Why reducing neonatal mortality rates and poverty levels should be prioritized over population growth in Africa.
A few days ago, President John Magufuli of Tanzania called on women in Tanzania to ‘set your ovaries free’, and bear more children as a way to help boost the economy into a regional powerhouse—a step, critics argue, would instead worsen inequality and poverty, and increase the already high rate of neonatal deaths in the country. According to the World Health Organization, at 38 per cent, the sub-Saharan Africa region has one of the highest rates of neonatal mortality in the world. While progress has been made globally in reducing deaths among children under 5, sub-Saharan Africa has shown the smallest drop in child mortality rates in the 25-year period between 1990 and 2015.
In sub-Saharan Africa, per-capita income is below $2,000 and has barely moved much over the past decade; in many of these countries, it is within the $500-$700 range. In countries where per-capita income is higher (some of which include middle-income, Global South countries in Asia and Latin America) neonatal mortality rates are substantially lower. There is a significant correlation between low levels of income and healthcare outcomes, and high neonatal mortality rates in Africa can be said to be a function of poverty and low levels of public expenditure on healthcare and other social services. This double whammy creates conditions—for example, a lack of clean water, poor sanitation, malnutrition, endemic infections, poor or non-existent primary healthcare services—in which babies who are not robust at birth do not receive the healthcare they need to overcome their vulnerability.
The United Nations’ newest goals, the Sustainable Development Goals launched in 2016, include reducing the neonatal mortality rate in all countries to 12 deaths per 1,000 live births. For perspective, during the Millennium Development Goal (MDG) era, many countries in Africa achieved marked reductions in under-5 and neonatal mortality. Yet the pace of progress toward these goals substantially varied at the national level, demonstrating an essential need for tracking even more local trends in child mortality. As a region, sub-Saharan Africa spends less than 7 per cent of its total GDP on health, far less than the roughly 9 per cent of GDP that the countries of the OECD spend on health.
Countries like Rwanda, Botswana and Ethiopia have recorded impressive decreases in child mortality rates since 2000, positioning them well to achieve SDG targets by 2030 or earlier. However, these countries are outliers—many areas, particularly in central and western Africa, continue to post high rates of neonatal mortality. In 2017, the annual NMR was highest in west and central Africa, at 30·2 deaths per 1000 live births. These regions need considerable investments in terms of training and health infrastructure to enable skilled birth attendants to deliver lifesaving interventions, especially during delivery and the first week of life.
Bearing the foregoing in mind, it is puzzling to hear an African head of state clamour for more population growth. This is especially poignant on the heels of the release of the 2019 Multidimensional Poverty Index, which found that sub-Saharan Africa (and South Asia) is home to the largest proportions of multidimensionally poor people in the world. Without getting too deep in the weeds of the concept, multidimensional poverty refers to a broader understanding of poverty beyond income measurements—one that considers additional factors such as malnutrition, education levels, as well as lack of clean water and electricity. Nonetheless, economic growth, jobs and wealth creation form a significant part of poverty reduction efforts, and the picture in sub-Saharan Africa is far from convincing on that score. While a number of sub-Saharan African countries such as Côte d’Ivoire, Senegal, Rwanda and Zambia have some of the fastest-growing economies in the world, economic growth has been projected by the World Bank to remain below population growth for the fourth consecutive year. The problem of low growth is particularly acute in some of the largest economies and/or most populous countries in Africa such as Nigeria, South Africa, DRC and Angola.
Beyond GDP figures, economic and population growth rates, the biggest obstacle to poverty reduction in Africa (as well as the second and third-order effects of poverty, which, of course, include high rates of neonatal mortality) is the imminent jobs crisis. The World Bank estimates that Africa’s working-age population will grow by 70 per cent (450 million) between 2015 and 2035. Where will the jobs needed to employ Africa’s young, rapidly growing population come from? In the past, the answer has been industry, but Africa has deindustrialized; its share of global manufacturing has shrunk since 1980 and African countries have struggled to keep up with East Asia in adapting to the growth of global value chains that depend on the capacity to move goods cheaply and efficiently. Considering that nearly 40 per cent of healthcare spending in sub-Saharan Africa comes from out-of-pocket payments and the strong relationship between macroeconomic performance and improved health outcomes, it becomes clear why Africa’s priority ought to be focused on poverty reduction and its potential aggregate effects on society, such as higher education attainment rates, lower infant mortality levels and increased spending on public services.
To be sure, much of the discourse surrounding population growth in Africa can be needlessly alarmist at best and demagogic at worst. Despite headlines about ‘demographic timebombs’, Africa’s total fertility rates (i.e. the average number of children born to women during their reproductive years) are actually falling and right about where they ought to be relative to income levels. The reality of Africa’s demographic profile presents a more nuanced picture where the variation on the continent is too vast and no general statement about African demography is true. But Magafuli’s demographic dividend argument isn’t entirely wrong, per se: highly populous countries can, indeed, harness their large populations to bolster economic growth and technological innovations, with the right set of policies and institutions. The United States and China are the best examples here, but Magafuli’s suggestion is a more complicated path to achieving this outcome; sound macroeconomic policies and investing in the health and education of women and young people seem like a better bet⎈