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Research Article

Assessing the impact of the “one-child policy” in China: A synthetic control approach

Contributed equally to this work with: Stuart Gietel-Basten, Xuehui Han, Yuan Cheng

Roles Conceptualization, Writing – original draft, Writing – review & editing

Affiliation Division of Social Sciences, The Hong Kong University of Science and Technology, Hong Kong, PRC

Roles Data curation, Formal analysis, Methodology, Software, Writing – original draft

Affiliation Asian Infrastructure Investment Bank, Beijing, PRC

Roles Conceptualization, Formal analysis, Methodology, Software, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Population Research Institute, LSE-Fudan Research Centre for Global Public Policy, Fudan University, Shanghai, PRC

• Stuart Gietel-Basten, 
• Xuehui Han, 

• Published: November 6, 2019
• https://doi.org/10.1371/journal.pone.0220170
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There is great debate surrounding the demographic impact of China’s population control policies, especially the one-birth restrictions, which ended only recently. We apply an objective, data-driven method to construct the total fertility rates and population size of a ‘synthetic China’, which is assumed to be not subjected to the two major population control policies implemented in the 1970s. We find that while the earlier, less restrictive ‘later-longer-fewer’ policy introduced in 1973 played a critical role in driving down the fertility rate, the role of the ‘one-child policy’ introduced in 1979 and its descendants was much less significant. According to our model, had China continued with the less restrictive policies that were implemented in 1973 and followed a standard development trajectory, the path of fertility transition and total population growth would have been statistically very similar to the pattern observed over the past three decades.

Citation: Gietel-Basten S, Han X, Cheng Y (2019) Assessing the impact of the “one-child policy” in China: A synthetic control approach. PLoS ONE 14(11): e0220170. https://doi.org/10.1371/journal.pone.0220170

Editor: Bruno Masquelier, University of Louvain, BELGIUM

Received: October 24, 2018; Accepted: July 2, 2019; Published: November 6, 2019

Copyright: © 2019 Gietel-Basten et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The Hong Kong University of Science and Technology provided support for this study in the form of salaries for SGB, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The Asian Infrastructure Investment Bank provided support for this study in the form of salaries for XH, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Fudan University provided support for this study in the form of salaries for YC, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.

Competing interests: The authors have read the journal's policy and the authors of this manuscript have the following competing interests: SGB is paid employee of The Hong Kong University of Science and Technology, XH is paid employees of Asian Infrastructure Investment Bank, YC is paid employees of Fudan University. There are no patents, products in development or marketed products associated with this research to declare. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.

Introduction

In 2015, China finally ended all one-birth restrictions [ 1 ]. The move to a national two-child policy is intended to facilitate a more balanced population development and to counter aging. There is currently a large focus placed on the appraisal of the population control policies (often erroneously thought of as the ‘one-child policy’) imposed in the late 1970s [ 2 ]. The world's most comprehensive national-level population control policy has been subject to many criticisms, both domestically and internationally [ 3 , 4 ]. Sanctioned and unsanctioned instances of forced abortion [ 5 ], sterilization [ 6 ], and institutional financial irregularities [ 7 ] have been identified as bases for criticism. The policies have also been cited as the root cause of other challenges [ 8 ], including skewed sex ratios at birth [ 9 ], the questionable demographic data because of hidden children [ 10 ], and social problems associated with the enforced creation of millions of one-child families (like the social, economic, and psychological plight of couples who lost their only child and are now unable to have more children) [ 11 ].

On the other hand, China's population control policies have also been recognized as being effective. This ‘effectiveness’ is based on the estimations that hundreds of millions of births had been ‘averted’ [ 12 ] and the penalty of “above-quota-births” was found reducing births in rural China [ 13 ]. According to an environmentalist narrative, these births (and the resultant population growth) would have contributed to further climate change [ 14 ]. In 2014, for example, The Economist labeled the ‘China one-child policy’ as the fourth largest ‘action’ to slow global warming, estimated at 1.3bn tonnes of CO2 [ 15 ]. Elsewhere, the popular media, as well as other commentators, regularly espouse a ‘one-child policy' as a panacea to respond to perceived ‘overpopulation' and associated concerns of both an environmental and Malthusian nature. Indeed, UN Resident Coordinator in Kenya, Siddharth Chatterjee, said in 2017 the first annual Africa-China Conference on Population and Development, "China is an example to the rest of the developing countries when it comes to family planning."

These calculations of ‘births averted’ are based on various models, which employ counterfactual history. The estimate of ‘400 million births averted’ is attributed to the one-child population policy [ 16 ], which is usually calculated by holding earlier, higher fertility rates constant. Other estimates compared the Chinese experience with either a country or group of countries considered to be similar to China in terms of certain socioeconomic and political indicators. The problem with such counterfactual histories is that they are inevitably subjective and indicators considered did not enter into the model in a systematic way. Contrast to the estimation of 400 million births averted, the effect of the one-child policy is found to be small, especially for the long-run [ 17 ], which was attributed to the aggressive family planning program in the early 1970s [ 18 ] based on the findings that the birth rate of 16 countries with similar birth rates to that of China in 1970 declined significantly after 1979 and even sharper than what was observed in China [ 19 ].

To evaluate the impact of China’s population control policies, we employ the Synthetic Control Method where we compare China to a constructed ‘synthetic’ control population, which shares similar features with China during the pre-intervention periods. This innovative data- and math-driven methodology is used extensively in many disciplines, including public health [ 20 ], politics [ 21 ], and economics [ 22 ]. One of the caveats of our paper is that we cannot single out the ‘cohort’ effects. In addition to the socio-economic factors, the decline of TFRs might partially be the result that females entering childbearing age in 1970s did not think giving more births is “fashionable” compared to those who entered childbearing age in 1950s. Such mindset changes have been observed in Brazil [ 23 ]. Unfortunately, our approach cannot differentiate the cohort effect from the impact of social-economic factors. We have to bear in mind this caveat in the following analysis.

In the case of China, the first intervention (or ‘shock’) we seek to evaluate is the ‘Later-Longer-Fewer Policy’ introduced in 1973 [ 7 ]. Under this policy, a minimum age of marriage was imposed, as well as mandatory birth spacing for couples and a cap on the total number of children [ 24 ]. The rules were differentiated for men and women in rural and urban areas. Also, like the case in other countries, widespread contraception (and free choice) was introduced, coupled with large-scale education on family planning [ 25 ]. The second ‘shock’ is the ‘One-Child Policy' introduced in 1979, where a one-child quota was strictly enforced. Following initial ‘shock drives' of intensive mass education, insertion of IUDs after the first birth, sterilization after the second birth, and large-scale abortion campaigns, the policy quickly became unpopular and was reformed in 1984 and onwards, creating a very heterogeneous system [ 26 ]. Despite the series of reforms, the majority of couples in China were still subject to one-child quotas in the 1980s and 1990s.

Institutional Background

With high birth rates in the 1970s, the Chinese government had grown increasingly concerned about the capacity of existing resources to support the ballooning population. In response, from 1973, the Chinese government widely promoted the practice of ‘later-longer-fewer’ to couples, referring respectively to later marriage and childbearing, longer intervals between births, and fewer children. Rules were more severe in urban areas where women were encouraged to delay marriage until the age of 25 and men at 28 and for couples to have no more than two children. In the rural areas, the age of marriage was set at a minimum of 23 for women, and 25 for men and the maximum family size was set at three children. Birth control methods and family planning services were also offered to couples. The policy at the time can be considered “mild” in a sense that couples were free to choose what contraceptive methods they would use and the policy on family planning was more focused on the education of the use of contraceptives [ 27 ].

However, such mild family planning program was deemed insufficient in controlling the population, since it would not be able to meet the official target of 1.2 billion people by 2000 despite the large decrease in the total fertility rate (TFR) in the late 1970s. In 1979, the government introduced the One-Child Policy in the Fifth National People’s Congress, a one-size-fits-all model and widely considered the world’s strictest family planning policy. Some exemptions were allowed, and a family could have more than one child if the first child has a disability, both parents work in high-risk occupations, and/or both parents are from one-child families themselves. The State Family Planning Bureau aimed to achieve an average of 1.2 children born per woman nationally in the early and mid-1980s [ 27 ].

From 1980 to 1983, the one-child policy was implemented through "shock drives" in the form of intensive mass education programs, IUD insertion for women after the first birth, sterilization for couples after the second birth, and abortion campaigns for the third pregnancy [ 27 , 28 ]. Policies were further enforced by giving incentives for compliance and disincentives for non-compliance, though these varied across local governments [ 27 ]. Liao [ 29 ] identified the following as the usual benefits and penalties at the local level. Families with only one child can obtain benefits like child allowance until age 14; easier access to schools, college admission, employment, health care, and housing; and reduction in tax payments and the opportunity to buy a larger land for families in rural areas. Penalties for having above-quota births, on the other hand, include reduction in the parents’ wages by 10 to 20 percent for 3 to 14 years, demotion or ineligibility for promotion for parents who work in the government sector, exclusion of above-quota children to attend public schools, and, in rural areas, a one-time fine which may account for a significant fraction of the parents’ annual income.

The tight one-child policy was met by resistance, and the government allowed more exemptions [ 27 ]. Exemptions were drafted at the local level as the Chinese Communist Party’s Central Committee took into account the diverse demographic and socioeconomic conditions across China [ 30 ]. In 1984, the program allowed two births per couple in rural areas if the first child is a girl or if the family is from a minority ethnic group, but this was done only in six provinces. One significant change in the family planning policy is that couples with one daughter in rural areas could have a second child after a certain interval, which ranges from four to six years, and this was fully implemented in 18 provinces by the end of 1989. The performance of local cadres was also evaluated with family planning activity as the top criterion [ 27 ]. The stringency of the one-child policy was further moderated amid China’s commitment to the International Conference on Population Development held in Cairo in 1994. In 1995, the family planning program changed its stance from being target-driven to client-centered in adherence to international reproductive health standards. More attention was given to individual contraceptive rights, and the government allowed couples to choose their contraceptive method with the guidance of the professional and technical staff [ 22 ].

Throughout the 1990s, provinces amended their own regulations about the exemptions under the guidelines of the State Family Planning Commission, now the National Population and Planning Commission [ 30 ]. According to Gu et al. [ 30 ], the provincial-level exemptions on allowing more than one child in a family can be classified into four broad groups: (1) gender-based and demographic (if the couple living in a rural area had the only daughter, or they belong to one-child family themselves); (2) economic (if the couple work in risky occupations or have economic difficulties); (3) political, ethical, and social (if the couple belong to a minority ethnic group, the man is marrying into a woman’s family, the family is a returning overseas Chinese, or the person has the status of being a single child of a revolutionary martyr); and (4) entitlement and replacement (if the couple’s first child died or is physically handicapped, the person who is divorced or widowed remarries, or the person is the only productive son in a family of multiple children in the rural area).

