state of world population 2015

United Nations Population Fund
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New York, NY 10158
Tel. +1 212 297 5000
www.unfpa.org

ISBN 978-0-89714-987-7

SHELTER FROM THE STORM: A TRANSFORMATIVE AGENDA FOR WOMEN AND GIRLS IN A CRISIS-PRONE WORLD

Delivering a world where
every pregnancy is wanted
every childbirth is safe andevery young person's
potential is fulfilledstate of world population 2015

SHELTER
FROM THE
STORM
A transformative agenda
for women and girls in acrisis-prone world

Sales No.E.15.III.H.1
E/7,025/2015

Printed on recycled paper.

HUMANITARIAN GLOSSARY

The State of World Population 2015
SENIOR RESEARCHER
Therese McGinn
Heilbrunn Department of Population and Family Health, Mailman
School of Public Health, Columbia University

EDITORIAL TEAM
Editor: Richard Kollodge

RESEARCHERS AND AUTHORSJacqueline Bhabha
Harvard T.H. Chan School of Public Health; François-Xavier Bagnoud
Center for Health and Human Rights, Harvard University; Harvard
Law School

Publication and web interactive design and production:
Prographics, Inc.

Richard Garfield
Emergency Response and Recovery Branch, United States Centers
for Disease Control and Prevention;
Columbia and Emory Universities
Kirsten Johnson, M.D.
Department of Family Medicine, McGill University,
Montreal Canada; Humanitarian U
Gretchen Luchsinger

Digital developer: Hanno Ranck

ACKNOWLEDGMENTS
Mengjia Liang, Edilberto Loaiza and Rachel Snow in the UNFPA
Population and Development Branch analysed and aggregateddata in the indicators section of the report and provided estimatednumbers of pregnant women in countries affected by conflict or
natural disaster.
Source data for the report’s indicators section were provided by the
Population Division of the United Nations Department of Economic
and Social Affairs, the United Nations Educational, Scientific andCultural Organization and the World Health Organization.

COMPLEX EMERGENCY
A multifaceted humanitarian crisis in acountry, region or society where there
is a total or considerable breakdown
of authority resulting from internal orexternal conflict and which requires amulti-sectoral, international responsethat goes beyond the mandate orcapacity of any single agency and/or
the ongoing United Nations country
programme. Such emergencies have,in particular, a devastating effect onchildren and women, and call for acomplex range of responses.

Ramiz Alakbarov, Björn Andersson and Arthur Erken at UNFPA
reviewed drafts and helped shape the report.

Lisa Oddy
Humanitarian U
Monica Adhiambo Onyango
Boston University School of Public Health,
Department of Global Health
Sarah Shteir and Louise Searle
Humanitarian Advisory GroupRESEARCH SUPPORT
Amiya Bhatia
Harvard T.H. Chan School of Public Health
Chantilly Wijayasinha
Boston University School of Public Health,
Department of Global HealthMélanie Coutu
Humanitarian Studies Initiative, McGill University
UNFPA ADVISORY TEAM
Prudence Chaiban
Henia Dakkak
Ugochi Daniels
Abubakar Dungus
Danielle Engel

Editorial associate and digital edition manager: Katheline Ruiz

Howard Friedman
Ann Leoncavallo
Jacqueline Mahon
Rachel Snow

Colleagues from UNFPA offices in Amman, Bangkok, Bogota, Cairo,
Dakar, Istanbul, Johannesburg, Kathmandu, Monrovia, Panama
City and Skopje supported or guided the development of featurestories and photographs included in the report: Ghifar Al Alem,
Tamara Alrifai, Daniel Baker, Mile Bosnjakovski, Santosh Chhetri,Jens-Hagen Eschenbaecher, Adebayo Fayoyin, Gema Granados,
Habibatou M. Gologo, Calixte Hessou, Ruba Hikmat, Jorge Parra,
Elina Rivera, Shible Sahbani, Alvaro Serrano, Sonja Tanevska, Giulia
Vallese and Roy Wadia.
Anna Maltby wrote the feature about the Ebola crisis in Liberia.
Assignment photographers and videographers:
Nake Batev (Former Yugoslav Republic of Macedonia)
Daniel Baldotto (Colombia)
Abbas Dulleh, AP Images (Liberia)
Salah Malkawi (Jordan)
MAPS AND DESIGNATIONS
The designations employed and the presentation of material inmaps in this report do not imply the expression of any opinion
whatsoever on the part of UNFPA concerning the legal status ofany country, territory, city or area or its authorities, or concerning
the delimitation of its frontiers or boundaries. A dotted line
approximately represents the Line of Control in Jammu andKashmir agreed upon by India and Pakistan. The final status of
Jammu and Kashmir has not been agreed upon by the parties.
Cover photo: © UNFPA/Nake Batev

UNFPA
Delivering a world where
every pregnancy is wanted
every childbirth is safe andevery young person’s
potential is fulfilled©The United Nations Population Fund, 2015

DIRECT AND INDIRECT
EFFECT
A direct effect is a death or otheroutcome which occurred directly andprimarily because of a catastrophic
event. An indirect effect is a death orother outcome which occurred as an
eventual, but not immediate, result ofa single destructive act. Often theseoutcomes can be identified only on a
population basis, where direct effects
can be specified to the individual. For
example, if the mortality rate rises afteran event and there is no other cause
identified, these additional deaths
are considered the indirect effectof the event.

HUMAN RIGHTS
All human rights derive from thedignity and worth inherent in thehuman person. The concept of humanrights acknowledges that every single
human being is entitled to enjoy his or
her human rights without distinction
as to race, colour, sex, language,
religion, political or other opinion,
national or social origin, property,
birth or other status.

HUMANITARIAN ACTION
Humanitarian action provides lifesaving services and facilitates thereturn to normalcy for people andcommunities affected by natural andhuman-made disasters. It also seeks
to lessen the destructive impact ofdisasters and complex emergencies.

HUMANITARIAN CRISIS
An event or series of events that
represents a critical threat to thehealth, safety, security or well-beingof a community or other large groupof people, usually over a wide area.
Armed conflicts, epidemics, famine,natural disasters and other major
emergencies may all involve or lead toa humanitarian crisis.

HUMANITARIAN RESPONSE
Material and logistical assistance topeople due to needs created by conflictor disaster, and provided on the basisof an appeal by the government orinternational organizations.

INTERNALLY DISPLACEDPERSONS
Individuals who have been forced or
obliged to flee or to leave their homes
or places of habitual residence, inparticular as a result of, or in order toavoid, the effects of armed conflict,situations of generalized violence,violations of human rights or naturalor human-made disasters, and who
have not crossed an internationallyrecognized State border.

NATURAL DISASTER
A large-scale event where life and/or property is destroyed. For an event
to be recorded as a disaster in theinternationally recognized Centre
for Research on the Epidemiology ofDisasters database, at least one of thefollowing criteria must be met:
• Ten or more people reported killed.
• One hundred or more people reported
affected.
• A declaration of a state of emergency.
• A call for international assistance.
Natural disasters include droughts,
earthquakes, epidemics, extreme heator cold, floods, storms, tsunamis,
volcanic eruptions and wildfires.

PEOPLE AFFECTED BY
CONFLICT OR DISASTER
Individuals requiring immediate
assistance during a period of
emergency, i.e., requiring basic
survival needs such as food, water,
shelter, sanitation and immediate
medical assistance as the result of
the emergency.

REFUGEE
A person who, owing to a well-foundedfear of being persecuted for reasons ofrace, religion, nationality, membershipof a particular social group or politicalopinion, is outside the country of hisor her nationality, and is unable to, or
owing to such fear, is unwilling to avail
himself or herself of the protection ofthat country.

state of world population 2015

SHELTER FROM THE STORM
A transformative agenda for
women and girls in a crisis-prone world
Foreword

page 2

Overview

page 4

1 A fragile world
2 The disproportionate toll on women and adolescent girls
3 Evolving response: from basic to comprehensive
4 Resilience and bridging the humanitarian-development divide
5 New directions in financing sexual and reproductive health in humanitarian settings
6 A transformative vision for risk reduction, response and resilience

page 12page 36

page 56

page 74
page 90

page 102

Indicators

page 115

Bibliography

page 131

Photo © Panos Pictures/Brian Sokol

Foreword
More than 100 million people are in need of humanitarian assistance—more than at
any time since the end of the Second World War. Among those displaced by conflict or
uprooted by disaster are tens of millions of women and adolescent girls. This report is acall to action to meet their needs and ensure their rights.

While remarkable progress has beenachieved during the past decade
protecting the health and rights
of women and adolescent girls in humanitarian settings, the growth in need has outstripped
the growth in funding and services. Yet, these
services are of critical importance, especially forvery young adolescent girls, who are the mostvulnerable and least able to confront the many
challenges they face, even in stable times.
Under normal circumstances in some developing
countries, a 10-year-old girl, for example, may bemarried off against her will, trafficked, separated
from her family and all social support and have
limited access to education, health or opportunities for a better life. When a crisis strikes, theserisks multiply, and so do that girl’s vulnerabilities.
Her prospects go from bad to worse. She may
become the target of sexual violence, infectedwith HIV, or pregnant the moment she reaches
puberty. Her future is derailed.
Every 10-year-old girl, no matter where she
is, has a right to health, dignity and safety,
and 179 governments pledged in 1994 at theInternational Conference on Population andDevelopment to uphold that right—in any

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and every situation. Yet for too many years,
humanitarian assistance has left the 10-year-old
girl behind, vulnerable to unsafe childbirth,and violence with devastating consequences.
Sexual and reproductive health and access to
information are essential for any girl’s safe transition from adolescence to adulthood. Imagine
that 10-year-old 15 years later with her rights
and health intact; now imagine her in a world
where armed conflict, devastation and dislocation deny her every human right, every
opportunity, every dignity.
Abandoning her, or her community or country, is not an option. We are, in the end, one
world, and governments have a responsibility
to protect human rights and abide by international law. As global citizens, we have a duty toprovide support and solidarity.
Today about three fifths of all maternal deaths
take place in humanitarian and fragile contexts.
Every day 507 women and adolescent girls diefrom complications of pregnancy and childbirth in emergency situations and in fragile
States. And gender-based violence continues totake a brutal toll, shattering lives and prospects
for peace and recovery.

Together we must transform humanitarian
action by placing the health and rights ofwomen and young people at the centre of ourpriorities. At the same time, we must invest
heavily in institutions and actions that build
girls’ and women’s human capital and agency
and in the resilience of communities andnations over the long run so that when a newcrisis strikes, disruption and dislocation may beminimized and recovery may be accelerated.
For its part, UNFPA remains committed to
the full realization of the sexual and reproductive health and rights of all women andgirls, wherever they live, and under all conditions, crisis or otherwise, at all times. The
surfeit of conflicts and disasters all around
us today means that UNFPA is delivering alarger share of its services in crisis settings.

deliberately tackle inequalities, the benefits ofinterventions grow exponentially and carry overfrom the acute phase of a crisis well into the
future as countries and communities rebuildand people reclaim their lives.
Together we must strive for a world where
women and girls are no longer disadvantaged
in multiple ways but are equally empowered torealize their full potential, and contribute to thedevelopment and stability of their communities
and nations—before, during or after a crisis.

Dr. Babatunde Osotimehin
United Nations Under-Secretary-General andExecutive Director
UNFPA, the United Nations Population Fund

When women and girls can obtain sexualand reproductive health services, along witha variety of humanitarian programmes that

Photo © UNFPA/Nezih Tavlas

THE STATE OF WORLD POPULATION 20153

Overview
More than a billion people alive today have seen their lives upended by crisis. War,instability, epidemics and disasters have left a long trail of turmoil and destruction.

Right now, more people are displaced by crisis
than at any time since the cataclysm of theSecond World War: an estimated 59.5 million.
Natural disasters now affect 200 million people a year.
For some, the setbacks are temporary. For others, they may consume a lifetime. Refugees now
spend an average of 20 years away from home.
Pregnancy and childbirth are additional vulnerabilities for women and girls in conflicts and crises.
Sixty per cent of preventable maternal deaths takeplace among women struggling to survive conflicts,
natural disasters and displacement.
In a series of international agreements, theworld has affirmed the sexual and reproductive
health and rights of women and girls. That promise

RISK
Photo © UNFPA/Sawiche Wamunza

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encompasses upholding and delivering on theserights in all cases, at all times; humanitarian crises do
not diminish this responsibility. Keeping that promise means guaranteeing that women and girls haveaccess to comprehensive services before, during andafter a crisis. What’s needed in many crisis-affected
countries are scaled-up commitment and action.
In a fragile world, women and girls pay adisproportionate price

By many measures, more countries are consideredfragile than five or six years ago, leaving them more
vulnerable to conflict or the effects of disasters.
Many factors make people and countries vulnerable.
Being poor is one—over 1 billion people still live

in extreme poverty. This traps individuals and evenwhole countries so far down the ladder of development as to make any upward climb the most distant
dream. It means decent work is unavailable, and thequality of services is unpredictable.
Geography is another factor. Some countries lie
squarely in the path of natural disasters, which are
increasing dramatically through climate change.
Historic levels of urbanization have raised risks forcity dwellers, especially the poor, many of whom
live in poorly constructed informal settlements infragile areas, such as on hillsides prone to mudslides.
For women and girls, compounding theseand other factors are discrimination and genderinequality. To start with, women and girls have lessof almost everything: income, land and other assets,
access to health services, education, social networks,a political voice, equal protection under the law,and the realization of basic human rights.

When a crisis strikes, they are thus disproportionately disadvantaged and less prepared or
empowered to survive or recover. During and after
any kind of crisis, gender-based violence may soar,
including in its use as a weapon of war.
Extreme financial hardship stemming fromdisaster or conflict can lead women to transactional sex or make them vulnerable to trafficking.
A lack of even basic sexual and reproductive health

When a crisis strikes, womenand girls are disproportionately
disadvantaged and lessprepared or empowered tosurvive or recover.

WOMEN AND GIRLS ARE DISPROPORTIONATELY DISADVANTAGED

More than

100 MILLION

people in need ofhumanitarian assistance,

ONE QUARTER ARE
WOMEN AND GIRLS,
AGES 15 TO 49.

At heightened risk of• Sexually transmitted infections, including HIV• Unintended, unwanted pregnancy• Maternal death and illness• Sexual- and gender-based violence

THE STATE OF WORLD POPULATION 20155

services makes giving birth in crisis settings apotentially deadly proposition, even more so foradolescent girls.
All of these dangers share a common cause: a lackof respect for the human rights to which everyone
is entitled, no matter their sex, age or any otherdistinguishing characteristic. These rights include
the reproductive rights agreed by 179 governments
at the 1994 International Conference on Population
and Development, culminating in a groundbreaking Programme of Action, which guides the workof UNFPA, the United Nations Population Fund.
Women and girls face obstacles to sexualand reproductive health before, during andafter crises

Of the more than 100 million people in need ofhumanitarian assistance in 2015, an estimated one
quarter were women and adolescent girls of reproductive age. Assistance that fails to meet all of theirneeds, including those specific to gender and age,can hardly be considered effective.

RESPONSE
Photo © Panos Pictures/Chris de Bode

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To date, the supply of assistance aimed atmeeting the sexual and reproductive healthneeds of women and girls has not kept pace withthe demand. Remarkable progress in targeting
humanitarian services to women and girls has
been achieved in the past decade. Still, large
gaps remain, in action and in funding.
Gender inequality and discrimination—by sex,
age or other factors—are among the explanations,manifesting even in well-intentioned humanitarian responses. Interventions that fail to account forthe different ways disasters and conflicts can affectdifferent groups can end up perpetuating inequalities, such as when general health care is provided
in a crisis, but not services related to pregnancy,
childbirth or contraception, leaving alreadydisadvantaged women and girls in an even more
precarious situation.
In the tumultuous early phase of a crisis, food,shelter and care for acute physical trauma often
seem the most compelling needs, with gender or
any other kind of discrimination something thatcan be put off for a safer day. Thinking this way,
however, can make a response blind to realities
on the ground—including those that shut womenand girls off from assistance or leave them vulnerable to violence.
A lack of concerted attention is fed in partby a very limited amount of data broken down
by sex or other parameters, and by a lack ofgender expertise among many first responders.
Given the scale of crisis in the world today,and given who most victims are, it is time totransform the conventional approach into one
that takes account of diversity in crisis-affected
populations, and wields that diversity for the
benefit of reduced risk, faster recovery andgreater resilience.
Move sexual and reproductive healthto the centre of humanitarian action

Until only 20 years ago, sexual and reproductive
health took a back seat to priorities such as water,food and shelter in humanitarian response. But

Remarkable progress intargeting humanitarian services
to women and girls has beenachieved in the past decade.
Still, large gaps remain, in
action and in funding.

a wealth of research and evidence since the early
1990s has helped make the health of women andgirls far more visible. Many humanitarian interventions now meet needs associated with pregnancy
and childbirth, and seek to prevent and address vulnerabilities to sexual or gender-based violence andsexually transmitted infections, including HIV.
Not only is it more widely accepted thatmeeting these needs is a humanitarian imperative
and a matter of upholding and respecting human

ESSENTIAL ACTIONS AND SERVICES FROM THE ONSET OF A CRISISPRIORITY SERVICES• Emergency obstetric andnewborn care
• Referral system for obstetricemergencies• Supplies for clean and safedeliveries

OBJECTIVES
Prevent maternal andinfant mortality
Reduce transmission of HIV• Contraception• Condoms• Anti-retrovirals• Clinical care for survivors of rape

Prevent and manage theconsequences of sexual
violence

THE STATE OF WORLD POPULATION 20157

rights, but it is also clear that ensuring accessto sexual and reproductive health is a pathway
to recovery, risk reduction and resilience. The
benefits extend to women and girls—and beyond.
When they can obtain sexual and reproductive
health care, along with a variety of humanitarian
programmes that deliberately tackle inequalities,
positive effects ripple throughout all aspects ofhumanitarian action.
Unsustainable funding calls for thetransformation of humanitarian action

The lion’s share of humanitarian action is coordinated and managed by major international players,
including the United Nations, and has been traditionally funded by donor nations that are membersof the Organisation for Economic Co-operation
and Development, but other countries and private
donations are beginning to play an important role
too. The demand for humanitarian assistance hasgrown every year since 2011, but funding has notincreased at the same pace, leaving unprecedented

RESILIENCE
Photo © UNFPA/Ben Manser

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A fundamental shift isneeded: away from reacting
to disasters and conflicts asthey unfold and sometimes
linger for decades, towards
prevention, preparedness andempowerment of individuals
and communities to withstandand recover from them.

gaps, translating into inadequate or insufficient responses for millions of people in need.
The ever-enlarging gaps suggest current
funding arrangements may be unsustainable.
So, too, may be a business-as-usual approachto humanitarian action.

Crises will continue to happen; acute needs will
always need to be met. But a fundamental shift isneeded: away from reacting to disasters and conflicts
as they unfold and sometimes linger for decades,
towards prevention, preparedness and empowermentof individuals and communities to withstand andrecover from them.
Tip the balance from reaction and response
towards preparedness, prevention andresilience

We must aim for a more resilient, less vulnerable
world. Such a world would be one where development, within and across countries, is fully inclusive
and equitable, and upholds all rights for all people.
Where women and girls are no longer disadvantaged in multiple ways but are equally empowered
to realize their full potential, and contribute to thedevelopment and stability of their communities
and nations.
It would be a world where every country canmanage its economy and its polity to guarantee

everyone’s access to decent work and high quality
essential services, including sexual and reproductive
health care. Among those who set the course of public policies, there would be a sound understandingthat investment in equitable, inclusive development
is about the best and certainly the fairest and mosthumane investment that can be made. Far-reaching
benefits include reducing the risks and impactsof crisis.
Transformation to a more resilient, less vulnerable
world also depends on better management of risks
and institutions with sufficient capacities in place
long before a crisis strikes. Risks first need to becomprehensively understood; only then can effective
investments be made in measures to reduce them.
For those risks not fully avoidable, proactive preparation is critical to limit the worst consequences.
One of the most central strategies in reducing risks
in all countries is making sure people are resilient in
the face of them. Those who are healthy, educated,have adequate income and enjoy all human rights
have far better prospects when risks become reality.

PREVENTION, PREPAREDNESS AND EMPOWERMENTManage risks
betterRectify genderinequality

Foster individuals’ resiliencethrough education and health

Build capacities of institutions
before disaster strikes

Enable realization ofsexual and reproductive
health and rights

Strive for long-term,
inclusive and equitabledevelopment

THE STATE OF WORLD POPULATION 20159

Break the vicious cycle of discriminationand inequality

One of the weakest areas of resilience currently
is among women and girls, and the institutions
that serve them. As long as inequality andinequitable access short-circuit their rights,

As long as inequality andinequitable access short-circuit
their rights, abilities andopportunities, women and girls
will remain among those mostin need of humanitarianassistance and least equipped
to contribute to recovery or
resilience.

MOVING FORWARD
Photo © Panos Pictures/Sven Torfinn

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abilities and opportunities, women and girls
will remain among those most in need ofhumanitarian assistance and least equipped tocontribute to recovery or resilience.
Transformation can begin, in part, in theaftermath of a crisis, but that largely depends
on the response. If it mainly replicates existing
discriminatory patterns, such as by failing toprovide quality sexual and reproductive healthservices from the first moments, it is nottransformative. It will fail as well on all scores ofeffectiveness and human rights. All humanitarian
issues involve some kind of gender perspective,
because men and women, girls and boys
experience the world in markedly different ways.
All types of humanitarian action therefore needto recognize and respond to these differences,
and actively correct any disparities.
Wherever feasible, humanitarian assistancecan challenge existing forms of discrimination,such as through providing comprehensive
services for survivors of gender-based violence.

It can enlist men and boys in building acceptanceof new social norms, such as around women’s
inherent rights and the peaceful resolution ofdifferences.

for long-term development. Development that
benefits all, enabling everyone to enjoy their rights,
including reproductive rights, can help individuals,
institutions and communities withstand crisis. It
can also help accelerate recovery.
Equitable, inclusive and rights-based
development, and the resilience fostered byit, can in many cases obviate the need forhumanitarian interventions. As the globallyagreedEffective
Agenda 2030 for sustainable development
response
begins, and the World Humanitarian Summit
approaches in 2016, now is the time to act on
this understanding and re-envision humanitarian
action, with the health and rights of women andgirls at its core.

Tear down the artificial divide between
humanitarian action and development

The surfeit of crisis and upheaval around theworld today demands that we do much better.
We need better development, better humanitarian
action, better risk management, better attention
to prevention, preparedness and resilience, andbetter connections among all of these. Running
through them is a common thread: gender and allother forms of equality, achieved in part throughfull realization of sexual and reproductive healthand rights, leads to far less vulnerability andmuch greater resilience for individuals andsocieties as a whole.
The distinction between humanitarian
response and development today is a false one.
Humanitarian action can lay the foundations

Recovery

Equitable,
inclusive
development

Prevention andpreparedness

A NEW VISION FOR HUMANITARIAN ACTION

Prevention andpreparedness

Effective
response

Resilience

SEXUAL AND
REPRODUCTIVE
HEALTH AND
RIGHTS

Equitable,
inclusive
development

At the core of theinterrelated elementsof humanitarian
action, from responseto resilience anddevelopment, are sexualand reproductive healthand rights

Recovery
THE STATE OF WORLD POPULATION 201511

CHAPTER 1

A fragile world
Natural disasters, especially floods and storms, occur twice as
frequently today as 25 years ago. Conflicts, especially thosewithin national boundaries, are driving millions from their homes.
Conflict, violence, instability, extreme poverty and vulnerability todisasters are deeply interrelated conditions, which today prevent
more than 1 billion people from enjoying the massive social andeconomic gains achieved since the end of the Second World War.

When time won’t wait:
meeting basic healthneeds for pregnant
women on the move

Ashur and family, Gevgelija.
Photo © UNFPA/Nake Batev

12

CHAPTER 1“I was three months pregnant andworried about what this trip would
do to my baby, but I didn’t have a
choice. We had to go,” says Leyla
Ashur, one of the few hundred Syrians
allowed to cross into the former
Yugoslav Republic of Macedonia
from Greece one day in August.
Ashur, 35, says she, her husband andtheir four sons had fled fighting in theirhome town of Dayr Az-Zawr, Syria, in2012 and lived for about a year in Iraq.
But the fear of violence from the selfproclaimed Islamic State in Iraq and theLevant, or ISIL, drove them across yet
another border, into Turkey, where they
stayed for three years until even thatsituation became untenable. She says
not only were they afraid of escalating
violence along the border, but they also

A FRAG I LE WO RLD

felt exploited and unwelcome in their
host community.
“When they saw we were Syrians,
we had to pay three times the rent
everyone else was paying,” she says.
“And everyone kept telling us, ‘Go away,
go away.’”
And so the family of six left with a few
belongings crammed into backpacks.
The journey across Turkey took 10 days,
with little rest and very little to eat along
the way. “We didn’t receive help fromanyone,” Ashur says.
When she and her family reached theTurkish coastal city of Bodrum, they
and about 20 others together paid asmuggler €10,000 to carry the group in
a rubber raft across the Aegean Sea toLeyla Ashur and family.
Photo © UNFPA/Nake Batev

the Greek island of Ios. From there, they
made their way to the former Yugoslav
Republic of Macedonia.
From the southern city of Gevgelija,
Ashur and her family began the next legof their journey north, with the aim ofcrossing through Serbia and Hungary
and then on to Belgium, where herhusband’s sister lives.
“We will reach our destination or die on
the way.”
While hundreds piled onto overcrowded
trains and buses, or simply walked the
178 kilometres to the northern frontiercity of Kumanovo, Ashur and her familyfound a taxi to take them for €100. Her
two younger sons waved goodbye fromthe back window.

Syrians like Ashur and her family
account for about 80 per cent of thepeople transiting through the country.
Afghans and Iraqis each account for
about 5 per cent. The others are from
Pakistan, Somalia, Palestine and fivecountries in sub-Saharan Africa.
Between June and August 2015, anaverage of 700 refugees and migrants
followed the same path to northern
Europe through the former Yugoslav
Republic of Macedonia every day. Of
that number, about one in four is awoman, and on average, 6 per cent of
those women are pregnant.
Many of the pregnant women have healthconcerns stemming from walking long
distances in the heat, poor nutrition, dehydration and the absence of sanitation, allof which can lead to pregnancy complications or even miscarriage. And many aretraumatized, says Suzana Paunovska of
the Red Cross in the capital, Skopje. “Yousee it immediately in their faces.”
The Government in June declared thatrefugees and migrants could accesshealth care, including obstetric andgynaecological services, for free frompublic health centres and hospitals,
including the one in Gevgelija.
But because refugees and migrants
are in a hurry to reach the borderwith Serbia within the 72 hours theGovernment allows for transiting
through the country, most choose not
to take advantage of free services rather
than risk missing one of the few trains orbuses traveling north.

THE STATE OF WORLD POPULATION 201513

O

ur world is in the midst of a paroxysmof violence, instability and upheaval notseen since the end of the Second World
War. Over the past two decades, disasters, includingones related to extreme weather events, have affectedbillions of people. Today, crises, such as mass movements of people in response to extreme as poverty
and unstable societies, are increasingly visible.
Whole regions of the world seem to be in turmoil,
and in a more connected world, even people in thestable zones feel more insecure than they once did.
Many crises linger for decades, with no real solutions in sight. Refugees are living away from homefor 20 years on average, with no access to durable
solutions and sustainable livelihoods. In some cases,
crises have persisted over generations (Milner andLoescher, 2011).
Each crisis, whether a war, a deadly epidemic,
earthquake or flood, brings unique challenges
to the health, safety, livelihoods and rights ofindividuals, families and communities.

Pregnant women will only use services
that are fast and within easy reach oftransit hubs near border crossings,
says Bojan Jovanovski, who heads
the Association for Health Education
and Research, or HERA, in the capital,
Skopje.

Lidija Jovcevska
Photo © UNFPA/Nake Batev

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CHAPTER 1

Today’s conflicts, devastation from disasters,
instability, and environmental and economic vulnerability have triggered an unprecedented demandfor humanitarian action from governments, civilsociety and international organizations.
Floods and storms: most frequent
natural disasters

The number of natural disasters tripled between
1980 and 2000, followed by a slight decline, but
still double the number today than what wasrecorded 25 years ago, according to data fromthe Centre for Research on Epidemiology ofDisasters.
In most years, there are between one and threelarge-scale disasters that cause a level of deathfar greater than other events. In most decades, there
are also one or two disasters so large and shocking to
public consciousness they are labeled mega-disasters.
For each person who dies in a disaster, there are
hundreds more who are affected by it and require

HERA deploys its only mobile healthclinic to the border with Greece, a few
hundred metres from Gevgelijia, one
day a week to provide free, quick, basic
gynaecological services for refugees andmigrants. UNFPA, the United Nations
Population Fund, helps cover the clinic’s
operating expenses.
Lidija Jovcevska is an obstetriciangynaecologist based in Kumanovo.
She volunteers one day a week for themobile clinic. The five or six women
she sees in a day mostly want to knowwhether their foetuses are healthy. She
uses an ultrasound machine to reassure
most expectant mothers but also lets
them know about any potential complications. Some women who have traveledfor days and sometimes months also ask
for vitamin supplements to increase the

A FRAG I LE WO RLD

chances they will deliver healthy babies.
Vaginal and urinary tract infections arecommon. Jovcevska prescribes antibiotics and other medications.
On occasion, there is a serious problem
requiring attention at a hospital.
Jovcevska refers these cases to the
nearby hospital, which can handle
emergencies as well as deliveries.
Jovcevska says the risks of travelingunder such extreme conditions while
pregnant are high. “It is unclear to me,
as a mother of two myself, how they caneven contemplate such a trip,” she says,
while acknowledging the desperationthat many of these women feel. “Onewoman I saw today told me, ‘It’s all rightif I die on the way.’”immediate basic survival needs, such as food,2014, affecting nearly 2.5 billion people. Storms
water, shelter, sanitation or immediate medical
were the second most frequent type of disaster,
assistance. Those affected by a disaster often lose
killing a total of more than 244,000 people andtheir homes and livelihoods, become separated
costing $936 billion in recorded damage over thatfrom families, face a lifetime ofnine-year period. This makes
illness, disability or restricted
storms the most expensive type
opportunities, and are disof disaster during the past twoplaced from their communities.
decades and the second mostFor each person who dies inControlling for populationcommon killer.
a disaster, there are hundreds
growth, the likelihood of being
Earthquakes (including tsumore
whoareaffectedbyitdisplaced by a disaster today
namis) killed more people thanandrequireimmediatebasic
is 60 per cent higher than it
all other types of disaster comsurvival needs, such as food,
was four decades ago. Over thebined, claiming nearly 750,000
water, shelter, sanitation orlast 20 years, there have been
lives between 1994 and 2013.
health care.
an average of 340 disasters per
Tsunamis were the most deadly
year, affecting 200 million peosub-type of earthquake, with anple annually, taking an average
average of 79 deaths for everyof 67,500 lives a year.
1,000 people affected, compared to four deaths
Flooding caused 43 per cent of reported disasper 1,000 for ground movements. This makes
ters in the Centre for Research on Epidemiology
tsunamis almost 20 times deadlier than land-basedof Disasters’ EM-DAT database between 1994 andearthquakes.

The mobile clinic also offers contraception, though few take advantage of it,says Vesna Matevska, a programme
coordinator for HERA. The refugees
and migrants she sees tend to be very
private people who are reluctant to ask
for or accept condoms or the pill, eventhough they are free of charge andavailable from non-judgmental service
providers. She says this sense of privacy, along with language barriers, also
make it difficult for many women to talkabout or report gender-based violence.
In addition to services provided by nongovernmental organizations and thecountry’s ministry of health, there arethose offered informally by individuals
like Lence Zdravkin, 48, a self-described
activist, who says she has helped
hundreds of pregnant women as theywalked north across the country toreach the Serbian border.

Lence Zdravkin
Photo © UNFPA/Nake Batev

Until June 2015, it was illegal forrefugees and migrants to use trains,
buses or taxis, so most simply walked
the distance, usually along the main
railway tracks, which pass 10 metresfrom Zdravkin’s home.
Zdravkin began offering refugees andmigrants food and water and opened
her home to people who simply neededa rest. She brought pregnant women
to a local clinic for checkups or to treat
the injuries that are inevitable when
walking for days in the summer heat.
“Everything was happening rightin front of me,” Zdravkin says.
“I couldn’t just close my eyes.”

THE STATE OF WORLD POPULATION 201515

RECORDED NATURAL DISASTERS, WORLDWIDE, BY TYPE
1994 TO 2014
Earthquake

Drought

Flood

Epidemic

Other types*

Storm

Number of disasters per disaster type

600

500
400

300
200

100

0
1994

1995

1996

1997

1998

1999

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

2011

2012

2013

2014

2012

2013

2014

Year
*Figures include disasters such as insect infestation, extreme temperature, landslide, volcanic activity and wildfire.
(CRED, 2015a)

ESTIMATED NUMBER OF PEOPLE AFFECTED BY NATURAL DISASTERS, BY TYPE
1994 TO 2014
Earthquake

Drought

Flood

Epidemic

Other types*

Storm

Number of people affected in millions

700
600
500
400
300
200
100
0
1994

1995

1996

1997

1998

1999

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Year
*Figures include disasters such as insect infestation, extreme temperature, landslide, volcanic activity and wildfire.
(CRED, 2015a)

16

CHAPTER 1A FRAG I LE WO RLD

2011

Drought affected more than 1 billion people
between 1994 and 2014, or about one in four
people affected by all natural disasters. Yet
droughts accounted for just 5 per cent ofdisaster events. Some 41 per cent of drought
disasters in that period were in Africa.
In absolute numbers, the United States andChina recorded the most natural disasters
between 1994 and 2014, due mainly to theirsize, varied landmasses and high population
densities. Among the continents, Asia bore
the brunt of disasters, with 3.3 billion people
affected in China and India alone. If data arestandardized to reflect the numbers of people
affected per 100,000, Eritrea and Mongolia were
the world’s worst-affected countries that are notisland States. Haiti suffered the largest numberof people killed both in absolute terms andrelative to the size of its population due to thetoll of the 2010 earthquake.
While disasters have been recorded more
frequently during the past 20 years, the average
number of people affected has actually fallenfrom one in 23 between 1994 and 2003, toabout one in 39 between 2004 and 2014.

43%
Flooding caused
43 per cent of reported
disasters between 1994
and 2014, affecting nearly
2.5 BILLION PEOPLE

Drought affected morethan 1 BILLION people
between 1994 and 2014, orabout ONE IN FOUR PEOPLE
affected by all natural
disasters

Disaster-related deaths higher in poorer
countries

TSUNAMISEARTHQUAKE

79
4
VS.
DEATHS
DEATHSper1,000 people affected
Photo © UNFPA/Ben Manser

The Centre for Research on Epidemiology ofDisasters’ data also show how income levels
impact disaster death tolls. On average, morethan three times as many people died per disaster in low-income countries (332 deaths) thanin high-income ones (105 deaths). A similar
pattern is evident when low- and lower-middleincome countries are grouped together andcompared to high- and upper-middle-income
countries. Taken together, higher-income countries experienced 56 per cent of disasters but
lost 32 per cent of lives, while lower-income

Making tsunamis almost
20 TIMES deadlier thanland-based earthquakes,
over two decades

THE STATE OF WORLD POPULATION 201517

RECORDED NATURAL DISASTERS, BY REGION
1994 TO 2014
Asia

Americas

AfricaOceania

Europe600

Number of disasters per continent

500
400

300
200

100

0
1994

1995

1996

1997

1998

1999

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

2011

2012

2013

2014

2013

2014

Year

(CRED, 2015a)

ESTIMATED NUMBER OF PEOPLE AFFECTED BY NATURAL DISASTERS, BY REGION
1994 TO 2014
Asia

Americas

AfricaOceania

EuropeTotal affected persons per continent in millions

700
600
500
400
300
200
100
0
1994

1995

1996

1997

1998

1999

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Year
(CRED, 2015a)

18

CHAPTER 1A FRAG I LE WO RLD

2011

2012

countries experienced 44 per cent of disasters
but suffered 68 per cent of deaths. This demonstrates that levels of economic development,
rather than exposure to hazards per se, are major
determinants of mortality.
Rise in conflicts within borders pushes
civilian death toll upward

Today, about ONE IN THREE
refugees resides in a camp.
Two in three live in urban areas

Today 1 BILLION PEOPLE
or about 14 per cent of theworld’s population live inareas of conflict

74%

Photo © Panos Pictures/Mikkel Ostergaard

The Second World War, the largest conflict inthe modern world, remains humanity’s reference point for mass harm. About 3 per cent of
the world’s people died as a direct result of thatconflict or its prelude and aftermath. Meanwhile,
more than one third of the world’s people wereaffected by it. For each death, therefore, 10 otherlives were radically disrupted.
After the Second World War, the number ofinternational conflicts declined dramatically,
while conflicts within national boundaries andwars of decolonization increased in the 1950s
and 1960s.
The increase in intra-State conflicts and thedecrease in international wars help explain an
increase in civilian deaths and a decrease indeaths among combatants. Regardless of whether
a conflict occurs within or across a nationalboundary, it invariably has an insidious impact
on the lives of many people, through chronic
insecurity and uncertainty, which in turn affect
the quality of life, social cohesion, livelihoods,
rights and development potential for all.
At the end of the Second World War, 940
million people—or 40 per cent of the world’s
population at that time—lived in areas ofconflict. By 1956, the number fell precipitously
to 210 million, or 8 per cent of the world’s
population. Afterward, the number continued
to rise, reaching about 1 billion people today(Garfield et al., 2012).

Seventy-four per cent of directconflict deaths between 1989
and 2008 occurred inCentral Africa, East Africa,
the Middle East and North
Africa and South Asia

THE STATE OF WORLD POPULATION 2015

19

GLOBAL TRENDS IN ARMED CONFLICT
1946 TO 2014200
Warfare totals

Magnitude of conflict*

160

120
Intra-state warfare

80Interstate warfare

40

0
1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

2010

Year
(Center for Systemic Peace, 2015)* The magnitude of a conflict is measured by the comprehensive effects on the State or States directly affected by warfare,including numbers of combatants and casualties, affected area, dislocated population and extent of infrastructure damage.

DEATHS DIRECTLY RELATED TO CONFLICTHigh & low adjusted estimates

Adjusted estimate

900,000
800,000

Direct deaths

700,000
600,000
500,000
400,000
300,000
200,000
100,000
01989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008Year

(Garfield and Blore, 2009)20

CHAPTER 1A FRAG I LE WO RLDCONFLICT’S IMPACT ON WOMEN AND MEN
Global conflict-related data disaggregated by sex are scarce, and when they are available, they are often unreliable.
Still, small area-specific surveys yield some insights showing that men are much more likely to die directly and duringconflicts, whereas women die or are otherwise harmed more often of indirect causes after a conflict (Ormhaug, 2009).
Every estimate of direct conflict deaths suggests that more than 90 per cent of all casualties occur among young adultmales (Cummings et al., n.d.).

