographic transition, sustainable development, gender equality and equity, human rights and self-determination and human development. They are closely associated with health care, social welfare and pension systems covered in the main subject of this article. Judging from population trends, the factors and impacts of demographic changes and the response to them, it can be said that the importance of the population and development issues is increasing rather than decreasing in the 21st century. From the perspective of development assistance strategies, the following points in particular are of great significance: (1) Expansion of population size and aggravation of resources and environment issues The world population is expected to reach an unprecedented size of some 10 billion in the mid-21st century. A significant number of countries will have populations exceeding 100 million and there will be a number of mega-cities with populations of over 10 million in developing regions. With the expansion in population size and the rising consumption level resulting in the dramatic expansion of total consumption (and disposal), the shortage of resources and the burden on the environment will be serious. Stabilizing population remains a top priority. It is essential to introduce a policy to complete the demographic transition, or achieve low fertility and mortality rates, as quickly as possible in every corner of the globe. 13
(2) Regional gap in demographic transition Even among neighboring countries, there is a gap in the progress of demographic transition and economic growth. For example, the median ages of Japan, China and Mongolia are 42, 30 and 22 years of age respectively, with disparities of ten years between the countries. This could generate social or political friction, but we must also pay attention to the potential to use the differences for international cooperation in economic and financial aspects. (3) Increasing pressure of migration At present, there are an estimated 150 million foreign expatriates worldwide, but it is thought that there is enormous potential pressure for international migration. Both developing countries and developed countries must implement multi-faceted measures, including efforts to tackle the population and development issues and promote international cooperation. (4) Enhancement in quality of life and expansion of choices The trends towards fewer births, longer life expectancy, aging population, urbanization, later marriage and smaller families lead not only to the enhancement in individual health and welfare levels but also expansion of choices. They will urge public services to enrich their quality and will call into question the relationship between individuals and the society. All systems and policies including social security will need to be revised and their relationship with demographic transition will be highlighted. Many developing countries have the advantage of benefiting from demographic bonus, which refers to the period when the proportion of the working-age population to the dependent population (young and elderly people) is largest, and it is hoped that they will make good use of that opportunity. (5) Reconstruction of population and development policies In 1990s, there were several large-scale UN conferences on such subjects as human rights, environment, social development, population and women held to build a foundation for general efforts to address global issues. It is necessary that the population and development policies be reconstructed in a general policy approach including new perspectives such as ethics (fairness), gender and environment. Also, collaboration among the United Nations, national governments, non-governmental organizations (NGOs) and specialists is considered increasingly important. Among others, the roles of women NGOs in developing countries attract greater attention. 14
(6) Emphasis on women s (or gender) perspective The gender approach based on women s empowerment and reproductive health and rights as two pillars is recognized as very effective to the population and development issues. First, it is ethically appropriate to the objective of realizing fairness. Second, it allows women s potential capabilities to be exerted to boost the economy. And third, it lowers fertility and is helpful to stabilization of the population. Also, from the viewpoint of cost-effectiveness, it is the most promising approach in the population and development strategies, as well as primary health care. (7) Improvement in health and welfare Designed to lower infant and maternal mortality and to control infectious diseases such as AIDS that strike the working-age population, the enrichment of primary health care programs is expected to produce a number of benefits, including (1) improvement in quality of life of people in developing countries, as a direct effect, (2) promotion of the stabilization of the population through lowered birth rates and (3) an increase in the working-age population for economic development. It is therefore favorable that assistance on primary health care be not only continued but also enhanced and expanded. With prolongation of life expectancy due to lowered mortality, developing regions are also facing challenges in the form of services for elderly and disabled people. Japan already has an abundance of experience and knowledge accumulated in this field, and is expected to use that experience for international cooperation both in technical and institutional aspects. (8) For establishment of social security systems Completion of the demographic transition necessarily requires social security systems and produces conditions that enable the establishment of these systems. Such conditions include the demographic structure with a trend towards an aging population after a period of increase in the working-age population, urbanization, shift in industrial structure, rising national income and shrinking family size. It can also be said that the 21st century claims social security systems as compensation for avoidance of population explosion. It is a massive project to create social security systems virtually from nothing in developing regions, which are expected to be home to 8 billion people in 2050 according to UN medium variant projections. It is of great significance to make use of the valuable experience of developed nations. Japan should focus its efforts on it as a key domain of international assistance. 15