While the central government had asserted that population control remains a basic state policy, it hardly implemented a uniform set of rules across the country, hence the varying exemptions across localities [ 30 ]. This was until the Population and Family Planning Law of 2001 was put into effectivity. The law summarized the rights and obligations of Chinese citizens in family planning and served as the legal basis for addressing population issues at the national level. This law still promoted the one-child policy, but couples were given more reproductive rights, including the right to decide when to have children and the spacing between children if having a second child is allowed, as well as the right to choose contraceptive methods. It also discussed the imposition of social compensation fees for those who violated the law, which will be collected by local governments and family planning officials [ 27 ].

The one-child policy was further loosened in 2013 when it was announced that two children would be allowed if one parent is an only child [ 31 ]. Basten and Jiang [ 32 ] summarized the popular views on the issues that can be addressed by this policy shift: skewed sex ratio at birth, projected decline of the working-age population, large number of couples who were left childless because of the death of their only child, and evasion and selective enforcement of fines for out-of-quota and unauthorized births. They, however, argued that this change in the one-child policy could only have minimal impact on the aging population and shrinking workforce because of fertility preferences to have only one child and a smaller likelihood of these births to occur.

It was announced in October 2015 that the one-child policy would be replaced by a universal two-child policy. Driven by some evidence that this relaxation of the policy has not achieved a significant birth boosting effect, the Chinese government has started in 2018 to draft a proposed law that will remove all the limits on the number of children families can have [ 33 ].

The Synthetic control method

As reflected in the above procedure, the core of this method focuses on finding the combination of countries that collectively resemble China before the intervention. The model automatically assigns different weights to different countries in such a way that the distance between the actual and synthetic China before the policy intervention will be minimized in terms of fertility rate and other related characteristics. The optimal weights then are applied to the other countries for the post-intervention period to obtain Synthetic China without either the 1973 intervention or the 1979 intervention.

The next step is to decide what variables should be included in vector Z. We chose to include the childbearing age, life expectancy at birth, and sex ratio of male to female between 0 and 4 years old as the non-economic variables. The childbearing age affects the mothers’ age-specific fertility intensity and the total fertility rate [ 34 , 35 ]. With the maximum fertility age being certain, higher childbearing age might imply lower TFR. The life expectancy at birth is related to age-specific mortality. With a lower mortality rate, fewer births are required to obtain a desired number of children. For example, as observed by Galor [ 36 ], the TFR declined while the life expectancy improved in Western Europe in the past half-century. The sex ratio of male to female represents the inner-gender competition. A higher sex ratio of male to female implies higher competition among males, so it is more rewarding for females to delay marriage and to give birth in exchange for opportunities to obtain a better match with males. Using data from England and a generalized linear model, Chipman and Morrison [ 37 ] confirmed the significant negative relationship between the sex ratio of male to female and birth rate, especially for the three age groups of females at 20–24, 25–29, and 30–34 years old.

The other group of variables included in vector Z is economic variables, such as GDP per capita and years of schooling. The New Home Economics approach [ 38 ] emphasizes the negative relationship between income and fertility rate through the role of the opportunity cost of parenting time. The model suggests that more children will consume more parenting time, which could otherwise be used to generate more income. Galor and Weil [ 39 ] strengthened the reasoning by arguing that the increase in capital per capita raises women’s relative wages because the complementary effect of capital to female labor is higher than to male labor. The increase in women’s relative wage raises the cost of children. Because of the resulting smaller population effect, the lower fertility further raises the GDP per capita. In addition to the parenting opportunity cost, the economic development might result in fertility declines through two other channels:(1)With economic development, the living standards improved and the mortality rate decreased so that parents can have the same desirable living kids with fewer births; and (2) With the economic development, people have more tools to save, for example, the pension system, which reduces the needs of having more offspring to finance the retirement. The relationships between the macro-economy and the fertility patterns are documented for China [ 40 , 41 , 42 ]. The years of schooling also affects fertility through the opportunity costs channel. Higher education is associated with higher productivity, which would induce the higher opportunity cost of raising children.

Our analysis uses the TFR data in the period of 1955–1959 from the United Nations’ World Population Prospects (WPP) and the annual TFR data in 1960 to 2015 from the World Bank’s World Development Indicators (WDI) except for the following five economies. For Curaçao, Luxembourg, Serbia, Seychelles, and Taiwan, we use the UN’s WPP data in the entire period of 1955 to 2015. Like in the TFR data, we use the life expectancy at birth data in the period 1955–1959 from the UN’s WPP data, while annual life expectancy data in 1960 to 2015 is obtained from the WDI, except for the following four economies. For Curaçao, Serbia, Seychelles, and Taiwan, we use the UN’s WPP in the entire period of 1955 to 2015. The whole data series of the male-to-female ratio of the population aged 0–4 years old are obtained from the UN. We use the expenditure-side real GDP at chained PPPs and the size of population data from the Penn World Tables 9.0 (PWT 9.0) to calculate the GDP per capita and get its natural logarithm. The average years of schooling data obtained from the Barro-Lee Database is used to measure the average level of education in a given country. Historical schooling data are only available at five-year intervals, so we apply a linear interpolation method to infer the annual data from 1950 to 2010. The average childbearing age data are from the UN’s WPP in the entire period of 1955 to 2015. Additionally, all WPP data, except the male-to-female ratio, are only available at a five-year interval, so we also employ the linear interpolation method to get the annual estimates.

The original dataset consisted of 184 countries, but after removing the countries with missing data for the needed variables from 1955 to 2010, only 64 countries remained in the final dataset for the analysis, including China. The final list of countries included in the analysis is provided in Table A in S1 File .

Empirical result

For simplicity, we label synthetic China as Synth China, whose characteristics are constructed using the values of the other countries and the countries’ corresponding weights. We present the average values of our target variable TFR and fertility-related variables for Synth China and our comparator in Table 1 . The column on China shows the actual numbers for China, while the column on Synth China displays the values for the counterfactual Synth China for the pre-1973 period and pre-1979 and post-1973 period. For comparison purposes, we also include the average values of all countries in the sample as our comparator to show how different it would be between actual China and the whole sample in the absence of synthesizing. Looking at the pre-1973 period, Synth China has the same average TFR of 5.85 as actual China, while our comparator has an average of 4.71. For the remaining variables, the values of Synth China are all closer to that of actual China than those of our comparator, which indicates that Synth China resembles actual China not only in terms of TFR but also in terms of other fertility-related characteristics. Looking at the pre-1979 and post-1973 period, the TFR of Synth China is again almost the same as that of actual China.

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https://doi.org/10.1371/journal.pone.0220170.t001

All the other variables of Synth China are more comparable to actual China than to our comparator, except for average years of schooling. The significant difference (1.65 years) in years of schooling for the period of 1973–1979 between China (4.66 years) and the Synthetic cohort (6.31 years) is mainly due to the school-year-reduction-reform to taken by the Chinese government during the cultural revolution period (1966–1976). The original 6 years of primary schooling, 3 years of middle school, and 3 years of high school (6-3-3) for the pre-1966 periods were reduced to 5-2-2, respectively [ 43 ]. That means the same length of years of schooling represented higher accomplishment in terms of a diploma during 1966–1976. Five years of schooling in this period indicated completion of preliminary school while it used to represent the unaccomplished preliminary school. Most countries included in the studies adopted the 12-year schooling system. If we measure the accomplishment of education by using the relative years of schooling, which is to scale down by the years required for completion of high school—52% (4.66/9) for actual China and 53% (6.31/12) for Synthetic cohort—we would have quite close level of relative years of schooling between China and the Synthetic cohort. Additionally, the difference in years of schooling between actual China and the Synthetic cohort was not as significant for the pre-1973 intervention period (1965–1973) as for the pre-1979 and post-1973 period is because even the implementation of the school-year-reduction-reform was started from 1966 it requires five years for the effects to be fully materialized. The education system was changed back to 6-3-3 system after 1976.

In the following simulation, we use the periods 1973–1979 and 1980–2015 as the post-intervention periods to quantify the impact of the first and second shocks, respectively.

The TFR simulated for Synth China assuming without the 1973 shock, with the 1973 shock but without the 1979 shock, and the actual TFR are plotted in Fig 1 . The dashed blue line represents synthetic China's simulated TFR in the period 1955–1979 assuming without 1973 shock. The gap between the Synth China and actual China (represented by the solid black line) between 1973 and 1979 is the reduction in the TFR caused by the 1973 intervention. The dotted green line is the TFR of Synth China estimated for the period 1973–2015 with the period 1973–1979 as the pre-intervention period set to search for the optimal weights, which is to find the best comparable countries with fertility behaviors like China with 1973 shock but without 1979 shock. The simulated TFR for periods after 1979 is supposed to represent the TFR of China with the 1973 policy but without the 1979 policy. Contrary to the commonly claimed radical effect, the “One-Child” policy in 1979 only induced a small dip in the TFR.

https://doi.org/10.1371/journal.pone.0220170.g001

As shown in Fig 1 , the TFR in synthetic China is already well above the real TFR, even before the 1973 shock. The reason is that the best fit found by the algorithm cannot match the whole pattern of actual TFR (a complete overlap of actual and simulated China) for the pre-intervention periods, especially for the pre-1973 period (blue line). As shown in section 3, the target function for optimization is ‖ X 1 − WX 0 ‖, which measures the distance between the mean of actual China and Syn China without the policy of 73&79 for years before 1973. When the pattern of actual TFR is not well regulated, the simulated TFRs for the pre-1973 periods cannot match actual China for each year of the time series but to match on the average over the periods. It is why for pre-1960 periods, the blue line is above the black line while for the periods of1960-1970, the blue line is below the black line. Our conjecture on the reason for the irregular pattern of actual China in pre-1973 periods is that the government had been in a population policy struggling during this period [ 44 ] and the after-effect of the great fluctuations caused by China's Great Leap Forward famine (1958–1962). For example, right after the promotion of birth control policy in 1957, the birth control was catalyzed as anti-government in 1958. Not until 1962, birth control was encouraged again. Such changes of direction of the policy were very hard to simulate by finding the best comparable. Additionally, we identify the official announcement of "Later-Longer-Fewer Policy" in 1973 as the "shock." The informal introduction of such an idea started from 1971 when the encouragement of birth control was included as a "national" strategic policy. But only until 1973, the policy was announced officially with details. This explains why the SynthChina with FP 73&79 is already above actual China in 1973.