MEN

DIRECT IMPACTS

INDIRECT IMPACTS• Higher rates of morbidity and mortality
from battle deaths• Risk of ex-combatants’
involvement in criminal or illegal
activities and difficulties in finding
livelihoods• Higher likelihood to be detained or
missing• Sexual and gender-based violence:
sex-selective massacres; forcibly
conscripted or recruited; subjected totorture, rape and mutilation; forced tocommit sexual violence upon others• Increased prevalence of otherforms of violence—particularly
domestic violence• Higher rates of disability from injury

COMMON• Depression, trauma andemotional distress• Asset and income loss
• Tendency towards increased
migration• Disrupted patterns of marriage
and fertility• Loss of family and social
networks, including insurance
mechanisms• Interrupted education• Eroded well-being, particularly
poor health and disability frompoverty and malnutrition

WOMEN• Higher likelihood to be internallydisplaced persons and refugees• Gender-based violence: being
subjected to rape, trafficking andprostitution; forced pregnancies
and marriages• Reproductive health problems• Women’s reproductive andcare-giving roles under stress• Changed labour market participationfrom death of family members and“added worker effect”• Higher incidence of domestic violence• Possibility for greater politicalparticipation(Anderlini, 2010)• Women’s increased economic
participation due to changing genderroles during conflict

THE STATE OF WORLD POPULATION 201521

Direct conflict deaths average
168,100 a year2014). In 2012, two out of five people worldwide
who died in battle were in Syria.
In addition, deaths that result from conflict but
are not directly due to fighting outnumber directconflict deaths, in some countries by a rate of three
to one. Most of these indirect deaths occur in lowincome countries, where vulnerable civilians are
cut off from vital lifelines to immunization, childnutrition and clean water.

The number of deaths is one indicator for intensity or magnitude of a conflict. A generation ofresearchers has tried to establish reliable estimates of the number of people killed in conflict.
Arriving at such estimates is especially complicated because conflicts are increasingly waged
by non-State actors in remote areas and often
in countries with institutions ill-equipped toaccurately track casualties.
Between 1989 and 2008, there were an estimated total 3,362,000 direct conflict deaths, oran average of 168,100 deaths per year (Garfieldand Blore, 2009). Seventy-four per cent of directconflict deaths between 1989 and 2008 occurredin Central Africa, East Africa, the Middle East andNorth Africa and South Asia.
Since 2008, increasing conflict in the Middle
East raised the total level of direct conflict deaths
to more than 200,000 per year (Price et al.,Other armed violence

Armed violence not associated with conflict also
takes a heavy toll on lives. The Global Burden of
Armed Violence in 2011 attempted to account for all
deaths due to firearms recorded through civil systems
in countries throughout the world, arriving at an
estimate of 400,000 firearms-related deaths outsideof conflict situations. Insecurity and fear of armed
violence have been major drivers of displacement andmigration in some countries in recent years, sparking
a situation that resembles a humanitarian crisis.

MAJOR SOURCE COUNTRIES OF REFUGEES

Syrian Arab RepublicTop
3

Afghanistan

53%*

Somalia

62%*

Sudan
South Sudan

Top
10Democratic Republic of the Congo

77%*

Myanmar
Central African Republic
Iraq
Eritrea
0.0

0.5

1.0

* Reflects proportion out of global number of refugees at end-2014

CHAPTER 1

1.5

2.0
Millions(UNHCR, 2015)

22

Top
5

A FRAG I LE WO RLD

2.5

3.0

3.5

4.0

In 2014, the total number of refugees and internally displaced people worldwide reached 59.5
million, the highest number since the Second
World War (UNHCR, 2015). The number ofinternally displaced people doubled from 2010
to 2015.
More than half of all new refugees in 2014
came from Syria, Afghanistan, Somalia andSudan. More than half of all internally displaced people reside in Syria, Colombia, Iraq
and Sudan (Internal Displacement Monitoring
Centre, 2015). Today, about one in four people in
Lebanon and one in 10 in Jordan is a refugee.
Today, only about one in three refugees resides
in a camp. Two in three today live in urban areas.
About two-thirds of the world’s refugees are in“situations of seemingly unending exile” (Milnerand Loescher, 2011). The 25 countries mostaffected by a prolonged refugee presence are allin the developing world. Today, there are some

30 major protracted refugee situations, with theaverage length of time in this state approaching
20 years. This average, however, does not include
many of the most chronic and long-term displaced
populations, such as those in urban settings or
those displaced in rural areas. It also does not

PROTRACTED REFUGEE SITUATIONSBY DURATION
14
Number of situations

Displacement from conflict

12
10
8
6
4
2
0

30+
years

20-29
years

10-19
years

<10
years

Duration of refugee situation, as of 2014
(UNHCR, 2015)

DISPLACEMENT IN THE 21ST CENTURY
2000 TO 2014
Internally displaced persons

Refugees and asylum-seekers

People newly displaced during the year*

60

50

in millions

40

30

20

10

0

2000

2002

2004

2006

2008

2010

2012

2014

Year
(UNHCR, 2015)* Displaced internally and across international borders. Newly displaced data available only since 2003.

THE STATE OF WORLD POPULATION 201523

include millions of Palestinian refugees underthe mandate of the United Nations Relief andWorks Administration.

remained broadly constant in recent years,
climate-related events, such as floods and storms,
are increasing. From 2000 to the present, there
have been an average of 341 climate-related
disasters per year, up 44 per cent from theaverage recorded between 1994 and 2000.
The Centre for Research on the Epidemiology
of Disasters estimates that 19.3 million people
were displaced because of disasters in 2014.
Over the last seven years, 85 per cent of thesedisaster-induced movements have been caused
by weather-related events, mainly flooding
and storms. About 15 per cent are due toearthquakes.

Disasters displace 26.4 million people
annually

According to the United Nations HighCommissioner for Refugees, an average of 26.4
million people worldwide have been displacedby disasters per year since 2008. Most of the displacement occurred in low- and middle-income
countries.
While the frequency of geophysical disasters—
earthquakes, tsunamis, volcanic eruptions­—has

NUMBER OF DISPLACED PERSONS BY REGION
2005 TO 2014

Middle East

Far East Asia

Africa, south of Sahara

North and Central America

South America

Africa, north of Sahara

South and Central Asia

Oceania

EuropeDisplaced persons in millions*

14
12
10
8
6
4
2
0
2005 2006 2007 2008 2009 2010

2011

2012

2013

2014

(Development Initiatives, 2015)

Photo © Ali Arkady/VII Mentor Program

24

CHAPTER 1A FRAG I LE WO RLD*‘Displaced persons’ includes refugees and people in refugee-like situations, internallydisplaced persons and asylum seekers. Internally displaced persons include only those
persons protected/assisted by United Nations High Commissioner for Refugees. Data areorganized according to definitions of country/territory of asylum. Countries are organizedaccording to the Organisation for Economic Co-operation and Development’s classificationof regions.

The forces of fragility

Co-operation and Development, “a fragile region
or State has weak capacity to carry out basic
governance functions, and lacks the ability todevelop mutually constructive relations with society.” Fragile States are more vulnerable to internalor external shocks, such as economic crises or
natural disasters (OECD, 2013). The relationshipbetween state and society can break down as aresult of both internal and external stress factors
including demographic shifts, technologicalinnovation and climate change.
A decade ago, most fragile States were low
income. According to recent estimates, about halfof fragile and conflict-affected States are now

Why are there so many crises in our world today?
Why does the world suddenly seem so fragile?
There are many explanations of fragility and its
causes. But regardless of the definition, fragility isclosely linked to forces such as poverty, inequality
and exclusion, which disproportionately affectwomen and girls.
Fragile States home to one in threepoor people

Fragility can manifest in several different
forms and in countries at any income level.
According to the Organisation for Economic

PEOPLE INTERNALLY DISPLACED BY CONFLICT AND VIOLENCE IN 2014
Bosnia andHerzegovina
100,400

Serbia*114,400

The former
UkraineYugoslav Republic 646,500
of Macedonia
200

Turkey953,700

Cyprus212,400

Georgia
232,700

Armenia Azerbaijan
568,900
8,400
Russian Federation
25,400
Uzbekistan
3,400
Turkmenistan
4,000

Palestine
275,000
Chad
71,000
Mexico281,400
Guatemala248,500
El Salvador
288,900
Honduras
29,400Colombia
6,044,200

Afghanistan
805,400

Libya
400,000

Pakistan
1,900,000

Niger
11,000

Nepal
50,000

Nigeria
1,075,300 Senegal
24,000Mali
61,600Liberia
23,000Iraq
3,276,000

Togo
10,000
Côte
Cameroond’Ivoire
40,000300,900

Peru
150,000
Central African
Republic
438,500
Republic of the Congo
7,800
Democratic Republic of the Congo
2,756,600
Sudan
3,100,000
South Sudan
1,498,200

Sri Lanka
90,000

Bangladesh
431,000

Syria
7,600,000

Philippines
77,700Yemen
334,100

Lao People’s
Democratic Republic
4,500

Lebanon19,700Zimbabwe36,000India
853,900

Eritrea
10,000Somalia
1,106,800
Ethiopia
397,200
Kenya
309,200
Uganda29,800

Papua New Guinea
7,500
Myanmar645,300
Timor-Leste
900
Thailand
35,000Indonesia
84,000Burundi77,600(Norwegian Refugee Council, Internal Displacement Monitoring Centre, 2015a)*Figure includes Kosovo

THE STATE OF WORLD POPULATION 201525

Two of three unattended births are infragile States

Despite global economic and social progress inrecent decades, there is a large and growing portion of humanity living with greater insecurity andinstability. It is from these countries that the major
challenges to stability, development, and achievement of social progress exist. Gates et al. (2010)
summarized the impact with data showing thatclose to half the people in low-income countries in2010 were in States that are fragile, in conflict, or
recovering from conflict. These same areas accounted for 60 per cent of the world’s people who areundernourished, 77 per cent of the children notattending primary school, 70 per cent of infant
deaths and 64 per cent of unattended births.

26

CHAPTER 1A FRAG I LE WO RLD

When States’ fragility is matched against key
reproductive health indicators, correlations emerge,
showing that extremely fragile countries are likely
to have fewer births assisted by skilled attendants,
higher rates of adolescent pregnancy and greater
unmet need for family planning.
Measuring fragility

A number of groups have developed means formeasuring whether a State is fragile, and thus
vulnerable to conflict or the effects of disasters.
(OECD, 2015).
The Organisation for Economic Co-operation
and Development (OECD) each year issues a
Fragile States Index, which shows countries’ andterritories’ vulnerability to conflict and disaster bylooking at five key dimensions: the level of violence, the extent to which there is access to justiceand rule of law, whether national institutions are
effective, accountable and inclusive, the level of
economic stability, and the level of resilience towithstand and adapt to shocks and disasters.

PERCENTAGE OF BIRTHS ATTENDED BYSKILLED HEALTH PERSONNEL LOWER INFRAGILE STATES
100

Percentage of births attended byskilled health personnel

middle-income countries. Despite this change inincome level, poverty remains concentrated in fragile States (OECD, 2013). Fragile middle-income
countries share common characteristics such as highlevels of urban and criminal violence, growth ofviolent megacities and large, underemployed youth
populations (Castillejo, 2015).
Fragile States are home to one third of theworld’s poor. More than 1 billion people, or about
15 per cent of the world’s population, are in extreme
poverty, according to estimates from the World Bank
(World Bank, 2015a). Extreme poverty, previously
concentrated in East Asia, has shifted to sub-SaharanAfrica and South Asia, which today accounts for
80 per cent of the world’s poor, the majority ofwhich are women and children (World Bank 2015b).
The poor are especially vulnerable to the effectsof conflict, and various measurements of fragility suggest that high levels of poverty and income
inequality can contribute to instability. The poor
have fewer economic, social and other resources
to help them withstand or recover from conflicts,
which can in turn exacerbate poverty.

80

60

40

20

0
0

20

40
60
80
100
Level of state fragility

120

140

Sapana Suwal, 25, with her children in shelter for earthquake survivors, Bhaktapur, Nepal
Photos © Panos Pictures/Brian Sokol

ADOLESCENT BIRTH RATES TENDTO BE HIGHER IN FRAGILE STATESUNMET NEED FOR FAMILY
PLANNING GENERALLY GREATER
AMONG MORE FRAGILE STATES

250

45

Unmet need for family planning,
women aged 15-49

Adolescent birth rate per
1,000 women aged 15 to 19

40

200

150

100

50

35
30
25
20
15
10
5

0

0

0

20

40
60
80
100
Level of state fragility

120

140

0

20

40
60
80
100
Level of state fragility

120

140

THE STATE OF WORLD POPULATION 201527

DIMENSIONS OF FRAGILITY
THE ORGANISATIONFOR ECONOMIC
CO-OPERATION FRAGILESTATES INDEX 2015
This index shows countries’ and territories’
vulnerability to conflict and disaster by looking
at five key dimensions: the level of violence, theextent to which there is access to justice and ruleof law, whether national institutions are effective,
accountable and inclusive, the level of economic
stability, and the level of resilience to withstandand adapt to shocks and disasters.

VULNERABILITY IN DIMENSIONS:

26 COUNTRIES

Algeria
Syrian Arab Republic

22 COUNTRIES

Cameroon
Lao People’s Democratic
Republic

India
PanamaSerbia (Kosovo)

AngolaLiberia

Iran
Iraq

Kenya
UgandaDjibouti

VIOLENCEJUSTICE

INSTITUTIONS

Comoros
Madagascar
Republic of the Congo
Sierra Leone

Papua New Guinea
Solomon Islands
ZambiaEquatorial Guinea
Eritrea
Guinea-Bissau
Mauritania
Togo
Zimbabwe

Bangladesh
Libya
Myanmar
PakistanVenezuela

Benin
Burkina Faso
Kiribati
São Tomé and Principe
Suriname

Afghanistan
Burundi
Nepal
South Sudan

GambiaMalawiMozambique
Niger
Timor-Leste

CambodiaFijiTajikistan
Turkmenistan

Ethiopia
Nigeria
Somalia

Honduras
LesothoMali
Palestine

Colombia
GuatemalaParaguay
Rwanda4 DIMENSIONS

3 DIMENSIONS

2 DIMENSIONS

13 COUNTRIESRESILIENCEECONOMIC
FOUNDATIONS

9 COUNTRIESCentral African Republic
Chad
Democratic Republicof the Congo
Côte d’Ivoire
GuineaHaiti
Sudan
Swaziland
Yemen

5 DIMENSIONS

28

CHAPTER 1A FRAG I LE WO RLD

Nine of the 50 most fragile places have low rankings in all five dimensions (OECD, 2015).
Another measurement, the Global Peace Index,gauges the level of peace in 162 countries. The
index, published by the Institute for Economics
and Peace, looks at the level of safety and security
in society, the extent of domestic and international
conflict and the degree of militarization. Between
2013 and 2014, 78 countries have become lesspeaceful, according to this index (IEP, 2014).
The Fund for Peace’s Fragile States Index looks at
12 dimensions of vulnerability, including whether
economic development is uneven or equitable,
whether there is respect for human rights and liberties, the extent of poverty and economic decline,
frequency of disasters, and whether key services,
particularly education and health, are available
to all. According to this index, four countries areon “very high alert,” with South Sudan at the topof the list, followed by Somalia, Central African
Republic and Sudan. Between 2013 and 2014,
measures of fragility on this index worsened tosome degree in 67 countries (FFP, 2015).
Regardless of the index, more and more countries
are considered fragile and therefore likely to be more
vulnerable to conflict or to the effects of disasters.
Assessing risk

Humanitarian crises and disasters cannot always be
prevented but their impact can be greatly reduced.
Understanding crisis and disaster risk is a criticalstep in reducing and managing it. Risk assessment
aims to identify and prioritize the people and places
most at risk of disaster and find ways to reduce andmanage the risks they face (INFORM, 2015).
The Index for Risk Management (INFORM), a
joint project of the United Nations, internationaland bilateral organizations and research institutions,uses 50 different indicators to measure hazards andpeople’s exposure to them, vulnerability and the

Residents of Union Balsalito, Colombia.
Photo © UNFPA/Daniel Baldotto

amount and type of resources available to help themcope (INFORM, 2015).
INFORM data show the risk of humanitarian crises has risen in three low-income countries, six lower
middle-income countries, four upper middle-income
countries and two high-income countries that are notmembers of the OECD (INFORM, 2015).
INFORM also shows that the risk has decreased
significantly in 22 low-income countries, 28 lower
middle-income countries, 43 upper middle-income
countries, 16 high-income countries that are not
OECD members and 29 high-income OECDmembers (INFORM, 2015).
The 11 countries most at risk of disaster-induced
poverty are Bangladesh, Democratic Republicof Congo, Ethiopia, Kenya, Madagascar, Nepal,
Nigeria, Pakistan, South Sudan, Sudan, and Uganda,
according to the Overseas Development Institute(ODI et al., 2013).
Discounting earthquake and cyclone exposure,and assessing just drought, extreme temperatureand flood hazards alone, reveal that as many as
319 million extremely poor people will be living in
the 45 countries most exposed to these hazards by
2030. This is a major concern as drought and flood

THE STATE OF WORLD POPULATION 2015

29

2015 RISKThe overall risk index identifies countries at risk from humanitarian crises and disasters that
could overwhelm national response capacity. It is made up of three dimensions—hazards and exposure,vulnerability and lack of coping capacity. This map shows details for the 12 countries with the highest
overall risk.

Sudan

Syrian Arab Republic

Iraq

Afghanistan

3-year trend:
Hazard: 7.29
Vulnerability: 7.18
Lack of coping
capacity: 7.26

3-year trend:
Hazard: 8.39
Vulnerability: 5.99
Lack of coping
capacity: 5.92

3-year trend:
Hazard: 8.21
Vulnerability: 5.98
Lack of coping
capacity: 7.02

3-year trend:
Hazard: 8.71
Vulnerability: 6.87
Lack of coping
capacity: 8.19

Risk: 7.24

Risk: 6.67

Risk: 7.01

Risk: 7.88

Chad

Risk: 6.84

3-year trend:
Hazard: 4.58
Vulnerability: 7.80
Lack of coping
capacity: 8.95

Mali

Risk: 6.73

3-year trend:
Hazard: 6.01
Vulnerability: 6.51
Lack of coping
capacity: 7.80

Central African Republic

MyanmarRisk: 8.16

Risk: 6.77

3-year trend:
Hazard: 7.78
Vulnerability: 8.15
Lack of coping
capacity: 8.56

3-year trend:
Hazard: 8.22
Vulnerability: 5.41
Lack of coping
capacity: 7.00

Democratic Republicof Congo
Risk: 7.00

South Sudan

SomaliaYemen

3-year trend:
Hazard: 6.96
Vulnerability: 7.72
Lack of coping
capacity: 8.92

3-year trend:
Hazard: 8.63
Vulnerability: 8.36
Lack of coping
capacity: 9.55

3-year trend:
Hazard: 7.95
Vulnerability: 5.65
Lack of coping
capacity: 8.19

Risk: 7.83

3-year trend:
Hazard: 5.42
Vulnerability: 7.60
Lack of coping
capacity: 8.33

Risk: 8.83

Risk: 7.17

INFORM RISK INDEX
3.29

2.30

0

4.64

10
KEY

Low

MediumHigh

Very highNot included(INFORM, 2015)30

CHAPTER 1A FRAG I LE WO RLD

Increasing risk

StableDecreasing risk

2015 VULNERABILITY
This dimension measures the susceptibility of people to potential hazards. It is made up of two
categories—socio-economic vulnerability and vulnerable groups. This map shows details for the
12 countries with the highest values in the vulnerability dimension.

Niger

Chad

Sudan

Afghanistan

3-year trend:
Socioeconomic
vulnerability: 7.71
Vulnerable groups: 5.61

3-year trend:
Socioeconomic
vulnerability: 6.79
Vulnerable groups: 8.58

3-year trend:
Socioeconomic
vulnerability: 5.44
Vulnerable groups: 8.39

3-year trend:
Socioeconomic
vulnerability: 6.89
Vulnerable groups: 6.86

Vulnerability: 6.78

Vulnerability: 7.80

Vulnerability: 7.18

Vulnerability: 6.87

Mali

Vulnerability: 6.51

3-year trend:
Socioeconomic
vulnerability: 7.06
Vulnerable groups: 5.88

Liberia

Vulnerability: 6.73

3-year trend:
Socioeconomic
vulnerability: 7.66
Vulnerable groups: 5.55

Central African Republic

Somalia

3-year trend:
Socioeconomic
vulnerability: 7.81
Vulnerable groups: 8.45

3-year trend:
Socioeconomic
vulnerability: 7.19
Vulnerable groups: 9.17

Vulnerability: 8.36

Vulnerability: 8.15

Democratic Republicof Congo

BurundiSouth Sudan

Ethiopia

3-year trend:
Socioeconomic
vulnerability: 7.01
Vulnerable groups: 8.11

3-year trend:
Socioeconomic
vulnerability: 6.66
Vulnerable groups: 6.61

3-year trend:
Socioeconomic
vulnerability: 6.59
Vulnerable groups: 8.57

3-year trend:
Socioeconomic
vulnerability: 6.28
Vulnerable groups: 6.51

Vulnerability: 6.63

Vulnerability: 7.60

Vulnerability: 7.72

Vulnerability: 6.40

INFORM VULNERABILITY INDEX
3.20

1.83

0

5.06

10
KEY

Low

MediumHigh

Very highIncreasing risk

StableDecreasing risk

Not included(INFORM, 2015)

THE STATE OF WORLD POPULATION 201531

FIVE-YEAR RISK TRENDS BY WORLD BANK INCOME GROUP, 2011 TO 2015
5 Year Inform Risk Trends By World Bank Income Group 2011-2015
Low income (35)

Lower middle
income (47)Upper middle
income (55)High income:non OECD (22)High income:OECD (31)Significant increase (>0.5)

3

6

4

2

0

Stable (<0.5 / >-0.5)

10

13

8

4

2

Significant decrease (<-0.5)

22

28

43

16

29

(INFORM, 2015)

hazards are among the most potent shocks whenit comes to causing long-term impoverishment(ODI et al., 2013).
Worldwide, natural disasters are increasing inseverity and becoming more costly. Classified
as either climate-related or geophysical, natural
disasters occur when natural hazards affect human
lives and livelihoods. Natural disasters today aremainly attributed to rising climate-related disasters,
including storms and floods (CRED, 2015).
A World Bank report, Turn Down the Heat,highlights the dramatic effects of global climate
and weather extremes as global temperatures rise
(World Bank, 2013). The impact of rising global
temperatures is disproportionately concentrated inlow- and middle-income countries and small island
developing States. The poor and most vulnerable
populations are likely to be the hardest hit and havethe least capacity or access to resources to enable
them to adapt and recover.
The frequency of droughts has gradually
increased in East Africa over the past 50 years,
but has declined in West Africa. Somalia, Burundi,
Niger, Ethiopia, Mali and Chad were classified
as countries with highest relative vulnerability todrought based on a drought vulnerability indicator(Shiferaw et al., 2014).

32

CHAPTER 1A FRAG I LE WO RLD

In sub-Saharan Africa, 90 per cent of food andfodder is produced through rain fed agriculture,
which also accounts for more than 70 per cent of
the population’s principal livelihood (Shiferaw et al.,2014). The lives and livelihoods of poor populations,especially women, who account for up to 70 per centof food production in the region, are most threatenedby drought as they possess the lowest adaptive
capacities to drought as a result of high levels ofchronic poverty. (Gawaya, 2008).
Gender, urbanization and humanitariancrisesUrbanization is reshaping our world and thenature of humanitarian crises and response. For the
first time in history, more than half of the world’s
population lives in cities. As more people settle inthe slums of megacities in developing countries,
they are in turn increasingly on the front lines ofdisaster. The rapid growth of urban populations,unprecedented influx of displaced populations
and increasing possibility of severe weather events
increase the risk of urban humanitarian disasters.
Urban population growth has become increasingly concentrated in developing countries, where
1.2 million people are migrating to cities every week
(UN-HABITAT, 2013). Sub-Saharan Africa and Asia

are experiencing unprecedented levels of urbanization
but are also the least developed regions and are most
unprepared and ill-equipped to manage the influx.
Rapid urbanization, inadequate planning andscarce land have forced poor and vulnerable populations to live in slums or informal settlements inareas with greater vulnerabilities to disasters.
An estimated 1 billion people live in informal
settlements, 90 per cent of which are locatedin developing countries (Norwegian RefugeeCouncil, Internal Displacement Monitoring
Centre, 2015a).
Migrants, refugees and internally displaced
people represent a significant and increasing
proportion of urban informal settlers as they areunable to afford better housing. Many of the settlements are located in poorly serviced areas that lackbasic infrastructure such as health services, accessto fresh water and sanitation.
Informal settlers are more vulnerable to the consequences of natural hazards such as earthquakes
than the general population as they are often forced
to live in poor-quality housing not built to withstand shocks. These makeshift dwellings are mostly
located in hazardous areas more likely to be affectedby natural disasters such as industrial waste lands,
flood plains and unstable cliffs.
A trend is emerging whereby increasing numbersof women are migrating from rural areas to urban
centres on their own. The underlying driving forcesof urban migration for women and its consequences
are related to issues of social inequality and gender.
Both men and women migrate to cities in searchof a better life, in terms of economic opportunities and access to services. Several gender-specificfactors may push women to migrate to cities, ranging from forced eviction, to increased domestic
violence, harmful practices such as child marriage,or health problems associated with HIV and AIDS(COHRE, 2008).

Women and girls are disproportionately affectedby the poor living conditions of urban slums andthe substandard housing as they spend more timein the home and community caring for their families. Women’s health and security is a major issue
in urban informal settlements as they are exposed
to poor sanitation conditions, security risks,
increased sexual violence, and the impact of disasters such as floods and fire outbreaks (COHRE,
2008). Poor street lighting, inadequate public
transport, a lack of security patrols and an absenceof doors with locks on dwellings contribute togender-based violence and make women more
vulnerable to rape (UN-HABITAT, 2013).
The proportion of the urban population living
in slums continues to grow in countries affected byor emerging from conflict. A recent study foundthat in 41 of 75 countries where sex-disaggregateddata were available, women are more likely to livein poverty.

Magbenteh Ebola Treatment Centre, Sierra Leone.
Photo © UN Photo/Martine Perset

THE STATE OF WORLD POPULATION 201533

Weak health sectors and fragility

Fragile countries have the poorest health indicators,
and poor health outcomes can contribute to fragility. But State fragility can in turn cause high disease
and mortality rates as a result of ineffective service
delivery (Haar and Rubenstein, 2012).
The largest Ebola epidemic in history hit West
Africa in 2014. The worst-affected countries,
Guinea, Liberia and Sierra Leone are fragile States(UNDP, 2015a).
A devastating 14-year conflict destroyed much of
Liberia’s infrastructure, so by the time the Ebola epidemic began, the health sector was ill-equipped andunderstaffed to manage the crisis (UNDP, 2015a).
Reproductive health indicators are poor in fragile
contexts as a result of weakened health service infrastructure and understaffed facilities, which together
can lead to reduced access to reproductive healthservices, supplies and information. Only $1.30 per

capita was spent annually on reproductive healthin 18 conflict-affected countries between 2003 and2006 (Patel, et al. 2009).
Crises hobbling development and leading to
profound vulnerability

Conflict, violence, instability, extreme poverty andvulnerability to disasters are deeply interrelated
conditions, which today prevent more than
1 billion people from enjoying the massive
social and economic gains since the end of theSecond World War.
A complex mix of overlapping hazards contributes to displacement and determines patternsof movement and needs in fragile and conflictaffected countries. Other additional aspects ofvulnerability—gender, ethnicity, income and residence—appear to be associated with heightenedchances for long-term harm and complicate

WOMEN FACE A GREAT RISK OF LIVING IN POVERTY
Ratio of women to men of working age (20 to 59) in the lowest wealth quintile of allhouseholds, selected developingcountries, 2000–2013
In 41 countries, women are
more likely than men
to live in poor households

In 17 countries, women are
equally likely as men
to live in poor households

In 17 countries, women areless likely than men
to live in poor households

130
120
110
100
90
80
70

0

15

30

45

60

75

Notes: This indicator is weighted by the ratio of females to males aged 20–59 in all households to reflect the fact that women may be overrepresented in the e ntirepopulation. It uses the wealth asset index in the Demographic and Health Surveys and Multiple Indicator Cluster Surveys as a proxy measure for poverty.Values
above 103 indicate that women are overrepresented in the lowest wealth quintile while values below 97 indicate that men are overrepresented in the lowest wealthquintile. Values between 97 and 103 indicate parity.
(United Nations, 2015a) Reprinted with permission of the United Nations.

34

CHAPTER 1A FRAG I LE WO RLDBoat in the Strait of Sicily, 40 miles from the Libyan coast.
Photo © Franco Pagetti/VII

recovery. And overlaying all aspects of social exclusion, poverty and low educational achievement
create profound vulnerability.
It is mainly the fragile, conflict, or disasteraffected countries that fell short in their pursuitof the Millennium Development Goals. And,
it is among fragile States where the majorityof maternal deaths in the world occur, as
emergent life-saving care or access to it is lacking.
The refugee and migrant crises of 2015 and theEbola epidemic are reminders of how crises andemergencies take, disrupt and undermine lives,
jeopardize prospects for countries’ development andcan have an impact on the entire international community. Abandoning the countries and communities
wracked by conflicts and disasters is not an option.
While the number of disasters and conflicts has
not risen in recent years, the scale, complexity andimpact have, particularly in the poorest countries,

and women and girls have been disproportionately affected because they are disproportionately
disadvantaged in terms of their access to services,
including sexual and reproductive health andfamily planning, and their access to economic
and social resources and institutions they need tobuild their social capital and better equip themto withstand and recover from crises.
Fragility and vulnerability to conflict or theeffects of disaster are exacerbated by many forces,
including poverty, unequal development, denialof human rights and weak institutions. Fragility
is a multi-dimensional challenge, requiring a
multi-dimensional response.
One way or another, we are, finally, one world,and our progress in moving forward will be
forever hobbled until instability, conflict, anddisaster are better mitigated or prevented andmanaged.

THE STATE OF WORLD POPULATION 201535

CHAPTER 2

The disproportionate
toll on women andadolescent girls
A crisis can heighten women’s and girls’
risks and vulnerabilities to HIV infection,
unintended and unwanted pregnancy,maternal death, gender-based violence,child marriage, rape and trafficking.

Vicious cycle of conflict,poverty and isolation
undermines health andrights of women and girls
in Colombia“I started working as a midwife 37 years
ago,” says Neida Waitotó, one of four
midwives in Docordó, a river community
with about 1,200 residents, mostly Afrodescendants, in a remote jungle area ofColombia two hours by boat from thenearest city.
“In 1978, the nuns came and taught us
how to deliver babies and gave us supplies.” Since then, she says, the midwivesof Docordó have had some additional
training but no new equipment. Still,they have managed to safely deliver
hundreds of babies over the years. “Andno mothers have died,” says Waitotó,
who, a week earlier, helped deliver twins.

Nimia Teresa Vargas
Photo © UNFPA/Daniel Baldotto

36

CHAPTER 2

Midwives are critical to the survivalof women and babies in Docordó anddozens more remote Colombian communities that have been effectively cut
off from government health services
not only because of geography but also
because of armed conflict and violence,
which have plagued large swaths of thecountry for more than 50 years. Conflicthas so far displaced about 7 million
people. 9 in 10 of the displaced
are from indigenous groups.
Non-state actors including the
Revolutionary Armed Forces ofColombia, or FARC, the National
Liberation Army, or ELN, paramilitaries,groups involved in organized crime andthe Colombian military have clashedfor decades, leaving many communities
literally caught in the crossfire and many

THE DI SP RO P O RTI O NATE TO LL ON WOM E N A ND AD OLE SCE NT GIRLSNeida Waitotó, left, and Maria-Estela Ibargüen, Docordó, Colombia.
Photo © UNFPA/Daniel Baldotto

more vulnerable to coercion, exploitation, intimidation and abuse.
Fighting and violence have taken a heavy
economic toll on communities in a
number of provinces, or “departments,”
including Chocó, where Docordó is situated, causing and exacerbating poverty
and underdevelopment in the region.
Four of five people in Chocó live in
extreme poverty.
Maternal deaths higher in
conflict-affected zones
Conflict and violence—and the isolation
stemming from them—have also takena heavy toll on the health of women.
Maternal deaths are almost eight times
higher in communities where armed
groups are present. Other health indicators also illustrate the negative impact

security problems have on the sexualand reproductive health of those wholive there: deaths from HIV and AIDS
are three times higher than the nationalrate, and pregnancies among adolescent
girls under age 15 are twice that in otherparts of the country.
Waitotó says there are some births inDocordó that are too complicated forher to handle on her own; a doctor’sintervention is needed to save lives.
But because of the security situation in
the area and the extreme isolation, thecommunity routinely lacks access to adoctor. “When doctors do come, they
never stay for long,” she says. Recently,
the community went four months
with no physician or other medical
professional.

So that means some women have totravel hours by boat to a hospital in
Buenaventura, at a cost prohibitively
high for most. And if the complications
arise at night, travel to a hospital is noteven an option because of the threatof violence after dark. Medicines that
can help save a mother and baby aremostly unavailable, even before the local
health station closed because of a lackof resources.
Maria-Estela Ibargüen is another
Docordó midwife. She and Waitotó
delivered each other’s babies. She
worries that the community’s midwives
are growing old, with no young people
stepping forward to take their places.
“What will the future look like oncethe old generation is gone?”

THE STATE OF WORLD POPULATION 201537

H

umanitarian crises disproportionately impact
women and adolescent girls. Whether sudden or protracted, crises expose women andgirls—and their sexual and reproductive health andrights—to layers of disproportionate risk.
Conflicts and disasters can make a bad situation
worse. For women and adolescent girls, the adventof a crisis can lead to an even greater risk of sexuallytransmitted infections, including HIV, unintended
and unwanted pregnancy, maternal morbidity anddeath, as well as other risks to the health of mothers
and newborns. Women and adolescent girls are also
at greater risk of gender-based violence, including
intimate partner violence, rape, early marriage andtrafficking.
Breakdown of services and gender inequality
compound vulnerability

Women and young people do not all have thesame story to tell. Their experiences are influenced
by a complex intersection of factors, such as age,

Health conditions for women are evenmore troubling directly across theriver in Union Balsalito, an indigenous
Wounaan community with about 360
residents. There, midwives use traditional birthing methods but lack themost basic supplies, such as rubber
gloves.
For the women of Union Balsalito,
accessing services, even in Buenaventura,is particularly difficult: most do not speak
Spanish and have even fewer resources
than their neighbours across the river.
And some who have managed to travel
to cities in search of services have faced
discrimination from providers.
The Government deploys roving healthbrigades throughout the country toprovide basic services to the poor and

38

CHAPTER 2

sex, marital status, economic status or placeof residence. Other vulnerabilities depend onwhether they are members of an ethnic minority,
living with HIV or disability, refugees orinternally displaced persons or poor, or havethe support of family or have dependents.
The intersection of these factors, often in complex and multiple combinations, influence therisks and vulnerabilities faced by individuals.
Research and experience are contributing toa deeper understanding of these differences anda more nuanced perspective on how womenand young people, especially adolescent girls,
are affected by crises. Still, unpacking thesedifferences of experience is often complicatedby a dearth of robust data, the collection of which
can be very difficult in crisis-affected settings.
Although there are important differencesamong women and young people in any givencrisis, there are two common overarching factorsthat contribute to heightened risk: The first is

marginalized in places like Docordó.
But the security situation in many partsof the country makes it impossible toreach many of the communities mostin need.

Wielding the weapon of sexual violence
While conflict has impeded access tohealth services, it has also taken a direct
toll on the health, lives and survival of
thousands of women and girls.

Access to supplies, medicines and services, including emergency obstetriccare and family planning, is routinely
blocked by conflict and violence aswell as natural disasters, especiallyfloods and landslides in this area, which
receives an average of 400 inches ofrain annually.

A study by Oxfam and House of Women
estimates that 500,000 women andgirls have been raped or suffered otherforms of sexual violence in the courseof the country’s decades-long conflict.
Sometimes rape has been deployed as aweapon of war. Other times, it has beenused to intimidate whole communities,
with perpetrators threatening to attack
others in a community that refuses topledge its allegiance to one armed
group over another. And, available
data suggest that one in 10 survivorsof sexual violence in conflict-affectedareas is male.

In the first six months of 2015 alone,an estimated 2 million people “sufferedlimitations on access or mobility” as aresult of “122 events related to armed
actions, natural disasters or mass protests,” according to the United Nations.

THE DI SP RO P O RTI O NATE TO LL ON WOM E N A ND AD OLE SCE NT GIRLS

gender inequality, which not only continues during
humanitarian crises but often increases.
Many societies are characterised by deeply
entrenched gender inequality and gender-based
discrimination, in which women and girls have lesspower and status in their families and communities
than men and boys. The inequality manifests itself
in less access to education, economic and politicalresources and social networks. It can also be fatal—
when parents facing food shortages direct most or all
nutrition to boys.
In contrast to adolescent boys, adolescent girls
typically have less access to information about sexualand reproductive health, peer networks and opportunities and resources that would help them develop
skills, capacities and capabilities (Women’s RefugeeCommission, 2014). Gender inequality places
women and girls in situations of heightened risk andvulnerability and limits their ability to safely navigate
the crisis-affected environment (Women’s RefugeeCommission, 2014; Plan International, 2013).

Nimia Teresa Vargas runs the
Departmental Network of Chocoan
Women, headquartered in Quibdó.
The network, which receives technicaland financial assistance and supplies,
such as clean birth kits, from UNFPAand other parts of the United Nations,began in 1991 as a women’s empowerment group but has since evolved into ahuman rights advocacy organization that
also provides services to survivors of
sexual violence.

Natural disasters andarmed conflict are…deeply
discriminatory processes
that affect women, men,
girls and boys in significantly
different ways.
Mazurana et al., 2011

The second overarching factor leading to heightened risk is the breakdown or disruption of criticalsexual and reproductive health infrastructure andservices that occur in crisis settings, and the difficulties in accessing these services, where they still
exist, as a result of chaos or insecurity.

“As women began learning about theirrights in our discussion groups, moreof them started talking about having
survived sexual violence,” Vargas says.
“Cases started coming to light about
armed actors trying to take control overcommunities, using sexual violence as a
strategy to show they had power.”

In response, Vargas’ organization started
organizing support groups for survivors,
but also began systematically reporting
incidents to Government authorities andmaking sure Chocoan women gained
access to not only quality health careand psychological support, but also tojustice.

She says often a perpetrator would rapea woman in front of her husband or agirl in front of her father to assert control
and to show what might happen to others if the community did not acquiesce
to the demands of whichever armed
group was threatening them.

Armed groups responsible for the sexual
violence have repeatedly threatened
Vargas’ life and, in one instance, killed awoman who participated in one of her
network’s training programmes and later
became an outspoken activist.

Waitotó, left, with mother whosechild she helped deliver.

New support for survivors
In 2011, Colombia enacted the Victims
and Land Restitution Law 1448, which
aimed to support the country’s estimated 7.3 million victims of armed conflict.