Population, Health Care, Welfare and Pension Systems 1 Introduction Relationship between Development Issues and Population Issues in Less Developed Regions Population is one of the critical factors in formulating development assistance strategies in the 21st century with an emphasis on sustainable development (economic growth and poverty alleviation) and global issues. Significant demographic changes in less developed regions are predicted in the 21st century, and these changes will inevitably have massive impacts socially, economically and environmentally. On the other hand, social, economic and environmental changes may influence the magnitude and direction of demographic change. Population and development issues and assistance are the subject of debate today based on agreements at UN conferences, in the 1990s, including the United Nations International Conference on Population and Development in Cairo, 1994, the World Conference on Human Rights, The United Nations Conference on Environment and Development, the Fourth World Conference on Women and the World Summit for Social Development. The core concepts of these conferences are population transition, sustainable development, gender equality and equity, human rights and self-determination rights and human development, and they are closely related to the health care, social welfare and pension systems. This report focuses on demographical trends in less developed regions, including factors and impacts, and appropriate policies in health care, social welfare and pension systems areas, respectively. In particular, this report observes less developed regions at the macro-level, and also examines actual cases in each country and region, including those related to Japan s ODA. 2 Demographic Trends in Less Developed Regions Population dynamics can be confirmed in a number of different aspects including population size, increases or decreases in population, population distribution and population structure. The increase in population has three determinants birth, death and migration and is observed from trends in 16
fertility and marriage, which is closely related to birth, as well as from trends in mortality and morbidity, closely tied to death. Other key factors in demographic phenomena include the population structure in terms of sex and age, family structure, residence status and education or workforce status. The next few sections of this report review the demographic changes over the past 50 years and forecasts the demographic changes for the next 50 years with the help of the 2000 Revision, which is the latest edition of the World Population Prospects from the UN (2001a). 2.1 Trends in Population Size The world population was about 2.5 billion in 1950, but reached 5 billion in 1987 and then 6 billion in 1999. It is expected to steadily rise to 9.3 billion in 2050. However, the increase in population is not progressing at an even pace in every part of the world; it differs significantly from country to country or from region to region. The picture of the countries in the North of the world (i.e. more developed regions) forms a contrast with that of the countries in the South (i.e. less developed regions), as seen in Figure 2.1. Here, it is to be noted that the UN statistics describe Europe, North America, Australia, New Zealand and Japan as more developed regions, whereas Africa, Latin America, Asia excluding Japan, and Oceania excluding Australia and New Zealand as less developed regions. Figure 2.1 Population of Major Development Groups, 1950, 2000 and 2050 (in billions) 9 8 7 6 5 4 3 2 1 0 1950 2000 2050 More developed regions Less developed regions Source: UN, World Population Prospects: The 2000 Revision (medium variant) 17
In more developed regions, the population experienced an increase of 0.4 billion in the second half of the twentieth century, from 0.81 billion in 1950 to 1.19 billion in 2000. Currently, however, the rate of increase is almost zero. And population in more developed regions is expected to start shrinking this century to 1.18 billion in 2050. In contrast, in less developed regions, the population has nearly tripled, from 1.71 billion in 1950 to 4.87 billion in 2000, and is expected to grow further to 8.14 billion, 1.7 times the current level, in 2050. The ratio of the population in more developed regions to that in less developed regions was 32:68 in 1950, became 20:80 in 2000 and is estimated to be 13:87 in 2050. And as seen in Figure 2.2, the population growth rate is particularly high in Africa: a nine-fold increase (from 0.22 billion to 2.00 billion) is expected in the 100 years from 1950 to 2050. That will give Africa a stronger global presence in the 21st century. In Asia, originally home to a large population, the number is expected to increase by some four billion in the same 100-year period, from 1.40 billion in 1950 to 5.43 billion in 2050. Figure 2.2 Population of Major Areas, 1950, 2000, and 2050 6 5 4 3 2 1 (in billions) North America Latin America Europe Africa Asia Oceania 0 1950 2000 2050 Source: UN, World Population Prospects: The 2000 Revision (medium variant) Table 2.1 shows a list of populous countries. It predicts the emergence of many countries with huge populations in less developed regions. In 2050, 19 countries are expected to have at least 100 million people, among which 16 will be less developed regions. The remaining three will be the United States, Japan and Russia. Strikingly, it is forecast that there will be five African countries with a population of 100 million or more: Nigeria (280 million), the Democratic Republic of Congo (200 million), Ethiopia (190 million), Egypt (110 million) and Uganda (100 million). In Asia as well, the population size is swelling. In particular, India, which 18