One interesting observation is that the TFR of Synth China with 1973 shock but without 1979 shock is lower than the observed TFR since 2003. Combining with the fact that the TFR reported in the Sixth Census in 2010 is lower than the TFR of Synth China, this appears to be providing indirect evidence on the common suspicion that the statistics on fertility rate might be “too low” and therefore the fertility effect of the 1979 policy could have been overstated.

Next, we apply the permutation test to evaluate the significance and robustness of the estimations. To do this, we produce a simulated sample of 500 countries by randomly drawing with replacement from the actual sample of 63 countries with China being excluded. Each country is treated as if it were China and is subjected to the 1973 and 1979 shocks. We construct the synthetic TFRs by following the same procedure carried out for Synth China. For each year, we calculate 500 simulated gaps between actual and synthetic TFRs, as shown in Fig 2 . The gaps for the simulated countries are represented by the grey lines, while the 95% confidence intervals by the red lines. The solid line denotes the gap between actual and Synth China, which is well below the lower bound of the 95% confidence interval from 1973 to 1979, indicating a significant reduction impact from the 1973 shock ( Fig 2 ). Meanwhile, the TFR gap between actual and Synth China stays within the confidence interval from 1980 onwards, implying that the 1979 shock had no significant impact ( Fig 2 ).

(A)Permutation test with 1973 policy–gap between true TFR and synthetic TFR. (B) Permutation test with 1979 policy–gap between true TFR and synthetic TFR.

https://doi.org/10.1371/journal.pone.0220170.g002

Population projection is carried out by using Spectrum 10 , wherein the actual TFR was replaced by the synthetic TFR from 1979 to 2015.

As Fig 1 and Fig 2 show, had China not implemented its later-longer-fewer set of population control measures in 1973, the fall in TFR would have been much shallower. Translating this into total population, this would amount to a difference of around 85 million by the end of the 1970s ( Fig 3 ). The impact of the second ‘shock,' namely the introduction of the stricter control measures in 1979, appears to be much more muted. While there are differences in the 1980s as a result of the reform involving the regulation on marriage age, the TFR for Synth China and actual China are broadly in sync from the early 1990s. In terms of total population difference, Synth China is some 70 million lower than actual China by 2015, as shown in Fig 3 . As discussed above, this puzzling outcome of the second shock might be due to the overstating tendency of the fertility statistics. Based on the permutation tests shown in Fig 2 , we can conclude that the 1973 policy significantly reduced the population by 85 million, while the 1979 policy does not have a statistically significant impact.

https://doi.org/10.1371/journal.pone.0220170.g003

Furthermore, we use a bootstrap strategy to get the confidence interval for the population estimates assuming without the shock of 1973 policy. We randomly drew 500 sub-samples with the size of 90% of the original sample without replacement. For each sub-sample, we repeated the synthetic control approach to search for the best synthetic China in terms of TFR. Among the 500 subsamples, two samples cannot converge. Therefore, in the end, we have 498 Synthetic China. We further get the 5% lower and upper bounds of TFRs among simulated Synthetic China. Building on the 5% lower and upper bounds of TFRs, we further calculate the resulted population, with which to compare the actual population and get the corresponding reduced population. The lower and upper bounds of the reduced population serve as the 90% confidence interval of Synthetic China in terms of the population without 1973 policy shock. The corresponding reduction of the population associated with the 1973 policy is between 60 and 94 million.

As shown in Table 2 , the countries used to construct Synth China differed significantly between the 1973 and 1979 shocks. Before the 1973 shock, the greatest contribution was made by India (with a weight of 36.9%), a country that implemented a weaker family planning system and was characterized by high fertility throughout the 1970s [ 45 ]. Jordan, Thailand, Ireland, Egypt, and Korea came as the second to the sixth most comparable countries to China. All of them, except Ireland, had family planning policies. Jordan started family planning measures in the 1980s [ 46 ]; Thailand had done three rounds of family planning measures starting from 1963 to 1980 [ 47 ]; Egypt implemented three rounds of family planning measures in 1966, 1970, and 1979 [ 48 ]; and the family planning policy started in Korea in 1961 and lasted until the 1980s [ 49 ]. Even without any institutional background information, the synthetic control model has been able to select countries with family planning programs automatically.

https://doi.org/10.1371/journal.pone.0220170.t002

In the period 1973 to 1979, Korea overtook India as the country that most resembled China (75.2%). While the GDP per capita was considerably different between these two countries in this period (even in the current period), in the 1980s, they shared similarities in terms of the other variables not included in the model, including the GDP growth rate and the presence of an authoritarian political regime [ 50 , 51 ]. Furthermore, the Korean family planning system was extraordinarily comprehensive and was founded on new social norms around family size, as well as the development of rural areas in general [ 52 ]. Thailand still played an important role with a contribution of 16% to Synth China.

Robustness check

We further carried out several robustness checks by including the add-on policy intervention or altering the data coverage.

We examined first the impact of the commonly acknowledged temporary relaxation of the one-child policy during the late 1980s until the beginning of 1990s by using 1991 as another intervention year (Table B and Fig A in S1 File ). No significant impact was found.

A second robustness check done was performed by extending the coverage of the dataset. The baseline dataset of 64 countries used in the analysis was constructed by excluding countries with any missing value for the input and output variables from 1955 to 2010. Therefore, there is a possibility that countries sharing great similarities with China were excluded because of unavailable GDP per capita data in 1955 and onwards. The GDP per capita data were obtained from PWT 9.0, which is mostly accepted as one of the most reliable and complete sources of GDP data, especially when comparison across countries is required. To examine whether such exclusions would alter our conclusion, we revised our data construction by relaxing the time coverage requirement and allowing an unbalanced dataset for each shock. That is, if the input variables of a country for the required years by the Synthetic Control Method were available, we included it in the dataset. For example, countries previously excluded from our baseline model because of missing data on GDP per capita from 1955 to 1964 were included for assessing the impact of 1973 shock, and the availability of the GDP per capita data was only required from 1965 to 1973. It resulted in a dataset containing 103 countries for the 1973 shock and 123 countries for the 1979 shock (Tables C and D in S1 File ). Consistent with our baseline results, there was a significant decline in the TFR associated with the 1973 shock but insignificant impact with the 1979 shock (Table E and Fig B in S1 File ).

The final main robustness check done is restricting the coverage of countries in the dataset. We selected 25 countries as a focus group that had been subjectively recognized by previous literature as having similar fertility behavior as China (Table F in S1 File ). The focus group dataset with available data consisted of 17 countries for the 1973 shock and 20 countries for the 1979 shock. India, Indonesia, and Thailand were selected for Synth China in evaluating the 1973 shock and Korea, and Thailand was selected for Synth China in evaluating the 1979 shock, which was fewer than in our baseline analysis (Table G in S1 File ). Interestingly, the permutation test showed that even for the 1973 shock, the gap between the TFR of Synth China and actual TFR is located within the 95% interval. This indicates the insignificant impact of the 1973 shock. However, since there were only 16 countries used to do the random draw for the 500 paths, the variation contained in the permutation test is very limited, which weakened the reliability of the test (Fig C in S1 File ). The lower bound of the 95% confidence interval was dominated by Korea. Korea experienced a much sharper decline in TFR in the 1970s. Excluding Korea, China had the largest gap in the TFR.

As a robustness check, we also replace the TFRs used in our analysis with the UN-provided interpolated annual TFRs. The result is consistent with our baseline findings (see Table H and Fig D in S1 File ).

Limitations and conclusions

Of course, our study has various limitations. Firstly, from a data perspective, it is arguable that the veracity evidence derived for China–and, indeed, reconstructed for other countries–over the past seven decades is to be open to interpretation. This potential challenge is acknowledged and would, indeed, affect any and all studies of Chinese population history. However, the main argument of the likely impact of these two shocks still holds. Secondly, by considering China as a national unit, we do not disaggregate and consider the impact of the interventions (and policy differentials) at the sub-national unit. For example, it may be that the 1979 intervention had a more significant impact in one province than in others, dependent on the social and economic conditions of that region, coupled with the particular ‘history’ of birth control policies there. By considering only the aggregate level, we lose this granularity. Such an exercise would be a fruitful future avenue of research. The final criticism is a more holistic one. Is the size, complexity, the political, and economic system of China so unique that it is possible to create a ‘synthetic China’ at all? For sure, China is ‘different’ to most, if not all, countries of the world. However, the principle of the synthetic control approach is simply to draw similarities from other places if and where they exist. In this way, such an approach is more systematic, transparent, and viable than simply drawing on a single country comparator or a basket of other regions. Indeed, it could be argued that all possible units of analysis (countries, regions, towns) are ‘unique’ in their own way.

In this paper, we used the synthetic control method to assess the impact of the "One-Child" policy in China. Our findings strongly suggest that had China followed a standard development trajectory combined with the continuation of its comprehensive population control policies introduced in 1973 (‘later-longer-fewer'), the decline in the TFR and hence total population size would have been similar under the conditions of the stricter one-child policy and its various reforms thereafter. While the policies implemented in 1973 were restrictive in terms of spacing, timing and the quantum total number of children, and were also stricter than almost any other contemporary family planning program, they were, undoubtedly, less restrictive than what followed.

The implications of this study are two-fold. Firstly, by suggesting that the impact of the birth control policies may have been exaggerated in the past, we can better understand why the response to their relaxation has been relatively muted–or, at least, well below popular expectation. Secondly: it is impossible to ignore the fact that the strict birth control policies introduced in 1979 brought with them numerous negative and possibly unforeseen consequences. As well as the sanctioned activities and corrupt abuses which occurred within the birth control policy framework, the policies have been linked to the highly skewed sex ratio [ 53 ], the presence of millions of shidu fumu families who have lost their only child [ 54 ] as well as other challenges in both the development of family systems and individual behavior. The long-term psychological consequences of prioritizing one-child families have yet to be fully explored, not least in the context of possible efforts to spur childbearing in the future.

In this context, our analysis suggests that the population control policies implemented from 1979 have no significant demographic effect compared to a looser operationalization of population control and economic development. An important lesson for other countries that are planning to introduce population controls: the stricter controls might not be the effective one.

Supporting information

S1 file. appendix..

https://doi.org/10.1371/journal.pone.0220170.s001

S2 File. Program and data.

https://doi.org/10.1371/journal.pone.0220170.s002

Acknowledgments

Disclaimer: The views expressed in this paper are those of the authors and do not necessarily reflect the views and policies of the Asian Infrastructure Investment Bank. The authors are responsible for any remaining errors in the paper.