Photo © UNFPA/Daniel Baldotto

THE STATE OF WORLD POPULATION 201539

It is a plain and simple truththat disasters reinforce,
perpetuate and increase
gender inequality, making badsituations worse for women.
Margareta Wahlström
Special Representative of the Secretary-Generalfor Disaster Risk Reduction

Limited access to sexual and reproductive
health services when they are needed most

Humanitarian crises often mean a loss of accessto critical quality sexual and reproductive healthservices. This may be due to a variety of factors.
The health infrastructure may be disrupted or
destroyed. Health workers may be killed, injured,
too distressed to work, displaced, or they may
have fled. In crisis-affected environments affected

This law also led to the establishmentof a Government Unit for Attention
and Integral Reparation to Victims, or
UARIV, which targets support to victimsof armed conflict, including survivors of
sexual violence.
Survivors who report their cases to
UARIV are entitled to cash restitution,
but also to integrated health, psychological, rehabilitation and other support
services, all provided in ways that
respect privacy. Those who come forward also learn, usually for the firsttime in their lives, about their rights.
According to Licet Ciénfuegos, in
UARIV’s women’s and gender group,
survivors accessing UARIV’s services“recognize that they aren’t alone, thatthey are citizens with rights and that40

CHAPTER 2

by violence, health facilities may be subject to air
strikes and small arms fire and health providers
exposed to physical assault, threats and sexual
violence (International Committee of the Red
Cross, 2015).
Services, where they do exist, may be delayedor disrupted, with stock-outs of medicine andother supplies, or they may be impossible to accessgiven insecurity and limitations on movement.
These circumstances can have severe, even fatal,consequences for survivors of gender-based violence, those who are forced to adopt risky survival
strategies such transactional sex, HIV positive populations, married girls, pregnant women and girls,
and new mothers and their babies.
Access to sexual and reproductive health services
varies widely across and within crisis-affected settings (Casey et al., 2015). Women and young
people may face significant variation in accessand quality of emergency obstetric and newborncare, clinical post-rape care, and family planningthey are change agents.”
She said many have goneon to create their own
advocacy or support
groups. “We are trying to help women see
themselves as actors ofchange and capable ofshaping the futures of
their own communities.”
As of September 2015, 9,892 women,
863 men and 53 people who identified
themselves as lesbian, gay, bisexual ortransgender have reported acts of sexual violence against them. Some of theseacts occurred in the past two years but
many occurred years ago.
UNFPA collaborated with UARIV indeveloping training for first responders

Wounaan woman, Union Balsalito,
Colombia.
Photo © UNFPA/Daniel Baldotto

to deliver culturally sensitive psychosocial support. “We teach them how to
speak to victims in a way that doesn’t
revictimize them,” Ciénfuegos says.
The conflict has also had an indirect but
perhaps more insidious impact on thehealth—and rights—of women and girls
in Chocó.

THE DI SP RO P O RTI O NATE TO LL ON WOM E N A ND AD OLE SCE NT GIRLS

services, including contraception, depending on
if they are in a stable refugee setting, an urban
or rural setting, a host population or a camp forinternally displaced people. Residents in stablerefugee camps may have better access to carethan neighbouring host communities or refugees’
home countries prior to the crisis (Chynoweth,
2015). Further complicating the picture, not all
refugee camps provide the same level of accessand quality, and the same can be said for camps
for internally displaced people.
Within displacement settings, access also varies
depending on factors such as age and disability. Populations with physical, psychological ordevelopmental disabilities have greater difficulty
accessing services. For refugee women and girls
with disabilities, negative attitudes and lack ofrespect expressed by health providers has been
identified as the “most significant barrier deterring” access to health and sexual and reproductive
health services (Consortium, 2015).

Conflict-driven poverty’s impact
on health
Violence or the threat of it has choked
off local economies in the region, leaving
many individuals and families with few or
no opportunities for jobs or livelihoods.
Poverty multiplies vulnerabilities, especially for women and adolescent girls.
In some instances, women and girls
engage in transactional sex with armed
groups to obtain food or other survival
items. In other instances, women andgirls are forced into prostitution.
There have also been cases where anarmed group will engage in what seem
like goodwill gestures with a community
by providing food or other goods. But
after a while, favours are expected tobe repaid, sometimes by giving away

Women and girls are particularly vulnerable tomalnutrition and disease, which are exacerbatedby the loss of sexual and reproductive health support. For example, the United Nations Officefor the Coordination of Humanitarian Affairs
estimates that there are almost 1 million pregnant and lactating women in the Democratic
Republic of the Congo who are affected byacute malnutrition (Save the Children, 2014).
Women are physiologically more prone tovitamin and iron deficiencies, including anaemia. These deficiencies are exacerbated in acrisis situation where there is a scarcity of food,because women and girls are often the first togo hungry. For pregnant and lactating womenand girls, who have greater food needs to begin
with, malnutrition or undernourishment canlead to birth complications and problems withbreastfeeding, which can present health risks to
newborns. For pregnant women and girls, anaemia heightens the risk of maternal mortality,

daughters, who may end up as sex
slaves or as armed combatants.
Poverty stemming from conflict also
drives men from remote communities
to cities to look for work. When they
return home, some also return withsexually transmitted infections, which
they in turn transmit to their spouses.
The dearth of health care in most ofthese communities means that sexually transmitted infections may go
undiagnosed and untreated.

when or how often to have children,”he adds. “The task ahead is monumental, but with the right resources
and political will, we can reach themost vulnerable women and girls
across the country.”
Residents of Docordó, Colombia.
Photo © UNFPA/Daniel Baldotto“Conflict has affected everyone in some way,” says UNFPA
Representative Jorge Parra. “Butit has disproportionately affected
women and girls and denied them
their basic rights to health, tosecurity, and to have the power
and the means to decide whether,

THE STATE OF WORLD POPULATION 2015

41

WOMEN DO NOT STOP GETTING PREGNANT OR HAVING BABIES WHEN A CRISIS HITS

Mother and children,
Domiz Camp, Iraq.
Photo © UNFPA/Aral Kakl

premature delivery and low birth weight (Savethe Children, 2014).
Unmet need for family planning

Family planning is a life-saving intervention: it
prevents unintended and unwanted pregnancy
and in turn reduces health risks of childbirthand recourse to unsafe abortions. Some of its
methods also reduce the risk of sexually transmitted infections (Save the Children, 2014).
This type of intervention is critical in humanitarian crises, often characterised by sexual
violence, intimate partner violence, early marriage and high risk behaviour such as survival,transactional and commercial sex. Yet, acrossand within crisis settings, family planning
services, including contraception are often
limited, inadequate or even non-existent(Casey et al., 2015).

42

CHAPTER 2

Even where family planning services do exist, thesubordinate status of women and girls within thefamily in many societies may deny them access tofamily planning services because they are unable tonegotiate use with their partners (Klasing, 2011;
Plan International, 2013). Unmarried and adolescent women may face particular difficulties accessing
family planning services, including contraception, asa result of gender norms that consider sexual activity
and interest inappropriate female behaviour (Casey
et al., 2015). These norms can also influence thebehaviour of healthcare providers and undermine
the care they provide (Casey et al., 2015).
Schools, even in displacement settings, are an
important avenue for comprehensive sexuality education and raising awareness about contraception.
Yet, schooling can be severely disrupted in a crisis,
resulting in significant gaps and limitations incomprehensive sexuality education.

THE DI SP RO P O RTI O NATE TO LL ON WOM E N A ND AD OLE SCE NT GIRLSNepalSierra Leone

An estimated 123,000
women were pregnant
in Ebola-affected
Sierra Leone in 2015.

UNFPA estimated that
there were approximately
126,000 pregnant womenat the time of the April
earthquake, including
21,000 of whom would
need obstetric care in
the coming months.

Philippines

An estimated 250,000
women were pregnant
when Typhoon Haiyan
hit in November 2013
and approximately
70,000 were due in thefirst quarter of 2014.

VanuatuAt the time of Tropical
Cyclone Pam (2015), there
were an estimated 8,500
pregnant and lactating
women in the affected
provinces.

Vulnerability to unintended and unwanted
pregnancy

Women and girls are at increased risk of unintended and unwanted pregnancy in crisis-affectedenvironments. Women and girls may find themselves with a pregnancy they do not want as aresult of rape, resorting to sex for survival, a lackof access to family planning, including contraception, and an inability to negotiate contraceptiveuse, including condom use, with their partners.
Unaccompanied girls are particularly vulnerable, especially in displacement settings (PlanInternational, 2013). A study in Haiti after theearthquake found the pregnancy rate three times
higher in the camps compared to the averageurban rate before the crisis, with approximately
66 per cent of pregnancies unwanted or
unplanned (Klasing, 2011). In many countries,
unintended and unwanted pregnancy exposes

women and especially adolescent girls to thedangers of unsafe abortion.
Pregnancy and childbirth without adequateprenatal care and delivery services

Being pregnant in a humanitarian crisis is often alife-threatening condition. Pregnant women may
find themselves without access to clean and safe
facilities, antenatal and obstetric services, criticalequipment and supplies, such as for blood transfusions, and skilled health workers to assist them(Casey et al., 2015). Without access to prenatal careand delivery services, women and girls are vulnerable to infection, miscarriage, premature delivery,
stillbirths, unsafe abortions, severe long-term
morbidity and mortality, such as obstetric fistula,and death. Without emergency obstetric care, complications, which are otherwise largely preventable
and treatable, may become life threatening to both

THE STATE OF WORLD POPULATION 201543

the mother and baby. The stress of crises can also
Pregnant women and girls need skilled healthphysically affect pregnant women and girls andworkers to ensure their own safety and that ofcan push women into premature labour. In thetheir babies during pregnancy and childbirth.
Philippines, for example, unusually high rates of
Yet health workers are also personally affected
preeclampsia—high blood pressure in pregnancy—
by crises. They may be injured or killed. In
were attributed to the stress of Typhoon HaiyanWest Africa, health workers risked infection(Save the Children, 2014).
from Ebola when assisting births, and conversely,
Girls, especially under 16, have immature pelvises
assisting women in childbirth was one avenue
which make childbirth more difficult and dangerthrough which patients contracted the virus
ous. Their lack of physical maturity can lead to(UNDP, 2015).
obstructed labour, and, where emergency obstetric
Crises can lead to increases incare is unavailable or delayed, obstetric fistula,unassisted births
uterine rupture, haemorrhage and death ofGiven the damage, disruption, distress, loss and fear
the mother and the baby (Save the Children andbrought by humanitarian crises, many pregnant
UNFPA, 2009). For adolescent mothers, they are
women and girls are giving birthalso at increased risk of spontawithout assistance from a skilled
neous abortion, premature births
health worker. This lack of assistanceand stillbirths (Save the Children
is a major contributing factor to
and UNFPA, 2009).
Given
the
damage,maternal mortality. In Syria before
During humanitarian crises,
disruption, distress,
the conflict, skilled birth attendants
antenatal and obstetric care
loss
and
fear
brought
assisted 96 per cent of deliveries. Now,
infrastructure and services thatby humanitarian crises,
access to antenatal care, safe delivery
pregnant women and girls need
many pregnant womenservices and emergency obstetrics has
may be destroyed, damaged or
and girls are giving birth
become extremely limited, and some
disrupted. In the Philippines,
without assistance fromareas, including parts of Homs, haveTyphoon Haiyan devastateda skilled health worker.
no reproductive services at all (Savereproductive health facilities
the Children, 2014).
in the affected areas. Leyte
In West Africa, where maternal mortality ratios
province lost most of its birthing centres. In an
were already among the highest in the world, theassessment of 52 reproductive health facilities,
Ebola epidemic led to an escalation in maternal
more than half had severe structural damage (Savemortality (Diggins and Mills, 2015): A recent
the Children, 2014). In Gaza in 2014, six hosUnited Nations report described access to sexualpitals were damaged, and six maternity facilities
and reproductive health services as “drasticallywere closed (UNFPA, 2014).
diminished” (United Nations Security Council,
In the Democratic Republic of the Congo, nearly2015). In Liberia, assisted deliveries decreased
two decades of conflict decimated the health caresignificantly from 52 per cent in 2013 to aboutsystem. According to Save the Children, many—if
38 per cent in May through August 2014, and, overnot most—health facilities in conflict-affected areasa similar period in Guinea, from 20 per cent tolack the capacity to perform Caesarean sections
7 per cent (IASC, 2015).
(Save the Children, 2014).

44

CHAPTER 2

THE DI SP RO P O RTI O NATE TO LL ON WOM E N A ND AD OLE SCE NT GIRLSPostnatal and newborn care often limited

Postnatal and newborn care, including breastfeeding support, are limited across many crisis
settings. New mothers also require postnatal carefor themselves especially where there have been
complications during childbirth.
Being a new mother and recovering fromchildbirth are daunting enough without the risks
and vulnerabilities associated with humanitariancrises. The situation is especially difficult foryoung mothers. Crises can present “obstacles anddisincentives” to breastfeeding (Save the Children,2014). These obstacles and disincentives explain
why breastfeeding rates decrease in some crisis
environments. Effective breastfeeding requires
instruction, guidance and individual, tailoredsupport. These are often lacking or limited ina crisis-affected environment.

Lactation problems can also increase in humanitarian emergencies. Severe malnutrition can reducemilk production. Stress can also disrupt milk flow
(World Vision, n.d.). Crises can also disrupt the
supply of breastmilk substitutes. This disruption,
along with breastfeeding and lactation problems,
can lead to malnutrition in babies and place themat heightened risk of disease and death.
Crises increase risk of sexually transmitted
infections

Humanitarian crises are fertile ground for thetransmission of sexually transmitted infections,
including HIV, and women and especially young
girls are disproportionately vulnerable. Sexual andgender-based violence, including rape and sexual
slavery, is one of the most significant risk factorsfor HIV transmission: for women and especially

Ebola epidemic led to significant
decrease in assisted deliveries
PERCENTAGE OF ASSISTED DELIVERIES
Liberia

Guinea

14%
52%
2013

38%
2014

(IASC, 2015)

Decrease

20%
2013

7%
2014

13%

Decrease

Health workers at Magbenteh Ebola
Treatment Centre, Sierra Leone.
Photo © UN Photo/Martine Perret

THE STATE OF WORLD POPULATION 201545

girls, violent or forced sex facilitates HIV transData collected by the United Nations Highmission (UNFPA, n.d.). Other factors leading toCommissioner for Refugees showed 56 refugeeincreased risk of HIV infection among women andcamps from 2007 to 2013 with inconsistent
girls include trafficking, intimate partner violence,
provision of condoms (Chynoweth, 2015).
and high-risk survival strategies, such transactional
The existence of services does not guarantee
sex and commercial sex work.
prevention; women and girls who have been
Even before a crisis hits, women and girls are
raped may choose not to seek out post-exposure
disproportionately vulnerable to sexually transmitprophylaxis against HIV transmission because
ted infections due to biological susceptibility andof fear they may be stigmatized for having been
pervasive gender inequality that exists in many
assaulted (Chynoweth, 2015).
societies (UNFPA, n.d.). Their subordinate status
For HIV-positive populations in humanitarian
denies them power within their relationships andemergencies, the impact of the crisis can denyin other interactions to influence their sexual activthem access to necessary life-saving treatment.
ity and that of their partners as well as their use of
Maintaining a treatment regime can becondoms, in particular where thedifficult in a crisis when there
relationship is between a girl andis only sporadic availability ofolder man (Plan International,
antiretroviral therapy, and often
2013; UNFPA, n.d.). Gender
only at large referral hospitals
Humanitarian crises are
fertile ground for thenorms about appropriate female
rather than at the primary caretransmissionofsexually
behaviour can deny unmarried andlevel (Chynoweth, 2015).
transmitted infections,adolescent girls access to informaDrug stocks and safe blood
includingHIV.
tion about sexual health and about
supply may be destroyed or
preventing sexually transmitted
unavailable, especially during
infections (Plan International, 2013; UNFPA, n.d.).
flight and later displacement (Plan International,
An assessment of displacement settings in Burkina
2013; UNFPA, n.d.). Displacement also disrupts
Faso, the Democratic Republic of the Congo andtreatment regimes. Other sexually transmitted
South Sudan found young unmarried women to
infections, such as chlamydia, gonorrhea andbe the “least knowledgeable” of HIV, other sexuallysyphilis, left untreated, can lead to complicationstransmitted infections and ways to minimize transin pregnancy, infertility, reproductive cancers, andmission, including condom use (Casey et al., 2015).
enhanced transmission of HIV (Chynoweth, 2015).
Gender norms can also make young men and boys
Pregnant women and new mothers who arevulnerable to infection by encouraging risky, domiHIV-positive need access to antenatal care andnant and aggressive sexual behaviour (UNFPA, n.d.).
medicine to prevent mother-to-child transmission
Crises can compromise access to preventionof the virus, yet crises can disrupt these criticaltreatment and information and thus exacerbate
services and availability of drugs. In an assessment
vulnerability to sexually transmitted infections,conducted in the Democratic Republic of the
including HIV. Even in previously stable environCongo, none of the health centres surveyed
ments, as a result of a humanitarian crisis, accessprovided adequate services for prevention of
to prevention can be often limited, inadequate andmother-to-child transmission, as a result of a lackeven non-existent (UNAIDS, 2015).
of supplies and trained staff (Casey et al., 2015).

46

CHAPTER 2

THE DI SP RO P O RTI O NATE TO LL ON WOM E N A ND AD OLE SCE NT GIRLS

Women and adolescents with disabilities
and HIV

Women and adolescents with disabilities faceparticular vulnerabilities in relation to HIV transmission in crisis-affected environments yet may
have limited access to the sexual and reproductive health services and information they need toprotect themselves, including antiretroviral drugs.
During research conducted on women with disabilities in northern Uganda, Human Rights Watch
spoke to two women with disabilities who had been
raped and “said that they did not undergo HIV
testing afterward because they were unable to reacha health clinic” (Human Rights Watch, 2010).
Societal perceptions about women and girls withdisabilities as “non-sexual beings” can restrict theiraccess to sexuality education, including information about how to identify inappropriate behaviour(United Nations Human Rights Council, 2012).
Women and young people with intellectual disabilities face particular challenges in developing
awareness of sexually transmitted infections andcontraception (Women’s Refugee Commission,
2014a).

In armed conflict situations, women and girls may
experience gender-based violence during housesearches, sweeps of residential neighbourhoods,
at checkpoints and in detention, during armed
attacks on their villages, to force displacement, andas part of systematic campaigns of domination,
intimidation and terror by armed groups.
Perpetrators may be partners, relatives, State andnon-State armed forces, camp officials, teachers,
and in some instances, even peacekeepers and aid
workers. And they may be male or female.
Risks of gender-based violence rise when ruleof-law and infrastructure have broken down or
weakened. In protracted conflicts, a culture ofviolence and impunity often emerges, supportedby the easy availability of small arms and light
weapons. Familial and community support
systems and networks are often weakened or
destroyed and families separated. Where families
have previously served as sources of protection,
separation or the death of parents can createa protection vacuum. Poverty, food insecurity,
financial hardship, distress, trauma, loss, andboredom, lack of privacy and overcrowded

Increased risk of gender-based violence

Gender-based violence against women and girls
often thrives in humanitarian crises. In settings
as diverse as Myanmar, Somalia and Syria, sexual
violence is described as “widespread,” “prevalent,”“a dominant feature,” and a “significant threat anda crisis” (United Nations Security Council, 2015).
Gender-based violence is not, however, a newphenomenon that emerges in crises; it is part of acontinuum of violence that women and girls experience in their everyday lives but that can become
more prevalent in crises.
Refugee and internally displaced women andgirls are particularly at risk, including in refugee
camps, temporary shelters or evacuation centres.

From January to September 2014,
UNFPA recorded 11,769 cases ofsexual and gender-based violencein the provinces of North Kivu,
South Kivu, Orientale, Katanga andManiema; 39 per cent of thesecases were considered to be directly
related to the dynamics of conflict,perpetrated by armed individuals.
United Nations Security Council, 2015

THE STATE OF WORLD POPULATION 201547

conditions become everyday realities that
influence behaviour within the family and wider
community, including the adoption of negative
or extreme coping mechanisms.
Armed groups may establish military bases
near population centres, and may establish sexual
violence as an institutionalized and intentional
practice as part of their wider strategic and tacticalefforts (United Nations Security Council, 2015).
Underlying many acts of sexual and gender-based
violence is a profound disrespect for the rights ofwomen and girls.
Double and triple discrimination

Multiple and intersecting forms of discrimination, based on sex, age, economic status or ethnic
minority status and other factors can increase
women’s and girls’ vulnerabilities to sexual andgender-based violence in crisis-affected settings(United Nations Human Rights Council, 2011).
For adolescent girls, being young and female,described by Plan International (2013) as “double
discrimination,” places them at heightened riskof gender-based violence in crisis settings, including rape, early marriage, sexual exploitation,
abduction and trafficking (Women’s RefugeeCommission, 2014).
Children under the age of 18 often make up
the majority of victims of sexual violence in
conflict-affected countries (Save the Children,2014).

The starting line is not thesame for all. Almost everyone
has a head-start compared toadolescent girls.
Women’s Refugee Commission, 2014a48

CHAPTER 2

The United Nations Secretary-Generaldescribed sexual violence against adolescent
girls in conflict situations in 2014 as a “disturbing trend” (United Nations Security Council,
2015). Being a refugee or displaced girl adds
a range of other layers of risk to the equation.
Unaccompanied girls who have lost or been separated from their parents face additional layers of
risk, since they lack the protection often provided
by family members. This type of risk was observed
during the Ebola epidemic where some children
were left unprotected in their homes when theirparents had died or were incapacitated (IASC,2015). A similar situation can occur in a context
of food insecurity if the parents are forced to leavechildren at home, especially with older girls incharge, to go in search of food or income (PlanInternational, 2013).
Women and girls with physical or developmental disabilities are particularly vulnerable
in crises, when community and family support erodes and rule of law collapses (Women’s
Refugee Commission, 2013; Ortoleva and Lewis,2012). According to the United Nations HighCommissioner for Refugees, 49 per cent of all

Ayan, 16, Minkaman Camp, South Sudan: "I feel unsafe
when I go to the bush because there are often men who
rape women."
Photo © Panos Pictures/Chris de Bode

THE DI SP RO P O RTI O NATE TO LL ON WOM E N A ND AD OLE SCE NT GIRLSLACK OF PRIVACY HEIGHTENS RISKS
The lack of privacy across many displacement settings

Menstruating women and girls may feel unable tocan have serious implications for the sexual and repro-

properly clean themselves, change and clean theirductive health of women and girls. Without privacy,

sanitary napkins, which can cause perineal rashes andmany women and girls may refrain from going to theurinary tract infections as well as affect their sense of

latrine or bathing facilities until it gets dark; this is espe-

self and confidence (WHO, 2002; Plan International,

cially the case for adolescent girls who are menstruating2013). Lack of privacy can also cause discomfort and(Plan International, 2013). This places them at increased

stress in breastfeeding mothers, which can disrupt

risk of gender-based violence (UNIFEM, 2010; Plan

milk flow, undermine a mother’s confidence, andInternational, 2013). Inadequate lighting and a sense ofconsequently impact a baby’s nutrition, health andinsecurity may prevent women and girls from using thesurvival (World Vision, n.d.). After the 2005 earthquake

latrines at all at night (Child Protection and Gender-Basedand the 2010 floods in Pakistan, reports suggest that

Violence Sub-Working Group, Jordan, 2013). Whether

many women stopped breastfeeding as a result of a lackdue to lack of privacy, insecurity or lack of cleanliness,of privacy and discomfort due to breastfeeding in front

women and girls may suppress their need to use latrinesof distant male relatives or other men in shared sheltersor toilets, sometimes resulting in urinary tract and other(Bradshaw and Fordham, 2013; UNIFEM, 2010).

infections (Pincha, 2008; Plan International, 2013).

adult rape survivors in the Bhutanese refugee
camps in Nepal between 2009 and 2011 werepersons with physical or developmental disabilities
or impairment (Women’s Refugee Commission,2013). Women and girls with disabilities are
identified as a particularly at-risk group for sexual
violence because of their limited mobility andability to communicate, and their social exclusion and greater likelihood of poverty (UNHCR,
2011a; Consortium, 2015; Women’s RefugeeCommission, 2013; Human Rights Watch, 2010).
Within this group, there are sub-groups that can

I was shamed because after
the disaster I couldn’t wash
and I had leaks thateveryone could see.
Mirasol, age 16, Philippines

face particular risk, due to what might be called
triple discrimination: older women with disabilities, female members of ethnic, linguistic or
religious minorities with disabilities, and lesbian,gay, bisexual or transgender persons with disabilities (UNHCR, 2011a; United Nations
Human Rights Council, 2012).
“We don’t have any doors to lock”

When earthquakes, cyclones, floods, violence
and war force people out of their homes andcommunities, many seek safety in refugee anddisplacement camps, temporary shelters, makeshift houses, spontaneous settlements, urban
slums, evacuation centres and transit sites. Risk
factors for gender-based violence are often foundin many of these settings. Even in establishedrefugee camps, sexual violence occurs. In Dadaab
refugee camp in Kenya, for example, the population increase has outpaced the establishment oflighting and fencing in new sections of the camp,

THE STATE OF WORLD POPULATION 201549

leading to an increase in sexual violence (United
Nations Security Council, 2015). The living
conditions and physical features in these displacement environments are a very real sourceof danger for women and girls.
In settings catering to disaster and conflictdisplaced populations, there tend to be a numberof characteristics that are commonly identified asrisk factors for gender-based violence: overcrowding, the lack of privacy, doors that have no locks,
shared latrines and sleeping facilities, inadequatebathing and latrine facilities, and inadequate
lighting or power outages (Women’s RefugeeCommission, 2014; CARE, 2014, 2015b; Plan
International, 2013; Internal Displacement
Monitoring Centre and the International Rescue
Committee, 2015; Inter-cluster Coordination
Group for the Humanitarian Country Team,
2014; UNFPA, 2014; Child Protection and
Gender-Based Violence Sub-Working Group,
Jordan, 2013). “We don’t have any doors tolock,” said one female resident of Za’atari refugee
camp in Jordan (Save the Children, 2014).
After Cyclone Pam in Vanuatu in March
2015, evacuation centres on Emae Island were“overcrowded, lacked privacy and lighting,particularly around toilet facilities…” (CARE,
2015b). In areas of the Philippines affected by

My daughter is 16…we were
too worried for her. They wereattacking women. We could notprotect her, so we had to marry
her…She did not want to getmarried, she wanted to study.
Syrian mother in Lebanon

50

CHAPTER 2

Typhoon Haiyan in 2013, women and children
were housed in “overcrowded” sites with “limited
security, inadequate bathing and latrine facilities
as well as a lack of privacy” (Inter-cluster
Coordination Group for the Humanitarian
Cluster Team, 2014). Plan International (2011)
has reported that in Bangladesh, cyclone shelters“do not usually provide separate dormitory rooms
for men and women, nor access to separate safe
sanitation facilities.”“We could not protect her, so we had tomarry her”

The impact of armed conflicts and natural
disasters can lead to an increase in child marriage
in crisis sites as well as in camps following
displacement. According to World Vision, fear
is a “major cause of early marriage” in fragile
contexts, including fear of sexual violence andhunger (World Vision UK, 2013). Given theirage and gender, girls are uniquely vulnerable
to this practice. In Syria, early marriage is a
traditional and widely accepted practice by
women and men alike (UN Women, 2013).
While the practice predates crises, there areindications that crises can exacerbate the practice,especially in protracted displacement settings,
including expanding the practice among families
that would not have considered it before, andthreatening even younger girls (CARE, 2015).
Where food is scarce, due to extreme poverty or
drought, families may marry off their daughters
so they have fewer mouths to feed, and as a formof income generation, where the practice of bride
price compensates the bride’s family (Save theChildren, 2014; CARE, 2015). It can also beviewed as a means to protect a daughter’s “honour,”which may be at risk if food insecurity forces her
to resort to survival or transactional sex (PlanInternational, 2013).

THE DI SP RO P O RTI O NATE TO LL ON WOM E N A ND AD OLE SCE NT GIRLS

The crisis in Syria has led to an increase in earlymarriages among Syrian refugee girls in Jordan, as
well as Lebanon and Egypt (CARE, 2015). Among
Syrian refugees, the perpetration and fear of sexual
violence, especially against girls, are cited as reasonsfor fleeing Syria in the first place (CARE, 2015;
International Rescue Committee, 2013).
For girls, early marriage brings significant risks
and disadvantages to their reproductive rights,
their health and their children’s and their own
well-being. Given their age and gender, married
girls have limited power and influence to determine what happens to their bodies. They are often
unable to make decisions about using contraception, how often they have sex, the spacing of theirpregnancies and how many children they have
(CARE, 2015). The repercussions of this lack of
power are significant and sometimes fatal. It places
them at risk of sexually transmitted infections,maternal morbidity and mortality.
Intimate partner violence

Crises often lead to changes in gender relations
within the family, which in turn can increase therisk of intimate partner violence. These changes
are especially prominent in displacement settings(UNFPA, 2010). While men face unemployment, the loss of their livelihoods, idleness andfrustration, women may assume breadwinningresponsibilities. As the preferred recipients offood aid, they may face new opportunities previously unavailable through programmes offered byhumanitarian organizations (International Rescue
Committee, 2015). This shift may lead to a “crisisof identity” among some men (Anderlini, 2010). In
eastern Democratic Republic of the Congo, where
this shift in gender roles has been observed andreported, Congolese men have described feelingsof humiliation, failure and “loss of personal value”(Lwambo, 2011). Inflicting violence against their

At Bachid Kendal Camp, Zakho, Iraq.
Photo © Ali Arkady/VII Mentor Program

partners, as well as children, is seen by some men
as a means to reassert their power, dominance andmasculinity.
Feelings of stress, loss, boredom and frustration
among men in displacement settings may also
lead to alcohol and drug abuse and other negative
coping mechanisms. These in turn fuel intimate
partner violence. For married girls, their positionof “extreme” dependence and lack of power, madeacute by their age and gender, places them at greatrisk of intimate partner violence (International
Rescue Committee, 2015; CARE, 2015).
A growing body of evidence suggests that intimate partner violence is the most common type

THE STATE OF WORLD POPULATION 201551

of violence women experience in humanitariansettings (International Rescue Committee, 2015).
In some conflict-affected environments, intimate
partner violence, including marital rape, anddomestic sexual violence by family members are
more frequent than sexual violence by combatants(Wood, 2015; Human Security Report Project,2012). In an assessment in Za’atari RefugeeCamp in Jordan in 2013, for example, community members and service providers identified
domestic violence as the “most prevalent type ofviolence” and “emerging as a prominent issue”
among Syrian refugees, with girls between ages
12 and 18 the most affected (Child Protection
and Gender-Based Violence Sub-Working Group,
Jordan, 2013).
An increase in intimate partner violence is often
observed following a natural disaster, including
recent ones:• Nepal earthquake: Although there are no
official numbers, counsellors and others involvedin humanitarian response in Nepal observed
a “dramatic increase” in sexual and domestic
violence against women since the earthquake(UN Women, 2015).
• Cylones Vania and Atu: In Vanuatu, which
already has high rates of gender-based violence
including intimate partner violence, a counselling
centre recorded a 300 per cent increase in referrals following Cyclones Vania and Atu in 2011
(CARE, 2015b).
• Increased intimate partner violence was also
reported following the Black Saturday bushfires in Australia (2009), the Christchurch
Earthquake in New Zealand (2011), Hurricane
Katrina in the United States (2005), the Indian
Ocean Tsunami (2004), in Japan following theearthquake (2011).

At a camp in Dohuk, Iraq.
Photo © Ali Arkady/VII Mentor Program

52

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THE DI SP RO P O RTI O NATE TO LL ON WOM E N A ND AD OLE SCE NT GIRLS

“What can you do?”Increased risk of trafficking

The risk of transactional sex increases incrisis-affected environments and in particular displacement settings where livelihood opportunities
are particularly limited. In crisis-affected settings,
sex becomes a survival strategy and an extreme
and negative coping mechanism for some womenand girls. Facing extreme financial hardship andfood insecurity, with no access to income generation, it is not uncommon for women, adolescent
girls and also boys to sell their bodies to ensure
their own survival and that of any dependents,
whether their own children or those of deceased
relatives (UNHCR, 2011). Sex is traded foressential items such as food, medicine or sanitarymaterials, gifts, or access to distributions (Klasing,2011; UNHCR, 2011).
Crisis-related transactional sex has been
observed, for example, in the Democratic
Republic of the Congo, South Sudan, thePhilippines, Haiti and Somalia (UNAIDS,
2015; CARE, 2014; The Inquirer, 2015;
Inter-cluster Coordination Group for the
Humanitarian Country Team, 2014; Klasing,2011).
Women and girls may also enter the commercial sex trade as a source of income generation. A
presence of peacekeeping forces or international
humanitarian workers increases the risk of sexual
exploitation, given the disparity in wealth (Human
Rights Watch. 2015b). Unaccompanied girls andwomen and girls with disabilities are especiallyvulnerable (Women’s Refugee Commission, 2013).
Research by Plan International found that, during periods of drought in Ethiopia, girls have beenresorting to prostitution to earn a living (PlanInternational, 2011). In Haiti, following the earthquake, girls, in particular unaccompanied girls,
established relationships with men specifically foreconomic security (Klasing, 2011).

Conflicts and natural disasters create opportunities
for those involved in human trafficking to exploit
the vulnerabilities of crisis-affected populations. The
International Organization for Migration (2015)
describes refugee and displaced persons camps asa “breeding ground of new victims for traffickers”
and informal settlements and host communities as“particularly at-risk locations” (2015). Women andgirls are particularly targeted by traffickers who may
force them into sex work in brothels, sexual slavery and forced labour (International Organization
for Migration, 2015). They may be lured with thepromise of a job or abducted. Those who resort
to risky survival strategies such as survival andtransactional sex, unaccompanied girls who lackthe protection of families, and children in general,lacking the structure and protection of schooling,
are at heightened risk of trafficking (International
Organization for Migration, 2015). Discrimination
can also be an important risk factor, reflected in thetargeting of ethnic and religious minorities, such as
the Yazidi group in Iraq (International Organization
for Migration, 2015).
The United Nations has reported a surge in the
trafficking of adolescent girls in areas of Myanmar
affected by conflict (United Nations Security

People will try to survive by theway they can. Women haverelationships with men so they
can feed their children. That
happens a lot...It’s not good tomake prostitution, but what can
you do? You have to eat.
Resident of camp in
Croix-de-Bouquets, Haiti

THE STATE OF WORLD POPULATION 201553

Khokhana, on the outskirts of Kathmandu after earthquake.

transmitted infections, broader medical care, as
well as mental health and psychosocial support
and legal support (Casey et al., 2015).
However, crises can prevent survivors fromreceiving quality clinical management of rape. Caremay be unavailable due to destruction of primarycare facilities, restricted humanitarian access or thelack of relevant training for the medical workers
who are available. Care may be compromised by
the lack of sufficient supplies, including drugs.
Survivors may be unable to reach the services due
to restrictions on movement. Even where services
exist, survivors may be unaware of their availability
or may choose not to seek out health services given
the climate of fear and silence that continues tosurround sexual violence across many societies(United Nations Security Council, 2015; Casey
et al., 2015).

Photo © Panos Pictures/Vlad Sokhin“Spoils of war”

Council, 2015). Trafficking has also been reported
in the aftermath of recent disasters in Nepal(Burke, 2015) and the Philippines (Inter-cluster
Coordination Group for the HumanitarianCountry Team, 2014). In the Philippines
however, UNICEF found no significant increase
in incidence as a result of the typhoon (Erakit,2014). Understanding of the relationshipbetween trafficking and crises remains limited:
its prevalence is not well documented, and data
are limited (International Organization for
Migration, 2015).
Sexual violence survivors need post-rapecare but may not get it in a crisis

Survivors of sexual violence need access toquality clinical post-rape care, which includes
post-exposure prophylaxis (within 72 hours) tominimize the chance of HIV transmission, emergency contraception, antibiotics to prevent sexually

54

CHAPTER 2

In northern Iraq and eastern Syria, the selfproclaimed Islamic State in Iraq and the Levant(ISIL) has institutionalized sexual violence,in particular rape, sexual slavery and forced
marriage, against “unbelievers” in areas under its
control (Reinl, 2015). Women and girls of the
Yazidi religious minority have been singled out(Amnesty International, 2014), though othernon-Arab and non-Sunni Muslim communities
such as Christian, Turkmen Shi’a and Shabak
Shi’a minority groups also appear to bevulnerable to these violations of human rights(United Nations Iraq, 2014).
Women and girls are abducted as “spoilsof war,” raped by ISIL fighters, forced into
“marriage,” sold in auctions to local and foreign
ISIL fighters, sometimes multiple times, andgiven as “gifts” (Human Rights Watch, 2015a;
OHCHR, 2015). The practice is not only seen
as “spiritually beneficial” but also has become an

THE DI SP RO P O RTI O NATE TO LL ON WOM E N A ND AD OLE SCE NT GIRLS

established practice for recruiting fighters to ISIL
(Callimachi and Limaaug, 2015).
TraumaInterest in the effects of trauma on individuals,
populations, between generations and on peaceand security are growing. Ideas about how
unresolved trauma and collective trauma maylead to intergenerational impacts and new cyclesof violence and conflict are gaining currency.
The mental health and well-being of people areat higher risk following conflict and crisis, andmuch more needs to be understood about themental health impacts, intergenerational violence,
how experience of violence may or may not leadto future perpetration, and how psychosocial
needs interconnect with peacebuilding at a
community-level (Searle, n.d.).
A need for change

Despite everything we know about gender inequality, gender-based violence and discrimination,
women and girls continue to be disproportionately
affected by disaster, conflict and displacement.
Whether in the home, in displacement settings
or in their wider communities, women and girls
experience much greater risks to their sexualand reproductive health and rights than men
and boys.
However their exposure to harm and experiences are not the same. Women and adolescent
girls experience additional layers of risk, dependingon their ethnicity, age, their health and disability
status, their economic situation and factors such as
displacement and migration.
Humanitarian actors involved in policy-making
and programme implementation need to live up
to commitments to unburden women and adolescent girls of overwhelming risks that exacerbate thealready-overwhelming experience of being uprooted

and losing the support of family, community andgovernment after a crisis occurs.
Changes are needed in some aspects of humanitarian response to make sure the acute sexual andreproductive health needs of women and adolescent
girls are met through, for example, immediate restoration of access to services and supplies, such as
contraception.
While crisis conditions may lead to reduced
access to contraception and family planning, they
may also create opportunities for improved accessthrough targeted humanitarian programming(Plan International, 2013).
But reducing risk also requires long-term investments and political will to rectify gender inequality,
which can multiply risks.
While some factors in crisis situations lead toheightened risk, they may also present opportunities for change. With HIV, for example, crises may
be opportunities for improved care or for reaching
those who had not previously been able to access it(UNAIDS, 2015). In well-managed and resourced
camps, displaced populations may actually havebetter protection, health education and services
than they experienced before the crisis.
Adolescent girls have special vulnerabilities, andhumanitarian actors must recognize from the start
the risks compounding these vulnerabilities andprioritize actions that address their needs, ensure
their safety and preserve their dignity.

THE STATE OF WORLD POPULATION 201555

CHAPTER 3

Evolving response:from basic tocomprehensive
When women and girls can obtain sexual andreproductive health services, along with a variety ofhumanitarian programmes that deliberately tackle
inequalities, the benefits of interventions growexponentially and carry over from the acute phaseof a crisis well into the future as countries andcommunities rebuild and people reclaim their lives.

Saving the lives of Syrian
women and adolescent
girls in Jordan

On one August morning at the Za’ataricamp in Jordan, thousands of Syrian
refugees began their routines before thepeak of the midday heat.
By 11 a.m., the temperature outside wasalready 30°C. But inside one of UNFPA’s
four reproductive health clinics in thecamp, air conditioning was keeping
five expectant mothers cool as theircontractions intensified.