currently has a population of 1.01 billion, is expected to be the most populous country on earth with 1.57 billion people in 2050, surpassing China (1.28 billion in 2000 and 1.46 billion expected in 2050), which has tight regulations in place to curb population growth. In contrast, the Japanese population as a proportion of the world population will fall steadily: from approximately 3.3% (one in about 30) in 1950, to 2.1% (one in about 50) in 2000 and 1.2% (one in about 90) expected in 2050. Table 2.1 Populous Countries, 1950, 2000 and 2050 (Unit: 1,000) 1950 2000 2050 Rank Country Total Population Country Total Population Country Total Population 1 China 554,760 China 1,275,133 India 1,572,055 2 India 357,561 India 1,008,937 China 1,462,058 3 United States 157,813 United States 283,230 United States 397,063 4 Russia 102,702 Indonesia 212,092 Pakistan 344,170 5 Japan 83,625 Brazil 170,406 Indonesia 311,335 6 Indonesia 79,538 Russia 145,491 Nigeria 278,788 7 Germany 68,376 Pakistan 141,256 Bangladesh 265,432 8 Brazil 53,975 Bangladesh 137,439 Brazil 247,244 9 United Kingdom 50,616 Japan 127,096 Congo, Dem. Rep. of the 203,527 10 Italy 47,104 Nigeria 113,862 Ethiopia 186,452 11 France 41,829 Mexico 98,872 Mexico 146,651 12 Bangladesh 41,783 Germany 82,017 Philippines 128,383 13 Pakistan 39,659 Vietnam 78,137 Vietnam 123,782 14 Ukraine 37,298 Philippines 75,653 Iran 121,424 15 Nigeria 29,790 Iran 70,330 Egypt 113,840 16 Spain 28,009 Egypt 67,884 Japan 109,220 17 Mexico 27,737 Turkey 66,668 Russia 104,258 18 Vietnam 27,367 Ethiopia 62,908 Yemen 102,379 19 Poland 24,824 Thailand 62,806 Uganda 101,524 20 Egypt 21,834 United Kingdom 59,415 Turkey 98,818 Source: UN, World Population Prospects: 2000 2.2 Demographic Transition The population dynamics in less developed regions, characterized by rapid growth, may appear contrary to that seen in more developed regions facing stagnation or a decline. Yet from the perspective of demographic transition, viewing modern and contemporary demographic history in the long run, the two movements can be understood as a single continuous stream. Demographic transition represents a great change in the dynamics of the population from high birth and death rates to low birth and death rates. Historically, it was first seen in European countries and later became a global phenomenon. Figure 2.3 illustrates a pattern of demographic transition, which depicts the changes in the birth rate, death rate and the rate of natural increase, which is the difference between the two rates and is equivalent to the rate of population growth assuming no migration. 19
Figure 2.3 Pattern of Demographic Transition birth rate natural increase rate death rate population In the pre-modern society based on high birth and death rates, the population size was stable with little difference between the birth rate and the death rate. There was, in other words, a limited rate of increase. When modernization triggers demographic transition, the change starts with a decline in the death rate to create an imbalanced situation of a high birth rate but low death rate. Later, the birth rate falls to the level of the death rate to restore stability in the form of low birth and death rates. In this process of demographic transition, there is a time lag between the preceding fall in the death rate and the subsequent drop of the birth rate. This time lag generates massive population growth. Figure 2.3 shows some fluctuation in the death rate at the stage of high birth and death rates before demographic transition, but it is a temporary rise in the death rate attributable to famine and plagues that was reflected in the fluctuation in the rate of increase. After demographic transition is complete, the death rate stays low, and the change in the rate of increase mainly reflects the variation in the birth rate, as in the period of the baby boom. Western European countries, as pioneers of the industrial revolution, already saw the start of a demographic transition in the 18th century. Many developed countries including Japan completed their demographic transition in the second half of the 20th century, entering an era of an aging society with fewer children, and later a phase of depopulation. In other words, developed countries already experienced substantial population growth in the process of modernization. But the demographic transition started rather more recently in less developed regions, which account for the great majority of the world population. And with the exception of East Asia (China and South Korea) and some Southeast Asian countries, the process has not finished. In other words, most of the less developed regions are still experiencing the phase of high birth rate and low death rate seen 20