The authors would like to thank Ma. Christina F. Epetia for her excellent research assistance.

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• v.1(1); 2019 Oct 31

Population aging in Japan: policy transformation, sustainable development goals, universal health coverage, and social determinates of health

Hiroki nakatani.

1 Human Resource Strategy Center for Global Health, National Center for Global Health and Medicine, Tokyo, Japan;

2 Keio University Global Research Institute, Tokyo, Japan.

Japan is aging rapidly, and its society is changing. Population aging and social change are mutually linked and appear to form a vicious cycle. Post-war Japan started to invest intensively in infectious disease control by expanding health services and achieving universal medical insurance coverage in 1961. The high economic growth in the 1960s contributed to generate a thick middle class layer, but the lingering economic slump after the economic bubble crisis after 1991 and globalization weakened this segment of society. Health disparity has been acknowledged and social determinates of health have been focused. In this article, the author reviewed the response course to health challenges posed by population aging in Japan, and aims to offer lessons to learn for Asian nations that are also rapidly aging. The core viewpoints include: i ) review health policy transformations until the super-aged society, ii ) discuss how domestic issues in aging can be a global issue, iii ) analyze its relationship with Japanese global health engagement, iv ) debate the context of social determinates of health, and v ) synthesize these issues and translate to future directions.

Introduction

Japan is aging rapidly, those over 65 already constituted 27.7% of the total population in 2017. This figure is the highest in the world and is projected to grow continuously up to 38.4% in 2065 ( 1 ). However, population aging is a result of remarkable success in health improvement and economic development in a country or region, and a similar trend is becoming visible globally, particularly in Asia. Hence, Japan is only a front runner of a future aging world, and her experience will be beneficial for countries that are to follow. However, the demographic impact of aging is more complicated than just a growing number of senior citizens. Another side of the coin is that decline in birthrate to below the death rate results in population decrease, and especially reduction of the young workforce. The population dynamics in Japan are very dramatic, as shown in Figure 1 . The Japanese population climbed to a peak within the twentieth century, and is projected to return to the level of the previous century within the next 100 years.

Long-term changes in total population and estimated future population. Data source: Population to 2010: materials prepared by National Spatial Planning and Regional Policy Bureau, Ministry of Land, Infrastructure Transport and Tourism (MLIT) based on the national census results by Ministry of Internal Affairs and Communications (MIC) and the analysis of long-term chronological population distribution data in the Japanese islands (1974) by National Land Agency. The population thereafter: materials prepared by National Spatial Planning and Regional Policy Bureau, MLIT based on Population Projection for Japan by National Institute of Population and Social Security Research (estimated in January 2012).

This demographic change poses challenges to all aspects of life for individuals and the society as a whole. How can we extend healthy lifespan, and not merely physical longevity? How is the extended lifespan supported financially? With an increasing in-need population and declining contributors, how can we sustain the social infrastructure including social security (medical insurance and pension) and other essential services such as transportation and response capacity to natural disasters? How can we perpetuate innovations and vitality in a predominantly aged society? All these are perceived as "clear and present dangers" and shared by Japanese leaders and the population as a whole.

Japanese were proud to achieve universal medical insurance coverage and pension in 1961 ( 2 ) and believe that this achievement has contributed to generate a thick healthy middle class layer, who has brought prosperity and stability in the 60', 70' and 80'. However, a success story itself could turn out to be a hurdle to introduce necessary changes, as Jared Diamond wrote in his book Collapse: How Societies Choose to Fail or Survive. The courage to make painful decisions about values, "Which of the values that formerly served society well can continue to be maintained under newly changed circumstances? Which of these treasured values must instead be jettisoned and replaced with different approaches?" is critical for sustaining a society ( 3 ). These words are particularly relevant to Japan, which is already a super-aged society with low birthrate and population decline.

With the above background, in this article, the author wishes to: i ) review health policy transformations until the super-aged society, ii ) discuss how domestic issues in aging can be a global issue, iii ) analyze its relationship with Japanese global health engagement, iv ) debate the context of social health determinates, and v ) synthesize these issues and translate to future directions.

Transformation of health policy until the super-aged society

Demographic change is not readily visible in daily life and is only appreciated when it becomes too apparent suddenly. However, while experts in demography can illustrate future population size and composition relatively easily, such "inconvenient truth" is difficult to communicate to the public as well as policymakers. Early warning was voiced. For example, the late Dr. Taro Takemi, Past President of Japan Medical Association published an article on Monthly Chuo- Koron, entitled "How can we cope with the growing number of senior citizens ?" in 1955. He foresaw that population aging required changes in health care delivery and demanded a critical review of future design in social security. All his concerns have proven to be real nearly half a century later when the "inconvenient truth" becomes too visible. Figure 2 illustrates the historical development or transformation of health policy in Japan until Japan becomes a super-aged society. Aging in other countries is also plotted to show how they may plan to introduce significant policy changes when their populations become aged progressively in the future as in Japan.

Aging rates of Asian countries and evolution of Japan's elderly care system. Data source: http://www8.cao.go.jp/kourei/whitepaper/w-2018/html/zenbun/s1_1_2.html

In this regard, the post-World War II health policies in Japan can be categorized into four phases: i ) towards UHC (until 1961); ii ) expansion of social security (until 1980); iii ) preparation for aging society (until 2000), and iv ) enhancing sustainability (until 2025).

Towards UHC (until 1961)

The central policy issues in the '50s were expansion of medical insurance and pension coverage for every citizen in Japan. Coverage started from large companies, public sectors and local communities, but small industry workers and their families were left behind. Universal coverage was finally achieved in 1961 when GDP per capita was US$563 (current equivalent) ( 4 ). At that time, the average life expectancy was 70.2 years for women and 66.0 for men, and the average age of the Japanese population was 28 years. The respective figures for 2017 were US$38,428, 87 years, 81 years for men, and 47 years.

Expansion of social security (until 1980)

The '60s were remembered for the amazing rate of economic growth, and Japan became the number 2 global economic power in 1968, replacing West Germany. Industrialization and urbanization progressed at a rapid pace. Old family-based welfare, while offering public support for impoverished people, was being challenged. The on Welfare for the Elderly Act was enacted in 1963, which expanded social support for senior citizens in need. According to the copayment system of medical insurance, service receivers should pay 30% of the cost each time they receive service (remaining 70% is directly claimed by the service providers to insurance bodies). Increasing political pressure that the 30% co-payment was discouraging senior citizens from accessing services drove the government to waive the copayment for seniors aged over 70 years in 1973. This scheme was judged feasible at that time, when the economy was strong and the proportion of senior citizens was less than 10%. The act was welcomed initially, but later proved too costly. Eventually, politicians paid a high political price when re-introducing the copayment, losing elections due to such an unpopular move. The evolution and remarkable outcomes as well as increasing challenges of the Japanese medical insurance system are well documented by Ikegami and Campbell ( 5 ).

Preparation for aging society (until 2000)

As the proportion of senior citizen increased to almost 10%, bureaucrats started to raise concerns over the trend of increasing medical expenditures. Mr. Hitoshi Yoshimura, Director-General of Insurance Bureau of Ministry of Health (1982 to 1984) and later Vice-Minister of Health (1984 to 1986) was a strong advocate of the urgent need for medical cost containment due to expensive health technologies and aging, among many other factors. Mr.Yoshimura was not shy to present his pessimistic view on the sustainability of social security, particularly medical insurance. He advocated various measures to "rationalize" medical cost. A significant outcome was the enactment of the Health and Medical Services Act for the Aged in 1982. The Act has two components: health promotion after age 40 and financial balancing mechanism to support medical insurance bodies, particularly community-based insurance bodies to pay medical bills of senior citizens.

Along with continued population aging and reduction of family size, Japan needed to consider socializing nursing care for the aged by expanding capacity of relevant institutions. Also, a consensus was reached that hospital admission due to "social" needs and not medical reasons should be a target of rationalization. This so-called "social hospitalization" phenomenon and the long waiting list to enter nursing homes became a political agenda in the national parliament as well as prefectural assemblies. This resulted in systematic investment from the public sector. The Ministry of Health, Ministry of Finance and Ministry of Home Affairs launched the "Gold Plan" in 1989 (over 65 population: 11.6%), investing 6 trillion yen to build more long-term care institutions. The plan was modified in 1994 (over 65 population: 14.1) to expand home care programs ( 6 ). These developments provided the infrastructure to introduce the long-term care insurance (LTCI) ( 7 ), which came into operation in 2000 (over 65 population: 17.4%). The LTCI covers both home and institutional care according to the assessed level of disability.

Enhancing sustainability (until 2025)

By implementation of the LTCI, the social security architecture for the aged was completed, with medical care insurance for sickness, pension for livelihood support and LTCI for long-term disability. However, upon entering the 21st century, the continuation of rapid aging and sharp birthrate decline questioned the sustainability of medical care insurance and pension. Attempts were made to increase the premium and copayment of service receivers and to enhance the efficiency of service providers as well as to expand public support for medical insurance bodies. Significant reforms were legislated in 2006 and 2015. However, it has been noted that the reform of medical insurance should be discussed in the broader context of social security. For example, the increase in demand for LTCI is greater than that for medical insurance. From 2000 to 2018, the number of users of the LTCI increased three-fold from 1.49 to 4.74 million. In response to such an increase in demand, the service cost rose from 3.6 to 10 trillion yen from 2000 to 2016, and the per capita insurance premium of senior citizens themselves also increased from 2911 to 5514 yen ( 8 ).

On the other hand, the medical cost grew but at a much moderate pace from 30.1 trillion yen in 2000 to 42.2 trillion in 2017. This was a result of tighter control of the health insurance reimbursement scheme, but this capping strategy posed challenges for both health care professionals and health care industries. A book entitled Collapse of Medical System ( 9 ) that addressed this issue became a bestseller in 2006.

In addition, due to the continued Japan economic slump after the economic bubble collapse in 1991, many young people failed to find full-fledged employment and accepted irregular jobs with less wages and lower insurance and pension contributions. Thus, social insurance premiums from workers were not raised. Altogether, balance sheets of both medical and long-term care insurance have deteriorated from reduced contributions and increased demand. The financial gaps are filled by transferring medical costs from young people to seniors within insurance bodies and infusion from tax revenues. Consequently, out of the 97.7 trillion yen government budget in FY 2018 ( 10 ), 33.8 trillion yen was spent on social security. Hence, health is the biggest budget item, six times larger than that for education, and science and technology, which is generally regarded as investment for future human capital.