Reema Diab with client.
Photo © UNFPA/Salah Malkawi

56

CHAPTER 3

On an average day, 10 babies are bornin Za’atari’s labour and delivery centre,
according to obstetrician-gynaecologist
Reema Diab. The centres are designed,
managed and monitored by UNFPA,
the United Nations Population Fund,
working with a local non-governmentalorganization, the Jordan Health Aid
Society, and with donor funding from

EVO LVI NG RESP O NSE: FRO M BASIC TO COM PRE HE NSIV E

the European Commission and theUnited States.
Diab is one of five doctors who, with thehelp of 17 midwives, deliver hundredsof babies every month despite the challenging conditions of a refugee camp. So
far, no mother has died in pregnancy orwhile giving birth in Za’atari.
But there have been plenty of close calls.
Diab says that one of the five womenin labour that August morning had preeclampsia, a potentially life-threatening
condition, and had to be transferred toa hospital equipped with an operating
room, anaesthesia and other essentials
for complicated deliveries and caesarian
sections. Sometimes cases are referred
to a nearby Jordanian hospital. But inFamily health clinic, Deir Allah, Jordan.
Photo © UNFPA/Salah Malkawi

most instances, women are transferred
within the camp to a hospital run by
the Moroccan military. That hospital
performs an average of three Caesarean
sections a day, and the surgeons arealso trained to repair cervical tears andobstetric fistulas.
Sajah, 25, is one of many who havebenefited from the specialized careavailable at the Moroccan hospital.
She was recently referred there for ahigh risk delivery, after experiencing
five miscarriages. A Caesarean section
resulted in a safe, healthy, delivery.
Integrated, comprehensive care
The labour and delivery centres are justone aspect of the comprehensive sexualand reproductive health services available to the residents of Za’atari, where

one in four is a woman or adolescent girlof reproductive age.

coping mechanisms, to forced childmarriage.

Women in the camp are also able toreceive antenatal care and post-partum
follow-up services. Women, men andyoung people can obtain information
about family planning and free modern
contraception. The centres’ health-care
staff have been trained to identify andprovide clinical management of sexualand gender-based violence and to makereferrals to the camp’s counselling andcase-management centres.

Heaping loss upon loss
That morning at the labour and delivery
centre, two 16-year-old girls gave birth.
Adolescent pregnancies are commonplace in Za’atari. Omar Laghzaoui, thelead obstetric surgeon at the Moroccan
hospital, says that about one in three ofthe births he assists are to girls 15 years
or younger. “The youngest I’ve seen was12,” he says. With early pregnancies
come heightened risks of complications
and, often, the need for Caesarean
sections.

Still, life in the camp is a struggle. Even
with readily available services, refugee
women and girls face a host of barriers
to good physical and psychologicalhealth, from the lingering trauma of theirdisplacement to the impact of negative

Special challenges for adolescentsand young people
These early pregnancies are usually
linked to child marriages in the camp,

THE STATE OF WORLD POPULATION 201557

I

magine being nine months pregnant, alone,
separated from family and friends, miles froma doctor or anyone who can help, and contractions begin. You are faced with the prospect ofdelivering on your own.
Such an unimaginably frightening scenario
was a reality for untold thousands of women
living through a conflict or disaster only 20
years ago.
Until recently, humanitarian response was mainly about meeting basic needs including water, food,and shelter. Other needs, including those related tosexual and reproductive health and childbirth, wereseen by many as secondary.
But to the woman delivering on her own, theneed for a midwife or for clean environment andinstruments to help her avoid an infection are
primary.
The absence of sexual and reproductive health incrises was the norm, not the exception. For example, one review in 1994 showed virtually no sexual

says Asma Nemrawi, a psychologist serving the camp’s young people.
Parents often arrange marriages for their
young daughters to eliminate the financial burden of caring for them, or out of
the misguided notion that a husband
will better protect them from sexual violence. Nemrawi routinely sees girls whoare, or are about to be, married. Someare as young as 14. “Some want to learn
how to have children,” she says. “Others
are already pregnant and want psychological support.”
Nemrawi says that some girls tell her
they want to have children to makeup for the losses they’ve experienced
in their lives. Some also say they fear
their husbands will become violent or
divorce them if they don’t have children.
For these difficult situations, she tries to

58

CHAPTER 3

and reproductive health services in multiple refugee
and internally displaced persons sites in eight
countries (Wulf, 1994).
Since then, however, humanitarian actors havecome to recognize the importance of ensuring sexual and reproductive health and rights in crises, notonly as an essential part of humanitarian response,
but also as a lever to more effective humanitarian
programming across sectors and as a foundation for
long-term recovery, rehabilitation and resilience.
The Programme of Action of the 1994
International Conference on Population andDevelopment, endorsed by 179 governments,
helped draw attention to the unmet sexual andreproductive health needs of women and girls inhumanitarian settings: “Reproductive health careshould be available in all situations and be basedon the needs and expressed demands of refugees,
particularly women, with full respect for thevarious religious and ethical values and cultural
backgrounds of the refugees while also conforming

meet with both the girl and herhusband at the same time to talk about
the health, psychological and economic
benefits of delaying pregnancies until
later in life, drawing attention to the challenges of raising a child in a refugee camp.
Nemrawi also talks to the camp’s youth
about family planning. “At the beginning,they didn’t want to hear about familyplanning,” she says. But her efforts to
explain how it works and how it is goodfor the health of the mother are paying off. About 60 per cent of the young
people who came to one of her sessions
leave convinced they should use it.
Reaching those not in the camps
Za’atari is home to about 80,000
Syrian refugees; four other camps houseanother 30,000. But these camp

EVO LVI NG RESP O NSE: FRO M BASIC TO COM PRE HE NSIV E

residents combined account for only
about 18 per cent of all Syrian refugees
in Jordan. The other 82 per cent live incities, towns and rural areas throughout the country, where many of themstruggle to obtain access to sexual andreproductive health care.
Providing services to refugees outside the camps is complicated. The
populations are dispersed, and manyare beyond the reach of the institutions
serving Jordanian citizens.
In addition, services in Jordan’s public
hospitals and Government-run clinics
are free only to insured citizens. Syrians
and refugees from other countries haveto pay a fee, which is not high compared to the cost of private services,
but is still often unaffordable for most.

IN TYPHOON’S TERRIBLE WAKE, WOMEN IN THE PHILIPPINES CONTINUED
GIVING BIRTH SAFELY
When the warnings were issued for Typhoon Haiyan, theFour million people were left homeless by Haiyan,

chief of the Felipe Abrigo Memorial Hospital wasted no

known locally as Yolanda, which struck in November

time. Dr. Lilia Daguinod gathered essential medicines

2014.

from her hospital and set up a small pharmacy in the
Hundreds of displaced women were giving birth every

front room of her small house.

day, and scores of them faced potentially life-threatening
As an obstetrician, Dr. Daguinod knew that womencomplications. Most damaged health centres restored

would continue to give birth and be at risk no mattersome services soon after the crisis, but staff in many

what happened. “I had to be ready,” she said.

places struggled to serve patients without equipment orelectricity and with few ambulances and scarce supplies.

In the first days after the typhoon’s ferocious winds
shredded this city and left her hospital in ruins,

In response to this crisis, UNFPA prioritized services to

Dr. Daguinod delivered three babies in that room.

ensure the safety of pregnant women and those who“Thank God, there were no complications.”

recently gave birth. UNFPA provided critical medical
equipment and supplies, including medicines, clean

After a makeshift birthing facility was set up next to adelivery kits and hygiene packs, to government androofless health centre, she continued to host post-partum

non-governmental partners to support health caremothers and their babies in her home.

in the worst-affected regions.

One alternative is to access services
from non-profit providers, such as theInstitute for Family Health, or IFH, which
has a nationwide network of clinics
offering sexual and reproductive healthservices to Syrians and Jordanians alike.
IFH implements programmes supported
by UNFPA.
Hanin Zoubi is the IFH-UNFPA
programme manager. “We take an integrated approach,” offering free antenatal
and postnatal care, family planningcounselling and services, treatment
of sexual transmitted infections andpsychosocial support for survivors ofgender-based violence and trauma, allunder one roof, she says.
But not everyone is able to come to theclinic, so IFH also provides community

outreach.“We go to where the people
are,” Zoubi says. They go, for example,
to schools to provide information toadolescents, or to community-basedorganizations to offer life-skills training
to young people.
People welcome the information, shesays, noting that vulnerable populations in the country often lack accessto the Internet and are unable to findout on their own about how to preventa pregnancy or a sexually transmitted
infection.
The refugee population living outside
the camps is different in key ways. Theirdemand for family planning is greater,according to Zoubi, and there are fewer
adolescent pregnancies.

Newborns, Za'atari Camp.
Photo © UNFPA/Salah Malkawi

Haya Badri, the IFH clinics coordinator,
says up to 65 Syrians and Jordanians
patients come to the facility in Amman
for services every day. Most of theclients come for check-ups, including
ultrasound examinations, but some

THE STATE OF WORLD POPULATION 201559

with universally recognized international humanrights” (United Nations, 1994). This approach was
further endorsed in the Beijing Platform for Actionof the 1995 World Conference on Women (United
Nations, 1995).
In 1995, UNFPA and the United Nations HighCommissioner for Refugees led the formation of
the Inter-Agency Working Group on Reproductive
Health in Crises (IAWG) in response to the increasing recognition of sexual and reproductive healthneeds among refugees and internally displaced persons and the general lack of response. Since then,
IAWG has grown into a global coalition of United
Nations, donor and academic organizations, local
and international non-governmental organizations
and ministries of health to expand and strengthen
access to quality sexual and reproductive healthservices for people affected by conflict and natural
disaster (IAWG, 2014).
Today, more refugees and internally displaced persons have more access to more services than in thealso receive treatment for anaemia
or request contraception. Many alsocome in to report or receive treatment
and counselling for sexual and genderbased violence. One-to-one counsellingsessions and support groups are alsoavailable for traumatized adults andchildren and even for torture survivors.
Confidentiality and respect
Whatever the service being provided,
privacy is critical. All staff have been
trained and have signed a code of conduct, committing to provide confidential
services to all without judgment. The
guarantee of confidentiality helps clients
overcome fear and maintain dignity inseeking help.
At another centre, in Deir Alla in the
Jordan Valley, Nadia om-Hassan, 35,60

CHAPTER 3

past. In 2014, UNFPA provided 8,437 reproductive
health kits with essential supplies, medicine, contraceptives, and equipment, targeting more than 35
million women, men and adolescents in humanitarian settings. But continuously growing populations
in need and increasing commitment to providingthem with comprehensive services mean that gaps
still exist and could become larger without concerted effort to meet the challenge.
The humanitarian community has come a longway over the past 20 years. In many of today’shumanitarian settings, a full range of services andsupport are available. But in others, some or many
aspects are still lacking. Sexual and reproductive
health is not yet comprehensive or universal acrossall crises.
One hundred seventy-nine Governments agreed in
1994 at the International Conference on Population
and Development that reproductive rights are
human rights. The international community has an
obligation to uphold these rights, even in crises.

comes for family planning, to see counsellors and participate in social support
groups. Three years ago, when she wasstill in Syria, she had just given birth toher fifth child by Caesarean section andwas still groggy from anaesthesia whenbombs struck the hospital, forcing an
emergency evacuation. In the following days, her surgical incision became
infected. Despite her condition, she, herhusband, their newborn and four otherchildren all fled to Jordan.
Afterward, om-Hassan’s husband pressured her to become pregnant again.
“He wanted more boys, to help support
the family,” she says. “I did get pregnant
after three months, [but] had a miscarriage.” IFH staff in Deir Alla told her
about family planning and explained
how it was important to her health.

EVO LVI NG RESP O NSE: FRO M BASIC TO COM PRE HE NSIV E“Now I explain to my husband that it’salso good for the health of the wholefamily.”“When I come to the clinic and have achance to talk about my problems, I feelso happy and relieved,” om-Hassan says.
The Deir Alla centre also supports
adolescents. Malak, 15, came to Jordan
from Damascus four years ago withher parents, grandparents and threesiblings. She attends secondary school,
where science is her favorite subject,
but says she wants to become a police
officer one day. Earlier this year, heraunt approached her parents to arrange
a marriage with her 20-year-old son.
“I wasn’t happy, but I couldn’t refuse.
I didn’t want to give up my education,”
Malak says.

Establishing a standard for the essentials

In 1998, the IAWG introduced what isnow considered the essential package ofreproductive health services and supplies thatshould be available at the outset of every crisis.
This minimum initial service package is theinternational standard for protecting the sexualand reproductive health and rights of womenand girls in the acute phase of conflicts anddisasters.
The objective of this is to prevent and manage
the consequences of sexual violence, reduce HIVtransmission, prevent maternal and newborn
death and illness, and integrate sexual andreproductive health care into primary health care.
Even though these essential services are now
widely accepted as the baseline for criticalservices and actions in crises, some responses
have fallen short, endangering the health ofwomen and adolescent girls and denying theirreproductive rights.

Comprehensive services after the initialphase

The IAWG identified additional important sexualand reproductive health services that should bemade available as soon as possible as a crisis
situation stabilizes.
The full range of family planning options

Although it is not possible to prevent disasters, it
is possible to prevent unintended pregnancies in
the aftermath of a crisis.
Since the April 2015 earthquake in Nepal,
for example, UNFPA and partners restored
women’s access to family planning in areas where
health facilities were damaged or destroyed.
UNFPA-trained health workers and community
volunteers spread the word about how to accessfamily planning and use it effectively. Outreachis undertaken with health posts in village development committees, the smallest administrative
units, to closely analyse local-level family

Then one day Malak accompanied hermother to the centre and found out
about information sessions on childmarriage, which they both attended.
Her mother, and later her father, cameto accept that it would be better for
Malak to stay in school and finish her
education. The engagement ended
after a month.

services, like maternal healthcare, is the responsibility of
the international humanitarian community so that life canbe sustained and that there issome hope for a better futurewhen the war ends.”

According to Daniel Baker, who coordinates the UNFPA effort to support Syrian
refugees in Jordan, Egypt, Iraq, Lebanon
and Turkey as well as Syrians who have
not yet fled the country, “The situationof Syrian refugees is dire in spite of thegenerosity of the neighboring host countries. As the war in Syria goes on with noend in sight, their situation is becoming
even more desperate as they deplete allof their resources. The provision of basic

Malak, Deir Alla, Jordan.
Photo © UNFPA/Salah Malkawi

THE STATE OF WORLD POPULATION 2015

61

UNITED NATIONS HUMANITARIAN ACTION
More than two thirds of all
humanitarian emergencies to which
the United Nations responds today
are natural disasters. In 2014 alone,
the United Nations responded to
60 disasters, compared with sevencomplex emergencies or conflicts.
Since 2013, the United Nations
has rated the magnitude and typeof emergencies on a three-point
scale, with the most severe Level
3 designated to need systemwide mobilization because of theirscale, complexity and urgency.
Level 2 emergencies may requirepredominantly a regional response.
Level 1 emergencies are those that
may be addressed by a given country
or managed and supported byagencies in that country.

As of September 2015, the United
Nations was responding to four Level 3
emergencies: in Iraq, where the surge
in violence between armed groups
and Government forces has resulted
in an estimated 1.9 million internallydisplaced people; in Syria, where
millions are in need of assistance andtrapped in hard-to-reach areas; inthe Central African Republic, where
over the past year, the country has
experienced a major political crisis
that has left 2.5 million people—over
half the population—in dire need ofassistance; and in South Sudan, where
1.7 million people have been displaced
and an estimated 4 million people face
food insecurity (UNOCHA, 2015).
Over the last 12 months there havebeen 30 United Nations humanitarianfunding appeals, nearly half of whichwere for countries in sub-SaharanAfrica.

According to the Assessment
Capacities Project (ACAPS), there
are “severe” humanitarian crises in:
Afghanistan, the Central African
Republic, the Democratic Republicof the Congo, Eritrea, Iraq, Niger,
Nigeria, Somalia, South Sudan, Sudan,
Syria, and Yemen. ACAPS is a nonprofit initiative of Action Contre laFaim, the Norwegian Refugee Council
and Save the Children Internationalthat together supporting thehumanitarian community withneeds assessments.
According to ACAPS, there are also
humanitarian crises in Cameroon,
Chad, Colombia, the Democratic
People’s Republic of Korea, Djibouti,
Ethiopia, Gambia, Haiti, Kenya,
Lebanon, Liberia, Libya, Malawi, Mali,
Mauritania, Nepal, Pakistan, Palestine,
Senegal, Sierra Leone and Ukraine.

UNITED NATIONS HUMANITARIAN RESPONSE, 2007–2014

2007

2008

124
115

Disasters

Conflicts

2009

2010

122

121

60
40

33

© UN Photo/Eric Kanalstein

62

CHAPTER 3

36© UN Photo/Martine Perret

EVO LVI NG RESP O NSE: FRO M BASIC TO COM PRE HE NSIV E© UN Photo/Sayed Barez© UN Photo/Logan Abassi

SETTINGS OF CONFLICT, DISPLACEMENT AND NATURAL DISASTERS ACCOUNT FOR:

THREE IN FIVE

53 PER CENT

45 PER CENT

preventable maternal deathsof under-five deaths

Of the more than
100 MILLION PEOPLE
in need of humanitarianassistance in 2015,
an estimated
26 MILLION WEREWOMEN AND GIRLS,
AGES 15 TO 49

2011

2012

118

124

of neonatal deaths

More than 80 PER CENT of thecountries that did not achieve the MDGs
for mothers’ and children’s survival haveendured a recent conflict, recurring
natural disasters or both. Indeed, most of theMillennium Development Goal targets in fragile
states were not met, and the 10 countries at thebottom of Save the Children’s Mothers’ Index are
all defined as conflict-affected or fragile.

2013

2014

116

60
35
17
© UN Photo/Eskinder Debebe© UN Photo//Logan Abassi

2

7© UN Photo/Albert González Farran

THE STATE OF WORLD POPULATION 2015

63

WHERE UNFPA PROVIDED HUMANITARIAN SUPPORT IN 2015
UNFPA’s role in any humanitarian situation
is to ensure that women have access tosafe delivery services, no matter what thecircumstances, in order to protect the lives
and health of both mothers and babies.

Burkina Faso

598,610

Burundi373,871

Cameroon

695,698

Central African Republic

150,727Chad

472,898

Chile

193,042

Democratic Republic of the Congo*The estimates of the number of women who are likely to be pregnant within a country or territory
as a whole—not only the areas specifically affected by conflict or disaster—are drawn from nationallygenerated data. The total number of pregnant women at any given time in each place would be lower
if the estimates were restricted only to the crisis-affected parts of each country or territory.
**Due to data availability, estimation for Vanuatu is using the total fertility rate instead of the general
fertility rate.
Data Sources
Demographic and health surveys: Burkina Faso, Burundi, Cameroon, Chad, the Democratic Republicof the Congo, Egypt, Eritrea, Ethiopia, Jordon, Malawi, Mali, Mauritania, Nepal, Niger, Nigeria, Peru,
Rwanda, Senegal, Tanzania, Uganda, Yemen; Censuses: Central African Republics, the People’s
Democratic Republic of Korea, South Sudan, Sudan, Vanuatu; Registration: Chile, Guatemala,the former Yugoslav Republic of Macedonia, Turkey, Ukraine; Pan Arab Project for Family Health:
Djibouti, Lebanon, Palestine; Multiple indicator cluster surveys: Iraq, Somalia; National statistics:
Myanmar, Syrian Arab Republic.

CHAPTER 3

2,753,898

Democratic People’s Republic of Korea

276,175

Djibouti

21,836

Egypt

1,991,512

Eritrea

134,236

Ethiopia

2,711,606

Guatemala

365,965

Iraq

934,973

Jordan157,846

Lebanon74,572

Malawi555,483

Mali

573,961

Mauritania

103,372

Myanmar609,344

Nepal

517,850

Niger

763,201

Nigeria

5,366,797

Palestine

128,179Peru

473,691

Rwanda310,901

Senegal432,879

Somalia

373,756

South Sudan

244,317

Sudan

860,404

Syrian Arab Republic

355,706

Tanzania

1,605,941

The former Yugoslav Republic of Macedonia

17,611

Turkey945,434

Uganda1,304,798

Ukraine306,902

Vanuatu**

6,839

Yemen

687,058

Total

28,451,889

Photo © Panos Pictures/Abbie Trayler-Smith64

Estimated
number of
pregnant
women at any
given time*

EVO LVI NG RESP O NSE: FRO M BASIC TO COM PRE HE NSIV E

planning use and develop strategies to meet unmet
Family planning is an indispensable element
need. A Government review of 30 facilities covof response, as well as rebuilding and recovery,
ered by the initiative found that the contraceptive
and directly benefits women and girls throughprevalence rate had increased from 34 per centincreased family savings and productivity, as well as
to 45 per cent.
better prospects for education and employment. It
In humanitarian crises where funding foralso improves health outcomes as fewer unintended
life-saving interventions is limited, family
pregnancies result in fewer complications during
planning is a sound investment. In general, eachchildbirth and fewer maternal deaths.
$1 spent on contraceptive services saves between
Data show different fertility desires of people$1.70 and $4 in maternal and newborn healthaffected by crisis; both high and low fertility havecare costs.
been observed in response to war, natural disaster,
Last year, UNFPA provided contraceptives
economic decline, political upheaval and forced
and other family planning supplies in emergency
marital separation (McGinn, 2000). However,reproductive health kits, whicha tenet of human rights and thetargeted the delivery of services
right to health is that health serto 20,780,000 women, men andvices must be available, accessible,
adolescents of reproductive age inacceptable and of the highest posUNFPA provided
humanitarian settings worldwide.
sible quality for those who choose
contraceptives andAccess to family planning services
to use them (Foreman, 2015). A
other family planning
is a human right, and neglecting
fundamental principle of family
supplies in emergency
to provide it can have serious
planning programmes is that
reproductive healthhealth consequences, especiallyclients make decisions based on
kits, which targeted thein humanitarian settings. In May
full, free and informed choicedelivery of services to2013, UNFPA and the International(Foreman, 2015; IAWG, 2010).
20,780,000 people ofPlanned Parenthood Federation
Good programming requires that
reproductive age.
established a partnership aimed at
all effective contraceptive methods
providing access to family planning and inforbe made available to women and men. Experiencemation to 22 million women in countries andin programmes that offer the full range of longterritories affected by conflicts and natural disasters.
and short-acting contraceptives has demonstrated
The initiative focuses on filling the gap inthat women will choose long-acting intrauterine
health-care infrastructure, boosting the qualdevices and implants when they are available andity of the health workforce, developing efficientwhen services are of good quality.
family planning distribution systems, andFamily planning programmes serving crisisensuring affordable family planning supplies.
affected women and adolescents primarily offer
Target countries, which have low contraceptive
short-acting methods of contraception, if they
prevalence rates and considerable unmet need forprovide contraceptives at all (Casey, 2015).
family planning, are Bolivia, Côte d’Ivoire, theBut programme experience suggests that
Democratic Republic of the Congo, Ethiopia,
women will use long-acting methods when they
Haiti, India, Kenya, Liberia, Myanmar, Nigeria,
are available. In the Democratic Republic of the
Pacific Islands, Pakistan and South Sudan.
Congo’s North Kivu Province, an area of chronic

THE STATE OF WORLD POPULATION 201565

conflict and insecurity, all reversible methods
are offered in some Ministry of Health facilities
supported by international non-governmentalorganizations. Not only was contraceptive
prevalence higher than the national rate, but theuse of long-acting reversible methods in North
Kivu was more than twice that of Kinshasa.
(Ministère du Plan et al., 2014).
Additional measures to save the lives of mothers
and newborns

The 10 countries with the highest maternalmortality ratios in the world are affected by,or emerging from, conflict.
UNFPA’s role in any humanitarian situation isto ensure that women have access to safe delivery services, no matter what the circumstances,in order to protect the lives and health of bothmothers and babies. UNFPA does not necessarily
provide these services through its own operations:typically some public and private health facilities
continue to function and there are many nongovernmental organizations that also specialize
in maternity services. But when there are gaps,
UNFPA fills them.
Creative means have sometimes been used toensure access to maternal and newborn healthservices to women who are distant or dispersed.
Community health workers responding to
Ebola in Guinea, for example, used smartphones
to register people exposed to the virus and relay
critical information to health officials.
In Somalia, nurses used global positioning
systems to facilitate the delivery of healthservices to internally displaced persons inremote areas (Shaikh, 2008).
Also in Somalia, UNFPA is supporting 34
maternity waiting homes for pregnant womenwith complications to provide care and protection
until it is time for delivery at a health facility.

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CHAPTER 3

In the Philippines, after Typhoon Haiyan,
UNFPA helped establish an emergency maternity
unit, in a “hospitainer,” where health care professionals assisted 14 normal births and performed
83 Caesarean sections. UNFPA also provided
clean delivery kits, which were used in emergency deliveries for as many as 26,000 women in
makeshift facilities in places such as municipal
buildings.
Refugees themselves have led on many initiatives. In Guinea, for example, refugee women
led maternal health education in communities
and facilitated delivery and use of other services(Howard et al., 2011). In Syria, where nearly 7.6
million people are internally displaced, reproductive health vouchers were introduced to enable
vulnerable women to obtain essential services,
including antenatal, delivery, postnatal and emergency obstetric care for free at designated healthcentres and hospitals. Of the women benefitingfrom UNFPA-supported reproductive healthservices in Syria since the crisis began, more than
810,000 went through safe deliveries and 93,000
internally displaced women benefited from thevoucher system.
In Gaza, four maternity centres and five
primary health care facilities used by 50,000
people a year faced chronic shortages of essential
medicines since 2006, but stocks dwindled to
critical levels after the 2014 conflict. UNFPA
replenished medicines and other supplies, whichhave so far enabled about 35,000 pregnant
women to have healthy pregnancies and safedeliveries.
Also in Gaza, the Harazeen Hospital, the only
facility serving the community of Shejaiia, wasseverely damaged by fighting in 2014. UNFPA
funded repairs. The Hospital provides antenatal,delivery and postnatal care to as many as 300
women a month.

EVO LVI NG RESP O NSE: FRO M BASIC TO COM PRE HE NSIV E

UNFPA SUPPORTS ACCESS TO SERVICES BY WOMEN AND GIRLS
Services and supplies provided January to September 2015
in Lake Chad Basin countries affected by Boko Haram crisis

NIGER

CHAD

53,312 condoms distributed

28,000 condoms distributed

10,913 women and adolescent girls accessedfamily planning

2,500 women, men, young people attended awarenessraising about gender-based violence

1,458 women assisted for safe deliveries

1,500 women received antenatal care

1,407 dignity kits were distributed to refugees

1,500 women received gender-based violence services

906 women received antenatal care

510 women assisted for safe deliveries

118 adolescents and youth received training as
reproductive health educators for refugees

500 women accessed contraception

40 health providers were trained
22 women survivors of gender-based violence
received psychological support

CAMEROON
4,075 kits for safe delivery distributed to health posts in camp
and centres

NIGERIA
2,108,441 people’s awareness raised about preventing
and responding to gender-based violence
27,293 women assisted for safe deliveries
22,000 women and adolescent girls received
dignity kits
214 reproductive health kits (1,759 cartons)
distributed, containing a range of life-saving medical
equipment, drugs and other supplies
213 health workers and programme managers weretrained in providing reproductive health services inhumanitarian settings

5,400 dignity kits delivered to pregnant and vulnerable womenand girls
10,000 male condoms distributed
110 women accessed contraception
11 cases of rape clinically managed
30 district health staff and 40 community health agents trainedand deployed
22 newly trained midwives deployed
5 youth centres equipped for skills development and adolescentcounselling
4 public health facilities serving refugees equipped to provide
quality reproductive health services
4 youth- and women-friendly spaces created in Minawao camp

56 midwives and nurses were trained in administering
long-acting reversible contraception

Girls who escaped Boko Haram,
Chibok, Nigeria.
Photo © Panos Pictures/Sven Torfinn

THE STATE OF WORLD POPULATION 201567

In addition, UNFPA funded mobile clinics toserve Gaza’s internally displaced pregnant womenin camps for internally displaced persons, makeshift
shelters and caravans in remote border areas wherean estimated 100,000 people remain homeless. In
July 2015 alone, mobile clinics brought services to389 women, including 156 who were pregnant.
Some humanitarian programmes have madenoteworthy progress in extending access to
reproductive health services to all in every setting.
Maternal and child health centres are accessible
to all residents of the Za’atari refugee camp in Jordan,for example, and additional centres are reaching
Syrian refugees not in camps (Krause et al., 2015).
Post-abortion care to save lives

Women and girls in humanitarian settings may
be at increased risk of unintended pregnancy andunsafe abortion due to higher levels of rape anddisrupted contraceptive use due to displacement(IAWG, 2010). Although national abortion laws
and access to safe abortion care vary by country,
99 per cent of the world’s population lives incountries where abortion is permitted undercertain circumstances; six States prohibit abortion
under all circumstances (RAISE, 2015; Center
for Reproductive Rights, 2014).
Post-abortion care is a life-saving service thatprevents death and illness from complications of
miscarriage or abortion. UNFPA’s policy on abortion is guided by the Programme of Action of the1994 International Conference on Population andDevelopment: where abortion is legal, it should besafe. Where it is illegal, post-abortion care should
be available to save lives.
An evaluation by the IAWG found that in threecrisis-affected countries of sub-Saharan Africa,
hospitals were deemed capable of providing
post-abortion care but the actual availability ofcare was limited (Casey et al., 2015).

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CHAPTER 3

Preventing and treating sexually transmitted
infections, including HIV

HIV has received progressively greater attention inhumanitarian settings during the last two decades andreceives greater funding and targeted assistance thanother sexual and reproductive health topics (Tanabe
et al., 2015). An evaluation by IAWG in 2014 foundthat many countries had made notable progress inincreasing access to antiretroviral therapy and prevention of mother-to-child transmission but progress
lagged in providing services to prevent or treat othersexually transmitted infections (Chynoweth, 2015).
In 2014, the United Nations Office on Drugs andCrime and the United Nations High Commissioner
for Refugees developed a programme comprising
comprehensive HIV prevention and harm reduction
as well as HIV testing and counselling and HIV
treatment for Afghan refugees in Iran and Pakistan
and returnees in Afghanistan. The programme distributed condoms and syringes and supported HIV
services across borders, thus promoting continuationof services after refugees’ return. In Afghanistan, theprogramme reached approximately 3,000 people
who inject drugs, including some 500 women(UNAIDS, 2015).
Protecting adolescents’ right to health

Humanitarian settings are accompanied
by inherent risks that increase adolescents’vulnerability to violence, poverty, separationfrom families, sexual abuse and exploitation.
Moreover, childbearing risks are compounded foradolescents, due to increased exposure to forced
sex, increased risk-taking and reduced availabilityof, and sensitivity to, adolescent sexual andreproductive health services (Women’s RefugeeCommission et al., 2012).
There is little evidence that adolescent sexual andreproductive health receives adequate attention inhumanitarian contexts.

EVO LVI NG RESP O NSE: FRO M BASIC TO COM PRE HE NSIV E

Still, there are several programmes withpromising approaches, providing adolescent sexualand reproductive health services within schoolbased programmes, working with urban displaced
populations and incorporating adolescent sexualand reproductive health into disaster risk reduction(Women’s Refugee Commission et al., 2012).
A topic of concern to all women of reproductive age in crisis, but that has special resonance foradolescent girls, is menstrual hygiene management.
The IAWG has called for safe, sex-specific hygiene
facilities in schools and the provision of cloth orother culturally appropriate sanitary materials foruse during menstruation. UNFPA was one of
the first agencies to provide sanitary napkins inhumanitarian settings and has been distributing“dignity kits,” which include sanitary napkins,
since the early 2000s.
Young people can be agents of positive change,
capable of advancing reconstruction and development in their communities. But to be engaged
in the process, they need access to an array ofprogrammes including formal and non-formal
education, life skills, literacy, numeracy, vocational
training and innovative strategies to address insecurity and staff shortages (IAWG, 2010). Theintersections among education, livelihoods andprotection for adolescents, however, are generally
overlooked (UNFPA, 2015b).
Preventing and addressing gender-based
violence

Response to gender-based violence in humanitarian settings requires services and support to preventand protect affected populations, to reduce harmful
consequences and prevent further injury, trauma,
harm and suffering. United Nations guidelines
for addressing the problem emphasize that all“humanitarian personnel ought to assume genderbased violence is occurring and threatening affected

CHARACTERISTICS OF SUCCESSFULADOLESCENT SEXUAL AND
REPRODUCTIVE HEALTH
PROGRAMMES• stakeholder involvement• adolescent participation and engagement to build
adolescent buy-in and increase demand for services• responsiveness to the different needs of adolescentsubpopulations• qualified and dedicated staff to serve adolescents• provision of comprehensive services for adolescentsat a single site
• holistic, multi-sectoral approaches to programming• structured supervision, recognition and ongoing
mentorship to peer educators• flexible outreach strategies, as well as the inclusionof transportation budgets• consideration of adolescent sexual and reproductive
health during emergency preparedness emergencies(Women's Refugee Commission et al., 2012)

populations; treat it as a serious and life-threatening
problem; and take actions…regardless of the presence or absence of concrete evidence” (IASC, 2005).
Gender-based violence includes sexual violence,
including rape, sexual abuse, sexual exploitationand forced prostitution; domestic violence; forced
and early marriage; harmful traditional practices
such as female genital mutilation, honour crimes
and widow inheritance; and trafficking (IAWG,
2010). Thus, in humanitarian settings, response
to gender-based violence requires a multi-sectoral
approach.
In August 2015, the Inter-Agency Standing
Committee (IASC), which helps coordinate
humanitarian assistance by the various United
Nations bodies and humanitarian partner organizations, issued updated guidelines on integrating
gender-based violence interventions into humani-

THE STATE OF WORLD POPULATION 201569

tarian action, calling on national and international
actors to protect crisis-affected populations: “failure
to take action against gender-based violence represents a failure by humanitarian actors to meet theirmost basic responsibilities for promoting and protecting the rights of affected populations” (IASC,2015).
Local women are usually the first to respondand the first to find solutions, sometimes simple
ones that can make the difference between life anddeath. When an earthquake rocked Haiti in 2010,
the incidence of rape increased markedly, as theinstitutions that might normally protect themcollapsed, women mobilized within displacement
camps to protect each other and support survivors.
The non-governmental organizations MADRE
and KOFAVIV distributed whistles to womenin displacement camps, which helped reduce theincidence of rape by 80 per cent in one camp. The
installation of lights powered by solar batteries also
contributed to a reduction in gender-based violencein the camps.
Women themselves also took the lead in thePhilippines after Typhoon Haiyan by forming
watch groups and “women-friendly spaces” toprotect themselves from gender-based violence. In
July 2014, when another typhoon was forecast to
strike the country, women dispatched watch groups
to evacuation centres in coordination with female
police officers and local authorities.
Shortly after Haiyan struck, the Philippines
Department of Social Welfare and Development
and UNFPA organized town halls in evacuation
centres in Tacloban to give women and girls aforum for reporting risks to their health andsafety. Many cited a lack of privacy, crowded
living conditions and inadequate lighting as key
threats. Adolescent girls said they were afraid to
use toilets at night. In response to a request for
more protection, the Philippines National Police

70

CHAPTER 3

deployed more female officers and trained them in
responding to gender-based violence. The presenceof female officers not only helped reduce the riskof gender-based violence but also increased thereporting of it.
Many programmes to address gender-based
violence in humanitarian settings have used
innovative measures to ensure an effective
response. Chad, for example, established shelters
for single women (Women’s Refugee Commission,2004) and safe spaces for survivors, who may
access psychosocial support and skills training(UNFPA, 2015c). In Jordan, and many othercountries, safe spaces enable women and girls todisclose sexual violence incidents and access safeand non-stigmatizing response services (UNFPA,
2015a).
The establishment of safe spaces for women andgirls affected by crisis is increasingly recognized as agood practice of emergency response and recovery,
and a key strategy for the protection, leadershipand empowerment of women and girls. Distinct
from shelters, safe spaces are formal or informal
places where women and girls feel physicallyand emotionally safe and can socialize, receive
social support, acquire skills, obtain gender-based
violence-response services and receive information
on issues related to women’s rights, healthand services.
The creation of community task forces andpatrols has proved to be an essential step in theprovision of protection services in humanitariansettings. In Malawi, for example, following devastating floods earlier this year, women reported fearof being assaulted while walking alone to the toilets. The Ministry of Gender, Children, Disability
and Social Welfare and UNFPA helped procuresome 50 tents to serve as safe spaces for women andgirls, and supported officials in establishing task
forces to address gender-based violence.

EVO LVI NG RESP O NSE: FRO M BASIC TO COM PRE HE NSIV E

Girls dance at the Za'atari Camp, Jordan.
Photo © Panos Pictures/Mads Nissen

In many countries, “psychological first aid” hasbeen used to mitigate the effects of gender-based
violence. CARE, for example, provided this service
to nearly 800,000 people affected by conflict anddisasters in 2014. Psychological first aid was piloted
in Haiti, resulting in positive improvements among
participants suffering mental distress (Schafer etal., 2010). In Tonga, front-line service providers
working with the Ministry of Health andnon-governmental organizations were trained inmental health and psychosocial support. In Fiji,
UNFPA led the development of psychosocial
first aid responses by government and nongovernmental organizations.
Programmes to involve men and boys in genderbased violence-prevention are critical and have included, for example, International Rescue Committee’s“Men’s Action Groups” in Liberia and CARE’s youthled school-based campaign, “Be a man,” in the Balkans(Holmes and Bhuvanendra, 2014; Shteir, 2014).
Most attention to gender-based violence has
focused on rape, but the growing spotlight has

expanded also to include early and forced marriage,
domestic violence, female genital mutilation, andtrafficking.
A systematic analysis of efforts to discouragechild marriage identified five core approaches:• Empower girls by building their skills andenhancing their social assets• Mobilize communities to transform detrimentalsocial norms• Improve girls’ access to quality formal education• Enhance the economic situation of girls and theirfamilies• Generate an enabling legal and policy
environment (UNFPA, 2012b).
Agencies have engaged in mass community
education to promote awareness around the detrimental health impacts of child marriage; theseinclude CARE’s Information Volunteer programmein Turkey and Oxfam’s Integrated Action on
Poverty and Early Marriage programme in Yemen(CARE, 2015; Oxfam, 2008; UNFPA, 2012a).

THE STATE OF WORLD POPULATION 2015

71

Most programmes focus on changing the underlying
social norms through community education efforts;
few programmes target law and policy surrounding
early marriage and even fewer serve girls who are
already married (UNFPA, 2012a; Feldman-Jacobs
and Ryniak, 2006a).
The chaos and family separation that occurs
during crises may make women and girls more
vulnerable to trafficking. ECPAT International(End Child Prostitution, Child Pornography andTrafficking of Children for Sexual Purposes) developed a guide specific to emergency situations thatadvises families to establish meeting places andidentification measures with children in the eventof separation (Delaney, 2007).
Adapting to changing demographics of
refugees

Today an estimated six in 10 refugees globally livein cities, not in refugee camps. The percentages
vary according to the context, with more thaneight in 10 refugees from Syria living in urban
areas. Understanding the growing trend of refugee

At a camp in Dohuk, Iraq.
Photo © Ali Arkady/VII Mentor Program

72

CHAPTER 3

urbanization is important to refocus protection
and programming strategies to meet the needsof refugees in diverse locations. In response,
UNFPA and the office of the United Nations HighCommissioner for Refugees developed a sexual andreproductive health toolkit to help aid workers andpartners in planning and programming for urban
refugees. The toolkit comprises tips for decisionmaking, analysis, mapping of health facilities andservices, planning, monitoring and evaluation,
advocacy, coordination, community mobilization,and options for the provision of health care.
Preparedness saves lives

More and more emergency preparedness and disaster risk reduction initiatives today are including
sexual and reproductive health as an essential service
before, during and after a crisis. In 2014, UNFPA
strengthened rapid response capacities in 48 countries to provide the minimal initial service packageof sexual and reproductive health services and supplies in the event of a crisis. The pre-positioning of
sexual and reproductive health supplies in Nepal
before the April 2015 earthquake, for example,
enabled humanitarian actors to distribute them
immediately after the disaster.
In Pakistan, monsoons of the past few years haverepeatedly inundated the Jhang district, destroying local health facilities and uprooting thousandsof people in about 250 villages. After each disaster,
UNFPA and Muslim Aid joined forces to restore
critical reproductive health services. But they also
helped communities and health providers in 2015
to prepare for future disasters by mobilizing womento lead local disaster risk reduction committees.
The committees include health outreach workers, midwives and community members who raiseawareness about the threat of natural disasters andexplain what individuals can do to mitigate
the effects.