in Figure 2.3. In these regions, population growth is expected to continue in the 21st century. The question is why does the fall in the death rate come earlier than that in the birth rate in the process of demographic transition. Roughly speaking, the death rate shrinkage (or prolongation of life) is a reflexive or non-deliberate result of improvements in nutrition, residential or working environment, health care and education, although it is impossible to ignore the effect of deliberate endeavors in sanitation. Meanwhile, the decline in the birth rate generally stems from a shift in thinking from an orientation to large families to an orientation to small families, or from a preference for early marriage to a preference for late marriage. Changes in thinking, cultural values or patterns of behavior require several decades. With these elements, the demographic transition coincides with economic and social development arising from modernization and with improvements in the quality of life. For individuals, it must therefore be welcome. However, it also creates problems in the form of dramatic population growth during the process and in an aging society with fewer children than previously experienced. In addition, the concept of demographic transition is of significance in formulating population policies. Simply put, promoting demographic transition to complete the process as quickly as possible is a central idea on which action to address population issues should be based. First, the demographic transition itself is consistent with social development and improvement in happiness and welfare. Second, the earlier the completion, the smaller the ultimate world population and the smaller the negative impact on earth and ecology. Above, this paper quoted the United Nations as estimating the world population in 2050 at 9.3 billion, but this was the medium variant figure, considered the most likely. The high variant equivalent, reflecting a case of delayed completion, was 10.9 billion. If there is no progress in demographic transition and the birth rate remains unchanged, the figure is expected to reach 13.0 billion, as shown in Figure 2.4. But the UN (2001a) also says that the world population could be 8.0 billion or less in 2050, the low variant figure, which reflects a quicker-than-expected progress in demographic transition. This paper considers the impact of changes in population size on society, the economy and the environment below. Before that, we review the trends in two factors for demographic transition: the death rate and the birth rate. 21
Figure 2.4 Estimated and Projected Population of the World According to the Different Projection Variants, 1950-2050 14 12 10 8 6 4 2 (in billions) Fertility rates unchanged High variant Medium variant Low variant 0 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 Note: Actual values for 1950-2000, projected values for 2005-2050 Source: UN, World Population Prospects: The 2000 Revision 2.3 Mortality Trends A decline in mortality can be translated into a faster rise in the surviving rate or growth of the average life expectancy at birth. According to UN projections, the life expectancy at birth in more developed regions rose from 63.6 years in 1950-55 to 71.1 years in 1995-2000 among males, and from 68.6 years to 78.6 years among females. Similarly, the index in less developed regions grew from 40.2 years to 61.4 years among males, and from 41.8 years to 64.5 years among females. Thus, people in more developed regions improved a ten-year increase in longevity, while those in less developed regions saw life expectancy rise by more than 20 years (see Figure 2.5). This outstanding growth in life expectancy at birth has been the basis for economic development and an impetus to major changes in concepts of life and lifestyle. Moreover, the expected longevity is expected to reach 72.9 years among males and 77.3 among females even in less developed regions by the period 2045-50. With the decline in fertility, discussed below, the aging of the population will be an issue in less developed regions as well. The estimated life expectancies at birth of males and of females in less developed regions in 2045-50 correspond to the levels of developed regions in 2005-10 and in 1985-90 respectively. This suggests that improvements in life expectancy among females is slower than among males in less developed regions, although these regions have experienced a significant fall in mortality. 22
Figure 2.5 Expectation of Life at Birth for Less Developed Regions by Sex, 1950-55, 1995-2000 and 2045-2050 Source: UN, World Population Prospects: The 2000 Revision (in years) 80 70 60 50 40 Male 30 Female 20 10 0 1950-55 1995-2000 2045-50 In less developed regions, acquired immune deficiency syndrome (AIDS) has a very serious impact on life expectancy. The World Population Prospects the 2000 Revision from the United Nations classifies 45 countries as severely affected by human immunodeficiency virus (HIV), with 2% or more of the population aged 15-49, or 29 million adults, estimated to be HIV-positive in the forecast in 1999. This number accounts for 88% of the total population of 33 million infected adults worldwide. Thirty-five of the 45 countries were Sub-Saharan African countries. In the group of 45, the life expectancy in 1995-2000 was estimated at 56.9 years, a figure that would have been 59.8 years without the impact of AIDS. This difference underlines the seriousness of the influence of the disease. Worrying among others are 11 African countries with infection rates higher than 13%. For example, Botswana s estimated life expectancy was 44.4 years in 1995-2000, but would have been 67.6 years without AIDS, according to the UN (2001a, pp. 12-13). Komatsu (2001) insists that the ethos of the action against HIV/AIDS ranges over three domains of prevention, care and research. Considered highly important are health education, consideration for human rights, a safety net for the socially vulnerable, the permeation of many different kinds of condoms, including female condoms, intensive treatment of sexually transmitted diseases, and the prevention of mother-to-child infection using antiviral drugs. Apart from AIDS, there are about 300 millions cases of curable sexually transmitted diseases developed every year, a great majority of which are apparently in less developed countries. The incidence rate among women is five times that among men, and it is believed that 23