All these generated needs to look at all aspects of social security by avoiding silo approaches to medical insurance and LTCI, as well as disproportionate consumption of the general budget. The government solution was to increase the consumption tax from 5% to 8% and eventually to 10% by 2019. A bipartisan agreement was reached in 2012 to use a considerable portion of the increased revenue to enhance the sustainability of social security, ahead of 2025 when the post-war baby boomers (1947-49) would reach the age of over 75 and demand greater medical and long-term care services. Hence, the National Council of Social Security Reform was called by the Cabinet Office, and a report ( 11 ) including a road map of "total reform" was submitted to the Office on 6 August 2013.

The report was perceived as unique in addressing challenges in a cross-cutting manner and recommending well coordinated policy change, taking into account changes of social, family and individual values. The report presented the grand vision and proposed reform on social measures to address the declining number of children, medical and long-term care insurance, and pension.

Convergence of global and domestic health agendas

If one turns attention to global health, it is surprising to see a convergence of the Japanese domestic agenda with the global health agenda. The life expectancy of the world has reached 71 years and many "developing countries" have graduated from being recipient countries to mid-income countries with limited access to development aid from more affluent countries. This was made possible by massive investments in control of diseases and infections (HIV/AIDS, tuberculosis, malaria, and neglected tropical disease) followed by maternal and child health. The former included access to medicine and preventive measures such as anti-retroviral medicines for HIV/AIDS and long lasting insecticide-treated bed-nets for malaria. These brought a drastic decrease in deaths and an increase in a healthy workforce that drove socio-economic development in once communicable disease-affected low-income countries. In the case of tropical diseases, a typical example is onchocerciasis or river blindness. This parasitic disease was a common cause of blindness among populations along the river side in tropical regions, particularly in West Africa. River side fertile farming land was abandoned due to the disease. However, mass preventive use of ivermectin (Mectizan) almost eliminated river blindness and led to economic recovery. The vicious circle of ill health and poverty was broken. The same was observed in Japan during the early post-war period. In 1954, the leading cause of death was tuberculosis, which consumed 28% of the medical care budget ( 12 ). The most affected population was young students and workers. Japan aggressively controlled tuberculosis by mass screening and case management at public health centers together with public financial support for care under official diagnosis and treatment regimens. That resulted in a sharp decline in mortality and morbidity. Healthier workers contributed to a remarkable economic growth, which was unprecedented in the world. Furthermore, the health infrastructure built for tuberculosis served as the basis for meeting changing health needs, such as control of non-communicable diseases (NCD). Mass screening originally designed for tuberculosis was used for early detection of hypertension, which was the main risk factor for brain hemorrhage and replaced tuberculosis as the leading cause of death in 1951.

This success story was convincing enough for Japanese leaders and politicians to engage themselves in global health cooperation. During the period of the economic bubble in Japan from 1986 to 1991, Japanese ODA was greatly expanded, which reaffirmed its "soft power" in foreign policy. Meanwhile, reflecting the end of the cold war, a new paradigm was sought globally. As a nation with a constitutional commitment to renounce war, Japan welcomed and promoted the new paradigm of international cooperation, from "security against war" to "human security", which addresses both "freedom from fear of war and other insecurity issues" and "freedom from want of better health and other human conditions" for all people. Human security became the principal value of Japanese diplomacy, and naturally Japan started to voice proposals for global health. At the 1998 Birmingham Summit, then Prime Minister Hashimoto proposed several steps to improve the effectiveness of international cooperation against parasitic diseases. In 2000, the Kyushu-Okinawa G8 Summit adopted the Okinawa Infectious Diseases Initiative, which led global fights against three major infections; HIV/AIDS, tuberculosis and malaria. In every subsequent G7/8 summit hosted by Japan, health was on the agenda in head of state meetings. For example, the G8 Hokkaido Toyako Summit in 2008 addressed the importance of health systems to support disease control activities. With this background, Japan welcomed sustainable development goals (SDGs), and the Prime Minister personally expressed his commitment repeatedly at the United Nations (UN) and in his contribution to the Lancet ( 13 ). The G7 Iseshima Summit in 2016 was the first summit meeting after the adoption of SDGs at the UN. The leaders addressed universal health coverage (UHC) as an approach for global health strategies for both communicable and non-communicable diseases under the SDGs framework. At the same time, they emphasized that health systems and UHC are the needed infrastructure to tackle health emergencies such as epidemics, which have been viewed as an increased risk in the interconnected world. The health topics at the summits had expanded from communicable diseases control to a more inclusive approach such as health systems and UHC, which is the course that Japan had taken with not only many successes but also bitter lessons. The Japanese experience can be useful for other nations, particularly Asian countries, which are experiencing a similar course of development and foreseeing rapid aging of their populations.

At the same time, Japanese politicians and business leaders have become more sensitive about the shrinking domestic market due to population aging and decline, and recognize the need to cultivate new industries beyond the production of consumer goods. Advisers to the Prime Minister identified the time gap of population aging among nations as business opportunities for health- and aging-related industries. Being a forerunner in population aging, Japan has been developing systems and technologies for the "silver" market, and hence may have a relative advantage. The linkage of domestic health and technology with global needs and issues as well as business is being formulated. To facilitate such transformation, The Health and Medical Strategy Promotion Act was promulgated in May 2014, which led to the establishment of Headquarters for Healthcare and Medical Strategy (hereinafter referred to as "Headquarters") in June 2014. The Headquarters served as an engine of coordinated policy, and the Cabinet approved the Healthcare Policy in July 2014, including a sentence "Healthcare Policy shall promote overseas activities of the healthcare sector by building mutually beneficial relationships with foreign countries, especially in the fields of medicine and long-term care". In addition, in preparation for the new paradigm of international cooperation beyond the millennium development goals (MDGs), the Headquarters approved the Basic Design for Peace and Health (Global Health Cooperation) in September 2015. The Basic Design emphasizes the importance of UHC and our commitment to SDGs. With this background, the Asia Health and Wellbeing Initiative (AHWIN) ( 14 ) was launched in 2016 with wide participation by public and private entities in Japan and international collaborators.

Japan's engagement in global health

The forum for Japanese health diplomacy was G7/G8 summits and multi-lateral UN agencies such as WHO, mainly on the basic framework of human security and SDGs. However, the global environment changed with the emergence of other groups such as BRICs, and G7 leadership also changed the global picture of engagement of G20 countries. The USA and the UK, which had been generous donors in the past, are paying more attention to their domestic issues, while the relative position of Japan and Germany in global health has gained more weight. Also, UHC involves non-health sectors, particularly the Ministry of Finance, private sectors and communities. From this perspective, Japan has started to expand collaboration with the World Bank group in establishing global financing facilities for health and nutrition for mothers and children, as well as pandemic emergency financing facilities. Such collaboration is being expanded to the Regional Banks such as the Asia Development Bank. Also, Japan's stewardship in organizing the G20 Meetings has several characteristics, including head of state meetings including both finance and health ministers, and a separate health minister meeting focusing on UHC, aging and emerging infections including antimicrobial resistance. The series of meetings and communiques left a legacy of serious involvement of G20 in global health as well as its own domestic issues.

In the World Health Organization (WHO), the new Director-General, Dr. Tedros Adhanom Gehbreyesus was appointed in July 2017 by direct voting of all member states. He started to transform WHO into the "engine" to accelerate the achievement of SDG3: ensure healthy lives and promote well-being for all at all ages, through the 13th General Programme of Work ( 15 ) (GPW13). The GPW13 sets the targets of triple billion by 2023: one billion more people benefit from UHC; one billion more people have better protection from health emergencies, and one billion more people enjoy better health and well-being. The main pillar of the triple billion is UHC which is defined in one of the 13 targets under SDG3. Each goal of SDGs has a set of targets and indicators for monitoring. Target 3.8 under SDG3 states "Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all". The legitimacy of the UN comes from the approval of the heads of states gathered in the UN by the General Assembly's formal adoption of the SDGs in September 2015. Hence, in the next few years, all global health initiatives will link with the SDGs to justify their legitimacy, and Japan is committed to engage in both domestic and international activities.

Recognition of social determinants of health challenges and mitigation through SDGs/UHC

Commitment to SDGs urged Japan to review critically domestic challenges; for example, health gaps that were difficult to recognize in Japan. Under the post-war regime, the bipartisan political agenda was to generate and maintain a thick middle class layer, and the idea of social gaps and their linkage with health conditions tended to be rejected. However, the long economic slump after the economic bubble crisis together with globalization diminished traditional life-long full-time employment, and blue color jobs were increasingly taken up by Asian neighbors. Also, there were significant changes in the family and its value. Under such a social environment, the Japanese political climate became fluid, except the Koizumi Cabinet (2001-2006) which enjoyed populist support. However, Koizumi's market-oriented approach fueled the demand for fundamental social changes, leading to social movement that brought landslide victory for the opposition party, the Democratic Party of Japan (DPJ), in 2009. The DPJ raised many untouched issues such as poverty among young parents. The Party promised drastic overhaul of the county and attracted initial support. However, due to the rapid ascension of the Party, the leadership lacked skill and experience in running the government. Handling of the 11 March 2011 Tōhoku earthquake/tsunami and nuclear accident highlighted their weakness in governance. Eventually, they lost the general election in 2012. During the period of DPJ rule, evidence such as health disparity and social determinates of health was accumulated. Thereafter, the Liberal Democratic Party regained power and gave priority to economic revitalization, but did not forget the need to address social issues caused by aging and its consequences.

If we look at healthy longevity, Japan has a national health promotion strategy endorsed by the Cabinet since 1978 (revised in 1988). The earlier strategy emphasized the life-course approach, early detection of major NCDs and health promotive activities. The third version was renamed Health Japan 21 and was launched in 2000 with a clear aim of extending a healthy life expectancy. However, the progress report released in 2011 showed that out of 59 targets, only 16.9% were accomplished, 42.4% showed some progress, 23.7% were unchanged and 15.3% deteriorated. The unchanged or worsened targets include decreases in prevalence of metabolic syndrome, hyperlipidemia, and diabetic complications, and the number of steps walked per day. These results raised alarm. The second version of Health Japan 21 ( 16 ) issued in 2012 clearly states that the overarching objectives of the second version were to improve healthy life expectancy and narrow health gaps among prefectures (difference in lifespan of two years for men and 2.7 years for women). Then it urged national policies in the following areas: prevention of onset and progression of NCDs, maintaining functions for social wellbeing, cultivating an environment to support health maintenance, and improving lifestyle and social environment for nutrition, exercise, rest, alcohol consumption, smoking, and oral health.