EVO LVI NG RESP O NSE: FRO M BASIC TO COM PRE HE NSIV E

Youth-led disaster risk reduction committees werealso established. These groups are in charge of canvassing communities about individuals’ blood types,
in case donors are needed and coordinating withgovernment health departments to come up withplans for reaching pregnant women in the event ofanother disaster.
Women- and youth-led committees together
also identified locations that are less vulnerable
to flooding for the storage of clean delivery kits,
neonatal-care supplies and even boats to transport
women in need of medical assistance.
Access to comprehensive services increasing
but gaps remain

Vast improvements have been made in sexual andreproductive health response in humanitariansettings, from its virtual absence in 1994 to morecomprehensive services and coverage today. The
current response in Jordan’s Za’atari is a case inpoint: services available to Syrian refugees include
family planning; antenatal, delivery and emergency
obstetric and newborn care; gender-based violence
response; prevention and treatment of sexuallytransmitted infections, including HIV; and attention
to adolescents.
The success of sexual and reproductive healthresponse to date is a result of collaboration among
humanitarian and development organizations, ministries of health and communities. More women andgirls who are refugees or displaced have more accessto services today than any time in the past.
But it is also clear that few such populations
have access to the full range of services to which
they have a right. The growing populations inneed signal a need to increase both depth andscope of services to ensure these populations can
exercise their right to reproductive health, evenin crises. Strategic action to prioritize support
for reproductive health is fundamental to humandignity. Such action must be more context
sensitive, adapted to changing circumstances andacross the life course. The health interventions
and overall response to crises in humanitarian andfragile settings must be better anticipated, planned,
and resourced.
As the world embarks on a new sustainable development agenda for the next 15 years, it does so ina period of emergent and protracted crises with the
majority of those affected being women, children
and adolescents, lacking access to lifesaving services,
facing grave exclusion, exploitation and perishing inhigher numbers.
In countries emerging from conflict, continued
lack of access to health care, psychological andsocial support, and justice, coupled with ongoing
gender-based violence, impede recovery anddevelopment. Often countries’ longer-term
development planning processes fail to include
preparedness, response and recovery. Meeting manyof the United Nations Sustainable Development
Goals will require tailored attention to sustainable,
inclusive development for women and adolescent
girls in humanitarian crises.
To help address the challenges ahead, experts from
United Nations agencies, governments, civil society,academia and foundations converged in Abu Dhabi
in February 2015 and called for a new global strategy to protect the health of every woman and every
child in every setting, including disasters and conflicts. The group’s “Abu Dhabi Declaration” statedthat building resilience and accelerating recovery ofcommunities affected by crisis depends on meeting
reproductive, maternal, newborn, child and adolescent health needs and human rights in humanitariancontexts, reducing preventable maternal and childdeaths as well as preventing and responding togender-based violence, while addressing fundamental
needs for nutrition, water, sanitation and hygiene(UNFPA, 2015).

THE STATE OF WORLD POPULATION 201573

CHAPTER 4

Resilience and bridging
the humanitariandevelopment divide
The profound human impact of disasters and conflicts on people,
communities, institutions and nations highlights the criticalimportance of building resilience so all may better withstand theeffects of crises and recover from them more quickly. Building
resilience can also help mitigate the potential negative effects on
the sexual and reproductive health of women and adolescent girls.

The collateral damageof Liberia’s Ebola crisis:
women and girls of
reproductive age

Dr. Jallah at hospital in Paynesville, Liberia.
Photo © Abbas Dulleh/AP Images for UNFPA74

CHAPTER 4

Comfort Fayiah is one of the lucky ones.
As the late-September 2014 due datefor her twin babies approached, theEbola crisis in Comfort’s native Liberia
was reaching a fever pitch. Since thefirst Ebola patient presented in Monrovia
in June 2014, the number of new cases
was growing every day: By August,it was topping 400 per week. The
Ministry of Health and Social Welfare
was forced to suspend virtually all
non-Ebola-related activities to focus on
managing the crisis. The unintended
result was that women of reproductive
age in Liberia experienced some of theworst fallout from Ebola, regardless of
their own infection status.
“The national health supply chain
abruptly ceased all its routine

operations, preventing health facilities
from accessing essential medical
supplies and commodities,” says Woseh
Gobeh, national programme officer for
reproductive health for UNFPA, theUnited Nations Population Fund. “Evenin counties considered less affected by
the outbreak, health facilities sufferedmassive stock out of drugs and medical
supplies.”
It was not just a supply issue: Liberia’s
already-scarce medical personnel (atthe start of the crisis, there were only
45 physicians practicing in the public
sector in the entire country, according
to a Ministry of Health estimate) werebeing crippled by Ebola. By May 2015,an astounding 8.07 per cent of Liberia’s
doctors, nurses and midwives would die
from Ebola, compared to 0.11 per cent of

RESI LI ENCE AND B RI DG I NG T HE HUM ANITA RIA N-D E V E LOPM E NT D IV ID E

Comfort Fayiyah and children.
Photo © Abbas Dulleh/AP Images for UNFPA

the general population. Fear of becoming infected—particularly because it isdifficult to determine whether a patient
has Ebola without a lab test—led many
health workers to turn people away.
“Health-care workers started getting
afraid and started refusing patients,”
says Dr. Wilhelmina Jallah, the chief
executive officer and medical directorof Hope for Women International, a
medical non-governmental organization, and a practicing physician basedin Paynesville, Liberia. “No healthcare
worker wanted to touch a pregnant
woman even with personal protective
gear.”
For pregnant women like Comfort,
now 29, that meant prenatal care was
scarce—while one common indicator of

positive maternal outcomes, completion of four antenatal care visits, hadbeen on the rise in Liberia, it declined
from 65 per cent in 2013 to 40 per centin August 2014. And delivering in an
appropriately appointed medical facility
became impossible. When Comfort’stime for delivery came, she went fromplace to place but was unable to find a
hospital or clinic that would admit her.
“They refused me; they said they could
not help me,” Comfort says. “I cannot
blame the health workers who refused toassist me, because everyone was afraidof the disease.”
And while expecting mothers without
Ebola (like Comfort) had trouble finding care, those who were infected had
almost no chance of a good outcome.
“It is more dangerous to treat pregnant

women with Ebola because the effectof Ebola in pregnancy is not understoodand there are no set guidelines to follow.
Pregnant women have blood and body
fluids that could expose health workers
to the virus,” Jallah says.
With no other choice, Comfort took
shelter from the pouring rain, lying downin the dirt to labour under a corrugated
tin roof. “I suffered a lot and was afraid I
was going to die. The only thing I hoped
for was for a miracle to happen,” shesays. One did: Comfort gave birth to two
healthy baby girls with the assistance ofa nurse aid who happened to pass by at
the right time.
Other women have not been so lucky.
Across the region, doctors reported
an increase in pregnant women dying

THE STATE OF WORLD POPULATION 201575

A

conflict or disaster can erase in a momenta generation of economic and social gains.
It can also permanently undermine anindividual’s prospects for a better life, shattering
opportunities and limiting choices.
And it can exacerbate existing inequalities insociety, resulting in even greater hardship for thepoor and marginalized, exacting a disproportionate
toll on women and young people, particularly
under the age of 20, who constitute about half
the population in many conflict and post-conflictsettings (OECD, 2015).
The profound human impact of disasters andconflicts on people, communities, institutions
and nations highlights the critical importance ofbuilding resilience so all may better withstandthe effects of crises and recover from them more
quickly. Building resilience can also help mitigate
the potential negative effects on the sexualand reproductive health of women and adolescent girls.

Who lives, dies and recovers during or after aconflict or disaster depends in part on the policies,
programmes and social, economic and politicalcontexts prior to the crisis.
Development that is inclusive, equitable andthat respects and protects everyone’s human rights,
including reproductive rights and the right tohealth, including sexual and reproductive health, iscentral to resilience. The principles of inclusiveness,
equity and rights are also the foundation for the
new generation of United Nations Sustainable
Development Goals, which will guide theinternational community in navigating the economic
and social challenges of the coming 15 years.
Guaranteeing the sexual and reproductive healthand rights of women and adolescent girls will go along way towards achieving the goal of inclusive,
equitable development, and can lead to more
resilient societies, more capable of withstanding
crises and rebuilding in ways that lead to evengreater resilience.

from preventable causes, including
haemorrhage, ruptured uterus andhypertensive disease. And because
healthcare workers cannot be instantly
replaced (consider the many years
it takes to educate and train a surgeon), the impact will only expand:According to a recent World Bank
report, the loss of health workers in
Guinea, Liberia and Sierra Leone may
result in an additional 4,022 deaths ofwomen each year from complicationsof pregnancy and childbirth. Maternalmortality could increase by 38 percent in Guinea, 74 per cent in Sierra
Leone, and 111 per cent in Liberia.
Woseh Gobeh.
Photo © Abbas Dulleh/AP Images for UNFPA76

CHAPTER 4

That’s not to mention the impact on
women’s ability to determine whether,when or how often to become pregnant. According to UNFPA estimates,

nearly half the health facilities in
Liberia were completely out of stockof injectable contraceptives during theheight of the Ebola crisis. Little morethan a third of health facilities were
providing family planning services,
according to the Ministry of Health.
Noticeable pre-crisis gains in contraceptive use have all but been wiped
out.
“The number of women and girls
who continue to die from preventable health conditions is unacceptably
high,” Gobeh says. “It’s a humanrights issue to deny a woman or girlaccess to quality reproductive healthservices.”
Efforts to improve the situation have
had some impact, however. UNFPARESI LI ENCE AND B RI DG I NG T HE HUM ANITA RIA N-D E V E LOPM E NT D IV ID E

But the new vision for sustainable development
for the coming 15 years may only be realized if
all of the world’s people are engaged and have a
stake in its success. This means that women andadolescent girls must play a central role in leading
and contributing to efforts to improve health andsustainable development at all levels—household,community, institutional and government—and not
be left behind or relegated to a secondary role.
The road to resilience, from Hyogo to
Sendai

Resilience, from the Latin verb, resilire, to reboundor recoil, has been used in diverse contexts, ranging
from the field of ecology to explain how an ecosystem responds to changes, to the field of psychology
to describe how individuals respond to trauma(McAslan, 2010; Manyena, 2014; Matyas andPelling, 2015). A common feature of these terms,
regardless of the discipline, is the focus on coping
with, and responding to, shocks.

and others are working to add workers
to the healthcare ranks by, for example,
encouraging retired midwives toreturn to the workforce. “With thiseffort, health facility-based deliveries
have increased from an average ofsix to 10 monthly to between 30 and
40 monthly in only two months,”
Gobeh says. UNFPA also launched anationwide condom promotion anddistribution campaign to help educate
young people about the importanceof preventing sexually transmitted
infections including Ebola. And thedwindling numbers of new Ebola cases

Resilience today occupies a central space in the conceptualization of response to natural disasters, conflict,emergencies and other hazards (Twigg, 2009, Matyas
and Pelling, 2015; DFID, 2011) and informs thedesign and delivery of sexual and reproductive healthservices and the health outcomes for women and girls.
Two global plans to make the world safe fromnatural disasters, the Hyogo Framework of Action
for 2005 to 2015 and the Sendai Framework for2015 to 2030, cite priorities for building resilience.
A key strategic goal in the Hyogo Framework
was the development and strengthening ofinstitutions, mechanisms and capacities at all levels,in particular at the community level, which cansystematically contribute to building resilience tohazards (UNISDR, 2005). The Framework statesthat a gender perspective should be integrated into
all disaster risk-management policies, plans anddecision-making processes, including those related
to risk assessment, early warning, information
management, and education and training.

in the region can only spell relief for
women of reproductive age.
“I give credit to Liberia and the international community for winning against
Ebola in a relatively short period oftime,” Gobeh says. But now, “the mostimportant responsibility and appeal to
the government of Liberia, the donor
community and all partners is that theneed to rebuild the health care delivery
system is now greater than ever.”Comfort Fayiah and family at home.
Photo © Abbas Dulleh/AP Images for UNFPATHE STATE OF WORLD POPULATION 201577

Birth attendant Christine Yakoundou examines client at Centre de Santé, Central African Republic.
Photo © Panos Pictures/Jenny Matthews

Building on the Hyogo Framework, the Sendai
Declaration broadened the definition of resilience
to explicitly include the importance of resisting,absorbing and recovering from hazards and toecho the importance of resilience at multiple levels: community, society and individual. Resilience
is defined as:“The ability of a system, community or society
exposed to hazards to resist, absorb, accommodate toand recover from the effects of a hazard in a timely
and efficient manner, including through the preservation and restoration of its essential basic structuresand functions” (UNISDR, 2015a).
The Sendai Declaration expands the Hyogo
Framework’s gender perspective by including
women in planning and designing approaches todisaster preparedness. It also stresses the need forstrengthening the design and implementation ofinclusive policies and social safety net mechanisms
like sexual and reproductive health.
Resilience is both a process and an end state,
which enable vulnerable communities and households to prevent, prepare for or respond to stresses

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and shocks without compromising their long-term
prospects.
Pre-empting poverty and inequality

The socioeconomic and structural factors that
determine the capacity of communities to beresilient are critical preconditions to the effectof a disaster or conflict and require unwavering
attention by governments. While resilience may beseen as an end state, it is also an ongoing process,requiring continuous efforts to address the socioeconomic and structural factors—poverty, harmful
gender norms and even food insecurity—that can
influence whether communities may withstand or
recover from a crisis or shock. Resilience-building
as a process must be prioritized at every level andguided by local adaptation strategies, culture, heritage and knowledge. This requires the involvementof actors across the humanitarian and development
continuum, but the process must be owned by thecommunity (Twigg, 2009).
Humanitarian emergencies, such as natural
disasters and conflicts, can lead to a broadening anddeepening of poverty and inequality (UNISDR,2015). Resilience can mitigate those effects.

RESI LI ENCE AND B RI DG I NG T HE HUM ANITA RIA N-D E V E LOPM E NT D IV ID E

Building resilience involves addressing
underlying causes of vulnerability, such as poverty
and inequity, and initiating pre-emptive measures
to build positive adaptation before a crisis
strikes (Hillier and Castillo, 2013; IFRC, 2012).
Investments in reproductive, maternal, newborn,child and adolescent health, and reproductive
rights will protect those most affected by disasters.

Investing in youth to boost shock-absorbing
capacities of communities and nations

Sexual and reproductive health and rights are acornerstone of young people’s transition to adulthood. When governments take steps to ensure thetransition is safe and healthy, they are also taking
steps to boost the “shock-absorbing” capacities
of communities and nations, thereby creating

RESILIENCE AND SEXUAL AND REPRODUCTIVE HEALTH
FROM MILLENNIUM DEVELOPMENT GOALS TO THE SUSTAINABLE DEVELOPMENT GOALS
Goals which refer to resilience

Goals that address SRH
MDGs (2000–2015)

Goal 5:NoneImprove maternal health
Target 5A: Reduce maternal death
Target 5B: Achieve universal access to
reproductive health

SDGs (2016–2030)
1.5 By 2030, build the resilience of the poor and those invulnerable situations and reduce their exposure andvulnerability to climate-related extreme events and othereconomic, social and environmental shocks and disasters.
11b By 2020, substantially increase the number of cities
and human settlements adopting and implementing
integrated policies and plans towards inclusion, resource
efficiency, mitigation and adaptation to climate change,
resilience to disasters, develop and implement, in linewith the Sendai Framework for Disaster Risk Reduction
2015-2030, holistic disaster risk management at
all levels.
13.1 Strengthen resilience and adaptive capacity
to climate-related hazards and natural disasters
in all countries.

3.7 By 2030, ensure universal access to sexual andreproductive health-care services, including forfamily planning, information and education, andthe integration of reproductive health into national
strategies and programmes.
5.2 Eliminate all forms of violence against all
women and girls in the public and private spheres,
including tracking and sexual and other typesof exploitation.
5.6 Ensure universal access to sexual and reproductive
health and reproductive rights as agreed in accordancewith the Programme of Action of the International
Conference on Population and Development andthe Beijing Platform for Action and the outcome
documents of their review conferences.

14.2 By 2020, sustainably manage and protect marine andcoastal ecosystems to avoid significant adverse impacts,
including by strengthening their resilience, and takeaction for their restoration in order to achieve healthy
and productive oceans.

THE STATE OF WORLD POPULATION 201579

environments where individuals can also become
resilient.
Building resilience can also help rectify and transcend longstanding inequities (UNSDR, 2015a).
For example, building health systems’ resilience incountries can help expand access to quality sexualand reproductive health services for those excluded
from them before the onset of a disaster.
To succeed, building resilience must be gendertransformative, challenging unequal power structures (Winderl, 2014). It must include women andgirls, not only as the recipients of health and social
protection services, but also as advocates, as healthworkers, as active members, representatives andleaders of communities.

Resilience linked to robust developmentthat takes individuals’ vulnerabilities into
account

The impact of natural disasters and conflict on
individuals and communities depends in large parton the extent and nature of poverty and social
deprivation before a crisis occurs (United Nations
International Strategy for Disaster Reduction,2015). Building resilience and protecting communities from the negative effects of a disaster must
therefore be connected to a robust development
agenda that takes into account individual, social,economic and cultural vulnerabilities.
The United Nations Sustainable Development
Goals for 2015 to 2030, and other efforts to reducesocial deprivation and poverty, within a robustinternational human rights framework, provide apathway for states and their development partners
to engage in building resilience (United Nations,
2015d). This pathway was also highlighted in
a General Assembly resolution on the Sendai
Framework for Disaster Risk Reduction for2015 to 2030:“States also reiterated their commitment to address
disaster risk reduction and the building of resilience
to disasters with a renewed sense of urgency within
the context of sustainable development and poverty
eradication, and to integrate, as appropriate,both disaster risk reduction and the building ofresilience into policies, plans, programmes andbudgets at all levels and to consider both withinrelevant frameworks.”

Nyantit, 10, South Sudan: "I want to look nice on thephoto, so I went home to change my shirt. It is the only
nice shirt I have, because I had to leave everything behindwhen we had to flee."Photo © Panos Pictures/Chris de Bode80

CHAPTER 4

Connecting efforts to build resilience to sustainable development ensures that resilience is notdefined through a separate set of standards, butrather is integrated into the process of countries’
overall achievement of a range of development
goals. Achieving health goals, for example, depends

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on improving the quality and scope of sexual andreproductive health and on ensuring universal
access, including in emergencies, crises and refugeesettings. Given that high maternal and child mortality are concentrated in countries with conflictand natural disasters, establishing robust connections between resilience-enhancement programmes
and development targets will be essential to bothachieving the Sustainable Development Goals andmitigating the effects of disasters.
Investing in disaster risk reduction to
improve maternal, child and adolescenthealthDisaster risk reduction is a critical element in resilience. While humanitarian response is a short-term
intervention, disaster risk reduction is a long-term
undertaking that addresses the root causes ofvulnerability during a crisis (Plan International,2013). Though some crises, such as earthquakes
and tsunamis, cannot be prevented, their impact
can be mitigated by pre-crisis investment in thebuilding of sexual and reproductive health systems
that are resilient and focused on the needs of themost vulnerable segments of the community.
To improve preparedness and reduce disaster
risk, the Sendai Framework for Disaster Risk
Reduction calls for the prevention of new disasters
and the reduction of existing disaster risk throughthe implementation of integrated and inclusive
economic, structural, legal, social, health, cultural,
educational, environmental, technological, political and institutional measures. This integrative
approach can prevent and reduce hazard exposureand vulnerability to disaster, increase preparedness
for response and recovery, and thus strengthen
resilience (UNISDR, 2015a).
Reducing risk and building resilience begins withknowledge of the changing hazards and physical,
social, economic and environmental vulnerabili-ties to disasters that most societies face, followedby action taken on the basis of that knowledge,
according to the Hyogo Framework for Action.
The scale of disasters has expanded due toincreased rates of urbanization, deforestation,and environmental degradation and tointensifying climate variables such as higher
temperatures, extreme precipitation, andmore violent wind and water storms (Leaning
and Guha-Sapir, 2013). Thus, efforts tostrengthen disaster resilience require a detailed
understanding of the socioeconomic and politicalfactors that cause people to be at risk, and asound understanding of how mortality andmorbidity differ across population groups andover time (Leaning and Guha-Sapir, 2013).
This understanding can seed systems that tackle
and decrease the underlying drivers of risk andvulnerability, taking into account differentials ofgender, class, caste, race, age, ethnicity, disability
and income that generate the geography of risk
inequality and of social and political exclusion(UNISDR, 2015).
Disaster risk reduction must also recognize,
include and respond to gendered risks and havegender equality as a key goal (Bradshaw, 2015).
Coping capacities vary within andacross countries

Analyses of risk should take into accountvariations across and within countries. The
Inter-Agency Standing Committee’s Index
for Risk Management (INFORM) shows the
coping capacity of countries based on a measureof: disaster risk reduction efforts, governance,
communication, physical infrastructure andaccess to the health system.
In West and Central Africa, women have a one
in 32 chance of dying a maternal death. This isnearly five times the risk facing women in SouthTHE STATE OF WORLD POPULATION 201581

Asia and almost 150 times the risk women in induscivil and vital registration systems would enable
trialized countries face (Save the Children, 2014). If
more nuanced understanding of risk.
data within countries are meaningfully disaggregatDeveloping robust early warning systems that are
ed, further evidence would emerge on how different
responsive to gender, age, and disability is a crucial
communities begin from different places on theway to ensure equitable access to information before
risk reduction spectrum; the effect of a disaster on aa crisis occurs (Development Initiatives, 2015).
woman in the highest income quintile living in an
Building resilience in conflict-related
urban environment is different from the effect of a
emergencies
disaster on a women in the lowest income quintile
While much early-warning innovation has focused onliving minutes away. Efforts to build resilience are
weather-related events, early warning and action forurgent in these unequal contexts and disaggregatedconflict remain more difficult, for both technical anddata should serve to influence national policies andpolitical reasons. Building resilience
resource allocation by helping toin humanitarian emergencies arisingidentify risks, build resilience andout of conflict requires a different,
prepare better for crises.
In
West
and
CentralAfrica,multifaceted set of prevention
Inequality of access to services
women have a one in 32
strategies, including implementationand safety nets affects the resilience
chanceofdyingamaternalof robust anti-discrimination andof different disaster-impacted
death. This is nearly five
violence-reduction measures, ingroups and individuals, especiallytimes the risk facing
addition to attention to structural
women and girls. And, inequality
women in South Asia andinequalities affecting sexual andof access to land, income and asset
almost 150 times the risk
reproductive health (Harris et al.,bases affects how households andwomen in industrialized2013). Increasingly, humanitariancommunities can manage their own
countries face.
emergencies are both disaster anddisaster risks. Inequality of protection
conflict related, with one set of factors interacting
through established rights, laws and regulations,with the other.
and inequality in voice and accountability will
impact any disaster risk reduction programme, andEbola
the capacity of countries to address the underlying
The Ebola crisis affected an estimateddrivers of disaster risk (UNISDR, 2015).
18.7 million people, including 9.8 million
A commitment to those who are least likely toadolescents and children (UNICEF, 2015). The
receive care or access services is also echoed in theepidemic shone light on how health systems
United Nations Secretary-General’s Every Woman
with weak primary care are not resilient to shock.
Every Child Global Strategy. Disaggregated data
In these contexts, resilience would have entailed
allow resilience-building to move away from relybuilding capacities, strengthening subnationaling solely on aggregate measures of health andhealth systems, improving access to and exchange
well-being that do not differentiate the impact ofof information, developing systems for engaging
conflicts and disasters on youth, women, migrants
actors across all levels of government, in additionand low-income or marginalized populations.
to the health sector, and building trust (Kieny and
Mainstreaming disaggregated data collection into
Dovlo, 2015).
routine data collection systems, and strengthening

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RESI LI ENCE AND B RI DG I NG T HE HUM ANITA RIA N-D E V E LOPM E NT D IV ID E

2015 LACK OF COPING CAPACITY
This dimension measures the lack of resources available that can help people cope withhazardous events. It is made up of two categories—institutions and infrastructure. This map showsdetails for the 12 countries with the highest values in the lack of coping capacity dimension.

Guinea

Niger

Chad

Afghanistan

3-year trend:
Institutional: 7.62
Infrastructure: 8.93

3-year trend:
Institutional: 6.11
Infrastructure: 9.40

3-year trend:
Institutional: 8.05
Infrastructure: 9.58

3-year trend:
Institutional: 7.89
Infrastructure: 8.46

Lack of coping
capacity: 8.35

Lack of coping
capacity: 8.95

Lack of coping
capacity: 8.18

Lack of coping
capacity: 8.19

Guinea-Bissau
Lack of coping
capacity: 8.66

3-year trend:
Institutional: 8.95
Infrastructure: 8.33

Haiti

Lack of coping
capacity: 8.17

3-year trend:
Institutional: 7.37
Infrastructure: 8.80

Central African Republic

Papua New Guinea

Lack of coping
capacity: 8.56

Lack of coping
capacity: 8.13

3-year trend:
Institutional: 8.03
Infrastructure: 9.00

3-year trend:
Institutional: 6.81
Infrastructure: 9.04

Democratic Republicof Congo
Lack of coping
capacity: 8.33

South Sudan

SomaliaYemen

3-year trend:
Institutional: 8.29
Infrastructure: 9.41

3-year trend:
Institutional: 9.31
Infrastructure: 9.76

3-year trend:
Institutional: 8.49
Infrastructure: 7.87

Lack of coping
capacity: 8.92

3-year trend:
Institutional: 7.99
Infrastructure: 8.64

Lack of coping
capacity: 9.55

Lack of coping
capacity: 8.19

INFORM COPING CAPACITY INDEX
4.92

3.32

0

6.73

10
KEY

Low

MediumHigh

Very highIncreasing risk

StableDecreasing risk

Not included(INFORM, 2015)

THE STATE OF WORLD POPULATION 201583

A resilient health system can respond to thechanging epidemiological profile of a population,
and adapt to adverse conditions. Rather thanoperating in isolation, a resilient health system hasconnections to regional and global partners thatallow Governments to trigger rapid deploymentof a wider set of resources (Kruk et al., 2015).
Working across sectors to situate humanitarianplans, priorities and processes within sustainable
development frameworks is an essential element ofresilient health systems (Kieny and Dovlo, 2015).
Integrating sexual and reproductive healthinto primary health critical to resilience

Sexual and reproductive health services within
national health policies are an essential prerequisite for building resilience in the face of
emergencies and ensuring reliable and secureaccess to lifesaving treatment, reproductive
health services and supplies necessary to protect
women and adolescent girls from preventable
death, including during complicated deliveries orunintended pregnancies. The quality of maternal
health services and maternal mortality ratios areindicators of the overall quality, functioning andinclusivity of the health system.
Sexual and reproductive health should be integrated into health risk assessment and early warning
systems for communities and vulnerable groups.
The World Health Organization reiterates theimportance of ensuring strong primary health carefacilities so they can sustain sexual and reproductive
health services, including emergency obstetric andnewborn care. Further, existing sexual and reproductive health services should be strengthened tomitigate the impact of, adaptation to, and recovery
from emergencies. The World Health Organization
also recommends that disaster preparedness planning take into account the needs of vulnerable
populations—women, adolescents, newborns,

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CHAPTER 4

people with disabilities and displaced populations(WHO, 2012).
Strengthening comprehensive reproductive healthcare and integrating it into primary care before acrisis can facilitate or help ensure the provision of aminimum initial service package, or MISP, when acrisis occurs. A set of political and legal structuresthat allow women and youth to benefit from theright to reproductive health make it harder forthese rights to be infringed during crisis.
As the United Nations General Assembly
affirmed in 2015, “meeting sexual and reproductive
health needs is critical for the resilience and more
rapid recovery of affected communities overall”(United Nations, 2015c).
Social protection and disaster risk reduction

The Sendai Framework for Disaster Risk
Reduction calls for social protection policies andprogrammes that meet the needs of the most vulnerable. Such interventions could, for example,
aim to prevent or respond to chronic malnutrition, provide access to identification documents,
ensure women have access to inheritance, or
prevent child marriage. An inclusive, broad-basedsocial protection system is needed to protect thepoorest households and children from extreme
deprivation and to provide opportunities for thepromotion of livelihoods and productive activities
for both women and men.
Given that most of the countries with the highest rates of child marriage are considered fragile
States or at high risk of natural disasters, existing
efforts to protect girls from child marriage andgender-based violence—enabling girls to stay inschool, providing targeted financial support tofamilies, providing comprehensive sexuality education and other measures—must be strengthened
to ensure these efforts continue during a crisis or
shock (Plan International, 2013).

RESI LI ENCE AND B RI DG I NG T HE HUM ANITA RIA N-D E V E LOPM E NT D IV ID E

Strengthening anti-trafficking measures is also an
important way to build the resilience of communities and countries facing exploitative and predatory
behaviour, often particularly targeted at children
and adolescent girls in the aftermath of a disaster.
The International Organization for Migration
has called for the adoption and implementationof national counter-trafficking laws. Countertrafficking measures should be integrated into
governments’ emergency preparedness and contingency planning (International Organization for
Migration, 2015) and will also contribute to fulfilling the commitment the Sustainable Development
Goals made to abolishing human trafficking.
Measures to address gender-based violence
are needed before, during and after crises

Post-conflict, adolescents, especially girls, are atheightened risk of abuse, exploitation and exposure torisky behaviour, situations that increase their vulnerability to early sexual initiation, unwanted pregnancy,and sexually transmitted infections, including HIV.
Young adolescents between ages 10 and 14, pregnant adolescent girls and marginalized adolescentsare at higher risk and require targeted interventions(UNFPA and Save the Children, 2009). Girls who
have survived gender-based violence often experience lifelong psychological and physical problems,and social stigma (DFID, 2013).
Inter-Agency Standing Committee guidelinesemphasize the need to integrate gender-based violence interventions in humanitarian assistance as acore action for building resilience (IASC, 2015).
Building resilience must both prevent andrespond to gender-based violence and work at
the community, institutional, and national levelto implement laws, policies and programmes thatprevent and mitigate gender-based violence, allow
survivors of gender-based violence and those at riskof it to access care and support.

Failure to address gender-based violence both
before and at the start of a crisis provides a poor
foundation for women’s resilience and health in themedium and longer term and is a barrier to reconstructing the lives and livelihoods of individuals,
families and communities (International Rescue
Committee, 2012).
Educating girls reduces vulnerability

Many studies have shown that educating girls is
one of the most effective investments a country
can make to lift families out of poverty and build
a better future. When educated girls grow up andbecome mothers, they tend to have healthier andbetter-educated children. Recent evidence suggests there is another powerful reason to educate
girls: empowering women through improved education reduces vulnerability to death and injury
from weather-related disasters (Save the Children,2014). Schools can impart an important sense of
normality and provide lifesaving information andservices. Increasing access to school for all may
also reduce feelings of injustice that have fuelled
conflicts. Importantly, ensuring future generations are well educated is vital for overcoming
conflict, aiding recovery, and ensuring future
development and security (Global Coalition toProtect Education from Attack, 2015).
Education about sexual development, sexuality andreproductive health and rights for adolescent boys
and girls is a critical element of comprehensive educational access. Disaster-specific education is also essential
to promote resilience: children who are uninformed
regarding hazards, warnings, evacuation and otherprotective behaviours are at greater risk of death andinjury when disaster strikes (Wisner, 2006). Broader
legal and policy measures, for example, to prevent theuse of schools by armed groups during conflict will also
contribute to building resilience (Global Coalition
to Protect Education from Attack, 2015).

THE STATE OF WORLD POPULATION 201585

Engaging women, young people, ethnic
minorities builds a solid foundation forresilience

Engaging a diversity of communities and actors inbuilding resilience creates a more solid foundation
for positive outcomes. This engagement should
include ethnic minorities, women, adolescentsand youth, people with disabilities and theelderly. While most disaster risk reduction laws
provide a mandate for the involvement of womenand vulnerable groups, this often consists ofgeneral aspirational statements without specificmechanisms for implementation (UNISDR,2015).
In many instances, young people are ignored indisaster risk reduction and resilience-building. Yet,
it is the same young people who are excluded fromthese pre-crisis processes who may end up playing
vital roles post-crisis, by assisting with evacuationand healing after a disaster (Peek, 2008), clearing
rubble, sharing news and information, distributing
food, and teaching or caring for younger children.
The meaningful participation of young people isvital to the localization of humanitarian action
to ensure improved effectiveness and resilience.
Young people can be important allies in the design
and implementation of emergency preparedness
and response (UNFPA and Women’s RefugeeCommission, 2015; Osotimehin, 2015).
When young people, including adolescents, areempowered and supported, they can contribute to
reducing intergenerational poverty and to building
a demographic dividend of inclusive and durable
economic growth. In other words, many countries,
including a number of those currently in crisis,
may gain from the transition of large numbersof young people into working age. Seizing andmaximizing a demographic dividend could spark
precisely the fast-track development that post-crisis
countries need to recover and move forward.

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Resilience in the humanitariandevelopment continuum

Building resilience requires a sustained partnershipof humanitarian and development actors. Given
that 43 per cent of the world’s poor now live infragile States (OECD, 2015) and that countries
exposed to the risk of disasters and shocks receive
lower levels of official development assistance percapita (OECD, 2015), a bridge between these
actors is more critical than ever. Such a bridge isalso necessary to ensure that investments towards
the new United Nations Sustainable Development
Goals do not neglect disaster risk reduction, emergency response and the transition from recovery tosustainable development.
A number of countries have carried out institutional reforms to support the integration ofdisaster risk financing into a broader, strategic
approach to disaster risk management (UNISDR,2015). Ministries of finance are increasingly
taking the lead in the development of nationaland regional insurance and credit schemes, andgovernments are developing new institutionalarrangements such as national risk boards that
include insurance supervisors, disaster management agencies and the relevant line ministries(UNISDR, 2015).
Sexual and reproductive health as apathway to poverty reduction and risk
mitigation

An increasing share of the sexual and reproductive
health services supported by the international
community is now being provided inhumanitarian settings. Achieving the objectivesof the Programme of Action of the International
Conference on Population and Development
increasingly means delivering services andinformation and protecting rights in the midstof conflict, large-scale population movements

RESI LI ENCE AND B RI DG I NG T HE HUM ANITA RIA N-D E V E LOPM E NT D IV ID E

AVERAGE POPULATION BELOW AGE 20
AS A PERCENTAGE OF TOTAL POPULATIONIN FRAGILE STATES COMPARED WITH
OTHER DEVELOPING COUNTRIES, 2015
FragilePercentage of total population that is 19 or younger

and epidemics or in the aftermath of a natural
disaster or climate-change-related catastrophe.
Protecting the sexual and reproductive healthand reproductive rights of women and adolescent
girls in crisis settings is essential and a matter ofhuman rights, but becomes complicated, costly andunsustainable in the absence of preparedness andresilience building.
Therefore, steps must be taken to address theunderlying causes of crises, especially underdevelopment and inequity, and to promote the resilience ofcountries, environments, communities and individuals to help mitigate the impact of crisis. Resilience
depends in part on development and how equitably
economic and social gains are realized in a society.
Where resilience is low, vulnerability to conflict anddisasters is high. Preparedness is another criticalvariable in the resilience equation.
Sexual and reproductive health is a humanright and is also key to achieving sustainable
development. The more a country is able to reducepoverty and social deprivation, the more resilient it
becomes, and the more likely it is to withstand or
recover from a crisis with lower social, economic,
and human loss. Emergency response is always more
expensive than preparedness and risk mitigation.
A framework for disaster-risk-reduction wasendorsed by the international community in
Sendai, Japan, earlier this year. The framework
cites four priorities: understanding disaster
risk; strengthening disaster-risk governance tomanage disaster risk; investing in disaster-riskreduction for resilience; and enhancing disaster
preparedness for effective response and “buildingback better” in recovery, rehabilitation andreconstruction. The framework relates directly
to the UNFPA mandate. Paragraph 30(j) of the
Sendai Framework States that at the national andlocal levels, there is a need to strengthen the design
and implementation of inclusive policies andOther developing

50%

40%

30%

20%

10%

0%

2030

2015

Year
(OECD, 2015)social safety-net mechanisms, including throughcommunity involvement, integrated with livelihood
enhancement programmes, and access to basic
health care services, including maternal, newborn
and child health, sexual and reproductive health,food security and nutrition, housing and education,
towards the eradication of poverty, to find durable
solutions in the post-disaster phase and to empower
and assist people disproportionately affected bydisasters (UNISDR, 2015a).
Investing in the sexual and reproductive health ofwomen and girls—before, during or after a crisis—contributes to development and will be pivotal tothe achievement of new Sustainable Development
Goals. It will also help reduce vulnerabilities tosome crises.
Women can play a central role in crisis recovery
and rehabilitation, but their participation depends
in part on whether they are in good health and

THE STATE OF WORLD POPULATION 201587Resilience is also central to what UNFPA
describes as the “humanitarian responsibility toprotect the rights and address the specific needs ofyoung people, including adolescents, and to engage
them and their unique capacities in humanitarian
preparedness, response and recovery” (UNFPA and
Women’s Refugee Commission, 2015).
Laying the foundations for long-term gains
in gender equality

Susila Bora, 19, Saurpani-4 village, which was destroyed when a
7.8 magnitude earthquake struck Nepal in April 2015.
Photo © Panos Pictures/Vlad Sokhin

have the power to decide whether or when to
become pregnant.
More lives can be saved if humanitarian,development and sexual and reproductive healthcommunities come together to support each otherand work in more complementary ways. Activities
to manage risks and build resilience must be simultaneous, instead of following a linear approach oftransition from relief to development. Cooperation
among actors with various areas of expertise canhelp bridge the gap between humanitarian anddevelopment objectives.
Resilience-building is a cumulative process thatworks across levels—global, regional, national,
community and individual—over time. It is also
an outcome that pre-emptively addresses theinequitable distribution of risk in emergencies bydeveloping institutional capacity and systemic
functions beyond their original baselines.

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A 2015 study by UN Women shows that genderequality programming in humanitarian settings canmultiply the impact of interventions and has “thepotential to embed the foundations of longer term
gender equality gains” (UN Women, 2015a).
Gender-equality programming recognizes that theneeds and vulnerabilities of women, men, girls andboys in any given crisis-affected population will be
specific and different.
According to the study, gender-equality programming in crisis-affected areas of Kenya, Nepal and
the Philippines, for example, had a positive impact
on improving access to and use of services, increasing the effectiveness of humanitarian outcomes andreducing gender inequalities.
This type of programming also had a “strong
impact” on health outcomes, especially for womenand girls, but extending to all household members.
In Nepal, for example, gender-equality provisionof health-related infrastructure, awareness-raising
campaigns about health and hygiene and encouragement to access health facilities “greatly improved”
maternal and child health and decreased death during pregnancy or childbirth. In addition, this typeof programming was found to reduce some formsof gender-based violence.
Natural disasters can also provide opportunities for
women to challenge and change their gendered status in society, often by taking on “traditionally male”
tasks, such as building houses and digging wells.