two thirds of infertility cases are due to sex transmitted diseases (UNFPA 1997, p. 20). Maternal deaths draw special attention as a core target of population and development strategies, given that its level sensitively reflects the situation of women and that it is closely related to reproduction. According to an estimate of the World Health Organization (WHO) in 1990 (UN 1998, pp. 16-147), there are nearly 600,000 cases of maternal deaths reported every year worldwide, with most in less developed countries, where the rate of maternal death to birth is 480 to 100,000. This is highest in Africa at 870 to 100,000. It is thought that approximately one in eight cases of maternal death (or 50,000 to 100,000 cases in absolute terms) may have resulted from unsafe abortion (UN, 1998, pp. 156-157). Clandestine abortion is deeply involved with the high maternal death rate in less developed countries. The United Nations (1999a) set a goal of ensuring that welltrained assistants will be present at 80% of the childbirth deliveries worldwide by 2005, and in 90% by 2010. 2.4 Fertility Trends Among the phases in demographic transition, a fall in the birth rate is called fertility transition. Today, the death rate is fairly stable the world over, and it is the change in the birth rate that is decisive to population change. Variation in fertility can best be indicated with the average number of lifetime childbirths per woman. The total fertility rate (TFR) is often used as a rough guide. TFR is the sum of the fertility rates by women s age in a specific year. If there is no variation in childbirth pattern depending on age, the index is equivalent to the average number of children born from a woman in her lifetime. According to an estimate of the United Nations (see Table 2.2 and Figure 2.6), the worldwide TFR nearly halved during the period between 1950-55 and 1995-2000, from 5.01 to 2.82. In less developed regions, TFR fell nearly 50%, from 6.16 to 3.10, while the figure shrank from 2.84 to 1.57 in more developed regions. 24
Table 2.2 Total Fertility Rate for the World, Major Development Groups and Major Areas, 1950-2000 Region 1950-55 1960-65 1970-75 1980-85 1990-95 1995-2000 World 5.01 4.97 4.48 3.56 3.01 2.82 Developed regions 2.84 2.68 2.13 1.85 1.69 1.57 Less Developed regions 6.16 6.03 5.42 4.12 3.37 3.10 Asia 5.88 5.64 5.07 3.66 2.95 2.70 East Asia 5.68 5.16 4.46 2.46 1.88 1.76 South Central Asia 6.08 6.00 5.60 4.79 3.99 3.58 Southeast Asia 5.95 6.09 5.53 4.24 3.24 2.83 West Asia 6.40 6.21 5.62 4.98 4.23 3.86 Africa 6.71 6.84 6.68 6.40 5.61 5.27 Eastern Africa 6.92 6.97 7.03 6.88 6.34 6.09 Central Africa 5.91 6.00 6.31 6.59 6.52 6.41 Northern Africa 6.80 7.08 6.34 5.54 4.09 3.58 Southern Africa 6.45 6.46 5.54 4.71 3.48 3.29 Western Africa 6.85 6.96 7.03 6.99 6.35 5.95 Latin America 5.89 5.97 5.03 3.86 2.97 2.69 Caribbean islands 5.21 5.47 4.38 3.38 2.72 2.50 Central America 6.87 6.85 6.43 4.49 3.42 3.04 South America 5.69 5.76 4.65 3.70 2.83 2.57 North America 3.47 3.34 2.01 1.80 2.02 2.00 Europe 2.66 2.58 2.16 1.88 1.58 1.41 Oceania 3.87 4.00 3.22 2.59 2.51 2.41 Souce: World Population Prospects: The 2000 Revision, United Nations, 2001. Figure 2.6 Estimated and Projected Total Fertility Rate for the World and Major Development Groups, 1950-2050 7 6 5 4 3 2 Less developed regions World More developed regions 1 0 1950-1955 1955-1960 1960-1965 1965-1970 1970-1975 1975-1980 1980-1985 1985-1990 1990-1995 1995-2000 2000-2005 2005-2010 2010-2015 2015-2020 2020-2025 2025-2030 2030-2035 2035-2040 2040-2045 2045-2050 Source: UN, World Population Prospects: The 2000 Revision (medium variant) TFR is also important as an index of fertility transition or of demographic transition. When the birth rate and the death rate are at what is called the replacement level, the population in the generation of parents is replaced with their children s generation. Given that mortality is at the current level, the 25
replacement level corresponds to a worldwide TFR of 2.1 to 2.3. This generally means that when TFR is higher than the replacement level the population growth continues, when TFR is close to this range the population size is stable and when it is lower the population is decreasing. But the population does not stop growing as soon as fertility falls below the replacement level. It continues to grow for some time (over the subsequent few decades) because the death rate is lower than the birth rate with the population structure slanted towards the younger generation as a result of the high birth rate of the past. This is called population momentum. According to Bongaarts (2001), population momentum generates a larger population growth in a less developed region than a drop in fertility or in the death rate below the replacement level. But a dip in fertility to close to the replacement level is a significant precursor of the completion of demographic transition. From this perspective, Table 2.2 tells us that there are some remarkable differences within less developed regions. In East Asia, which means