After the turn of the century, the bipartisan political agenda has been the sustainability of social security; first pension, followed by medical insurance, and finally the long-term care insurance scheme. After several reform attempts of individual components, it was recognized that the individual approach had limitations and all components should be reviewed comprehensively. Also, there is broad consensus that our UHC would not be sustainable in the face of increasing senior citizens, declining workforce and increasingly intensive and costly care, as illustrated by the National Council of Reform of Social Security Report ( 11 ). The report proposed systematic and comprehensive reform across pension, medical insurance, long-term care insurance and support for child care. According to the Report, the government is moving to ensure universal coverage of client-centered comprehensive health, medical and nursing care support at the community level. This requires significant transformation of service provisions. For example, for a community with a high proportion of senior citizens, acute care service is likely over-supplied while services for chronic illness and rehabilitation may remain under-supplied. All prefectures are mandated by the revised Medical Care Act to plan and transform service provisions ahead of 2025 when the baby boomers become over 75.

However, aging challenges will continue. As illustrated in Figure 3 , the absolute number of senior citizens over 65 will reach a peak around 2042 when the sons or daughters of baby boomers become over 65. The ratio of senior citizens will continue to increase, but the absolute number will decline. However, the cohort of new seniors will be entirely different from previous generations. The likelihood of them being single and part-time workers before retirement will be much higher than the previous generation. The social determinants of health will matter very much because this generation may be disadvantaged in social capital.

Changes of age groups in Japan. Data source: http://www.ipss.go.jp/pp-zenkoku/j/zenkoku2017/pp_zenkoku2017.asp http://www.ipss.go.jp/ppzenkoku/j/zenkoku2017/db_zenkoku2017/db_s_suikeikekka_1.html

The ways forward: review and comments on recent policy

Prime Minister Abe was in office for 2,616 days at the end of February 2019 and became the second longest serving prime minister in post-war Japan, after Mr. Eisaku Sato who served 2,798 days. His priority for domestic policy is economic revitalization and active measures against aging and low birthrate. Moreover, he views these also from an international perspective, particularly Asia where rapid aging is progressing. In this context, the Basic Principles of the Asia Health and Wellbeing Initiative launched in 2016 was revised in 2018 ( 14 ). The underlying philosophy is to enhance cooperation to meet the common challenges of aging by i ) sharing Japanese experience (both positive and negative), ii ) expanding services with the concept of UHC, iii ) accepting care workers to train in Japan who will return home to serve their own aging populations, and iv ) R&D taking advantage of Japanese health services and products. This initiative is coordinated by the Cabinet Office, and inter-ministerial works have begun. For example, to accept more care workers, the Immigration Act was amended in 2018 to expand the target from care for the elderly to broader aspects of services and products that support long life, including housing and food.

As describe above, the Cabinet Office launched the Headquarters in May 2016 aiming to lead implementing the SDGs both domestically and internationally. Furthermore, the initiatives include establishment of the SDGs Promotion Roundtable Meeting, where a wide range of stakeholders (including government, NGO/NPOs, experts, private sectors, international organizations and domestic organizations) engage in constructive dialogue. Business communities also participate because they see tremendous opportunities. Echoing such government initiatives, the Japan Business Federation launched Society 5.0 for SDGs ( 17 ) with broad participation by business communities.

Synergetic efforts participated in by both public and private sectors have been started to address both domestic and international health challenges. Such spirit of public-private partnership to achieve win-win relations is a rare phenomenon in Japan, and is anticipated to create new value out of collaboration beyond social/ corporate responsibilities. SDGs serve as a catalyst for collective efforts toward sustainable development and surely will occupy a central position in future health agendas in Japan and beyond.

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Please note you do not have access to teaching notes, homelessness: challenges and opportunities in the “new normal”.

Mental Health and Social Inclusion

ISSN : 2042-8308

Article publication date: 29 March 2024

This paper – the final paper of a series of three – aims to discuss the implications of the findings from a service user needs assessment of people experiencing homelessness in the Northwest of England. It will expand on the previous paper by offering a more detailed analysis and discussion of the identified key themes and issues. The service user needs assessment was completed as part of a review of local service provision in the Northwest of England against the backdrop of the COVID-19 pandemic.

Design/methodology/approach

Semi-structured questionnaires were administered and used by health-care professionals to collect data from individuals accessing the Homeless and Vulnerable Adults Service (HVAS) in Bolton. The questionnaires included a section exploring Adverse Childhood Experiences. Data from 100 completed questionnaires were analysed to better understand the needs of those accessing the HVAS.

Multiple deprivations including extensive health and social care needs were identified within the cohort. Meeting these complex needs was challenging for both service users and service providers. This paper will explore key themes identified by the needs assessment and draw upon further comments from those who participated in the data-gathering process. The paper discusses the practicalities of responding to the complex needs of those with lived experience of homelessness. It highlights how a coordinated partnership approach, using an integrated service delivery model can be both cost-effective and responsive to the needs of those often on the margins of our society.

Research limitations/implications

Data collection during the COVID-19 pandemic presented a number of challenges. The collection period had to be extended whilst patient care was prioritised. Quantitative methods were used, however, this limited the opportunity for service user involvement and feedback. Future research could use qualitative methods to address this balance and use a more inclusive approach.

Practical implications

This study illustrates that the needs of the homeless population are broad and varied. Although the population themselves have developed different responses to their situations, their needs can only be fully met by a co-ordinated, multi-agency, partnership response. An integrated service model can help identify, understand, and meet the needs of the whole population and individuals within it to improve healthcare for a vulnerable population.

Social implications

This study highlighted new and important findings around the resilience of the homeless population and the significance of building protective factors to help combat the multiplicity of social isolation with both physical and mental health problems.

Originality/value

The discussion provides an opportunity to reflect on established views in relation to the nature and scope of homelessness. The paper describes a contemporary approach to tackling current issues faced by those experiencing homelessness in the current context of the COVID-19 pandemic. Recommendations for service improvements will include highlighting established good practices including embedding a more inclusive/participatory approach.

• Homelessness
• Social exclusion
• Health inequalities
• Mental health
• Partnerships

Acknowledgements

The authors received no financial support for the research, authorship and/or publication of this article. The authors wish to acknowledge the contributions made by those with lived experience who completed the survey. Recognition and thanks are also given to those involved in the delivery of services that seek to improve the lives of those who are homeless.

Woods, A. , Lace, R. , Dickinson, J. and Hughes, B. (2024), "Homelessness: challenges and opportunities in the “new normal”", Mental Health and Social Inclusion , Vol. ahead-of-print No. ahead-of-print. https://doi.org/10.1108/MHSI-02-2024-0032

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International Population Policy Research Paper

Sample International Population Policy Research Paper. Browse other research paper examples and check the list of political science  research paper topics for more inspiration. If you need a research paper written according to all the academic standards, you can always turn to our experienced writers for help. This is how your paper can get an A! Also, chech our custom research proposal writing service for professional assistance. We offer high-quality assignments for reasonable rates.

There are two distinct but highly interrelated elements within international population policy. The policy set of goals and activities by states or international entities intended to influence and shape population outcomes in countries beyond their own national boundaries finds expression in both bilateral relationships and in multilateral activity. Bilateral activities seek to change population outcomes in specific countries. The collectivity of policies of the international community, expressed in multiparty international agreements, charters, covenants, and—most important for the population field—in international conferences and conference resolutions are multilateral. This activity is designed to standardize views and practices, and to form a world-view of desirable goals and outcomes. The two are linked. Countries with active national or bilateral programs also seek to influence the direction of multilateral, international population policy.

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Get 10% off with 24start discount code, 1. the unique context of the twentieth century.

Humans have probably always tried to manage fertility at the level of the individual and family. Rites and rituals to encourage fertility are time honored. There are also specific hieroglyphs in Egyptian antiquities citing herbal methods of contraception or abortion. More than a century before Christ, Polybius deplored both the tendency of comfortable urban Greeks to delay marriage and sharply reduce family size, and the resultant decline in population.

National concern and international preoccupation with population issues is very much a phenomenon of the last half of the twentieth century. While anxiety for the health impact on women of large families and unwanted pregnancy has been of long standing concern to health care providers, the major upsurge in interest in population issues originated in concern for the impact of rapidly accelerating global population numbers. Some appreciation of the remarkable quality of twentieth century demographic developments is therefore essential to understanding this policy evolution.

Never before the twentieth century did a human being live through a doubling of population; indeed the global population quadrupled between 1900 and 2000. The population increase in the 1990s alone was the equal of all of those who lived in the seventeenth century. In the preceding millennia, a good century for the human race was one in which the population grew at all. Plagues and normal high death rates in most societies ensured that this was not always the case.

Although everyone dies eventually, human death or mortality at an early age is what keeps population levels low. Absent high levels of mortality, migration, or decreasing fertility, population levels will increase. With the relative decline of famines and epidemics and increases in transport, communication, public health, and control of infectious diseases, nineteenth century Europe grew rapidly. About one-third of this increase was exported to colonies and overseas, a series of deliberate but minimally enunciated international population policies. The same spurt happened in post W.W. II in the nonindustrialized countries emerging from colonialism, or ‘developing world.’ The increases in numbers were bigger, and the pressure valve of migration was no longer available. The world was regarded as settled by the major players who controlled immigration flows.

When the global population numbers really began to grow, when the ability to count them improved markedly, and when attitudes regarding sexuality and family issues began to change in the industrialized world, population issues arrived on the global scene and international population policy began.

Twentieth century population growth changed the shape and weight of international relationships. Over 95 percent of the population increase of the last decades took place in the developing world. At the beginning of the century, almost one person in five was European; at the end, less than one-tenth of the world lived in Europe. The six billionth child was born in the last year of the century. That child will very likely live long enough to see the peak of human population and the stabilization of population numbers. The trends that will cause the decline of high fertility are well begun. Although another huge population increase will take place in the first two decades of the twenty-first century, the end of the high fertility period is in most places now in sight. International population policy in the twenty-first century will likely focus on different issues, already emerging.

2. The Content Of Population Policy: Sensitive, Fragmented, Confrontational

There has never been policy consensus on the nature, importance, or remedies in this field. The first stage of policy making revolved around the question of whether rapid population growth and high levels of fertility were in fact a threat, and what to do about them if they were. Many continued to insist that high levels of population growth were a transitory factor that would decrease with development and progress. The answer was seen to be investment in accelerated general development, not specifically targeted programs, i.e., ‘development is the best contraceptive.’