RESI LI ENCE AND B RI DG I NG T HE HUM ANITA RIA N-D E V E LOPM E NT D IV ID E

Achieving synergies

Investing in disaster risk reduction for resiliencebuilding means public and private, multi-sectoral
investments to address the root causes that determine who survives and recovers in a disaster, to save
lives and livelihoods, and prevent and reduce losses
and ensure effective recovery and rehabilitation(UNISDR, 2015a).
A humanitarian-development continuum isessential to make a sustained commitment toadvancing sexual and reproductive health and rights.
Humanitarian crises halt, and in some cases, reverse
development gains. Development investments soften
the impact of crisis and natural disaster, and canprovide a solid foundation for rebuilding a society(UNFPA, 2010). Humanitarian and development
action needs to be coherent, mutually reinforcing
and contiguous and underpinned by a common
understanding of shared longer-term outcomes that
ensure effective risk management (United Nations,2015b). Women and young people must remain
at the centre of their communities’ preparedness
response and at the core of the transition fromcrisis to development. If the rights and needs ofthe most vulnerable are not at the center of development planning, programmes and funding, it

will be impossible to achieve the United Nations
Sustainable Development Goals by 2030.
From aspiration to reality

The challenge policymakers face in 2015
and beyond is to transform the aspiration ofresilience into reality. New models for integrated
development that include a commitment
to disaster risk reduction are needed. Suchmodels might include building strong primary
health care systems with integrated sexual andreproductive health services, taking a multi-sectoral
approach to adolescent health, using schools todisseminate disaster preparedness information,or mainstreaming climate adaptation, ensuring acommitment to inclusion, consultation and equity
forms the core of integrated development.
Integrated approaches that can manage conflictand natural disaster risk are increasingly needed. If
natural disasters can exacerbate or trigger conflicts,
then they should be considered within conflict andstate building frameworks. Conversely, if conflict
and fragility increase vulnerability and exposure tonatural disasters, epidemics, or famine then theyshould be considered in disaster risk assessments
and natural disaster frameworks.

THE STATE OF WORLD POPULATION 201589

CHAPTER 5

New directions infinancing sexual andreproductive health inhumanitarian settings
The number of people in need of humanitarian assistance is growing as is
the amount of funds provided by institutional, governmental, corporate andindividual donors. But funding gaps are also growing, suggesting that current
funding arrangements may not be sustainable.

Protecting the healthof South Sudanesemothers and adolescents
An average of 45 women give birth eachweek at the health centre in the Tierkidi
refugee camp in Ethiopia.
The number wasn’t always so high,according to health centre manager
Yonas Zewdu. Until recently, most
women were delivering in their own
living quarters, without the help of askilled birth attendant.

Mother and newborn, Tierkidi Camp, Ethiopia.
Photo © UNFPA/A. Haileselassie

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CHAPTER 5

Zewdu says the centre has deployed outreach staff to visit women where they live,
encourage them to come for antenatal
care and make arrangements for them

NEW DI RECTI O NS I N FI NANCING SE XUAL AND RE PROD UCTIV E HE A LTH IN HUM ANITA RIA N SET T I N GS

Mothers and children at Tierkidi health centre.
Photo © UNFPA/A. Haileselassie

to give birth in the centre, where two
midwives manage all deliveries.
One of the midwives, Lelisa Bekele,says whenever a pregnant woman who
has come in for one antenatal care visit
does not turn up for a follow-up visit,
outreach staff check on her to make sureshe is all right.
To pregnant women who live far fromhealth centres, UNFPA, the United
Nations Population Fund, distributes
clean delivery kits, consisting of a towel,
blade, gloves, plastic sheets, cord ties
and soap.
UNFPA stocks the centre withemergency reproductive healthkits, which include everything fromequipment and medicines for safedeliveries, surgical repair of cervical andvaginal tears, as well as treatments forsexually transmitted infections, and avariety of contraceptive methods.
According to Peter Lam Gony, whooversees community outreach for sexualand reproductive health, more and more
women are learning about and choosing
to use family planning, often against thewishes of their partners.

of the confidential services also learn
that aside from condoms, contraceptives
only prevent a pregnancy, not a sexuallytransmitted infection, such as HIV.
The centre also makes free condoms
available through free dispensers
available throughout the camp.
Tierkidi camp houses about 52,000
refugees from South Sudan.

“Their husbands think that their wives
will be seeing other men if they use
family planning,” Gony says.
An increasing number of adolescents arealso choosing to use contraception in
the camp. Those who avail themselves

THE STATE OF WORLD POPULATION 201591

M

ore than 100 million people were inneed of humanitarian assistance in2015, up from 88 million in 2014 and78 million in 2013. Women and adolescent girls
between the ages of 15 and 49 account for about
one in four of the total.
As the world’s crises multiply and become
increasingly complex so do the sexual and reproductive health needs of women and girls.
Because of the large quantity and scale of crises
around the world, an increasing share of total sexual and reproductive health needs is being met by
the international community in humanitarian settings. Achieving the sexual and reproductive healthand rights objectives of the Programme of Actionof the International Conference on Population
and Development, therefore increasingly meansdelivering services and information in the midstof conflict, large-scale population movements,
epidemics or in the aftermath of a natural disasteror climate-change-related catastrophe.
Protecting the sexual and reproductive healthand reproductive rights of women and girls in

Students in shelter established after school in
Damsijhang, Nepal, was destroyed by earthquake.
Photo © Panos Pictures/Brian Sokolcrisis settings is essential and a matter of humanrights, but it is also complicated and unsustainable
without a change in the way humanitarianassistance is provided and funded.
An imperative for a long-term shift in the way
the international community and affected governments themselves approach and fund humanitarian
action is emerging. In addition to mobilizing
resources to address acute humanitarian needs, allstakeholders must also increase attention to longterm investments that can help address underlying
causes of crises, especially underdevelopment, andbuild the resilience of individuals, communities
and nations to help mitigate the impact. Resilience
depends in part on development and how equitably
economic and social gains are realized in a society.
Where resilience is low, vulnerability to conflict anddisasters is high. Preparedness is another criticalvariable in the resilience equation.
Sexual and reproductive health is not only ahuman right but it is also key to achieving sustainable development. The more a country develops,
the more resilient it becomes, and the more likely

CONTRIBUTIONSIn 2014, a year marked by multiple
large-scale emergencies, contributions
rose to new heights, totalling $24.5 billion,
a 19.5 per cent rise from the previous
record $20.5 billion in 2013. This is thethird consecutive year that international
humanitarian assistance has substantiallygrown.
$24.5
billion$20.5
19.5%
billionIncrease

2013

92

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2014

NEW DI RECTI O NS I N FI NANCING SE XUAL AND RE PROD UCTIV E HE A LTH IN HUM ANITA RIA N SET T I N GS

it is to withstand or recover from a crisis at lower
cost. Emergency response is always more expensive
than preparedness and risk mitigation.
A framework for disaster-risk-reduction wasendorsed by the international community in
Sendai, Japan, earlier this year. Parts of this framework relate directly to the UNFPA mandate
because it cites a need to strengthen the design
and implementation of inclusive policies and social
safety-net mechanisms, including through community involvement, integrated with livelihood
enhancement programmes, and access to basic
health care services, including maternal, newborn
and child health, sexual and reproductive health,food security and nutrition, housing and education,
towards the eradication of poverty, to find durable
solutions in the post-disaster phase and to empower
and assist people disproportionately affected bydisasters.
Also this year, a declaration of experts who converged in Abu Dhabi called for a more strategic
focus on reproductive, maternal, newborn, childand adolescent health and well-being across withina development and humanitarian “contiguum,”and for national and subnational strengthening andincreased resilience of health systems so that quality
services are more likely to be available in crisis settings and in the context of disasters and conflicts.
Record need for humanitarian funding

Conflicts and natural disasters, including extreme
weather events, along with other protracted crises
and extreme poverty have together led to the largest number of people forcibly displaced from theircommunities or countries since the Second World
War, in turn driving international humanitarianfunding requirements to record levels (Kim et al.,2015; Bond for International Development, 2015).
UNFPA’s funding requirements for humanitarian
action in the areas of sexual and reproductive healthand rights has also reached an all-time high, risingfrom about $78 million in 2006 to about $175
million in 2014.
Today’s challenge is to meet the wide andmultidimensional needs of more people affectedby humanitarian crises. Today’s opportunity is toleverage new donors, partnerships with the private
sector and other innovative strategies to findsustainable solutions.
International humanitarian assistancetotalled $24.5 billion in 2014

International humanitarian assistance worldwide
averaged $19.8 billion annually between 2009 and2014 (Development Initiatives, 2015). However in
2014, a year marked by multiple large-scale emergencies, contributions rose to new heights, totalling$24.5 billion, a 19.5 per cent rise from the previous record $20.5 billion in 2013. This is the third
consecutive year that international humanitarianassistance has substantially grown.
Major donor governments and institutions led
financing responses to large-scale humanitariancrises, providing $18.7 billion in 2014. About
90 per cent—$16.8 billion—came from the 29
member States of the Organisation for Economic
Co-operation and Development’s Development
Assistance Committee (OECD-DAC, 2014b;
UNFTS, 2015). These same countries accounted
for 94 per cent of reported international humanitarian assistance from governments over the last
decade. The United States accounted for about 32
per cent of all international humanitarian assistancein 2014.
Also in 2014, Saudi Arabia and the United ArabEmirates joined the list of 20-largest humanitarian
donors. Contributions by Arab States rose 120
per cent between 2013 and 2014, from $764 million to $1.7 billion, mostly in response to crises
in Iraq and Syria. Most of the funding came fromTHE STATE OF WORLD POPULATION 201593

Kuwait, Qatar, Saudi Arabia and the United ArabEmirates.
Turkey’s contributions have also considerablyincreased, making it a leading donor to the Syrian
crisis, allocating $1.6 billion towards Syrian refugees (Start Network, 2014).
East Asian donors increased their humanitarianfunding 11 per cent between 2013 and 2014, withJapan contributing $882 million, followed by the
Republic of Korea and China, contributing $81.7
million and $53.7 million, respectively.
Contributions from emerging national economies are also increasing. Brazil’s contributions rose,for example, from $2.6 million in 2005 to $14.9
million in 2014. Sierra Leone mobilized $17.2 million of its own resources for the Ebola response.

foundations and corporations, funded about
27 per cent of international humanitarian assistance between 2009 and 2013 (Stoianova, 2013;
Gingerich and Cohen, 2015; Development
Initiatives, 2015).
Private donors as a group were the largest
international humanitarian contributor to the
Typhoon Haiyan response in 2013 and the thirdlargest to the Ebola response in 2014 (Stoianova,
2013; Development Initiatives, 2015).
Diasporas provide assistance through thereturn of remittances. Religious organizations,some acting independently of the humanitariansystem, also provide assistance. Faith-basedorganizations play a key role in humanitarianfinancing, accounting for 16 per cent of all
assistance channelled through non-governmentalorganizations.

Other sources of humanitarian funding

The private sector and the general public are otherimportant sources of humanitarian assistance,channeled mainly through international nongovernmental organizations. This diverse groupof donors comprising individuals, trusts andUnited Nations consolidated appeals

United Nations-led consolidated appeals are basedon the needs assessed and responses plannedby United Nations agencies and international

INTERNATIONAL HUMANITARIAN RESPONSE
2009–2014
Governments and European Union institutions

Private30
25

5.8

US$ billions

20
6.1

15

5.4

5.7

5.0

3.5

10
5

18.7
12.9

14.0

13.9

12.8

2009

2010

2011

2012

15.1

0
2013

2014

Year
(Development Initiatives, 2015)94

CHAPTER 5

NEW DI RECTI O NS I N FI NANCING SE XUAL AND RE PROD UCTIV E HE A LTH IN HUM ANITA RIA N SET T I N GS

non-governmental organizations active in specificcountries or responding to specific emergencies.
In 2014, the United Nations requested an
unprecedented $19.5 billion in 31 appeals.
Donors contributed $12 billion towards this total,leaving an unprecedented gap of $7.5 billion, or
38 per cent of the total needed.
United Nations-managed “pooled” funds,
such as the Central Emergency Response Fund(CERF), consist of un-earmarked resources tomeet surges in humanitarian need. In 2014, the
CERF allocated $290 million to rapid response
projects and $170 million to under-funded projects. In addition, Country-Based Pooled Funds,
which rely on contributions from governments
and private donors, allocated $386 million to 19
countries in 2014. Pooled donor contributions in2014 came primarily from Denmark, Germany,
the Netherlands, Norway, Qatar, Sweden and theUnited Kingdom.
Funding gaps widening

International humanitarian assistance alone has
not kept pace with the rising needs and increasing complexity of today’s humanitarian crises, letalone the underlying drivers, such as instability,
poverty and vulnerability (Gingerich and Cohen,
2015; Development Initiatives, 2015).
Over the past 10 years contributions towards
international humanitarian appeals have risen 300
per cent (Bond for International Development,2015). Meanwhile, funding gaps are growing
wider (Development Initiatives, 2015).
These shortfalls are further exacerbated by thelack of resources and capacity in the places mostvulnerable to crisis, especially in conflict-affected
contexts where domestic response is limited or
non-existent. Furthermore, pressures on the system are sure to intensify in the years ahead dueto the effects of climate change, vulnerabilities

THE ECONOMIC TOLL
In 2013, the combination of direct consequences(damage to infrastructure, housing, crops) andindirect consequences (loss of revenues, loss of
production, market destabilization and loss of
employment) from natural disasters were valued
at an estimated $118.6 billion (UNOCHA, 2014).
In 2014, economic damages due to heavy rainfall,
storms, flooding and harsh winter conditions alone
resulted in economic losses valued at $110 billion(UNISDR, 2014). Since 2000, economic losses
from disasters are estimated at $2.5 trillion(UNISDR, 2014).
The numbers of multi-billion-dollar natural disasters
are becoming more and more common.
Global statistics on economic loss due to conflictand other protracted emergencies are more difficult
to ascertain. Complex and chronic humanitarian
emergencies usually take place in highly insecureand impoverished environments, with failed or failingStates and State-based institutions and in a context ofdevastated infrastructure.

associated with urbanization and the need arisingfrom fragile or conflict-affected States. Of the 20
countries that received the majority of international
humanitarian funding in the last decade most haveexperienced conflict, most are highly vulnerable tothe effects of climate change and have little capacity
to adapt, prepare or cope with the impact, and all
are considered fragile States (Inomata, 2012).
The widening gaps suggest that current funding
arrangements for humanitarian action may beunsustainable.
Funds are unequally distributed

Some countries and emergencies faced greater funding gaps than others in 2014. Smaller humanitarian

THE STATE OF WORLD POPULATION 2015

95

FUNDING AND UNMET REQUIREMENTS, UNITED NATIONS-COORDINATED APPEALS
2005 TO2006
2011
2012
2013
2014
2005
2014 2007 2007 2009 2009
Funding

Unmet requirements
25

US$ billions

20
7.5

15

2.8

3.6

2.3
5

4.7

4.9

10

2.0

2.0

1.6

4.0

3.9

4.0

5.7

2005

2006

2007

2008

4.3
12.0

7.1

8.0

2009

2010

5.8

6.2

2011

2012

8.5

0
2013

2014

Year
(Development Initiatives, 2015)

appeals tended to have a lower percentage of theirneeds met. With the exception of the high-profile
crisis in Ukraine, all were less than 50 per centfunded. In contrast, South Sudan, Iraq and theEbola response, which each requested over $1 billion, were 90 per cent, 75 per cent and 81 per centfunded, respectively (Gingerich and Cohen, 2015).
Relatively little humanitarian assistance goes
directly to national and local actors in crisis-affected
countries. Between 2007 and 2013, these actors
received less than 2 per cent of total annual humanitarian assistance (Gingerich and Cohen, 2015).
Smaller share allotted for preparedness andearly recovery

Humanitarian funding is mainly directed towards
the response to crises, with relatively little directed
to prevention and preparedness. Approximately
60 per cent of humanitarian assistance goes toemergency relief, 35 per cent to reconstruction
and rehabilitation and only 5 per cent to disaster

96

CHAPTER 5

preparedness and mitigation. Over the past five
years, the biggest donors have allocated between
3 per cent and 6 per cent of their total humanitarian spending on reducing the risk and impact(Gingerich and Cohen, 2015).
The 2015-2030 Sendai Framework for Disaster
Risk Reduction demonstrates a growing recognitionof the importance of investments to prevent andbetter prepare for disasters caused by natural hazards.
Over the last decade, there has been an evolution
in humanitarian financing. But the bulk of funding
continues to be allocated to responses to protracted
emergencies, rather than prevention and preparedness (Inomata, 2012).
Funding targeted to sexual and reproductive
health accounts for small share of total

Funding for sexual and reproductive healthin humanitarian emergencies is relatively low,
both in amount and share of all humanitarian
resources.

NEW DI RECTI O NS I N FI NANCING SE XUAL AND RE PROD UCTIV E HE A LTH IN HUM ANITA RIA N SET T I N GS

FUNDING REQUIREMENTS COMPARED TO FUNDING RECEIVED, BY PURPOSE, 201443%
$5.5bn14%

57%

86% $24m
Safety andsecurity

56%
$42m

44%

34%
$4.4bnMulti-sector

Mine action

66%
Food

49%

65%

35%
$518m

Health

Education$2.0bn

51%
56%

44%
$606m

Shelter andnon-food items

Agriculture$1.8bnCoordination andsupport services

25%
$653m

Water andsanitation

Economic recovery
and infrastructure

75%
$699m

71%

74%
48%

Protection

29%

26%

$987m

47%
$753m

52%

53%

KEY
Requirement
unmet

AmountNeeded$Requirement
met(Development Initiatives, 2015)

THE STATE OF WORLD POPULATION 2015

97

Family health clinic, Sweileh, Jordan.
Photo © UNFPA/Salah Malkawi

Although requests for funding and absolute
funding received for reproductive health in humanitarian appeals have increased since 2002, only
43 per cent of the need was met between 2002
and 2013, compared to 68 per cent for total
humanitarian sector funding (Tanabe et al., 2015).
Among the 11,347 funding proposals presented
to the international donor community for support
for health and protection in 345 emergencies
between 2002 and 2013, 3,912—34.5 per cent—were relevant to reproductive health (Tanabe etal., 2015). The number of proposals containing
specific reproductive health activities increasedby an average of 22 per cent per year, while theproportion of health and protection sector appeals
with reproductive health activities increased byonly an average of 10 per cent per year.
In recent years, the donor community has stepped
up its support for services to address sexual andgender-based violence, especially in conflict settings,

98

CHAPTER 5

with contributions more than doubling from $50
million in 2012 to $107 million in 2014. However,despite the increase in funding to address this problem in humanitarian emergencies, the share of total
humanitarian assistance remains low, at only 0.5
per cent in 2014 (Development Initiatives, 2015).
Tanabe et al. (2015) show that 57 per cent of all
funding appeals for “gender-targeted” humanitarianassistance between 2002 and 2013 included specificproposals for maternal and child health. About 46
per cent included funding requests to address sexualand gender-based violence, 38 per cent for HIV
and sexually transmitted infections, 27 per cent for
general reproductive health, and about 15 per centfor family planning. For the same period, proposals
that included all of the components of a minimum
initial service package, or MISP, for reproductive
health in crisis situations increased about 40 per cent
(Chynoweth, 2015).
There is a marked lack of attention to adolescent
reproductive health in terms of funding, access toservices, programming and programme evaluation(Women’s Refugee Commission, 2014). Since 2009,
proposals for adolescent sexual and reproductive
health and rights through United Nations Flash andConsolidated Appeals have constituted less than
3.5 per cent of all health proposals per year, and68 per cent of them have gone unfunded (Women’s
refugee Commission, 2014).
More than half of refugees, internally displaced
persons and asylum seekers are women and young
girls, with a need for access to essential reproductive health care. Displacement increases their needfor reproductive health services. The lack of services
and lifesaving interventions, such as obstetric care,
results in increased unintended pregnancies andunsafe abortions and in an increase in morbidity
and mortality from gender-based violence andpregnancy-related complications (International
Rescue Committee, 2012).

NEW DI RECTI O NS I N FI NANCING SE XUAL AND RE PROD UCTIV E HE A LTH IN HUM ANITA RIA N SET T I N GS

Looking at humanitarian funding in a
new light

A fundamental shift in the humanitarianbusiness model

The needs for humanitarian action are growing
every day, as protracted conflicts displace record
numbers of people for years and sometimes even
decades, and as water scarcity, food insecurity
and extreme weather have a greater impact on
lives of people, particularly the poor in densely
populated urban areas.
With the growing need comes an even greater
imperative to support women and girls and meettheir sexual and reproductive health needs, whichin the past were seen by the international community as secondary to meeting basic needs forwater, food and shelter.
In recent years, a new understanding has
emerged about the critical importance ofensuring sexual and reproductive health inhumanitarian settings and a realization that
achieving humanitarian objectives in other sectors, such as education, food security and childsurvival depends in part on whether women andgirls have the power and the means to determine
whether, when or how often to become pregnant,whether and when they will marry, and how toprotect themselves from sexually transmitted
infections, including HIV.
Also emerging is an understanding of how
sexual and reproductive health and rights
are critical to disaster preparedness and risk
reduction, recovery, rehabilitation and resilience.
Everywhere, but especially in the poorest
countries, women and girls are disproportionately disadvantaged, even in stable settings. They
have reduced access to services and opportunities, have less economic power, are less likely to
exercise their rights and face additional healthrisks related to pregnancy and childbirth. Whena disaster strikes or a conflict erupts, inequalities
are exacerbated.

Like humanitarian funding in general, funding
targeted to sexual and reproductive health has
not yet kept pace with the rapidly growing need.
Gaps in humanitarian financing—for
humanitarian action in general and sexual andreproductive health—persist, suggesting thatcurrent arrangements may not be able to meetneeds in the years ahead. Innovative approaches
to funding are needed, but so are innovations
in overall approaches to humanitarian action
in general.
The independent Future Humanitarian
Financing (FHF) group advises the United
Nations Inter-Agency Standing Committee,
a coordinating body with nine full members,
including UNFPA. FHF’s 2015 report, Looking
Beyond the Crisis, recommends a number ofmajor changes to the way humanitarian action
is financed and carried out, starting with a“fundamental shift in the humanitarian businessmodel,” moving away from “a culture andset of practices that tend towards insularity,
reactiveness and competition towards anenterprise rooted in anticipation, transparency,
research and experimentation, and strategic
collaboration.”A radical global agenda for meeting
humanitarian funding needs

According to FHF, humanitarian actors need
to focus not only on meeting humanitarianneeds today but also need to work towards a
future in which, wherever possible, international
humanitarian response is unnecessary or
exceptional, and the majority of needs are met
by local actors. This shift requires “long-term
vision and strategic alliances with a broad
range of actors who can deliver transformative

THE STATE OF WORLD POPULATION 201599

changes to vulnerability and the managementof risk.”
It also requires “a radical global agenda” tomeet the humanitarian financing challenges ofthe future by engaging and enabling a wider
range of actors in meeting costs associated withmanaging risk and by approaching post-crisis
situation as a matter of “shared responsibility
and a public good.”
Fundraising is no longer a “Western” prerogative.
In January, for example, a Red Crescent telethon
in Dubai for Syrian refugees fleeing a deadly snowstorm raised $40 million in six hours. In the future
it is likely that regional organizations and donors
will take more of a leading role in responding todisasters where they share high levels of culturaland geographic affinity.
Linking humanitarian funding todevelopment

The United Nations Secretary-General, in a reportto the General Assembly in 2015, called for morepredictable funding for humanitarian action andfor improved efficiency in response by prioritizing resources for the most urgent needs and forstrengthening links to development financing withthe aim to build resilience of vulnerable populations and institutions before, during and after crises(United Nations, 2015c).
The United Nations Economic and Social Council
earlier this year issued a resolution with similar recommendations: Member States, the United Nations
system, the private sector and other relevant entities
to provide adequate funding and investment in building preparedness and resilience-building, includingfrom humanitarian and development budgets, as wellas unearmarked core funding and flexible funding
for multi-year appeals, in order to bridge the divide
between humanitarian and development financing(United Nations, 2015c).

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Another important challenge ahead is theshort-term nature of humanitarian funding cycles
within the United Nations. The Secretary-Generalstated that the arrangement makes it difficult toundertake effective, risk-informed, multi-year
humanitarian planning: “Raising money on a
yearly basis for crises that are protracted is notcost-effective and does not allow humanitarianagencies to benefit from the potential efficiencies
to be gained from multi-year planning” (United
Nations, 2015c).
Data shortcomings hamper targeting offunds to sexual and reproductive health

One of the challenges in mobilizing resources
specifically for sexual and reproductive health inhumanitarian settings—and indeed, for humanitarian action in general—is a dearth of sex- andage-disaggregated data on individuals affected bycrises. But reliable or complete data are also scarceabout which and how many funds are being targeted to actions for sexual and reproductive healthand from where the funds are coming. While there
are some data on contributions from the private
sector, foundations and others, the figures are often
incomplete. Without a complete picture of funding
from all sources in any given humanitarian setting,developing coordinated responses is more difficult,and opportunities for achieving synergies are sometimes missed.
Towards predictable funding with more
attention to preparedness and risk
reduction

Over the past decade, the numbers of people inneed of humanitarian assistance have grown and,while actual funding provided has also grown, so
too have the gaps in funding needed. This same
trend applies to humanitarian action in the area of
sexual and reproductive health.

NEW DI RECTI O NS I N FI NANCING SE XUAL AND RE PROD UCTIV E HE A LTH IN HUM ANITA RIA N SET T I N GS

At the same time, the cost of providing criticalsexual and reproductive health services and supplies
has grown, largely because an increasing share ofthese services and supplies are being provided incrises and emergency settings.
The current funding arrangements for humanitarian action may therefore be unsustainable,
requiring new approaches not only to funding, butalso to humanitarian assistance in general. Funding
modalities that allow for longer-term planning,
coupled with measures to improve predictabilityof financing and flexibility in allocating resources,
could result in more effective programming andbetter targeting to where resources are needed most.
Also, monitoring and reporting systems should
be strengthened and transparency improved sothat donor countries may better demonstrate totheir constituencies that contributions are making
a difference in the lives of individuals affected bydisasters and conflict.
While continuing to meet acute humanitarian needs, the international community andgovernments themselves should invest more incapacity-building to increase resilience, as well as
in disaster preparedness and risk reduction, withthe aim to reduce vulnerability to conflicts anddisasters and to accelerate recovery if or when
they do occur.
The international humanitarian system mayfind suitable models for sustainable financing in
the development sector. Emergency assistanceshould be provided in ways that will be supportive of long-term development, in order to ensure
a smooth transition from relief to rehabilitationand development. Meanwhile, development
assistance organizations should integrate disasterpreparedness, risk reduction and resilience-building
measures into their programming (United Nations
Intergovernmental Committee of Experts on
Sustainable Development Financing, 2014).

Afghan refugees in Shiraz, Iran.
Photo © UNHCR/Sebastian Rich

Earlier this year, the Secretary-General appointed
a high-level panel on financing for humanitarianassistance to review current and future challenges
and identify ways to close funding gaps.
The upcoming World Humanitarian Summit
will present donor countries, international organizations and governments an unprecedented
opportunity to revisit how humanitarian action iscarried out and financed, and to align future interventions so they reinforce and are aligned with theUnited Nations Sustainable Development Goals for2015 to 2030 (United Nations, 2015c).

THE STATE OF WORLD POPULATION 2015101

CHAPTER 6

A transformative vision
for risk reduction,
response and resilience
Humanitarian action can lay the foundations for long-term
development. Development that benefits all, enabling everyone
to enjoy their rights, including reproductive rights, can help
individuals, institutions and communities withstand crisis.
It can also help accelerate recovery.

From despair to hopein Nepal
When Nepal’s worst earthquake in almost a
century struck on April 25, Ishwori Dangol’slife changed forever.
Seven months pregnant at the time, the30-year-old woman frantically searched forher seven-year-old son who was playing in
her neighbour’s home in Betrawati village in
Nuwakot district, only to realize that he wasamong the almost 9,000 people who losttheir lives in the disaster that day.
Consumed by grief, Ishwori also worried
about the health of her foetus and whether
Ishwori Dangol.
Photo © UNFPA/Santosh Chhetri

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A TRANSFO RMATI VE VI S I O N FOR RISK RE D UCTION, RE SPONSE A ND RE SILIE NCE

Dangol (centre).
Photo © UNFPA/Santosh Chhetri

she would have to deliver on her own,
since the 7.8 magnitude earthquake
damaged or destroyed 70 per cent of
the birthing centres in Nepal’s 14 mostaffected districts, including Nuwakot.
Thousands of pregnant women like
Ishwori were left with little or no accessto crucial health services to ensure safedeliveries.
Sushila, a local female community
health volunteer, told Ishwori about areproductive health camp supported by
UNFPA, the United Nations Population
Fund, and run by Manamohan Memorial
Community Hospital and the Adventist
Development and Relief Agency incoordination with the Ministry of Healthand Population.

and health care for survivors of genderbased violence.

The camp provided Ishwori and morethan 400 others lifesaving informationand services in the first three daysof operation. UNFPA supported andsecured funds for 109 such camps anddistributed reproductive health supplies
to 124 health facilities, reaching an
estimated 1.8 million people in the first
five months after the earthquake.

Dr. Suman Panta, the camp doctor who
examined Ishwori said her foetus wasin an abnormal position in her womb.
Ishwori was referred to the nearby
Trishuli Hospital, which continued
providing services despite damage tothe facility. Ten weeks after losing her
first child in the earthquake, Ishwori
gave birth via Caesarean section toa healthy baby boy.

Camp services included antenatal topostnatal care, safe delivery, familyplanning, testing and treatment
for sexually transmitted infections,
including HIV, psychosocial support

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103

W

e live in a world where humanitariancrises extract mounting costs from
economies, communities andindividuals. Wars and natural disasters makethe headlines, at least initially. Less visible but
also costly are the crises of fragility, vulnerability
and growing inequality, confining millions ofpeople to the most tenuous hopes for peace anddevelopment.
All crises, whether those that strike in the hoursof a ferocious storm, or that keep peace at bay for
decades, destroy prospects for development, often
profoundly. People lose their lives and livelihoods,
their homes and communities, sustain profoundinjuries and may become disabled. Education andhealth services disappear, depriving people of theirrights to them, and setting in motion long-term
consequences that make eventual recovery evermore difficult.
Foremost among the losses are those to sexualand reproductive health. While sexual andreproductive health services are increasingly
provided in humanitarian responses, striking gaps
remain. For the woman giving birth or the girl who
has been raped in the chaos of fleeing the bombs
falling on her city, the consequences, including
death and disability in the worst cases, can multiply
harms many times over.
The world has repeatedly affirmed the sexual andreproductive rights of women and girls. Now itneeds to deliver in all cases, including humanitariancrises.
Conflicts and disasters do not exempt any government or humanitarian actor from obligations,embodied in the Programme of Action of the1994 International Conference on Population andDevelopment, to uphold the right of the individual
to sexual and reproductive health, including theright to decide freely and responsibly whether,when or how often to become pregnant.

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Eliminate silos preventing integrated action

A time of burgeoning crisis has demanded
a ballooning humanitarian response. While
humanitarian “fires” will always need to be fought,
particularly as natural disasters accelerate in a timeof climate change, much more could be done to
cut root causes of crises and reduce underlying
vulnerabilities.
The sources of risk are many. Political marginalization and economic inequity can explode into
conflict. A slum built by the poor on the cheap
land of a floodplain will suffer the worst damages
from a violent storm. Gender discrimination may
leave women without enough income or education
to protect themselves from catastrophe.
Many risks stem from development that ispoor in quality—because it excludes groups ofpeople from decent work and essential services,
for instance, or destroys shared natural resources.
Around the world, people and countries at higher
levels of development typically have a better capacity to withstand the worst fallout from crisis. In
natural disasters, three times as many people die in
low-income countries as in high-income ones.
For women and girls, gender discrimination
further undercuts development prospects. They
are often more vulnerable than men and boys innatural disasters, sometimes for reasons as simple as
the inability to swim. Their abilities to seek refuge
and eventual recovery are hobbled by more limitedaccess to income and assets, social networks andtransportation, among other issues, leading to a“double disaster.”
Despite strong links between development andcrisis, much of the humanitarian world remains
concentrated in “response” mode, acting only oncea crisis begins. Emergency operations may remain
entirely separate from development assistance inglobal organizations offering both, even where
emergency intervention proves far more expensive

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than development investments, which can
reduce risks.
This approach is questionable in terms of its
adequacy and, from the perspective of inclusion,
its fairness. It is time to make closer connections
and act across the continuum that stretches fromdevelopment to humanitarian response, a notionthat reflects the United Nations Agenda 2030
emphasis on integrated, interdependent actions.
Doing so could reduce risks and vulnerabilities,
and build resilience. It would imply embedding all
major elements of people’s rights and development
in all humanitarian responses, including sexualand reproductive health care. Agenda 2030 is theinternational plan of action for people, planet andprosperity for the coming 15 years that recognizes
eradicating poverty in all its forms and dimensions,
including extreme poverty, is the greatest global
challenge and an indispensable requirement forsustainable development.
Food and shelter have traditionally been seen as“primary” humanitarian needs. But sexual and reproductive health care saves lives, protects families andspeeds recovery, on top of upholding commitments
to human rights made by 179 governments at thehistoric International Conference on Population andDevelopment. All people affected by crisis, particularly women and girls, need quality services related
to pregnancy, contraception, prevention and treatment of sexually transmitted infections, including
HIV, and protection from gender-based violencealong with support services for survivors.

Family health centre, Sweileh, Jordan.
Photo © UNFPA/Salah Malkawi

Establish comprehensive disaster risk
management

The Sendai Framework for Disaster Risk Reduction
for 2015 to 2030 outlines core priorities in understanding and managing disaster risks, revisiting
financing arrangements and bolstering disaster
preparedness. Its success depends on adequate
resources and institutions as well as inclusive
practices such as participation by all potentiallyaffected groups. Globally, humanitarian actors
must better prepare for crisis response throughmore sophisticated, coordinated analysis of capacities and dynamics, since these can heavily influence
the success of interventions (ALNAP, 2015).

Be proactive, not reactive

Understanding risks can help guide better development choice for individuals, communities andnations. It can inform advance preparation andbuild resilience, so that if a crisis does occur, theconsequences are fewer, the need for humanitarian
intervention is lower, and recovery is faster.

Aim for continuity in essential services

Efforts to address crisis risk should be situatedwithin actions to reduce social deprivation andpoverty, including under Agenda 2030 and the newUnited Nations Sustainable Development Goals
for 2015 to 2030. Services should be designed

THE STATE OF WORLD POPULATION 2015

105

People displaced by Typhoon Haiyan, Tacloban, the Philippines.
Photo © Panos Pictures/Andrew McConnell

to maintain continuity, including throughapplying integrated models that may help extend
availability. Examples include strong primary
health care systems that incorporate sexual andreproductive health services, and adolescenthealth care that links to education, sexual healthand livelihoods services.
Plans should be in place to manage potential
gaps in personnel and supplies. Measures to preposition commodities for emergencies should
by default involve those essential for sexual andreproductive health, such as contraceptives.
Invest in social protection now

Social protection programmes offer a hedge
against diverse risks, particularly for the mostvulnerable people—among them children andyouth, women and the poor. They can makevital contributions to resilience and survival
in a crisis. In the wake of catastrophe, they
may offer critical support during the transition
from reliance on external humanitarianassistance, ensuring continued ability to meetneeds for food and health care, among otheressentials.

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Tackle intersecting risks

Too often, risk is assumed to be the same for different people. Everyone in the path of a landslide
is at risk of losing their home, for instance. Yet
many factors influence the level of risk, the ability
to prepare and the capacity to recover. Sex, age,
race, disability and many other issues intersect incomplex ways. These need to be better reflectedin data used to assess risk, as well as planning for
preparedness.
The direct participation of women and young
people, especially adolescent girls, in framing
emergency preparedness plans helps ensure theirrights and needs will not be overlooked during
emergency response. Engaging men and boys
in initiatives to reduce risks of gender-based
violence can foster greater respect for women’s
rights and thus increased resilience.
Muster the will and resources for better urban
planning

Rapid urban development has concentrated
populations and taxed environmental resources,
making cities epicentres of risk. Disaster preparedness planning needs to better reflect the

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likelihood that the face of crisis will be increasingly urban. As part of managing risks, city andnational planners need the capacities, resources
and political will to orchestrate growth well.
Slums in remote locations with poor hygiene may
pose health risks and cut people off from essential
public services.
Integrate disaster risk financing

Disaster risk financing often remains inadequate, so
efforts by some countries to make it a centerpieceof a strategic approach to disaster risk management
should be shared and encouraged (UNISDR,2015). National risk boards that bring together
insurance supervisors, disaster management
agencies, and relevant ministries, including thoseworking on health and gender equality, are also a
step forward.
Meet acute needs

A number of priorities stand out in the early daysof a humanitarian prevention. While some of thesehave appeared in many crisis responses, they are all
essential across all situations.
Save lives from day one through internationally

Close emergency health care deficits

In providing health services in humanitariancrises, care for physical trauma is often
prioritized. Yet, this can create dangerous gaps,
including in sexual and reproductive healthcare services, which are critical to saving lives.
There is also scope for increased investment inearly interventions with psychosocial services,
particularly for the most acute cases, since
psychological trauma can drive rising rates ofgender-based and other forms of violence, andresult in multiple forms of risky behaviours, illhealth and disability.
Protect women from unintended pregnancy

Where sexual and reproductive health services
are provided as part of a crisis response, attention
to family planning tends to be limited (Casey
et al., 2015). This persists despite obvious links
to reducing the transmission of infections,
unintended pregnancies, the health risks ofchildbirth and unsafe abortions. People affectedby crisis need access to the full range of familyplanning supplies and services, which, among
other issues, requires greater attention to reliablesupply chains and avoidance of shortfalls.

agreed essential services

In the acute phase of a crisis, the minimum initialpackage of essential services for reproductive healthin crisis situations should be immediately applied
to stop and respond to sexual violence, reduce
HIV transmission, and prevent maternal andnewborn death and illness. The package also assists
in planning to provide comprehensive sexual andreproductive health care as soon as conditions allow.
An accepted international standard and applicable
to any context, the package is still not used by someproviders of humanitarian assistance. Greater reachand effectiveness depend on improved coordination
and a common commitment to applying it.

Prevent gender-based violence

Gender-based violence is prevalent in societiesthat are not in crisis, and often increases once
people are displaced or otherwise under extreme
stress. A failure to address gender-based violencein the beginning of a response undercuts women’s
and girls’ resilience and health later on, and is abarrier to recovery. Specific efforts may be needed
to counteract the stigma that usually keeps large
numbers of women and girls from reporting
violations. Outreach and services targeted tomen and boys recognizes that sexual violence isperpetrated against them too.

