Journal of International Development

This paper examines the impact of structural adjustment programmes (SAPs) on social sectors in Sub-Saharan Africa and its implications for demographic change. Our analysis suggests a continuing deterioration of social sectors which may have been accelerated by a decade of implementation of SAPs. In that context, two speculative scenarios are envisioned for the region's demographic change: a delayed demographic transition justified by the persistence of conditions that sustain high fertility; and a crisis-led transition where hardship might accelerate the transition. Country specific studies are more suited than comparative studies to unravel these issues.

PIP Policy change is a political process. Political analysis is therefore necessary to understand how and why policies change. Noting that the politics of setting the international health policy agenda are poorly understood, the author compares such politics, with regard to child health and adult health, along the following political streams: organizational, symbolic, economic, scientific, and politician politics. This approach is a modified version of Kingdon's garbage can model of how public policy agendas are set. The five political streams were all found to long favor child health over adult health as an issue on the international health policy agenda. In the early 1990s, however, the World Bank has asserted greater influence on the agenda than before, with a concerted effort to shift the focus from child health to adult health and to give greater attention to the preventive aspects of adult health in poor countries.

This paper examines changing patterns of reproduction in two West African countries, Senegal and Ghana, which conducted both World Fertility Survey and Demographic and Health Survey enquiries. It aims to estimate fertility levels and trends in these countries, examine how changes in marriage, contraceptive use, breastfeeding and post-partum abstinence are affecting family building patterns and discuss whether a fertility transition has begun. While fertility remains high in both Senegal and Ghana, it has begun to decline. In Ghana, the drop in fertility commenced in the late 1960s but has slowed recently. In Senegal, fertility decline began a decade later but is now more rapid. With these declines, residential and educational differentials in fertility have widened, particularly in Senegal. Both rises in ages at marriage and increases in the use of contraception have contributed to the fall in fertility. However, most women of high socieconomic status still want four or live children. Other women want even more. Although a transition to the control of fertility by contraceptive means has begun, the transition to low fertility may progress slowly.

"This paper gives an overview of the recent demographic history of countries in sub-Saharan Africa, especially the start of a fertility decline. After discussing the evidence for a decline, and the nature of changes in fertility behaviour, the paper moves on to look at possible causes, in relation to development policy. Mortality, cultural structure, the status of women, education and economic crisis are all considered as candidates. The conclusion is reached that available evidence raises as many questions about the causes of fertility decline as it resolves, particularly in our understanding of the process of change. Finally, the potential consequences of falls in fertility and population growth slowdown in sub-Saharan Africa are considered."

PIP In 1993, the World Bank released the World Development Report: Investing in Health, its public statement of what it believes to be sound international health policy. This paper critically examines the report with regard to the applicability of its recommendations to the Third World. It looks at the World Bank and its critics, the Bank's view of development, the globalization of health policy making, and profits for multinationals. Report recommendations on privatization, decentralization, cost recovery fees, nutrition, and essential drug programs are analyzed, with the authors concluding that the World Bank's approach to health fits its ideologically-driven development model which favors Northern nations at the expense of the South. Moreover, the DALY index has major theoretical flaws and is of little value as a guide to health policy makers. The index could be used to deny essential health services to the poor in developing countries.

Fertility trends in Botswana have been the subject of much debate in recent years as a number of surveys in the mid to late 1980s suggested that a fertility decline was under way. This paper first reviews the demographic evidence for a fertility decline and argues that the magnitude of the decline was rather less than some commentators had suggested. The paper then places the trends in fertility in the social and economic context of Botswana in the 1980s. It is argued that there could have been a short-term decline in childbearing as a result of economic crises brought on by a major drought and helped by the government of Botswana's strategies to alleviate the effects of the drought on its people.

Fertility in Tanzania has declined from seven children per woman in the early 1980s to about six in the early 1990s. This trend is a result of a rise in the age at first marriage for women, a decline in infant and child mortality, a rise in the percentage of the population with education, and rural development. The continuing universal and prolonged breastfeeding also has a significant negative effect on fertility. A further fertility decline in Tanzania will depend mainly on the success of the family planning programme, which in turn will improve the performance of the economy, health, education, employment, agriculture and the environment. Mortality levels have declined but are still high owing to various factors, including short birth intervals, teenage pregnancies, the low status of women, the lack of adequate health services and facilities and a lack of proper programmes targeted at regions and families with relatively high mortality.

Reduced-form demand relations for weight, height and weight gain since birth are estimated using data on 7,907 children in Kenya. Maternal education is a significant determinant of all indicators, with secondary schooling having larger although not significantly different effects than primary schooling. Per capita household expenditure has highly significant but numerically small effects. Birth weight has a strong negative effect on subsequent weight gain. The effect becomes even more negative (indicating almost complete catch-up by age one) when birth weight is treated as an endogenous variable. These results indicate that small deficits in birth weight are not permanent.