China, South Korea and other countries (including Japan in this figure, although it makes little difference if it is excluded), demographic transition has already finished. In Southeast Asia and in Latin America, fertility has come down to nearly that level. However, TFR in South/Central Asia and in West Asia is still 3.0 or higher. The figure is over 5.0 in Africa. In particular, what is called Sub-Saharan Africa, consisting of Central Africa, Eastern Africa and Western Africa, has an incomparably high birth rate and a long way to go until the replacement level is reached. African countries with high birth rates have some traits in common: extremely high infant mortality rates, a tradition and culture that favor prolificacy for the family workforce, early marriage and polygamy, high numbers of Muslims or believers in traditional religions as a percentage of the national population and low rates of contraception use (Hayase 1999, pp. 29-30). Here, it should be noted that TFR, as an index of the period fertility rate, is prone to exaggerate a fall in the birth rate when it is underway. In general, when the birth rate is falling, the childbearing age rises rapidly. So attention also needs to be paid to mean ages at childbearing and at the first childbearing as additional indices of fertility apart from TFR. They are also valid as indices of the timing of childbearing. A rise in mean age at the first birth has been confirmed in less developed regions in a comparison between the outcome of the World Fertility Survey (WFS) mainly conducted in the 1970s and the results of the Demographic and Health Surveys (DHS) since the mid-1980s: for instance, from 19.5 years of age to 23 in Thailand, from 16.5 to 17.9 in Bangladesh, from 20.8 to 21.1 in Mexico, 26
from 21.3 to 21.5 in Columbia, from 18.8 to 19.3 in Kenya and from 19.4 to 22.8 in the Sudan (UN 1998, p. 58). Apart from the average number of lifetime childbirths per woman, the birth interval is another key fertility index, and a prolongation of the birth interval is effective in controlling population size. For example, Bongaats and Greenhalgh (1985) explain that a milder policy as a combination of a two-child policy, delayed marriage and prolongation of the birth interval has an effect comparable to that of the one-child policy that China has introduced. An extension of the birth interval is thought to be a valid strategy in less developed regions with high fertility, as it is expected to have the positive impact of curbing the death rate of mothers and children and of enhancing child nutrition. According to the World Population Prospects the 2000 Revision (UN 2001a), as discussed earlier, the worldwide TFR was 2.82 in 1995-2000 and 64 countries, among which 43 were economically developed, were at or below the replacement level while 123, among which 122 were underdeveloped countries, had TFR figures higher than 2.1. Among the second group, TFR was 5.0 or higher in 48 countries, most of which were classified into the least developed countries. No outstanding rise in fertility is expected in the future until 2050 in the first group of countries, with a total population of 2.7 billion, or 44% of the whole world population, in 2000. On the other hand, the second group, with a total population of 3.4 billion, or 56% of the world population, in 2000, is expected to have a steady fall in fertility overall and a population of 6.4 billion in 2050. Sixteen countries where birth rates remain high and where the start of fertility transition has not been confirmed, most found in Sub-Saharan Africa, are believed likely to fail to reach the replacement level in the middle of the 21st century if they experience a one-point decline in TFR every ten years after 2005. And in such populous countries as Bangladesh and Nigeria, the drop in fertility was not as sharp as expected in the 1990s. The decline in fertility in India proved slightly lower than expected in the previous estimate. As a consequence, the 2000 revision of the World Population Prospects (UN 2001) estimates the world population in 2050 at 9.3 billion, up 0.4 billion from the previous 1998 revision. 2.5 Trends in Sex/Age Structure Not only in more developed regions but also in less developed regions is the declining death rate and birth rate transforming the population pyramid, which shows the age structure of the population. The change is from a triangle-shape 27
featuring high birth and death rates to a square-like pyramid featuring low birth and death rates. In the meantime, there is a change in the proportions of the young population (aged 0-14), the working age population (15-64) and the elderly population (aged 65 and older). The change generates a period called the demographic bonus, during which there is a fall in the dependency population index, which is the ratio of the dependent population of the young and the elderly to the working-age population. With the smaller social burden this produces, this period is conducive to the accumulation of capital and is a good opportunity for economic growth and the establishment of social security systems. National governments around the world can take advantage of this demographic bonus to ease the burdens that arise from later growth of the elderly population (UNFPA 1998, p. 14 in translation). Figure 2.7 shows the transitions in median ages worldwide, in more developed regions and in less developed regions. The median age evenly splits the population into the older group and the younger group. In more developed zones, the change in median age reflects the remarkable development in the aging of the population: 28.6 years of age in 1950, 37.4 in 2000 and 46.4 expected in 2050. In less