THE STATE OF WORLD POPULATION 2015107

Engage and reach youth

All humanitarian crisis responses should build
in interventions for youth, responding to theirright to be included, and the reality that half ofall forcibly displaced people are under the age of
18. Other risks arise when adolescents are sexually active but protective services are unavailable.
Young people need to be engaged as participants and leaders in all aspects of humanitarian
action—policies, programmes and budgets. Thisbuilds their buy-in, makes it more likely that they
will use services, and increases responsiveness totheir actual needs.
Shift from response to recovery andresilience

While some links between development assistanceand humanitarian action are made before a crisis,
as part of efforts to prevent it or mitigate risks,
others can be forged as the acute phase of an
emergency eases into recovery. Early recovery can
open new opportunities to mitigate future risks
and enhance resilience, such as by instituting better protections for people’s rights, improving thequality of services, and encouraging moves towards
more equitable, inclusive development overall.
Move early and quickly to comprehensive
services

As recovery begins, provision of the internationally agreed package of essential services shouldcede to the provision of comprehensive sexual andreproductive health services, based on a detailed
needs assessment and longer-term programme
planning. Comprehensive family planning,
emergency obstetric and newborn care, trainingof service providers, community awareness, preventing and addressing all forms of gender-based
violence, antenatal and postnatal care, comprehensive services to prevent and treat sexually

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CHAPTER 6

transmitted infections, including HIV, and addressing adolescent sexual health are among the top
priorities.
Tear down barriers to urgently needed services

Multiple barriers can prevent access to sexualand reproductive health services, many of which
may stem from discrimination related to age,sex, disability or other issues. Obstacles that
may need to be addressed include the need totravel long distances to service points, the lack ofadequate transport, safety concerns, a perceptionof “unfriendliness” to groups such as unmarried
women and youth, language barriers and a lackof knowledge that services exist.
Challenge discriminatory gender roles

The social disruption imposed by a crisis may yieldsome positive results, including in breaking longstanding gender roles and practices. In modelingnew and valued roles, women and girls diminish
earlier assumptions that they are less capable ofacting in the public arena.
Where women and girls take on new roles themselves, they should be encouraged, and where they
do not, providers of humanitarian assistance cancreate opportunities, such as through equal
opportunities for job training.
Achieving gender parity in leadership in disaster management should be a goal of all national
and international efforts. United Nations Security
Council Resolution 1325 already recognizes women’s central participation across all aspects of peaceand security.
Leave no aspect of gender-based violence
unaddressed

Gender-based violence takes many forms, and nosociety can be understood as fully at peace or freefrom crisis until all forms are prevented. A variety

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of essential health, legal and psychosocial services
are necessary to shield women and girls fromgender-based violence, and to care for survivors.
Often these are best provided as an integrated
package, reducing burdens on survivors who needto access them. Judicial services need to be restored
as soon as possible. Some legal systems may still
include discriminatory statutes and legal practices,such as insufficient penalties for perpetrators; theseshould be early priorities for judicial reform.
The recovery process may allow scope to question social norms that permit different forms ofviolence, like the acceptability of men arguing with
their fists within their home. These efforts might
involve community conversations aimed at building awareness and establishing new norms, and theengagement of men and boys in encouraging new
thinking and behaviours.

Other opportunities to stop gender-based
violence can come through peace dialogues andnegotiations, as has now been done in multiple
instances around the world. This process can raiseawareness, allow survivors a voice, produce reparations, and lead to formal commitments in peaceagreements to establish laws and institutions
effective in stopping all forms of violence.
A priority in some contexts will be stopping
early marriage. It can be a shattering consequence
for young girls in crisis, caused by reasons ranging
from protecting honour to having one fewer
mouth to feed. Understanding child marriage
as a negative coping mechanism and planning
to prevent it should be in place early in a crisis
response. Prevention may require careful workaround changing social norms, backed by greater
guarantees of safety, such as through protected

Syrians leaving Gevgalija, the former Yugoslav Republic of Macedonia.
Photo © UNFPA/Nake Batev

THE STATE OF WORLD POPULATION 2015109

spaces for girls in schools and safe houses orspaces.
Some economic drivers may be eased through theextension of livelihood activities equally available towomen and men; these may also offer opportunities
to communicate, for instance, the risks of early marriage and the value of girls remaining in school.
Acknowledge and respond to the reality of
traumaWhile much of the focus of humanitarian response
is on people’s immediate physical needs, trauma
counselling also should be viewed as a primary andpotentially life-saving intervention. Trauma produced by the extreme mental stress of displacement,
conflict and loss has multiple implications andcosts. It can lead to suicide, drug and alcohol abuse,and higher rates of gender-based violence, and it
may be transmitted across generations, dampening
prospects for full recovery, possibly for decades. As
recovery gets under way, it may mean people cannot return to being productive workers and businesspeople engaged in rebuilding their economy. Or it
can fuel unresolved grievances that eventually spill
into conflict.
Counselling should be readily accessible and integrated into other health services to ease referrals andreduce stigma incurred by visiting a separate facility.
To be most effective, it must be grounded in a close
understanding of local contexts and norms, andavailable to and welcoming of all individuals.
Brighten long-term prospects for womenand girls: say no to business as usual

The imperative of making humanitarian responses
to crises both more effective and sustainable
underlines new ways of operating. The system
as it stands today, with scattered funding andweak links to development, will not suffice tomeet mounting needs.

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End paternalistic response and action

States have the primary role in humanitarian preparedness and response (Gingerich and Cohen,2015). Where the engagement of international
actors becomes necessary, they can do much more
to engage with local systems and groups.
Working with local partners, including thosewhere relationships may already be long establishedthrough earlier development assistance, can be
one way forward. They offer local knowledge
that external actors may find impossible or timeconsuming to duplicate. Establishing referrals
for emergency obstetric and newborn care, forexample, could build on existing networks.
Reproductive health education led by displaced
people might be more effective in using terms
and communication styles most appropriate toa given context.
Through the use of technology, some localgroups are mounting increasingly sophisticatedresponses, as in Nepal, where they used cell phone
GPS data to map earthquake-affected areas andguide relief efforts (Barnett and Walker, 2015)
Engaging with a variety of local and national
actors is also part of supporting more inclusive
societies that underpin resilient states. Some, suchas women’s and youth groups, deserve specificemphasis as part of reducing discrimination andrelated vulnerabilities.
The potential pitfalls of expanding engagement
include increased fragmentation in relief efforts,
norms that may contradict international standards,
and leaders who in some contexts will be mostly
male. But the process of working together canbegin to address these.
It may also foster understanding of different
comparative advantages—including thoseof international organizations. With somedeveloping countries now spending much moreon humanitarian responses than traditional

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Mother and daughters outside new home built after tsunami inundated her community in Lhoknga, Indonesia, in 2004.
Photo © Panos Pictures/Abbie Trayler-Smith

aid agencies (Gingerich and Cohen, 2015),
organizations within the United Nations system
in particular may increasingly be looked toas sources of expertise and bearers of agreed
standards, rather than implementers of on-theground actions.
In some respects, humanitarian actors need towork towards a future where their responses are
exceptional or unnecessary, since local actors meetmost needs. Equitable and sustainable development
will be the foundation for progress in this direction.
End the false distinction between development
and humanitarian action

While the resolution of a crisis very rarely takes alinear path, connections between development andhumanitarian issues may be relevant along the way,
helping to steer the recovery process overall. Somehumanitarian interventions can build on pre-crisis
development initiatives, as is now the case with 55
per cent of gender-based violence programming. By
the same token, activities begun during a crisis can
carry over afterward, as has happened with

81 per cent of gender-based violence programmes
initiated through humanitarian assistance.
A sense of continuity is built, particularly, where
feasible, through consistent relationships withnational partners. This may expand the scopefor cultivating greater capacities that will sustain
progress over the long term. Other benefits include
bolstering perceptions of normalcy and stability.
When the Ebola crisis struck West Africa, countries such as Guinea, Liberia and Sierra Leone had
only 10 per cent to 20 per cent of the internationally recommended health workforce (WHO).
What suddenly erupted as a humanitarian crisis
had clearly long been a development crisis forcountries trapped in poverty and unable to pay
for basic services. The roots of that inability extend
in many directions, including inequities built into
the global economy.
The experience underscores the false divide
between humanitarian and development work.
That recognition needs to filter into the waysthat international and national institutions operate, such as through more integrated institutional

THE STATE OF WORLD POPULATION 2015111

structures and policies, links across different sectors,
and longer term planning and financing geared
towards reducing risks and building resilience.
Systematic partnerships can help break down silos.
Within the United Nations system, humanitarian
response plans could be aligned with development
assistance frameworks, and jointly embedded innational planning.
Such an approach might have slowed Ebola at amuch earlier stage in West Africa, perhaps obviating
the need for a massive humanitarian intervention.

It would have achieved a higher level of justiceand inclusiveness, one of the main promises ofAgenda 2030. In other cases, it might prove moreacutely sensitive to slow onset crises like drought,
which currently tend to receive a slower response(Gingerich and Cohen, 2015).
Fill the data deficit gap

The use of targets, indicators and data is a majorpart of Agenda 2030, and a significant shortfall in humanitarian work. With short response

Photo © Panos Pictures/Mads Nissen/Berlingske

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times and funding cycles, data are frequently
not collected, leaving little evidence of whichinterventions work best and which actors are
best positioned to collaborate on them.
The absence of data, especially sex- andage-disaggregated data, obscures links acrosshumanitarian sectors that might prove mutually
reinforcing. Data on sexual and reproductive
health indicators, for instance, might be valuable for education measures, such as those toimprove life skills and raise awareness of risks
such as early pregnancy that can result in girls
leaving school.
Overhaul entrenched funding arrangements

Current patterns of financing humanitarianassistance explain some of its challenges andshortfalls. Driven internationally by donors,
finance is often reactive, inefficient and poorly
coordinated, despite growing emphasis on
improved performance. Earmarking pushes
forward issues that do not necessarily correspondclosely to priorities in countries struck bycrisis, and funds tend to flow to more visible
emergencies, or those viewed as strategicallysignificant. So-called “donor accountability”
has reduced tolerance for risk because it links
primarily to mandates and funding conditions,
not always to what people actually need (IASC,
2014)
The concentration of funds in a few large
grants deepens the tendency for humanitarian
action to be the province of a few large players. Amounts being spent are often unclear. No
marker currently tracks spending on sexual andreproductive health interventions, a gap thatshould be redressed.
Donors need to reevaluate these issues. In
tandem, an inclusive intergovernmental process
to regularly review all sources of humanitarianfinancing could bring different perspectives
to light.
There is also a clear case for more investment
in some areas of humanitarian assistance. Bothnational and international finance should prioritize disaster risk reduction and preparation, whichcurrently attracts minimal amounts. More money
should go to sexual and reproductive health. An
increasing number of countries are equipped toprovide domestic resources, but for those thatare less developed, international funding should
be provided within a framework of common but
differentiated responsibility. This underscores theobligation of those with more resources and capabilities to assist those with less. The same principle
might be applied within countries in terms of vulnerable groups, such as poor women and youth.
Private financing can be explored, but withcaution. Private actors play active roles indevelopment and humanitarian assistance, yetthere is also a history of private interests resulting
in imbalances, as in the dominance of in-kind foodaid and some health issues (Gingerich and Cohen,2015). All forms of private involvement must alignwith international standards. They could be better
tracked and measured for effectiveness against
agreed global norms.
Reform laws and policies that perpetuate
violence and discrimination

A number of legal reforms are important to build
resilience in countries prone to crisis, such as thosethat bar gender discrimination and penalize genderbased violence. But with a record number of people
now on the move, within and across borders, andin light of the universal nature of Agenda 2030,
other legal measures may be needed even in countries that are not experiencing crisis.
Laws against trafficking—such as the recent
Modern Slavery Act in the United Kingdom—

THE STATE OF WORLD POPULATION 2015113

reflect how what starts as displacement in one
country ends up a human rights violation in another. Women, in this case, are the primary victims.
Other issues revolve around the management ofrefugees, including the isolation of people for years
in camps, where they are unable to find legal employment and services in surrounding communities.
A new platform for humanitarian action

In 2016, the World Humanitarian Summit will
convene, providing an opportunity for countries
around the world to share ideas and set new

directions. The process should commit to greater
investment in sexual and reproductive healthservices as a primary element of all humanitarian
responses, in line with existing agreements outlinedin the Programme of Action of the International
Conference on Population and Development. It
should uphold the high ambition and hopes ofAgenda 2030. Aiming for a transformed world,
where development is inclusive, sustainable andsufficient to forestall crisis or resist its worst
consequences, would render many forms ofhumanitarian assistance progressively obsolete.

Photo © Ali Arkady/VII Mentor Program

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Indicators
Monitoring ICPD goals: selected indicators

page 116

Demographic indicators

page 122

Technical notes

page 128

THE STATE OF WORLD POPULATION 2015115

Monitoring ICPD Goals – Selected Indicators

Monitoring ICPD goals:
selected indicators
Maternal and Newborn HealthCountry,
territory orother area

Births attended
by skilled healthpersonnel, per centa
2006-2014

Adolescent birth rate
per 1,000 women
aged 15-19
1999-2014

Sexual and Reproductive HealthContraceptive
prevalence rate,
women aged
15-49,
any method
2015†

Contraceptive
prevalence rate,
women aged
15-49, modern
method2015†

Unmet need forfamily planning,
women aged
15-49
2015†

Education
Proportionof demandsatisfied,
women
aged 15-49
2015†

Secondary school
Adjusted primary
Genderschool enrolment, net parity index, enrolment, net percent of secondary
per cent of primaryprimaryschool-age children,
school-age children, education
1999-2014
1999-2014 1999-2014
malefemalemale
femaleGenderparity index,
secondaryeducation
1999-2014

Afghanistan

39

90

29

24

27

52

–

–

–

60

33

0.55

Albania

99

18

66

19

13

84

93

90

0.96

66

64

0.96

Algeria

97

12

59

51

13

82

98

96

0.98

–

–

–

Angola

47

191

19

13

28

40

97

74

0.77

15

12

0.81

Antigua and Barbuda

100

67

63

60

14

82

87

85

0.98

88

94

1.07

Argentina

97

70

62

58

15

80

100

99

0.99

86

92

1.07

Armenia

100

23

59

30

13

82

89

98

1.10

83

96

1.16

Aruba

–

34

–

–

–

–

94

98

1.04

73

81

1.10

Australia

99

14

68

65

10

87

97

98

1.00

85

86

1.01

Austria

99

8

68

65

10

87

–

–

–

–

–

–

Azerbaijan

97

47

57

22

14

80

90

88

0.98

88

86

0.98

Bahamas

98

40

67

65

12

85

94

99

1.06

80

86

1.07

Bahrain

100

15

66

43

11

85

100

98

0.99

95

92

0.97

Bangladesh

42

83

64

57

12

84

94

98

1.05

44

51

1.16

Barbados

98

49

60

57

16

79

97

97

0.99

84

96

1.15

Belarus

100

22

65

54

11

86

92

94

1.02

96

97

1.01

Belgium

–

8

69

67

9

88

99

99

1.00

96

97

1.01

Belize

96

64

58

54

17

78

100

100

1.00

72

77

1.08

Benin

77

98

17

10

31

36

100

88

0.88

50

34

0.68

Bhutan

75

28

68

66

11

86

89

92

1.03

56

64

1.15

Bolivia (Plurinational State of)

85

89

63

40

18

78

82

81

0.99

71

72

1.02

Bosnia and Herzegovina

100

11

48

17

17

74

–

–

–

–

–

–
1.16

Botswana

95

39

56

55

17

77

90

92

1.02

56

65

Brazil

98

65

79

75

8

91

–

–

–

–

–

–

Brunei Darussalam

100

17

–

–

–

–

95

95

1.00

91

93

1.02

Bulgaria

100

43

67

48

14

83

96

97

1.00

89

86

0.97

Burkina Faso

66

136

19

18

27

41

69

67

0.96

23

20

0.87

Burundi

60

65

28

23

30

48

100

90

0.90

22

21

0.93

Cabo Verde

78

92

62

58

15

81

99

97

0.98

65

75

1.14

Cambodia

89

57

58

40

13

82

100

97

0.97

40

36

0.92

Cameroon, Republic of

64

128

29

17

22

56

100

89

0.89

43

37

0.87

Canada

98

13

73

71

8

90

99

100

1.01

–

–

–

Central African Republic

54

229

24

13

23

50

81

64

0.79

18

10

0.52

Chad

23

203

6

3

23

21

96

75

0.78

16

5

0.33

Chile

100

50

65

62

13

83

92

92

1.00

86

89

1.03

China

100

6

83

83

4

96

–

–

–

–

–

–

China, Hong Kong SAR

–

4

80

75

5

94

100

99

0.99

87

87

1.00

China, Macao SAR

–

3

–

–

–

–

–

–

–

77

80

1.04

Colombia

99

85

78

72

8

91

91

91

1.00

71

77

1.08

Comoros

82

71

24

17

31

43

86

81

0.95

46

49

1.07

116

CATORS
I NDI NDI
ICATO
RS

Monitoring ICPD goals: selected indicators
Maternal and Newborn HealthSexual and Reproductive Health

Education
Secondary school
Adjusted primary
Genderschool enrolment, net parity index, enrolment, net percent of secondary
per cent of primaryprimaryschool-age children,
school-age children, education
1999-2014
1999-2014 1999-2014
malefemalemale
femaleGenderparity index,
secondaryeducation
1999-2014

Births attended
by skilled healthpersonnel, per centa
2006-2014

Adolescent birth rate
per 1,000 women
aged 15-19
1999-2014

Contraceptive
prevalence rate,
women aged
15-49,
any method
2015†

Contraceptive
prevalence rate,
women aged
15-49, modern
method2015†

Unmet need forfamily planning,
women aged
15-49
2015†

Proportionof demandsatisfied,
women
aged 15-49
2015†

80

135

23

9

27

45

Congo, Republic of the

93

147

47

23

18

73

88

96

1.09

–

–

–

Costa Rica

99

67

79

76

6

93

90

91

1.01

71

76

1.07

Country, territory
or other area
Congo, Democratic
Republic of the

37

35

0.95

–

–

–

Côte d'Ivoire

59

125

20

15

24

46

81

75

0.93

–

–

–

Croatia

100

12

66

42

11

85

98

100

1.02

92

95

1.03

Cuba

99

50

74

72

9

90

96

97

1.00

88

89

1.01

Curaçao

–

–

–

–

–

–

–

–

–

–

–

–
1.02

Cyprus

99

4

–

–

–

–

98

98

1.00

91

93

Czech Republic

100

11

78

69

7

92

–

–

–

–

–

–

Denmark

98

2

71

66

9

88

98

99

1.01

90

93

1.03

Djibouti

87

21

24

23

30

44

69

60

0.86

29

21

0.72

Dominica

100

47

63

60

14

82

96

99

1.03

76

82

1.07

Dominican Republic

98

90

72

69

11

87

90

88

0.98

58

66

1.15

Ecuador

94

100

73

61

9

89

96

98

1.02

82

85

1.04

Egypt

92

56

60

58

12

83

100

97

0.97

86

85

1.00

El Salvador

98

63

71

64

12

86

92

92

1.01

61

64

1.03

Equatorial Guinea

68

177

16

11

33

33

62

62

0.99

25

19

0.77

Eritrea

34

85

20

16

29

41

–

–

–

–

–

–

Estonia

99

16

65

59

13

84

97

97

1.01

88

90

1.02

Ethiopia

16

71

36

36

25

59

69

63

0.92

18

11

0.61

Fiji

100

28

50

43

19

72

98

100

1.02

79

88

1.11

Finland

100

7

75

72

8

91

99

99

1.01

94

94

1.01

France

97

9

74

72

6

92

99

99

1.01

97

98

1.02

French Guiana

–

84

–

–

–

–

–

–

–

–

–

–

French Polynesia

–

40

–

–

–

–

–

–

–

–

–

–

Gabon

89

115

34

21

25

57

–

–

–

–

–

–

Gambia

57

88

11

10

28

28

67

72

1.07

–

–

–

Georgia

100

40

52

37

17

75

96

97

1.01

92

92

1.00

Germany

99

8

67

62

10

87

99

99

1.00

–

–

–

Ghana

68

65

22

20

34

40

89

89

1.00

55

54

0.97

Greece

–

9

69

46

10

87

99

100

1.01

99

99

1.00

Grenada

99

53

64

60

13

83

98

98

1.00

80

81

1.02

Guadeloupe

–

21

58

51

16

78

–

–

–

–

–

–

Guam

–

60

54

45

17

76

–

–

–

–

–

–

Guatemala

63

92

57

48

17

77

88

88

0.99

49

45

0.92

Guinea

45

154

8

5

25

23

82

71

0.86

37

23

0.63

Guinea-Bissau

45

137

17

13

22

44

73

69

0.95

11

6

0.56

Guyana

92

97

45

44

27

63

70

80

1.14

86

100

1.16

Haiti

37

65

38

34

33

53

–

–

–

–

–

–

Honduras

83

99

73

64

11

87

89

91

1.02

45

53

1.19

Hungary

99

20

75

68

8

90

96

96

1.00

92

92

1.00

Iceland

–

7

–

–

–

–

98

98

1.01

89

89

1.00

India

52

39

60

52

13

82

92

89

0.97

–

–

–

Indonesia

87

47

63

59

11

85

95

96

1.01

77

76

0.98

THE STATE OF WORLD POPULATION 201 5

117

Monitoring
Selectedindicators
Indicators
Monitoring ICPD
ICPD Goals
goals: –selected
Maternal and Newborn HealthCountry, territory
or other area

Births attended
by skilled healthpersonnel, per centa
2006-2014

Adolescent birth rate
per 1,000 women
aged 15-19
1999-2014

Sexual and Reproductive HealthContraceptive
prevalence rate,
women aged
15-49,
any method
2015†

Contraceptive
prevalence rate,
women aged
15-49, modern
method2015†

Unmet need forfamily planning,
women aged
15-49
2015†

Education
Proportionof demandsatisfied,
women
aged 15-49
2015†

Secondary school
Adjusted primary
Genderschool enrolment, net parity index, enrolment, net percent of secondary
per cent of primaryprimaryschool-age children,
school-age children, education
1999-2014
1999-2014 1999-2014
malefemalemale
femaleGenderparity index,
secondaryeducation
1999-2014

Iran (Islamic Republic of)

96

35

77

59

7

92

98

96

0.98

84

79

0.95

Iraq

91

68

55

38

14

79

97

86

0.89

49

40

0.81

Ireland

100

9

67

62

11

86

100

100

1.00

99

100

1.01

Israel

–

10

71

53

9

89

97

98

1.01

97

100

1.03

Italy

100

6

65

49

11

85

99

98

0.99

91

92

1.01

Jamaica

99

72

72

68

10

88

92

91

1.00

72

76

1.05

Japan

100

4

57

50

16

78

100

100

1.00

99

100

1.01

Jordan

100

27

62

43

12

84

98

96

0.98

86

89

1.03

Kazakhstan

100

31

56

52

16

78

98

100

1.02

91

92

1.01

Kenya

62

101

57

56

19

76

83

87

1.04

57

55

0.97

Kiribati

80

49

28

22

27

51

–

–

–

66

73

1.11

Korea, Democratic People's
Republic of

100

1

70

63

11

87

–

–

–

–

–

–

Korea, Republic of

100

2

79

69

6

93

98

97

0.99

98

97

0.99

Kuwait

99

8

56

44

16

78

99

98

0.99

86

88

1.03

Kyrgyzstan

98

42

42

39

17

71

99

98

0.99

82

83

1.00

Lao People's
Democratic Republic

42

94

54

46

18

75

98

96

0.98

46

43

0.95

Latvia

99

15

68

60

12

85

97

98

1.01

86

88

1.01

Lebanon

–

18

63

40

13

83

99

93

0.94

67

68

1.00

Lesotho

78

94

60

59

18

77

78

82

1.05

27

42

1.56

Liberia

61

147

20

20

32

39

39

37

0.95

18

15

0.83

Libya

100

4

49

28

20

71

–

–

–

–

–

–

Lithuania

100

14

63

53

13

83

97

97

1.00

97

96

0.99

Luxembourg

100

6

–

–

–

–

95

96

1.01

84

87

1.04

Madagascar

44

147

46

37

19

71

77

78

1.00

30

31

1.02

Malawi

87

143

58

56

19

75

90

97

1.07

32

30

0.96

Malaysia

99

13

57

42

15

79

98

95

0.96

71

67

0.95

Maldives

99

14

42

34

25

63

93

94

1.01

46

53

1.14

Mali

56

178

12

11

27

31

78

68

0.88

39

32

0.80

Malta

1.05

100

16

81

59

5

94

95

95

1.00

80

84

Martinique

–

20

60

54

15

80

–

–

–

–

–

–

Mauritania

65

71

14

13

31

31

72

75

1.05

23

20

0.87

Mauritius

100

31

76

53

7

92

98

98

1.00

80

81

1.01

Mexico

96

84

73

67

11

87

97

99

1.02

66

69

1.04

Micronesia (Federated States of)

100

33

–

–

–

–

82

84

1.02

–

–

–

Moldova, Republic of

99

25

63

45

13

83

91

91

1.00

77

78

1.01
1.11

Mongolia

99

40

58

52

14

80

96

94

0.98

78

86

Montenegro

99

12

34

10

24

59

98

99

1.01

–

–

–

Morocco

74

32

68

58

10

88

99

98

0.99

59

53

0.90

Mozambique

54

166

18

16

28

39

90

85

0.95

19

18

0.98

Myanmar

71

17

52

49

16

76

–

–

–

46

48

1.05

Namibia

88

78

57

57

17

77

87

90

1.04

45

57

1.27

Nepal

56

87

52

48

24

69

98

97

0.99

58

62

1.06

Netherlands

–

5

68

65

10

87

97

97

1.00

92

93

1.01

CATORS
118118 I NDI NDI
ICATO
RS

Monitoring
ICPD
Goals
– Selected
Monitoring
ICPD
goals:
selected Indicators
indicators
Maternal and Newborn HealthSexual and Reproductive Health
Proportionof demandsatisfied,
women
aged 15-49
2015†

Genderparity index,
secondaryeducation
1999-2014

Adolescent birth rate
per 1,000 women
aged 15-19
1999-2014

New Caledonia

–

23

–

–

–

–

–

–

–

–

–

–

New Zealand

97

22

71

67

9

89

98

98

1.00

97

98

1.01

Country, territory
or other area

Unmet need forfamily planning,
women aged
15-49
2015†

Secondary school
Adjusted primary
Genderschool enrolment, net parity index, enrolment, net percent of secondary
per cent of primaryprimaryschool-age children,
school-age children, education
1999-2014
1999-2014 1999-2014
malefemalemale
femaleBirths attended
by skilled healthpersonnel, per centa
2006-2014

Contraceptive
prevalence rate,
women aged
15-49,
any method
2015†

Contraceptive
prevalence rate,
women aged
15-49, modern
method2015†

Education

Nicaragua

88

92

80

75

7

92

93

94

1.01

42

49

1.14

Niger

29

210

15

10

18

47

69

58

0.84

15

10

0.66

Nigeria

38

123

16

11

22

42

71

60

0.84

–

–

–

Norway

99

6

79

72

6

93

100

100

1.00

95

95

1.00

Oman

99

12

37

25

28

57

97

98

1.02

77

91

1.19

Pakistan

52

48

39

28

20

65

77

67

0.87

43

32

0.74

Palestine1

100

67

57

43

15

79

93

94

1.01

77

84

1.10
1.08

Panama

92

89

61

58

16

80

92

91

0.99

74

79

Papua New Guinea

53

65

37

29

25

60

90

83

0.92

–

–

–

Paraguay

96

63

77

68

6

92

81

81

0.99

63

68

1.07

Peru

90

68

74

52

9

89

95

94

1.00

76

77

1.01

Philippines

73

59

55

38

18

75

91

91

1.00

60

70

1.16

Poland

100

14

69

48

10

87

97

97

1.00

92

93

1.01

Portugal

–

12

77

70

7

92

95

97

1.01

93

97

1.04

Puerto Rico

–

45

78

69

6

93

83

87

1.05

72

77

1.07

Qatar

100

16

44

37

19

69

99

95

0.96

91

100

1.10

Reunion

–

43

72

70

9

89

–

–

–

–

–

–

Romania

99

36

69

54

10

88

90

90

1.00

–

–

–

Russian Federation

100

27

69

56

10

88

97

98

1.01

–

–

–

Rwanda

91

41

54

47

20

73

92

95

1.03

–

–

–

Saint Kitts and Nevis

100

75

59

55

16

79

81

84

1.04

82

88

1.07

Saint Lucia

99

50

57

54

17

77

95

93

0.97

80

81

1.01

Saint Vincent and the
Grenadines

99

70

65

62

13

84

97

95

0.98

84

87

1.03
1.12

Samoa

81

39

32

31

42

43

95

97

1.03

75

84

San Marino

–

1

–

–

–

–

93

93

1.00

–

–

–

São Tomé and Príncipe

82

110

41

36

33

55

93

92

0.99

46

53

1.17

Saudi Arabia

97

7

37

31

24

60

96

99

1.03

101

101

1.01

Senegal

59

80

18

17

30

38

76

83

1.08

24

18

0.76

Serbia

98

22

58

22

13

81

96

97

1.01

92

94

1.03

Seychelles

99

62

–

–

–

–

96

95

0.99

61

66

1.07

Sierra Leone

60

131

17

15

26

39

–

–

–

40

36

0.92

Singapore

100

3

66

58

11

86

–

–

–

–

–

–

Slovakia

100

21

71

59

10

88

–

–

–

–

–

–

Slovenia

100

5

75

64

8

90

97

98

1.01

94

95

1.01

Solomon Islands

86

62

39

32

21

64

82

79

0.97

33

29

0.88

Somalia

33

123

24

6

29

44

–

–

–

–

–

–
1.10

South Africa

94

54

65

64

12

84

95

95

1.00

62

69

South Sudan

19

158

7

3

30

19

48

34

0.71

–

–

–

Spain

–

9

67

63

12

85

98

99

1.00

95

97

1.02

Sri Lanka

99

24

72

56

7

91

94

94

1.00

83

87

1.05

Sudan

23

102

16

13

29

36

53

56

1.05

–

–

–

STAT EOF
OF WORLDWOR L D POPU
L AT ION 20 1201
2 5 119
119
THE STATEPOPULATION

Maternal and Newborn HealthCountry, territory
or other area

Births attended
by skilled healthpersonnel, per centa
2006-2014

Adolescent birth rate
per 1,000 women
aged 15-19
1999-2014

Sexual and Reproductive HealthContraceptive
prevalence rate,
women aged
15-49,
any method
2015†

Contraceptive
prevalence rate,
women aged
15-49, modern
method2015†

Unmet need forfamily planning,
women aged
15-49
2015†

Education
Proportionof demandsatisfied,
women
aged 15-49
2015†

Secondary school
Adjusted primary
Genderschool enrolment, net parity index, enrolment, net percent of secondary
per cent of primaryprimaryschool-age children,
school-age children, education
1999-2014
1999-2014 1999-2014
malefemalemale
femaleGenderparity index,
secondaryeducation
1999-2014

Suriname

91

66

52

51

19

73

80

81

1.01

48

57

1.20

Swaziland

82

89

64

62

15

81

84

86

1.02

32

39

1.20

Sweden

–

3

70

62

10

88

100

100

1.00

95

94

0.99

Switzerland

–

3

77

72

6

92

100

100

1.00

82

80

0.97

Syrian Arab Republic

96

75

58

41

15

79

66

65

0.98

44

44

0.99

Tajikistan

87

47

33

30

22

60

100

97

0.97

88

79

0.90

Tanzania, United Republic of

49

128

41

34

23

64

83

86

1.03

–

–

–

Thailand

100

60

79

77

6

93

96

95

0.99

77

82

1.06

The former Yugoslav Republicof Macedonia

98

19

49

17

18

73

92

92

1.00

79

77

0.97

Timor-Leste, Democratic
Republic of

29

54

29

26

26

53

92

91

0.98

36

40

1.11

Togo

59

77

21

19

34

39

98

87

0.89

32

15

0.48

Tonga

98

30

35

30

28

56

83

86

1.03

67

71

1.05
1.07

Trinidad and Tobago

100

36

50

44

19

72

99

98

0.99

70

75

Tunisia

99

7

64

53

11

86

100

100

1.00

–

–

–

Turkey

97

29

74

48

6

92

96

95

0.99

90

87

0.97

Turkmenistan

–

100

21

57

51

15

79

–

–

–

–

–

Turks and Caicos Islands

–

29

–

–

–

–

77

84

1.08

–

–

–

Tuvalu

98

42

34

27

28

55

85

87

1.02

70

89

1.28
0.95

Uganda

57

140

30

28

33

47

90

93

1.03

23

22

Ukraine

99

27

67

51

10

87

97

99

1.02

87

87

1.00

United Arab Emirates

100

34

48

39

20

71

99

97

0.98

73

79

1.09

United Kingdom

–

21

81

80

5

94

100

100

1.00

98

98

1.01

United States of America

99

27

75

69

7

92

92

92

1.00

86

88

1.02

United States Virgin Islands

–

59

69

62

11

87

–

–

–

–

–

–

Uruguay

98

60

77

74

8

91

100

99

0.99

68

76

1.12

Uzbekistan

100

26

67

61

10

88

93

90

0.97

–

–

–

Vanuatu

89

78

47

37

24

66

98

97

0.99

51

53

1.04

Venezuela (Bolivarian
Republic of)

96

101

70

64

12

85

95

93

0.98

72

78

1.09

Viet Nam

94

36

77

65

7

92

–

–

–

–

–

–

Western Sahara

–

–

–

–

–

–

–

–

–

–

–

–

Yemen

45

67

38

28

27

58

95

81

0.85

51

34

0.66

Zambia

64

145

51

45

20

72

93

93

1.01

–

–

–

Zimbabwe

80

120

66

65

11

85

93

95

1.02

44

44

1.01

CATORS
120120 I NDI NDI
ICATO
RS

Monitoring
ICPD
Goals
– Selected
Monitoring
ICPD
goals:
selected Indicators
indicators
Maternal and Newborn HealthSexual and Reproductive Health

Education
Secondary school
Adjusted primary
Genderschool enrolment, net parity index, enrolment, net percent of secondary
per cent of primaryprimaryschool-age children,
school-age children, education
1999-2014
1999-2014 1999-2014
malefemalemale
femaleGenderparity index,
secondaryeducation
1999-2014

Births attended
by skilled healthpersonnel, per centa
2006-2014

Adolescent birth rate
per 1,000 women
aged 15-19
1999-2014

Contraceptive
prevalence rate,
women aged
15-49,
any method
2015†

Contraceptive
prevalence rate,
women aged
15-49, modern
method2015†

Unmet need forfamily planning,
women aged
15-49
2015†

Proportionof demandsatisfied,
women
aged 15-49
2015†

Arab States

75

56

51

43

17

76

86

82

0.95

64

58

0.92

Asia and the Pacific

71

33 b

69

63

10

87

95

95

1.00

69

65

0.94

Eastern Europe andCentral Asia

98

30

65

47

11

86

95

94

1.00

89

89

0.99

Latin America andthe Caribbean

93

76 c

73

67

11

87

93

94

1.00

73

78

1.06

East and Southern Africa

56

112

39

34

24

62

86

84

0.97

35

33

0.93

West and Central Africa

48

128

18

13

24

42

78

69

0.89

38

31

0.83

More developed regions

–

18

70

61

10

88

96

96

1.00

90

91

1.01

Less developed regions

70

56

63

57

12

84

91

90

0.98

64

61

0.95

Least developed regions

–

113

40

34

22

64

–

–

–

–

–

–

World

71

51

64

57

12

84

92

90

0.99

67

65

0.96

World andregional data

NOTES
Data not available.
Women currently married/in union.
Figures include surveys conducted between 2006-2014 only. Live births for 2010-2015 is used as this is the mid-year of the included surveys.
Figures exclude Cook Islands, Marshall Islands, Nauru, Niue, Palau, Tokelau, and Tuvalu due to data availability.
Figures excludes Anguilla, Bermuda, British Virgin Islands, Cayman Islands, Dominica, Montserrat, Netherlands Antilles, Saint Kitts and Nevis,
and Turks and Caicos Islands due to data availability.
1 On 29 November 2012, the United Nations General Assembly passed Resolution 67/19, which accorded Palestine “non-member observer Statestatus in the United Nations…”

–
†
a
b
c

STAT EOF
OF WORLDWOR L D POPU
L AT ION 20 1201
2 5 121
121
THE STATEPOPULATION

Monitoring ICPD Goals – Selected Indicators
Demographic
indicators
Population

Life expectancy

Fertility

Country, territory
or other area

Total
populationin millions
2015

Average annual
rate of population
change, per cent2010–2015

Population
aged 10-24,
per cent
2015

Population
aged 0-14,
per cent
2015

Population
aged 15-64,
per cent
2015

Population
aged 65 andolder, per cent2015

Dependency
ratioLife expectancy at birth(years), 2010-2015

Total fertility rate,
per woman

2015

male

female2010-2015

Afghanistan

32.5

3.0

35

44

54

3

87.0

59

61

5.1

Albania

2.9

0.0

25

19

69

12

44.8

75

80

1.8

Algeria

39.7

1.9

24

29

66

6

52.6

72

77

2.9

Angola

25.0

3.3

33

48

50

2

99.9

50

53

6.2

Antigua and Barbuda

0.1

1.0

25

24

69

7

45.7

73

78

2.1

Argentina

43.4

1.0

24

25

64

11

56.5

72

80

2.3

Armenia

3.0

0.4

20

18

71

11

41.3

71

78

1.6
1.7

Aruba

0.1

0.4

21

18

70

12

44.0

73

78

Australia1

24.0

1.6

19

19

66

15

50.9

80

84

1.9

Austria

8.5

0.4

17

14

67

19

49.2

78

84

1.5

Azerbaijan2

9.8

1.4

23

22

73

6

38.0

68

74

2.3

Bahamas

0.4

1.5

23

21

71

8

41.2

72

78

1.9

Bahrain

1.4

1.8

22

22

76

2

31.4

76

77

2.1

161.0

1.2

30

29

66

5

52.5

70

72

2.2

Bangladesh
Barbados

0.3

0.3

20

19

67

14

50.4

73

78

1.8

Belarus

9.5

0.0

16

16

70

14

43.0

65

77

1.6

Belgium

11.3

0.7

17

17

65

18

54.2

78

83

1.8

Belize

0.4

2.2

32

33

64

4

56.8

67

73

2.6

Benin

10.9

2.7

32

42

55

3

82.0

58

61

4.9

Bhutan

0.8

1.5

29

27

68

5

46.9

69

69

2.1

Bolivia (Plurinational State of)

