Few outsiders are likely aware of the stagnation of Pakistan's family planning program, which provides key services and affects the country's larger demographic trajectory....Pakistan was among the vanguard countries in Asia in starting a family planning program more than five decades ago, with intermittent support from international donors including the United States. Yet fertility has declined more slowly in Pakistan than in most other Asian countries.

Weak infrastructure and limited distribution systems in low-income countries complicate access to health services, especially in rural areas. Government health outlets may be relatively few and widely dispersed, and private-sector sources often favor wealthier urban areas, resulting in uneven service availability within a country. In the absence of a solid heath infrastructure, strengthening primary health care and innovative community-based health service delivery systems help provide more equitable access to health services.

HIV prevention has long been approached at the level of individual behaviors, operating to some extent under the assumption that behavior is determined by a person's conscious decisions. However, a paradigm shift toward considering the physical and social environments in which individual HIV risk behavior takes place is gradually gaining momentum. These structural factors-whether political, economic or cultural-may directly or indirectly affect an individual's ability to avoid exposure to HIV.1 The Dominican Republic offers an example of this progression from successful individual HIV behavioral interventions among sex workers, toward broader community approaches and policy initiatives.

Whatever one's view about population as an issue, few people fervently wish the world were home to a lot more human beings than it is. Some may wonder if another Mahatma Gandhi or an Albert Einstein or a Mother Theresa missed out on being born due to the declining global birthrates of the past few decades. But most know that such a question is fundamentally unanswerable and don't stay awake at night thinking about it.

A generation has passed since the onset of the HIV/AIDS pandemic. During this time, 65 million people have been infected with HIV and more than 25 million people died of AIDS. Despite the devastation, many countries, using a variety of interventions, have been successful in slowing the spread of the virus. The interventions that have been most successful are those that are congruent with the local epidemiology. With the overall HIV/AIDS epidemic being composed of a series of smaller local epidemics interconnected by space or time, a range and mix of responses in the fight against HIV/AIDS is necessary. And the relative impact of each response will always depend upon the level, stage and pattern of the epidemic in each locale. Therefore to be effective, interventions should respond to local needs.

Britain's recent pledge of US$15 billion to fund education in developing countries over the next ten years comes as good news for the estimated 493 million school-age children who are not enrolled in school, the majority of whom are girls. The gender gap-the difference between boys' and girls' school enrollments-is an indicator of gender equity and of a country's level of development. The gap is widest among countries in sub-Saharan Africa and a few Asian countries, including Yemen and Pakistan. Education has a profound impact on the future course of women's lives, influencing employment opportunities, earning potential and political participation. Access to quality education is also one of the best defenses against HIV infection, providing young people with the skills and knowledge to make informed decisions. Education is especially critical to HIV prevention in girls, as it reduces the power imbalances and social and financial dependencies that typically make females more vulnerable to infection. Moreover, a large body of evidence suggests that education of girls is associated with their roles in family decision-making and patterns of childbearing, resulting in improved maternal and child health, improved childhood nutrition, higher educational attainment among children, and a lower likelihood of experiencing unwanted and high-risk pregnancies.

An unchallenged fixture of many news stories about population aging and decline in developed countries today is the idea that “replacement fertility”-the number of children women must have, on average, over their childbearing years to produce a stationary population-is 2.1 children. The extra tenth of a child is needed, the explanation often goes, to make up for the children who don't themselves survive to parenting age.

In this era of tight financial resources for international family planning – as evidenced by the recent budget cuts proposed by President Bush in the United States – are the world's donated contraceptives reaching the women and men who need them most? A review shows that while donors of such supplies often focus their resources on countries with high need, they could do so even more effectively.

A recent report by an independent task force enlisted by the Council on Foreign Relations (CFR, More Than Humanitarianism: A Strategic U.S. Approach toward Africa, 2005) recommends that the U.S. government step up funding to international family planning programs in sub-Saharan Africa as part of a strategy to increase U.S. engagement and prioritize assistance to that region (see p. 16, pp. 119-120).1

The West African nation of Niger was propelled to the headlines several months ago over reports of starving and dying children amid denials by its government that the country was enduring a sustained food emergency (seasonal fluctuations in the availability of food are not unusual in the arid Sahel region, they argued). Niger is perhaps better known as the country falsely accused by the Bush Administration of selling uranium to Iraq – an issue that later became the object of the Valerie Plame scandal. But Niger is confronting a genuine scandal: one-quarter of its people are facing yearly food shortages. Meanwhile, its population is set to double in less than 20 years and contraceptive use among Niger's men and women remains at one of the lowest levels of any country in the world.