This paper will consider the implications for gender relations, for the family, and particularly for women of the current rural to urban migration in China. As migration never takes a balanced cross section of a sending community, it inevitably alters the age and sex structure of the population left behind. It also creates migrant settlements in the receiving areas dominated by the young and in which the sex balance may be highly unequal. Information on current migratory flows in China indicates that migrants are overwhelmingly young, and that males out-number females. The aggregate data masks striking differences at the micro level. Certain flows, such as those from some Sichuan counties to the new industries of Guangdong Province are dominated by females, in other cases the reverse is true. The implications of migration are many. The sending areas may lose a large number of their young people of one sex or both, but migration may relieve other problems such as surplus agricultural labour. Moreover remittances and returnees with capital to invest may provide some compensation … Strong family networks provide the background support which the migrant needs in undertaking the risky business of migration. Life in the cities is not easy for migrants. Most retain their links with home and return to the villages after a period working in the town. This paper discusses the impact on family and gender relations in the sending areas of this circulation type migration.

Recent fertility decline in Kenya has taken place at an uneven pace. According to the demographic and health survey (DHS) in 1989, one of the highest levels has occurred in Coast Province, and almost no decline has taken place in Western Province. It is a puzzling aspect that use of modern contraceptives in both these provinces is lower than the national average. The aim of the article is to broaden the understanding of the uneven pace of fertility decline. Attention is given to the social value of children and the role of women. It is argued that the impact of child mortality and sterility is underplayed in analyses based upon the DHS. The data are based upon two case studies, from Kwale in Coast Province and Bungoma in Western Province.

PIP Health policies worldwide have changed dramatically over the past few decades. Currently, practically every country is engaged in or considering health sector reform. The authors reflect upon those changes, highlight current trends, and identify key issues and challenges. They comment upon the concepts of health and policy and the historical developments which have influenced policy. The context in which health policies in low-income countries are formulated and implemented is discussed, including macropolitical and macroeconomic developments, health needs and determinants, financing, approaches to health planning and priority setting, and the key international health policy actors. An overview of the content of current health policy proposals in less developed countries is presented, with key issues identified for the future. Reference is made to the 1993 World Bank Development Report, Investing in Health, and other health sector reform efforts.

The general outline of the demographic transition in western Europe is reviewed as a background for understanding demographic changes occurring in Asia and Africa. Although a number of scholars have held that Africa is somehow “different” and would not follow the path to demographic transition in the near future, recent evidence from Kenya indicates that contraceptive prevalence is rising and fertility is falling. Factors related to this change include relatively high levels of education, availability of health services, exposure to modernizing media and urban lifestyles, and a greatly strengthened family planning service delivery system.

Data sources from the 1980s are used to examine the main features of Nigeria's population patterns and trends. Fertility has remained relatively constant up until very recently, when there has been evidence for a decline in fertility in the south of the country. In the north, fertility remains high, contraceptive use remains low, and women continue to marry at young ages. The mortality declines of the oil boom years are threatening to reverse, as economic crisis hits health services. Although there is some evidence of rising contraceptive knowledge and use in the south, certain features of Nigerian family structures militate against fertility decline. This situation is likely to change only through education and the transformation of women's status.

"Using the 1986/87 Household Budget Survey of Lesotho, we measure the extent of inequality, identify the determinants of economic well-being and decompose total inequality by population subgroups. The results show large inequality in economic well-being. Many households in Lesotho are heavily dependent on miners' remittances from the Republic of South Africa. In the study we quantify their effects on the level of well-being and the extent of inequality. It is concluded that remittances decrease inequality in Lesotho."

"In the early 1960s James Meade visited Mauritius as adviser to a Commission evaluating population structure and growth. Out of that visit emerged two papers which were Malthusian in their prognosis of economic prospects for Mauritius. This paper reconsiders the Meade Evaluation and compares his predictions with actual outcomes. As it turns out, his pessimism was not justified. The factors which led him to reach his set of conclusions, and the factors which explain actual economic performance, are both assessed in detail."

In sub-Saharan Africa, programmes to restructure the nature of the provision of health care frequently include measures for cost-sharing, increased local management and popular participation. However, similar reform programmes may have very different expression in different country contexts and there is a need for detailed studies of implementation processes. At the same time, common analytical categories need to be found to facilitate some comparison across such individual case studies. Two concepts are offered as starting points in this: veto points within an interaction, feedback model of the policy process and a view of power as having three dimensions, overt, covert and latent. These concepts have not been practically applied to case studies of health reform in low income countries and their relevance is demonstrated through a study of Lusaka, Zambia. The study describes how different actors in a health system, from the national Ministry down to the local population, interpret and experience reform directives and activities. © 1997 by John Wiley & Sons, Ltd.

What is distinctive about development management? This paper first discusses different views of development and management separately, and goes on to characterize development management both as management in the context of development as a long-term historical process and as the management of deliberate efforts at progress by means of intervention in the social change process on the part of a variety of agencies. Thus development management should be thought of in terms of process and is distinctive in aiming at social goals external to any particular organization in the context of value-based conflicts. The paper concludes with a list of conceptual and skill areas which this view implies are important to development management as a new academic and professional field.

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The consequences of the evolving HIV|AIDS epidemic have not been properly considered by any agency. Most existing development indicators do not pick up the impact of AIDS nor do they measure the complex adverse consequences the disease may have in the decades ahead. Incomplete and conflicting demographic and health indicators compound the problem. This epidemic is a 'long wave' event and its effects will be seen in Africa and elsewhere for many decades ahead. The result is that development targets may be unattainable and the way development is carried out may need to be rethought in many countries. Copyright © 2001 John Wiley & Sons, Ltd.