10.7

1.6

30

32

61

7

63.7

65

70

3.0

Bosnia and Herzegovina

3.8

–0.1

16

14

71

15

40.7

74

79

1.3

Botswana

2.3

2.0

29

32

64

4

55.3

62

67

2.9

207.8

0.9

25

23

69

8

44.7

70

78

1.8

BrazilBrunei Darussalam

0.4

1.5

25

23

73

4

38.0

77

80

1.9

Bulgaria

7.1

–0.7

14

14

66

20

51.9

71

78

1.5

Burkina Faso

18.1

2.9

33

46

52

2

92.2

57

59

5.6

Burundi

11.2

3.3

31

45

53

3

89.7

54

58

6.1

Cabo Verde

0.5

1.2

31

30

66

5

52.0

71

75

2.4

Cambodia

15.6

1.6

30

32

64

4

55.6

66

70

2.7

Cameroon, Republic of

23.3

2.5

33

43

54

3

84.3

54

56

4.8

Canada

35.9

1.0

18

16

68

16

47.3

80

84

1.6

Central African Republic

4.9

2.0

33

39

57

4

75.2

48

51

4.4

Chad

14.0

3.3

34

48

50

3

100.7

50

52

6.3

Chile

17.9

1.1

22

20

69

11

45.2

78

84

1.8

China31376.0

0.5

19

17

73

10

36.6

74

77

1.6

7.3

0.8

15

12

73

15

37.0

81

87

1.2

China, Hong Kong SAR4
China, Macao SAR

0.6

1.9

16

13

78

9

28.2

78

83

1.2

Colombia

48.2

1.0

26

24

69

7

45.6

70

77

1.9

Comoros

0.8

2.4

32

40

57

3

75.6

61

65

4.6

Congo, Democratic Republicof the

77.3

3.2

32

46

51

3

95.9

57

60

6.2

5

Congo, Republic of the

4.6

2.6

31

43

54

4

86.2

60

63

5.0

Costa Rica

4.8

1.1

24

22

69

9

45.4

77

82

1.9

22.7

2.4

33

43

55

3

83.5

50

52

5.1

Côte d'Ivoire

122
122

I NDI CATORSI ND ICATO R S

Demographic indicators
Population

Life expectancy

Total
populationin millions
2015

Average annual
rate of population
change, per cent2010–2015

Croatia

4.2–0.4Country, territory
or other area

Population
aged 10-24,
per cent
2015

16

Fertility

Population
aged 0-14,
per cent
2015

Population
aged 15-64,
per cent
2015

Population
aged 65 andolder, per cent2015

Dependency
ratioLife expectancy at birth(years), 2010-2015

Total fertility rate,
per woman

2015

male

female2010-2015

15

66

19

51.1

74

80

1.5

Cuba

11.4

0.1

18

16

70

14

43.4

77

81

1.6

Curaçao

0.2

1.3

19

19

66

15

51.1

75

81

2.1

Cyprus6

1.2

1.1

20

17

71

13

41.6

78

82

1.5

Czech Republic

10.5

0.1

15

15

67

18

49.5

75

81

1.5

Denmark

5.7

0.4

19

17

64

19

55.9

78

82

1.7

Djibouti

0.9

1.3

31

33

63

4

58.5

60

63

3.3

Dominica

0.1

0.4

–

–

–

–

–

–

–

–

Dominican Republic

10.5

1.2

28

30

63

7

57.8

70

76

2.5

Ecuador

16.1

1.6

28

29

64

7

55.6

73

78

2.6

Egypt

91.5

2.2

27

33

62

5

62.3

69

73

3.4

El Salvador

6.1

0.3

30

27

65

8

54.3

68

77

2.0

Equatorial Guinea

0.8

3.0

30

39

58

3

72.9

56

59

5.0

Eritrea

5.2

2.2

32

43

55

3

83.2

61

65

4.4

Estonia

1.3

–0.3

15

16

65

19

53.5

72

81

1.6

Ethiopia

99.4

2.5

35

41

55

4

81.6

61

65

4.6

Fiji

0.9

0.7

26

29

65

6

52.8

67

73

2.6

Finland

7

France

5.5

0.5

17

16

63

21

58.3

78

83

1.7

64.4

0.5

18

19

62

19

60.3

79

85

2.0

French Guiana

0.3

2.8

27

34

61

5

63.2

76

83

3.5

French Polynesia

0.3

1.1

25

22

70

8

42.2

74

79

2.1

Gabon

1.7

2.2

31

37

58

5

73.1

63

64

4.0

Gambia

2.0

3.2

32

46

52

2

94.2

59

61

5.8

Georgia8

4.0

–1.2

18

17

69

14

45.7

71

78

1.8

Germany

80.7

0.1

15

13

66

21

51.8

78

83

1.4

Ghana

27.4

2.4

31

39

58

3

73.0

60

62

4.2

Greece

11.0

–0.4

15

15

64

21

56.2

78

84

1.3
2.2

Grenada

0.1

0.4

27

27

66

7

50.7

71

76

Guadeloupe9

0.5

0.5

20

22

63

15

57.6

77

84

2.2

Guam

0.2

1.3

26

26

66

9

52.0

76

81

2.4

Guatemala

16.3

2.1

33

37

59

5

70.9

68

75

3.3

Guinea

12.6

2.7

32

43

54

3

83.8

58

58

5.1

Guinea-Bissau

1.8

2.4

32

41

56

3

78.4

53

57

5.0

Guyana

0.8

0.4

34

29

66

5

51.1

64

69

2.6

Haiti

10.7

1.4

31

34

62

5

62.3

60

64

3.1

Honduras

8.1

1.5

33

32

63

5

57.8

70

75

2.5

Hungary

9.9

–0.3

16

15

68

18

47.9

71

79

1.3

0.3

0.7

21

20

66

14

51.6

81

84

2.0

India

Iceland1311.1

1.3

28

29

66

6

52.4

66

69

2.5

Indonesia

257.6

1.3

26

28

67

5

49.0

67

71

2.5

Iran (Islamic Republic of)

79.1

1.3

23

24

71

5

40.2

74

76

1.7

Iraq

36.4

3.3

31

41

56

3

78.7

67

71

4.6

Ireland

4.7

0.3

18

22

65

13

53.7

78

83

2.0

Israel

8.1

1.7

23

28

61

11

64.1

80

84

3.1

Italy

59.8

0.1

14

14

64

22

56.5

80

85

1.4

THE STATE OF WORLD POPULATION 201 5

123

Monitoring ICPD
Demographic
indicators
Goals – Selected Indicators
Population

Life expectancy

Fertility

Total
populationin millions
2015

Average annual
rate of population
change, per cent2010–2015

Population
aged 10-24,
per cent
2015

Population
aged 0-14,
per cent
2015

Population
aged 15-64,
per cent
2015

Population
aged 65 andolder, per cent2015

Dependency
ratioLife expectancy at birth(years), 2010-2015

Total fertility rate,
per woman

2015

male

female2010-2015

Jamaica

2.8

0.4

28

24

67

9

48.6

73

78

Country, territory
or other area

2.1

Japan

126.6

–0.1

14

13

61

26

64.5

80

86

1.4

Jordan

7.6

3.1

30

36

61

4

64.8

72

76

3.5

Kazakhstan

17.6

1.6

22

27

67

7

50.3

64

74

2.6

Kenya

46.1

2.7

32

42

55

3

80.9

59

62

4.4

Kiribati

0.1

1.8

29

35

61

4

63.0

63

69

3.8

Korea, Democratic People's
Republic of

25.2

0.5

23

21

69

10

44.3

66

73

2.0

Korea, Republic of

50.3

0.5

18

14

73

13

37.2

78

85

1.3

Kuwait

3.9

4.8

19

22

76

2

32.1

73

76

2.2

Kyrgyzstan

5.9

1.7

27

31

64

4

55.3

66

74

3.1

Lao People's Democratic Republic

6.8

1.7

33

35

61

4

62.8

64

67

3.1

Latvia

2.0

–1.2

15

15

66

19

52.2

69

79

1.5

Lebanon

5.9

6.0

28

24

68

8

47.3

77

81

1.7

Lesotho

2.1

1.2

34

36

60

4

67.3

49

50

3.3

Liberia

4.5

2.6

32

42

55

3

82.9

59

61

4.8

Libya

6.3

0.0

25

30

66

5

52.4

69

74

2.5

Lithuania

2.9

–1.6

17

15

67

19

50.1

67

79

1.6

Luxembourg

0.6

2.2

18

16

70

14

43.7

79

84

1.6

Madagascar

24.2

2.8

33

42

56

3

80.3

63

66

4.5

Malawi

17.2

3.1

33

45

51

3

94.5

60

62

5.3

30.3

1.5

27

25

70

6

43.6

72

77

2.0

Maldives

0.4

1.8

28

28

68

5

47.4

75

77

2.2

Mali

17.6

3.0

32

48

50

3

100.2

57

57

6.4

Malaysia

10

Malta

0.4

0.3

18

14

66

19

50.8

79

82

1.4

Martinique

0.4

0.1

19

17

64

19

57.0

78

84

2.0

Mauritania

4.1

2.5

31

40

57

3

76.1

61

64

4.7

Mauritius11

1.3

0.4

23

19

71

10

40.6

71

78

1.5

127.0

1.4

28

28

66

7

51.7

74

79

2.3

Micronesia (Federated States of)

Mexico

0.1

0.2

36

34

62

4

62.4

68

70

3.3

Moldova, Republic of12

4.1

–0.1

19

16

74

10

34.6

67

75

1.3

Mongolia

3.0

1.7

24

28

68

4

47.6

65

73

2.7

Montenegro

0.6

0.1

20

19

68

14

47.7

74

78

1.7

Morocco

34.4

1.4

26

27

67

6

50.1

73

75

2.6

Mozambique

28.0

2.8

33

45

51

3

94.8

53

56

5.5

Myanmar

53.9

0.8

28

28

67

5

49.1

64

68

2.3

Namibia

2.5

2.3

32

37

60

4

67.3

62

67

3.6

Nepal

28.5

1.2

33

33

62

6

61.8

68

70

2.3

Netherlands

16.9

0.3

18

17

65

18

53.3

79

83

1.8

New Caledonia

0.3

1.3

23

22

68

10

47.9

74

79

2.1

New Zealand

4.5

0.7

21

20

65

15

54.0

80

83

2.1

Nicaragua

6.1

1.2

30

30

65

5

54.1

71

77

2.3

Niger

19.9

4.0

31

51

47

3

113.0

60

62

7.6

182.2

2.7

31

44

53

3

87.7

52

53

5.7

5.2

1.3

19

18

66

16

52.2

79

83

1.8

Nigeria
Norway13

124

I NDI CATORS

CATO
124124 I NDI NDI
ICATO
RS RS

Demographic indicators
Population

Life expectancy

Total
populationin millions
2015

Average annual
rate of population
change, per cent2010–2015

Oman

4.5

8.4

Country, territory
or other area

Fertility

Population
aged 0-14,
per cent
2015

Population
aged 15-64,
per cent
2015

Population
aged 65 andolder, per cent2015

Dependency
ratioLife expectancy at birth(years), 2010-2015

Total fertility rate,
per woman

2015

male

female2010-2015

21

21

77

3

30.0

75

79

2.9
3.7

Population
aged 10-24,
per cent
2015

Pakistan

188.9

2.1

30

35

61

5

65.3

65

67

Palestine14

4.7

2.7

34

40

57

3

76.0

71

75

4.3

Panama

3.9

1.6

26

27

65

8

53.4

74

80

2.5

Papua New Guinea

7.6

2.1

31

37

60

3

67.1

60

64

3.8

Paraguay

6.6

1.3

30

30

64

6

56.6

71

75

2.6

Peru

31.4

1.3

27

28

65

7

53.2

72

77

2.5

Philippines

100.7

1.6

30

32

64

5

57.6

65

72

3.0

Poland

38.6

0.0

16

15

70

16

43.8

73

81

1.4

Portugal

10.3

–0.4

16

14

65

21

53.5

77

84

1.3

Puerto Rico

3.7

–0.1

22

19

67

15

50.0

75

83

1.6

Qatar

2.2

4.7

19

16

83

1

20.1

77

80

2.1

Reunion

0.9

0.7

23

24

66

10

51.2

76

83

2.2

Romania

19.5

–0.8

16

16

67

17

48.9

71

78

1.5

Russian Federation

143.5

0.0

16

17

70

13

43.1

64

76

1.7

Rwanda

11.6

2.4

32

41

56

3

78.1

60

66

4.1

Saint Kitts and Nevis

0.1

1.2

–

–

–

–

–

–

–

–

Saint Lucia

0.2

0.8

26

23

68

9

47.3

72

78

1.9

Saint Vincent and the Grenadines

0.1

0.0

26

25

68

7

46.8

71

75

2.0

Samoa

0.2

0.8

31

37

58

5

74.0

70

76

4.2

San Marino

0.0

0.7

–

–

–

–

–

–

–

–

São Tomé and Príncipe

0.2

2.2

32

43

54

3

84.2

64

68

4.7

Saudi Arabia

31.5

2.3

24

29

69

3

45.9

73

75

2.9

Senegal

15.1

3.1

32

44

53

3

87.6

64

68

5.2

Serbia15

8.9

–0.5

19

16

67

17

50.1

72

78

1.6

Seychelles

0.1

0.7

21

23

70

7

43.5

69

78

2.3

Sierra Leone

6.5

2.2

33

42

55

3

81.9

50

51

4.8

Singapore

5.6

2.0

19

16

73

12

37.4

80

86

1.2

Slovakia

5.4

0.1

17

15

71

14

40.8

72

80

1.4

Slovenia

2.1

0.1

14

15

67

18

48.7

77

83

1.6

Solomon Islands

0.6

2.1

32

40

57

3

75.1

66

69

4.1

Somalia

10.8

2.4

33

47

51

3

98.1

53

57

6.6

South Africa

54.5

1.1

29

29

66

5

52.1

55

59

2.4
5.2

South Sudan

12.3

4.1

33

42

54

4

83.7

54

56

Spain16

46.1

–0.2

14

15

66

19

50.8

79

85

1.3

Sri Lanka

20.7

0.5

23

25

66

9

51.2

71

78

2.1

Sudan

40.2

2.2

32

41

56

3

78.0

62

65

4.5

Suriname

0.5

0.9

26

27

66

7

50.8

68

74

2.4

Swaziland

1.3

1.5

35

37

59

4

69.3

50

49

3.4

Sweden

9.8

0.8

18

17

63

20

59.3

80

84

1.9

Switzerland

8.3

1.2

16

15

67

18

48.8

80

85

1.5

Syrian Arab Republic

18.5

–2.3

33

37

59

4

70.0

64

76

3.0

8.5

2.2

30

35

62

3

60.9

66

73

3.6

Tajikistan
Tanzania, United Republic ofThailand

17

53.5

3.2

32

45

52

3

93.8

63

66

5.2

68.0

0.4

19

18

72

11

39.2

71

78

1.5

STATE
OF OF
WORLD
POPULATION
20 1201
5 5 125
125
THE
STATE
WORLD
POPULATION

Monitoring ICPD
Demographic
indicators
Goals – Selected Indicators
Population

Life expectancy

Fertility

Total
populationin millions
2015

Average annual
rate of population
change, per cent2010–2015

Population
aged 10-24,
per cent
2015

Population
aged 0-14,
per cent
2015

Population
aged 15-64,
per cent
2015

Population
aged 65 andolder, per cent2015

Dependency
ratioLife expectancy at birth(years), 2010-2015

Total fertility rate,
per woman

2015

male

female2010-2015

The former Yugoslav Republicof Macedonia

2.1

0.2

20

17

71

12

41.4

73

77

1.5

Timor-Leste, Democratic
Republic of

1.2

2.3

32

42

52

6

92.3

66

70

5.9

Togo

7.3

2.7

32

42

55

3

81.8

58

60

4.7

Country, territory
or other area

Tonga

0.1

0.4

32

37

57

6

74.3

70

76

3.8

Trinidad and Tobago

1.4

0.5

20

21

70

9

43.2

67

74

1.8

Tunisia

11.3

1.1

23

23

69

8

44.8

72

77

2.2

Turkey

78.7

1.7

25

26

67

8

49.7

72

78

2.1

Turkmenistan

5.4

1.3

28

28

68

4

47.9

61

70

2.3

Turks and Caicos Islands

0.0

2.1

–

–

–

–

–

–

–

–

Tuvalu

0.0

0.2

–

–

–

–

–

–

–

–

Uganda

39.0

3.3

34

48

49

3

102.3

56

59

5.9

Ukraine

44.8

–0.4

15

15

70

15

43.3

66

76

1.5

United Arab Emirates

9.2

1.9

17

14

85

1

17.8

76

78

1.8

United Kingdom

64.7

0.6

18

18

65

18

55.1

78

82

1.9

United States of America

321.8

0.8

20

19

66

15

50.9

76

81

1.9

United States Virgin Islands

0.1

0.0

20

20

62

18

61.2

77

83

2.3

Uruguay

3.4

0.3

22

21

64

14

55.9

73

80

2.0

Uzbekistan

29.9

1.5

27

29

67

5

49.7

65

72

2.5

Vanuatu

0.3

2.3

29

37

59

4

68.7

70

74

3.4

Venezuela (Bolivarian Republic of)

31.1

1.4

27

28

66

6

52.4

70

78

2.4

Viet Nam

93.4

1.1

24

23

70

7

42.5

71

80

2.0

Western Sahara

0.6

2.2

25

26

71

3

40.2

66

70

2.2

Yemen

26.8

2.6

34

40

57

3

75.6

62

65

4.4

Zambia

16.2

3.1

33

46

51

3

95.4

57

60

5.5

Zimbabwe

15.6

2.2

33

42

55

3

80.4

54

56

4.0

126126 I ND ICATO R SMonitoring ICPD Goals
Demographic– Selected Indicators
indicators
Population

World andregional data

Total
populationin millions
2015

Life expectancy

Average annual
rate of population
change, per cent2010–2015

Population
aged 10-24,
per cent
2015

Population
aged 0-14,
per cent
2015

Population
aged 15-64,
per cent
2015

Population
aged 65 andolder, per cent2015

Fertility

Dependency
ratioLife expectancy at birth(years), 2010-2015

Total fertility rate,
per woman

2015

male

female2010-2015

Arab States

339

2.0

29

34

61

5

63.9

67

71

3.5

Asia and the Pacific

3865

1.0

25 b

25 b

68 b

7b

46.3

68

72

2.2

Eastern Europe and Central Asia

265

0.8

22

22

68

10

47.7

68

76

2.0

Latin America and the Caribbean

629 a

1.1

26 c

26 c

67 c

8 c

50.1

71

78

2.2

East and Southern Africa

547

2.7

32

42

54

3

84.2

58

61

4.8

West and Central Africa

403

2.7

32

44

53

3

87.3

54

56

5.5

More developed regions

1251

0.3

17

16

66

18

51.5

76

82

1.7

Less developed regions

6098

1.4

26

28

66

6

52.5

68

72

2.6

Least developed regions

954

2.4

32

40

57

4

77.1

63

66

4.3

World

7349

1.2

25

26

66

8

52.3

69

74

2.5

NOTES
Data not available.
Figures exclude Netherlands Antilles due to data availability.
Figures exclude Cook Islands, Marshall Islands, Nauru, Niue, Palau,
Tokelau, and Tuvalu due to data availability.
c Figures exclude Anguilla, Bermuda, British Virgin Islands, Cayman
Islands, Dominica, Montserrat, Netherlands Antilles, Saint Kitts andNevis, and Turks and Caicos Islands due to data availability.
1 Figures include Christmas Island, Cocos (Keeling) Islands and Norfolk
Island.
2 Figures include Nagorno-Karabakh.
3 For statistical purposes, the data for China do not include Hong Kongand Macao, Special Administrative Regions (SAR) of China, and Taiwan
Province of China.
4 As of 1 July 1997, Hong Kong became a Special Administrative Region(SAR) of China.
5 As of 20 December 1999, Macao became a Special Administrative
Region (SAR) of China.
–ab

6 Figures include Northern-Cyprus.
7 Figures include Åland Islands.
8 Figures include Abkhazia and South Ossetia.
9 Figures include Saint-Barthélemy and Saint-Martin (French part).
10 Figures include Sabah and Sarawak.
11 Figures include Agalega, Rodrigues and Saint Brandon.
12 Figures include Transnistria.
13 Figures include Svalbard and Jan Mayen Islands.
14 Figures include East Jerusalem. On 29 November 2012, the United
Nations General Assembly passed Resolution 67/19, which accorded
Palestine “nonmember observer State status in the United Nations…”
15 Figures include Kosovo.
16 Figures include Canary Islands, Ceuta and Melilla.
17 Figures include Zanzibar.

STAT EOF
OF WORLDWOR L D POPU
L AT ION 20 1201
2 5 127
127
THE STATEPOPULATION

Monitoring ICPD Goals – Selected Indicators
Indicators of Mortality

InfantLife expectancy
Technical notes
mortality
M/F
Total
per
Data sources and definitions
1,000 live

Indicators of Education
Maternal
mortality
ratio

Primary enrolment(gross) M/F

Proportion
reaching grade 5
M/F

Reproductive Health Indicators
Secondaryenrolment(gross) M/F% Illiterate(>15 years)
M/Fbirths

The statistical tables in The State of World Population 2015 include
indicators that track progress toward the goals of the Programmeof Action of the International Conference on Population andDevelopment (ICPD) and the Millennium Development Goals(MDGs) in the areas of maternal health, access to education,
reproductive and sexual health. In addition, these tables include avariety of demographic indicators. The statistical tables support
UNFPA’s focus on progress and results towards delivering a world
where every pregnancy is wanted, every birth is safe, and every
young person’s potential is fulfilled.
Different national authorities and international organizations may
employ different methodologies in gathering, extrapolating or
analyzing data. To facilitate the international comparability of data,
UNFPA relies on the standard methodologies employed by themain sources of data. In some instances, therefore, the data in thesetables differ from those generated by national authorities. Data
presented in the tables are not comparable to the data in previous
issues of The State of World Population due to regional classifications
updates, methodological updates, and revisions of time series data.
The statistical tables draw on nationally representative household
surveys such as Demographic and Health Surveys (DHS) andMultiple Indicator Cluster Surveys (MICS), United Nationsorganizations estimates, and inter-agency estimates. They also
include the latest population estimates and projections fromWorld Population Prospects: The 2015 revision and Model-based
Estimates and Projections of Family Planning Indicators 2015
(United Nations Department of Economic and Social Affairs,
Population Division). Data are accompanied by definitions, sources,and notes. The statistical tables in The State of World Population 2015
generally reflect information available as of August 2015.

Monitoring ICPD goals: selected indicators
Maternal and newborn healthMaternal mortality ratio, per 100,000 live births. Updated
maternal mortality ratios are not included in this report because
they were not yet available when this publication went to press.
Births attended by skilled health personnel, per cent,
2006/2014.
Source: United Nations Inter-Agency and Expert Group on
Millennium Development Goals Indicators. Regional aggregatescalculated by UNFPA based on data from United Nations Inter-­Agency and Expert Group on Millennium Development Goals
Indicators. Percentage of births attended by skilled health personnel(doctors, nurses or midwives) is the percentage of deliveries
attended by health personnel trained in providing life-­saving
obstetric care, including giving the necessary supervision, care andadvice to women during pregnancy, labour and the post-­partum
period; conducting deliveries on their own; and caring for newborns.
Traditional birth attendants, even if they receive a short training
course, are not included.

CATORS
128128 T ECI NDI
HNICA
L NOTES

Births per Contraceptive
1,000
Prevalence
women
Any
Modernaged
methodmethods
15-19

HIV
prevalence
rate (%)(15-49)M/F

Adolescent birth rate, per 1,000 women aged 15-­19, 1999/2014.
Source: United Nations Population Division and United Nations
Inter-­Agency and Expert Group on Millennium Development Goals
Indicators. UNFPA regional aggregates calculated by UNFPA basedon data from United Nations Population Division. The adolescentbirth rate represents the risk of childbearing among adolescent
women 15 to 19 years of age. For civil registration, rates are
subject to limitations which depend on the completeness of birth
registration, the treatment of infants born alive but dead before
registration or within the first 24 hours of life, the quality of thereported information relating to age of the mother, and the inclusionof births from previous periods. The population estimates may
suffer from limitations connected to age misreporting and coverage.
For survey and census data, both the numerator and denominator
come from the same population. The main limitations concern age
misreporting, birth omissions, misreporting the date of birth of thechild, and sampling variability in the case of surveys.

Sexual and reproductive health
The United Nations Population Division produces a systematicand comprehensive set of annual, model-­based estimates andprojections for a range of family planning indicators for a 60-­year
time period. Indicators include contraceptive prevalence, unmet
need for family planning, total demand for family planning and thepercentage of demand for family planning that is satisfied among
married or in-­union women for the period from 1970 to 2030.
A Bayesian hierarchical model combined with country-­specifictime trends was used to generate the estimates, projections
and uncertainty assessments. The model advances prior workand accounts for differences by data source, sample population,and contraceptive methods included in measures of prevalence.
More information on family planning model-­based estimates,
methodology and updates can be found at <http://www.un.org/
en/development/desa/population>. The estimates are based on the
country-­specific data compiled in World Contraceptive Use 2015.
Contraceptive prevalence rate, women currently married/inunion aged 15-­49, any method and any modern method, 2015.
Source: United Nations Population Division. Model-­based estimatesare based on data that are derived from sample survey reports.
Survey data estimate the proportion of married women (including
women in consensual unions), aged 15-­49, who are currently using,respectively, any method or modern methods of contraception.
Modern or clinic and supply methods include male and female
sterilization, IUD, the pill, injectables, hormonal implants, condoms
and female barrier methods.
Unmet need for family planning, women aged 15-­49, 2015.
Source: United Nations Population Division. Unmet need for familyplanning. Women with unmet need for spacing births are those
who are fecund and sexually active but are not using any methodof contraception, and report wanting to delay the next child. This isa subcategory of total unmet need for family planning, which also
includes unmet need for limiting births. The concept of unmet need

points to the gap between women’s reproductive intentions andtheir contraceptive behavior. For MDG monitoring, unmet need isexpressed as a percentage based on women who are married or in aconsensual union.
Proportion of demand satisfied, women currently married/in union aged 15-­49, 2015. Source: United Nations Population
Division. Percentage of total demand for family planning among
married or in-­union women aged 15 to 49 that is satisfied.
Proportion of demand satisfied (PDS) = Contraceptive prevalence(CPR) divided by total demand for family planning (TD).
Where total demand = Contraceptive prevalence rate plus unmet
need for contraception rate (UNR), that is
TD = CPR + UNR and
PDS = CPR /(CPR+UNR)

Education
Male and female adjusted primary school enrolment, net
per cent of primary school-­age children, 1999/2014. Source:
UNESCO Institute for Statistics (UIS). The adjusted primary school
net enrolment ratio indicates the percentage of children of theofficial primary age group who are enrolled in primary or secondary
education.
Male and female secondary school enrolment, net per cent of
secondary school-­age children, 1999/2014. Source: UNESCO
Institute for Statistics (UIS). The secondary school net enrolment
ratio indicates the percentage of children of the official secondary
age group who are enrolled in secondary education.
Gender parity index, primary education, 1999/2014. Source:
UNESCO Institute for Statistics (UIS). The gender parity index (GPI)
refers to the ratio of female to male values of adjusted primaryschool net enrolment ratio.
Gender parity index, secondary education, 1999/2014. Source:
UNESCO Institute for Statistics (UIS). The gender parity index (GPI)
refers to the ratio of female to male values of secondary school net
enrolment ratio.

Demographic indicators

Division. These figures refer to the average exponential rate of
growth of the population over a given period, based on a medium
variant projection.
Population aged 10-­24, per cent, 2015. Source: UNFPA calculation
based on data from United Nations Population Division. These
indicators present the proportion of the population between age
10 and age 24.
Population aged 0-­14, per cent, 2015. Source: UNFPA calculation
based on data from United Nations Population Division. These
indicators present the proportion of the population between age
0 and age 14.
Population aged 15-­64, per cent, 2015. Source: UNFPA calculation
based on data from United Nations Population Division. These
indicators present the proportion of the population between age
15 and age 64.
Population aged 65 and older, per cent, 2015. Source: UNFPA
calculation based on data from United Nations Population Division.
These indicators present the proportion of the population between
aged 65 and older.
Dependency ratio, 2015. Source: United Nations Population
Division. Regional aggregates calculated by UNFPA based on datafrom United Nations Population Division. These indicators present
the ratio of dependents (people younger than 15 or older than 64)
to the working-­age population (those ages 15-­64). Data are shownas the proportion of dependents per 100 working-­age population.
Male and female life expectancy at birth (years), 2010/2015.
United Nations Population Division. Regional aggregates calculated
by UNFPA based on data from United Nations Population Division.
These indicators present the number of years newborn children
would live if subject to the mortality risks prevailing for the crosssection of population at the time of their birth.
Total fertility rate, 2010/2015. United Nations Population
Division. Regional aggregates calculated by UNFPA based on datafrom United Nations Population Division. These indicators present
the number of children who would be born per woman if she lived
to the end of her childbearing years and bore children at each age
in accordance with prevailing age-­specific fertility rates.

Total Population, in millions, 2015. Source: United Nations
Population Division. Regional aggregates calculated by UNFPA
based on data from United Nations Population Division. These
indicators present the estimated size of national populations atmid-­year.
Average annual rate of population change, per cent, 2010/2015.
Source: United Nations Population Division. Regional aggregatescalculated by UNFPA based on data from United Nations Population

THE STATE OF WORLD POPULATION 201 5

129

Monitoring ICPD Goals – Selected Indicators
Regional Classification
Indicators of Mortality

Indicators of Education

InfantLife expectancy
Maternal
Primary enrolment Proportion
Secondary% Illiterate
Births per Contraceptive
mortality
M/F
mortality(gross) M/F
reaching grade 5
enrolment(>15 years)
1,000
Prevalence
UNFPA averages presented atTotal
theperend of the statisticalratio
tables are calculated using
data
from
countries
and
areas
as
classified
below.
M/F(gross) M/F
M/F
women
Any
Modern
1,000
live
aged
The regional classifications include only the countries where UNFPA works.
methodmethods
births
15-19

Arab States Region
Algeria; Djibouti; Egypt; Iraq; Jordan; Lebanon; Libya; Morocco;
Oman; Palestine; Somalia; Sudan; Syrian Arab Republic; Tunisia;
Yemen
Asia and Pacific Region
Afghanistan; Bangladesh; Bhutan; Cambodia; China; Cook Islands;
Fiji; India; Indonesia; Iran (Islamic Republic of); Kiribati; Korea,
Democratic People’s Republic of; Lao People’s Democratic Republic;
Malaysia; Maldives; Marshall Islands; Micronesia (Federated Statesof); Mongolia; Myanmar; Nauru; Nepal; Niue; Pakistan; Palau;
Papua New Guinea; Philippines; Samoa; Solomon Islands; Sri Lanka;
Thailand; Timor-­Leste, Democratic Republic of; Tokelau; Tonga;
Tuvalu; Vanuatu; Viet Nam
Eastern Europe and Central Asia Region
Albania; Armenia; Azerbaijan; Belarus; Bosnia and Herzegovina;
Bulgaria; Georgia; Kazakhstan; Kyrgyzstan; Moldova, Republicof; Romania; Serbia; Tajikistan; The former Yugoslav Republic ofMacedonia; Turkey; Turkmenistan; Ukraine.
East and Southern Africa Region
Angola; Botswana; Burundi; Comoros; Congo, Democratic Republicof the; Eritrea; Ethiopia; Kenya; Lesotho; Madagascar; Malawi;
Mauritius; Mozambique; Namibia; Rwanda; Seychelles; South
Africa; South Sudan; Swaziland; Tanzania, United Republic ofUganda; Zambia; Zimbabwe
Latin American and the Caribbean Region
Anguilla; Antigua and Barbuda; Argentina; Aruba; Bahamas;
Barbados; Belize; Bermuda; Bolivia (Plurinational State of); Brazil;
British Virgin Islands; Cayman Islands; Chile; Colombia; Costa
Rica; Cuba; Dominica; Dominican Republic; Ecuador; El Salvador;
Grenada; Guatemala; Guyana; Haiti; Honduras; Jamaica; Mexico;Montserrat; Netherlands Antilles; Nicaragua; Panama; Paraguay;
Peru; Saint Kitts and Nevis; Saint Lucia; Saint Vincent and the
Grenadines; Suriname; Trinidad and Tobago; Turks and Caicos
Islands; Uruguay; Venezuela (Bolivarian Republic of)

CATORS
130130 T ECI NDI
HNICA
L NOT ESHIV
prevalence
rate (%)(15-49)
M/F

West and Central Africa Region
Benin; Burkina Faso; Cameroon, Republic of; Cape Verde; Central
African Republic; Chad; Congo, Republic of the; Côte d’Ivoire;
Equatorial Guinea; Gabon; Gambia; Ghana; Guinea; Guinea-­Bissau;
Liberia; Mali; Mauritania; Niger; Nigeria; São Tomé and Príncipe;
Senegal; Sierra Leone; Togo
More developed regions comprise Europe, Northern America,
Australia/New Zealand and Japan.
Less developed regions comprise all regions of Africa, Asia
(except Japan), Latin America and the Caribbean plus Melanesia,
Micronesia and Polynesia.
The least developed countries, as defined by the United Nations
General Assembly in its resolutions (59/209, 59/210, 60/33,
62/97, 64/L.55, 67/L.43) included 49 countries in June 2013: 34
in Africa, 9 in Asia, 5 in Oceania and one in Latin America and the
Caribbean. The group includes 49 countries —Afghanistan, Angola,
Bangladesh, Benin, Bhutan, Burkina Faso, Burundi, Cambodia,
Central African Republic, Chad, Comoros, Democratic Republic of
the Congo, Djibouti, Equatorial Guinea, Eritrea, Ethiopia, Gambia,
Guinea, Guinea-­Bissau, Haiti, Kiribati, Lao People’s Democratic
Republic, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania,
Mozambique, Myanmar, Nepal, Niger, Rwanda, Samoa, São Toméand Príncipe, Senegal, Sierra Leone, Solomon Islands, Somalia,
South Sudan, Sudan, Timor-­Leste, Togo, Tuvalu, Uganda, United
Republic of Tanzania, Vanuatu, Yemen and Zambia. These countries
are also included in the less developed regions.

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HUMANITARIAN GLOSSARY

The State of World Population 2015
SENIOR RESEARCHER
Therese McGinn
Heilbrunn Department of Population and Family Health, Mailman
School of Public Health, Columbia University

EDITORIAL TEAM
Editor: Richard Kollodge

RESEARCHERS AND AUTHORSJacqueline Bhabha
Harvard T.H. Chan School of Public Health; François-Xavier Bagnoud
Center for Health and Human Rights, Harvard University; Harvard
Law School

Publication and web interactive design and production:
Prographics, Inc.

Richard Garfield
Emergency Response and Recovery Branch, United States Centers
for Disease Control and Prevention;
Columbia and Emory Universities
Kirsten Johnson, M.D.
Department of Family Medicine, McGill University,
Montreal Canada; Humanitarian U
Gretchen Luchsinger

Digital developer: Hanno Ranck

ACKNOWLEDGMENTS
Mengjia Liang, Edilberto Loaiza and Rachel Snow in the UNFPA
Population and Development Branch analysed and aggregateddata in the indicators section of the report and provided estimatednumbers of pregnant women in countries affected by conflict or
natural disaster.
Source data for the report’s indicators section were provided by the
Population Division of the United Nations Department of Economic
and Social Affairs, the United Nations Educational, Scientific andCultural Organization and the World Health Organization.

COMPLEX EMERGENCY
A multifaceted humanitarian crisis in acountry, region or society where there
is a total or considerable breakdown
of authority resulting from internal orexternal conflict and which requires amulti-sectoral, international responsethat goes beyond the mandate orcapacity of any single agency and/or
the ongoing United Nations country
programme. Such emergencies have,in particular, a devastating effect onchildren and women, and call for acomplex range of responses.

Ramiz Alakbarov, Björn Andersson and Arthur Erken at UNFPA
reviewed drafts and helped shape the report.

Lisa Oddy
Humanitarian U
Monica Adhiambo Onyango
Boston University School of Public Health,
Department of Global Health
Sarah Shteir and Louise Searle
Humanitarian Advisory GroupRESEARCH SUPPORT
Amiya Bhatia
Harvard T.H. Chan School of Public Health
Chantilly Wijayasinha
Boston University School of Public Health,
Department of Global HealthMélanie Coutu
Humanitarian Studies Initiative, McGill University
UNFPA ADVISORY TEAM
Prudence Chaiban
Henia Dakkak
Ugochi Daniels
Abubakar Dungus
Danielle Engel

Editorial associate and digital edition manager: Katheline Ruiz

Howard Friedman
Ann Leoncavallo
Jacqueline Mahon
Rachel Snow

Colleagues from UNFPA offices in Amman, Bangkok, Bogota, Cairo,
Dakar, Istanbul, Johannesburg, Kathmandu, Monrovia, Panama
City and Skopje supported or guided the development of featurestories and photographs included in the report: Ghifar Al Alem,
Tamara Alrifai, Daniel Baker, Mile Bosnjakovski, Santosh Chhetri,Jens-Hagen Eschenbaecher, Adebayo Fayoyin, Gema Granados,
Habibatou M. Gologo, Calixte Hessou, Ruba Hikmat, Jorge Parra,
Elina Rivera, Shible Sahbani, Alvaro Serrano, Sonja Tanevska, Giulia
Vallese and Roy Wadia.
Anna Maltby wrote the feature about the Ebola crisis in Liberia.
Assignment photographers and videographers:
Nake Batev (Former Yugoslav Republic of Macedonia)
Daniel Baldotto (Colombia)
Abbas Dulleh, AP Images (Liberia)
Salah Malkawi (Jordan)
MAPS AND DESIGNATIONS
The designations employed and the presentation of material inmaps in this report do not imply the expression of any opinion
whatsoever on the part of UNFPA concerning the legal status ofany country, territory, city or area or its authorities, or concerning
the delimitation of its frontiers or boundaries. A dotted line
approximately represents the Line of Control in Jammu andKashmir agreed upon by India and Pakistan. The final status of
Jammu and Kashmir has not been agreed upon by the parties.
Cover photo: © UNFPA/Nake Batev

UNFPA
Delivering a world where
every pregnancy is wanted
every childbirth is safe andevery young person’s
potential is fulfilled©The United Nations Population Fund, 2015

DIRECT AND INDIRECT
EFFECT
A direct effect is a death or otheroutcome which occurred directly andprimarily because of a catastrophic
event. An indirect effect is a death orother outcome which occurred as an
eventual, but not immediate, result ofa single destructive act. Often theseoutcomes can be identified only on a
population basis, where direct effects
can be specified to the individual. For
example, if the mortality rate rises afteran event and there is no other cause
identified, these additional deaths
are considered the indirect effectof the event.

HUMAN RIGHTS
All human rights derive from thedignity and worth inherent in thehuman person. The concept of humanrights acknowledges that every single
human being is entitled to enjoy his or
her human rights without distinction
as to race, colour, sex, language,
religion, political or other opinion,
national or social origin, property,
birth or other status.

HUMANITARIAN ACTION
Humanitarian action provides lifesaving services and facilitates thereturn to normalcy for people andcommunities affected by natural andhuman-made disasters. It also seeks
to lessen the destructive impact ofdisasters and complex emergencies.

HUMANITARIAN CRISIS
An event or series of events that
represents a critical threat to thehealth, safety, security or well-beingof a community or other large groupof people, usually over a wide area.
Armed conflicts, epidemics, famine,natural disasters and other major
emergencies may all involve or lead toa humanitarian crisis.

HUMANITARIAN RESPONSE
Material and logistical assistance topeople due to needs created by conflictor disaster, and provided on the basisof an appeal by the government orinternational organizations.

INTERNALLY DISPLACEDPERSONS
Individuals who have been forced or
obliged to flee or to leave their homes
or places of habitual residence, inparticular as a result of, or in order toavoid, the effects of armed conflict,situations of generalized violence,violations of human rights or naturalor human-made disasters, and who
have not crossed an internationallyrecognized State border.

NATURAL DISASTER
A large-scale event where life and/or property is destroyed. For an event
to be recorded as a disaster in theinternationally recognized Centre
for Research on the Epidemiology ofDisasters database, at least one of thefollowing criteria must be met:
• Ten or more people reported killed.
• One hundred or more people reported
affected.
• A declaration of a state of emergency.
• A call for international assistance.
Natural disasters include droughts,
earthquakes, epidemics, extreme heator cold, floods, storms, tsunamis,
volcanic eruptions and wildfires.

PEOPLE AFFECTED BY
CONFLICT OR DISASTER
Individuals requiring immediate
assistance during a period of
emergency, i.e., requiring basic
survival needs such as food, water,
shelter, sanitation and immediate
medical assistance as the result of
the emergency.

REFUGEE
A person who, owing to a well-foundedfear of being persecuted for reasons ofrace, religion, nationality, membershipof a particular social group or politicalopinion, is outside the country of hisor her nationality, and is unable to, or
owing to such fear, is unwilling to avail
himself or herself of the protection ofthat country.

state of world population 2015

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ISBN 978-0-89714-987-7

SHELTER FROM THE STORM: A TRANSFORMATIVE AGENDA FOR WOMEN AND GIRLS IN A CRISIS-PRONE WORLD

Delivering a world where
every pregnancy is wanted
every childbirth is safe andevery young person's
potential is fulfilledstate of world population 2015

SHELTER
FROM THE
STORM
A transformative agenda
for women and girls in acrisis-prone world

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