Those on the other side of the issue used phrases such as ’population bomb’ to describe what Malthus in the late eighteenth century foresaw as predictable crisis deriving from the geometric nature of human growth expansion, not sustainable by the foreseen linear growth of agricultural production. Concerns about the real and also postulated but never provable impacts of population growth expanded beyond food production.

Early advocates for international fertility reduction efforts voiced fears that such growth would lead to mass starvation, perpetual economic underdevelopment, internal conflict, and external wars to expand boundaries. In late 1960s there were confident assertions from certain US thinkers that the battle to feed humanity was over and that widespread famine would shortly begin. In later years, the list of concerns expanded to include the impact on the environment, climate change, and the battle to preserve biodiversity.

On the other side of the ledger, concern for the human rights implications of family planning programs and the emergence of feminist concerns in their turn significantly reshaped the content of international debate and many population programs. Family planning and contraception services began in the industrialized world with Margaret Sanger and Marie Stopes in the USA and UK, respectively. These programs were delivered through the medical model of a doctor–patient relationship. What developed in the 1960s and 1970s was the novel idea that the state, or a public health service provider, should provide these services on a mass basis in order to bring down the number of births. Thus was born the idea of officially endorsed (or at least tolerated) family planning programs. Begun in Southeast Asia in the 1960s, family planning programs spread throughout the developing world in the subsequent 20–30 years. Internationalization occurred as foreign states and international actors intervened in such domestic programs, sometimes providing the impetus for their creation. The full impact on policy of the multilateralization efforts came somewhat later, with the creation of an international network, influenced by and influencing the existing programs.

The tools of the family planning part of population policy were largely unavailable until the 1960s. Such contraceptives as existed in the first half of the twentieth century were unwieldy, unmentionable, and often illegal. The advent of the contraceptive pill in 1960 provoked a revolution in behavior in the industrialized world. With it grew the conviction that new contraceptives, especially those which could be injected, implanted, inserted, or swallowed as opposed to being applied at the time of sexual relations, had the potential to stop or slow the rising levels of population in the developing world.

Yet another part of debate centered on the degree of importance that should be accorded to these tools and to the provision of contraception services vis-a-vis other fertility-influencing interventions such as girls education. This issue was characterized as the ‘beyond family planning’ debate. Later, with feminism came a strong concern that women’s health issues must override concern for demographic increase in the population agenda. Included were preoccupations related to both the mechanism of program delivery, particularly targets, and several of the recently developed contraceptives. This discernibly altered and shaped population policy programs from the 1990s onward. The emergence of AIDS similarly pulled new elements related to the reproductive health of individuals into the population policy ambit.

These debates and uncertainties and the transitory coalitions that have endorsed particular actions at specific times have given changing goals and forms to international population policy.

While demographic trends can be discussed in statistical and abstract terms, and contraceptive techniques discussed in terms of their mechanisms of action, the reality of population change is grounded in the most personal human relationships, in human sexuality, and in highly sensitive social issues. These include the nature and power relationships that establish marriage, the role and status of women, the behavior of adolescents, definitions of morality and immorality, the ethical judgments related to sexual activity, and to the very value attached to life at various stages.

For this reason, the myriad of social institutions that define different societies, including organized religions and political forces, have strong interests in most population issues. The major religious have been supportive with the notable exclusion of official Roman Catholic policy and the orthodox elements of many established churches. The moral and ethical issues are complex and the introduction of state activity in these areas therefore often highly contentious. That foreign states might have an interest in the decision of a man and woman in another country to have or not have more children could not but raise very complicated issues indeed.

3. Population Issues Enter Foreign Policy

For most of human history, countries did not have population policies, domestic or international. There was a long tradition of hope for population increase as a sign that prosperity was edging out pestilence and disease. The 1901 Census reports for India expressed the cautious hope that population would increase in the decades ahead. Nongovernmental activity preceded both governmental and intergovernmental activities in the national and international spheres. A major step forward was the formation of the International Planned Parenthood Federation (IPPF) in 1952, which grew by the end of the twentieth century to be a federation of advocacy and service providing organizations in over 150 countries, supported by another 20. The Indian Family planning program began the same year, as did several US nongovernmental organizations (NGOs).

There was a major upsurge in population activities in the late 1960s. Governments became less timorous and more active. Several dozen heads of government agreed to come out in favor of moderating global population growth, and agreed to be featured with photos and quotations in a widely used poster campaign. The World Health Organization (WHO) began population activities. The UN Secretary General established in 1967 a Trust Fund which later became the UN Population Fund or UNFPA. The World Bank adopted a policy to lend for population activities after President Robert McNamara declared that population growth constituted a threat second only to the prospect of nuclear war. (Continuing ambivalence within the Bank about the actual impact of population growth on development has, however, meant that while loans are available in aid of Health Ministry programs, Finance and Planning ministries were never pressed by bank officials to support or give any special priority to population programs. Many other aspects of national management have been subject to such suasion over the years.)

3.1 The International Community Response: A Wide Spectrum Of Policy Perspectives, And Some Domestic Determinants

As foreign policy is the pursuit abroad of domestic policy goals, it could be postulated that even though the desired impact of bilateral population programs was to change outcomes abroad, donor countries would normally not have international population policies until they began to have domestic population policies. This was by and large the case. Most states approached the issue of their domestic population issues with a great deal of diffidence. President Eisenhower is widely quoted as saying that he could imagine ‘no subject less fit for government activity’ than family planning. The United States became the unquestioned global leader in this field (see Sect. 3.2), while a variety of stances characterized the roles and programs of other countries.

Sweden and the other Nordics countries were early financial supporters of family planning in developing countries, reflecting their relative lack of embarrassment in dealing with these issues domestically. In the later decades, as the influence of women’s health advocates grew at home and abroad, Sweden in particular disclaimed linkage between providing contraceptives to women to support them in their own family size decisions and any demographically related outcome.

Successive French governments pursued strong pronatalist policies at home in France and perceived that strong support for family planning programs abroad could well be seen as somewhat racist. There has never been major French support. The UK bilateral programs in many areas included a vigorous population component. Italian governments were widely believed to have exchanged peace with the Vatican on the domestic contraception abortion front in Italy, in exchange for Italian inactivity abroad. Canada was at one time the third largest supporter of population programs. Interest and support declined rapidly in the 1990s, probably reflecting aid officials’ desires to distance themselves from US programs, and some political level wish to avoid exacerbating deemed Quebec sensitivities. Both are longstanding elements of Canadian domestic policy.

The Netherlands from the mid-1990s dedicated a full 4 percent of their aid programs to population and reproductive health. They often played the role of coordinator and host to conferences and meetings on a variety of population-related issues. Their domestic belief in frank discussion and the provision of open explicit information starting at an early age has translated into an active international program.

Japan, under heavy US pressure, dedicated fairly large amounts of funding to population programs, very broadly defined. Once again, the impact of domestic constraints for a long time meant that the nonavailability of hormonal contraceptives to Japanese women precluded their inclusion in the aid package.

The developing world presented a mixed picture. Thinkers in Mexico, Egypt, and India before independence worried about population gains destroying the positive impacts of their own development efforts. India’s 1951 five-year plan had population program expenditures. The Southeast Asian countries were early and enthusiastic advocates with national programs established in Thailand, Taiwan, Singapore, and Korea. Over a two-decade period, most southern countries adopted some form of population policy, after a period of initial resistance on the part of many. Virtually all countries eventually formulated population policies, influenced by their own cultural and religious backgrounds, and development aspirations. Until the advent of the international conferences described below, only industrialized countries had international dimensions to their population policies. The advent of the conferences gave developing countries the opportunity to express views on population issues on the world stage.

Bilaterally, the Vatican has acted not as a state but as religious advisor to governments. It has been especially powerful in keeping official support away from these services in Latin America, and to some extent in Africa. This reluctance to endorse any form of contraceptive device continued to include proscriptions against condom use, even as the AIDS epidemic affected millions.

The Marxist countries during the Cold War period had an avowedly antifamily planning stance. The states of the former Soviet Union accorded little or no importance to the provision of contraception with subsequent high reliance on abortion. Population levels dropped sharply in many socialist countries and desperate, coercive measures were adopted by several. The pronatalist policies of Ceaucescu in Romania provided the sharpest example. The Marxian view was that difficulties caused by population growth really reflected maladjustment in wealth distribution. Although they did not proselytize to any major extent, this view was very strongly echoed by many developing countries in the early years. Particularly since it fit well with other themes of the New International Economic Order, the ‘development is the best contraceptive’ theme became the most commonly used rhetorical position in opposition to the new enthusiasm.

3.2 Global Leadership—The United States Role

Unquestionably, the global leader in this field has been the United States. American activity began in the 1960s and the US quickly became the most enthusiastic proponent of population programs. A bipartisan, centrist coalition in Congress maintained support for international family planning programs, even in the Reagan years. Domestic NGOs appeared in the US for the express purpose of lobbying for greater global attention to this issue. The early name of one such group—ZPG or Zero Population Growth—indicates the intensity of public policy concern that underlay US policy aimed stabilization of global population levels.

Later with the resurgence of the religious right and the 1990s shift to political conservatism, the abortion issue re-emerged to cause violent schisms in US society. It defined presidential campaigns, filled the courts, and provoked violence against domestic abortion providers. The bipartisan consensus that had supported the family planning programs shattered. Republicans’ public policy stance became the equation of family planning with abortion, and therefore opposition to all forms of public involvement in it. Democrats remained the champions of such programs.

The international policy reflection of this schism caused sharp reductions and severe restrictions on US support. Migration for economic improvement and to escape unfavorable political and social situations around the world will continue to be a growing population issue.

Specific measures of censure for China’s one-child policy were included in funding conditions. Multi-lateral organizations were cut off from funding. A so- called gag rule was enacted. It prohibited the release of US family planning funds to international or foreign NGOs which use their own funds to provide abortion services or participate in policy debates on abortion outside the United States. This measure, which would be unconstitutional in the USA itself, was put into effect once by administrative decree in the Reagan years, and again by law in the final Clinton years.

The US flag has flown higher over population assistance in most countries than anyone else’s. One of the advantages was the creation of unparalleled expertise in American government, nongovernmental, academic, and program delivery circles. The visibility was also a liability, especially in the early years when sensitivities were high about western enthusiasm for reducing southern births. Because of the intensity of US internal debate, and the rapidity of policy shifts, the US has often been at odds with the rest of the world. It was far out in front on global targets and Malthusian rhetoric in 1974, then pulled back a decade later when just about everyone else was finally coming to some policy consensus in favor of attenuating population growth.