developed zones, the median age was 21.4 in 1950 and still 24.3 in 2000, but is estimated at 35.0 years in 2050 with a rapid aging in the second half of the century. In the regional review (with Figure 2.8), Africa is expected to have a fairly low median age of 27.4 years even in 2050, but Latin America, Asia and Oceania will have median ages higher than 35, with their aging levels reaching the current level in developed regions. The population is aging worldwide but there are some massive regional differences. This can mean a gap in the progress of demographic transition and of economic development between neighboring countries. To take an example, in the East Asian region, the current median ages of Japan, China and Mongolia are 41, 30 and 21 respectively. There are two gaps of nearly ten years. These gaps may produce social or political frictions but at the same time it should be noted that it is also possible to use them for international economic and financial cooperation. 28
Figure 2.7 Median Age for the World and Major Development Groups, 1950, 2000 and 2050 (in years of age) 50 45 40 35 30 More developed regions 25 World 20 Less developed regions 15 10 5 0 1950 2000 2050 Source: UN, World Population Prospects: The 2000 Revision (medium variant) Figure 2.8 Median Age for Major Areas, 1950, 2000 and 2050 50 45 40 35 30 25 20 15 10 5 0 (in years of age) 1950 2000 2050 Source: UN, World Population Prospects: The 2000 Revision (medium variant) Africa Latin America Asia Oceania North America Europe 2.6 Changes in Families In addition to birth and death (that is, the reproduction of the population), migration, distribution of the population and family status are also among important population phenomena. Family structure and views on family are subject to national or cultural differences, and there are few statistics on an internationally unified standard. But it is thought that the world is trending towards smaller families, with some facts common worldwide, such as later marriage and childbearing (or an increase in unmarried single people and in couples without children), rising divorce rates and a growing number of elderly people living alone. 29
2.7 Urbanization and Internal Migration Urbanization is one of the notable worldwide changes seen in the 20th and 21st centuries. A United Nations estimate (2001b, p. 7) shows that the urban population rate worldwide experienced a massive increase from 29.7% to 47.0% in the 50 years between 1950 and 2000. In more developed regions, the rate rose from 54.9% to 76.0%, which means that three in four people are city dwellers. In less developed regions as well, the rate went up from 17.8% to 39.9%, which means that nearly 40% of the population live in cities (Figure 2.9). With urbanization in the 21st century, the urban population rate is estimated at 83.5% in more developed regions, at 56.2% in less developed regions and at 60.3% worldwide in 2030 (Figure 2.9). The 21st century is an era of urbanization on a global scale. Figure 2.9 Percentage Urban for Major Development Groups, 1950, 2000 and 2030 (as a percentage) 90 80 70 60 50 40 30 20 10 0 More developed regions Less developed regions 1950 2000 2030 Source: UN (2001), World Urbanization Prospects: The 1999 Revision What cannot be missed is the rapid emergence of cities with populations of 10 million or more, called mega cities. In 1975, the world had five mega cities: Tokyo (19.8 million), New York (15.9 million), Shanghai (11.4 million), Mexico City (11.2 million) and Sao Paolo (10.0 million). Now, there are 19 mega cities. And the count is expected to rise to 23 in 2015, of which 19 cities are in less developed regions. In particular, Mumbai (26.1 million), Lagos (23.2 million), Dhaka (21.1 million) and Sao Paolo (20.4 million) are projected to have populations over 20 million (UNFPA 2001, pp. 32-33 in translation). 30
2.8 International Migration In a report on international migration, Osaki (2001) in the Population Division of the United Nations argues that international migration has the potential to assume greater importance in population issues. For less developed, it could become a serious international political issue given the slowdown in the world population growth rate. The Division estimates that there were about 150 million foreign expatriates worldwide at the beginning of this century, though there were 75 million in 1965 (Osaki 2001). Certain future possible circumstances will provide potential momentum for migration. These circumstances include an aging population and fewer children in developed countries and in some developing countries that complete their economic growth periods, a labor shortage, population growth, or a high proportion of younger people, in a large majority of less developed countries, development of means of information and transport, deterioration in the situation surrounding resources and environment, an outbreak of regional conflicts and an increase in international marriage or international adoption. 3 Factors in Demographic Change hanges in Less Developed Regions The three major factors of demographic change are fertility, mortality and migration. This chapter focuses on changes in fertility. 3.1 Approaches for Research on Fertility Determinants To explain what has generated the significant regional differences shown in Table 2.2, a huge number of studies have been made on determinants of the fertility level. These determinants can be broadly divided by the research framework into three approaches. 3.1.1 Proximate Determinants Approach This approach pays attention to bio-demographic factors that directly increase or decrease opportunities for pregnancy and childbearing, such as marriage, fertility, contraception, induced abortion and the period of postpartum infecundability (or the period of breastfeeding and postpartum abstinence). These factors are called proximate determinants since they directly define the fertility 31
level in demographical terms. In general, early marriage and low rates of contraception use in less developed countries constitute the mechanism that directly produces high fertility rates in those countries. Here, the concept of marriage refers to the start of regular sexual unions irrespective of legal recognition status. The definition or concept of marriage is often vague, especially in Africa, but in any case early marriage of women in their teens may not only lead to a high birth rate but may also affect their own health and alienate women from education, income and independence (UN 1998, p. 14). According to the Demographic Health Surveys (DHS) (UN 1998, p. 15), 20% or more of the female population aged 15 to19 are married in Kenya, Pakistan, Nigeria and Zambia, 40% or more in Cameroon and Bangladesh, 50% or more in Niger, and 70% or more in Mali. In the meantime, the rate of contraception use in less developed regions was apparently below 10% early in 1960s (UN 1998, p.84), rising 55% around 1995. But as shown in Table 3.1, there are substantial regional differences: the rate of use in Africa (20%) is much lower than that in Latin America and Caribbean countries (66%) or in Asia excluding Japan (60%) (UN 1999b). Table 3.1 shows the rates of contraception use in recent times, around 1995, in different regions of the world. The rate refers to the ratio of married and unmarried couples that practice some form of contraception at the time of the survey of married and unmarried couples, in which the women are of reproductive age (normally from 15 to 49 years of age). Among the less developed regions, Latin America has a rate of 66%, which is close to the average value in developed regions. The Asian figure is also close to that. But the rate in Africa is extremely low at 20%. As for the methods, female sterilization and the pill are among the most common in Latin America. It should be noted that the ratio of female sterilization to male equivalents in this region is remarkably high at 28:1, which forms a contrast with the European ratio of 3:2 with a narrower sex gap. This is thought to reflect the male chauvinism strongly embraced in the region. In Asia, intrauterine devices (IUDs) are the second most common method after female sterilization, supposedly owing to the common use of this method in populous China. The total rate of contraception use is lower in less developed regions than in more developed regions, but modern or medical methods including sterilization surgery, IUDs and the pill are more commonly employed in less developed regions because of their relatively short history of family planning activities. (IUDs and contraception pills were developed and put into practical use only in the 1960s.) 32
Table 3.1 Percentage of Married Women of Reproductive Age Currently Using Contraceptive Methods for the World, Major Development Groups and Major Areas p Rate of Contraception (%) Reproductive All Methods Normal Contraception Oral IUD Condom Other Methods Offered Methods not Offered Age(million) Women Men Contraception by Health Care by Health Care World 982.2 58 19 4 8 13 4 3 8 Less Developed Regions 799.2 55 21 4 6 14 2 2 5 Africa 111.2 20 2 0.1 7 4 1 2 4 Asia (except Japan) 611.5 60 24 5 5 17 3 2 4 in America & Caribbean islands 75.4 66 28 1 14 7 4 2 9 Oceania 1.1 29 9 0.2 5 1 1 6 7 Developed Regions 183.0 70 9 5 17 6 14 2 19 Japan 18.4 59 3 1 0.4 2 46 1 6 Europe 119.6 72 3 2 20 8 10 2 26 North America 41.9 71 24 14 15 1 10 4 3 Australia & New Zealand 3.2 76 26 12 23 5 6 1 4 Note: Couples of reproductive age refers to couples in which the woman is aged between 15 and 49 inclusive and is married or in sexual relationship. Other methods offered by health care refers to other methods offered or provided by those engaged in health care or medical services, including injection, diaphragm, cervical cap and spermicide. Methods not offered by health care refers to periodic abstinence using the rhythm method, extravaginal ejaculation, the cleaning method as well as abstinence, folk methods and other methods that cannot separately be reported but that are used for contraceptive purposes. Source: UN (1999), World Contraceptive Use 1998 3.1.2 Economic Rationality Approach This approach is based on the idea that individuals or families choose to marry or bear children in a way that maximizes economic utility, or in other words, from the perspective of the demand of parents for children. In less developed countries, children are thought to have enormous utility as workers or for support after retirement, while imposing little cost to the parents as education is not considered essential. In this situation, high birth rates in less developed states are consistent with economic rationality. This conflict between the microeconomic interests (of individual households) and macroeconomic interests (of society) is often explained with the economic theory of externality to childbearing. The market mechanism is imperfect and it creates an insufficient, excessive or instable supply of goods and services. This is called market failure and it is one of the major areas of research of economic policy studies and public economics. When there is an externality to childbearing involved, microeconomic interests conflict with macroeconomic interests, and it leaves room for political intervention (Obuchi, 1998). 3.1.3 Cultural Norms Approach The third approach emphasizes that thinking and behavior are bound by 33