3.3 The Tools Of Population Policy: Aid Programs

The tools of bilateral population programming have included policy statements, speeches, persuasion, advertising, and funding. Assistance has included policy-influencing computer simulations, assistance to demographic and census departments, soap opera presentations, and research on a wide variety of reproductive health elements. Much program activity focused very directly on the provision of family planning services. Funds have been provided for contraceptive development, dissemination, and for the creation of national family programs.

Family planning programs had no real counterpart in developed countries, and were often ‘vertical’ or stand-alone programs, like some immunization campaigns. They occasionally became the focus of religious, traditional, and xenophobic criticism. These clinics often provided the only services available or available to poor women. In terms of impact on fertility, family planning programs were deemed to have succeeded; they probably accounted for about 40 percent of the decline in otherwise anticipated births that characterized the world as the demographic transition progressed in the countries of Asia and Latin America.

Because of the sensitivity of population and reproductive health issues, many donor countries directed a substantial percentage of their assistance through multilateral and international delivery mechanisms. Almost US$500 million flowed through multilateral agencies two years after the 1994 Cairo Conference. The programs of the primary multilateral agency, the UN Population Fund, reached $320 million in its high water years, usually providing a channel for about 25 percent of available donor funding. World Bank lending at one point reached $500 but declined at the end of the century. The regional banks have not been major players, with some exception for the Asian Development Bank. An increasingly important element of support was the assistance provided by (largely US) foundations to the population field, reaching as high as $150 million just after the 1994 Cairo Conference.

Aid or official development assistance to population family planning was never large in relation to overall expenditures in the field or to overall levels of overseas development assistance. By the end of the twentieth century, developing countries were paying three-quarters of the costs of their own reproductive health and population programs.

Nor have population programs dominated the overall aid programs. Even within the US program, population assistance only ever represented about 7 percent of all US aid. Australia, Denmark, Finland, The Netherlands, Norway, and UK the population comprised about 3 percent and in France and Italy only 1 percent of their respective ODA programs. In dollar terms, when the totality of all countries’ official development assistance was running around US $60 billion per year, population assistance (mostly family planning) never got above $2.0 billion in total. Eight countries almost always supplied 90 percent of all population assistance. The US gave the biggest amount, usually about half of all bilateral aid to population. Denmark, Norway, Sweden, and The Netherlands gave higher percentages, relative to their own economic weight.

If not significant as a percentage of overall aid, or as a proportion of each countries’ aid program, foreign aid to population has often been very significant in relation to the total health budget of many developing countries. It has had a catalytic impact in determining the scope, content, impact, and in some places existence of programs across the world.

4. Multilateral Policy Making

The second zone of international population policy activity is multilateral or many sided in nature. It is important for two reasons. As just noted, multilateral organizations have been important sources of technical and capital assistance, and vital to program delivery. The second key multilateral activity relates to international population policy making within the international community. Here, all countries have roles; the multilateral organizations provide the venue and organization for this policy-making activity.

4.1 The Population Conferences—Policy Tracers Par Excellence

It is through the phenomenon of the international population conferences that the changes and shifts of international policy in this area can be traced. Margaret Sanger organized an international population conference in Geneva in 1920. It resulted in the formation of the first international nongovernmental population organization, the International Union for the Scientific Study of Population (IUSSP), mostly but not exclusively demographic in purview.

Modern population conferences are not like those of the World International Trade Organization where treaties are negotiated and monitored. Unlike conferences such as the 1948 Universal Declaration of Human Rights, they do not require countries to take legal steps to bring domestic activity into line with new policy norms. They are rather international conclaves of policy expression, where undertakings of good faith are made by all, and statements are made and resolutions drafted which together give a comprehensive picture of how the world’s thinking has evolved on an issue. They also give the world the opportunity to comment on individual programs: the one-child policy of China and the specific programs of Indonesia and India have from time to time drawn attention.

The preparatory work preceding such conferences is key, often including the collation of detailed country statements which can include reviews and revisions of laws, budgets, policies, and program descriptions. Most important, the preconference activity occasions consultation and negotiation on the domestic front in most countries. As the issue has internationalized, comparable activity takes place on a regional basis, and globally among NGOs. As NGOs and women’s groups have become more important players, both the openness of the preparatory process and the difficulty in reaching consensus have grown. At the conferences themselves, NGO representatives have come to take part in the delegations and to play a role in formulating the consensus documents. Generally, countries reflect at these conferences the positions they have adopted domestically. The Vatican chooses on this issue to behave as a State in terms of attendance at international conferences. It works through lobbying, diplomatic demarches, and public diplomacy.

Population conferences as international policy making occasions therefore provide highly visible venues for intense debate about sensitive reproductive health issues of safe abortion, genital cutting, violence against women, and services for adolescents. These continue to provoke confrontation and contention.

4.1.1 Bucharest—1974. By the end of the 1960s, there was considerable enthusiasm—in the industrialized world—for serious attention to be given to population levels in the developing world. Serious attention in this era really meant a focus on family planning. In Bucharest, the developing countries both contested the view that population growth was deleterious, and asked to be paid more for going along with the industrialized country view. The socialist states and developing countries successfully insisted on bringing development, broadly and loosely defined, into the equation. The industrialized world did not disagree—John D. Rockefeller stated that ‘… the only viable course is to place population policy solidly within the context of general economic and social development in such a manner that it will be accepted at the highest levels of government and adequately supported.’

Post-Bucharest, program content did not change appreciably, concentrating primarily on family planning with some maternal and child health elements.

4.1.2 Mexico—1984. Many countries in the developing world, notwithstanding enunciated public positions, implemented population-limiting policies and programs in the largest growth period in family planning program activity, from 1974 to 1994. The last region to adopt population policies was Africa, following the landmark African regional conference in 1984, part of the lead-up to the Mexico City Conference. The 1984 world, except for the Vatican and allies, was reasonably united behind these programs, and was demanding more support for them. The US administration was by that time in full retreat from former enthusiasm. ‘Population growth is neither positive nor negative; it is a neutral phenomenon’ became the leitmotif of the American administration position. Despite this policy level coolness, US budgetary and program support for continued growth in these programs were maintained.

4.1.3 Cairo—1994: A Near Universal Consensus On A 20-Year Program Of Action. The preparatory sessions for Cairo were extremely contentious with severe criticisms of the existing approach to population programs coming from both conservative forces and from the new strong feminist voices. The preconference work was arduous, and the result was a complex, far reaching program of action that scarcely touched demographic forecasts and forces, but acknowledged at great length the complex context within which decisions about childbearing are made. The conference and action plan focused on health services, education, economic development, and livelihoods for women.

There was general acceptance that family planning must be voluntary and available, something never before achieved in conference documentation. The programs were to be centered on the needs of the individual and provided in a context which would take the client’s entire reproductive health into account, particularly exposure to sexually transmitted diseases and AIDS. Targeted development interventions such as female education, credit for women, gender equity in inheritance and land ownership, infant and maternal mortality reduction, became explicit components of population policy.

Ninety percent of the 180 governments representing about 95 percent of the world’s population approved the action plan in totality; a few conservative countries and the Vatican approved it in part. A price tag of $17 billion was established for achieving the program.

There is fairly general agreement that the Cairo Conference made an appreciable difference to the field. Five years after Cairo, progress under the Action Plan was reviewed. Although the same issues provoked the same dissent from many of the same sources, there was consensus that considerable progress has been made in policy, program redesign, increased partnership, and collaboration directed toward implementation of the action plan. International aid fell away from rather than toward the $7.5 billion target collectively undertaken in Cairo, but many developing countries were found to have made policy legislative and or institutional changes in the area of population and development and reproductive health and rights. Improved transparency in governance, expanded activity of voluntary associations, improvements in communications, and legal and policy modifications were found to have advanced the prospects for the participatory approach seen to be at the center of successful implementation of reproductive health and rights programs. Much of course remained to be done: enormous problems of maternal mortality, violence against women, and unmet need for contraceptive services all persisted, and at the end of century, two-thirds of the world’s illiterates were girls and women.

5. The Future Of International Population Policy

Is international attention to population growth finished? One of the results of the Cairo Conference was a sharp refocusing of debate away from demographic concerns toward reproductive health issues. Analysis has continued but with a sharp diminution on discussion of several former key elements. In terms of program content, many now realized to be most important in addressing high levels of fertility, especially girls education, are being addressed for their own importance. As the world continues to urbanize, and as the situation of women improves in many areas, fertility levels will continue to decline, and with them, demographic growth. It is indeed possible that countries and groups will begin to discuss policy measures that have succeeded in raising family fertility intentions.

Judging from declining flows of development assistance, and of international attention, there will probably be relatively less attention paid to assisting with service provision. Some continuing attention will be given to the high levels of maternal mortality. Violence ainst women will continue to be addressed both nationally and internationally. The same levels of international assistance and interest do not, however, seem to be available in the service of reproductive rights, as could be mobilized to slow population growth, before it became politically incorrect to speak of doing so.

This is the case despite very high levels of measurable unmet need for contraceptive services and even though an additional two billion will be added to the global population before stability is reached, with most of that two billion added in areas where food and water are critical now. These pressing global issues will be addressed primarily by applying resources to freshwater availability, food production and availability, etc., and rather less to addressing the numbers of people in need of them.

There are three main issues that will likely form the core of international population policy in the future: reproductive health issues touching infectious disease, and the linked issues of migration and aging.

Reproductive health issues will occupy an expanding place in the global agenda, particularly those related to the spread of AIDS and other sexually transmitted diseases. The realization of the security threat posed by these diseases began to accelerate with the turn of the century.

Migration for economic improvement and to escape unfavorable political and social situations around the world will continue to be a growing population issue. A different set of international institutions and government departments from those concerned with fertility are the central actors on this issue.

While the dramatic nature of fertility increase in the twentieth century is widely known, there is considerably less appreciation of the fact that the equally dramatic decline in fertility has radically changed the number of people within age groups in many countries. Aging may well be the dominant policy issue of the twenty-first century. The spread of aging populations is uneven. While there are more Europeans moving into the over-65 year old category than the under 16 year old group, at the turn of the century there was still a 26:1 ratio in the other direction in the totality of the developing world. In developing countries that initiated rapid declines of fertility in the 1960s, such as Taiwan, Korea, China, Thailand, Mexico, and Brazil, issues connected with aging are now rising on the agenda. This issue will internationalize primarily because of the impact on migration created by declining labor force size, and the worries that this creates vis-a-vis social security pressures and health system financing.

Bibliography:

• Bongaarts J 1994 Population policy options in the developing world. Science 263: 771–76
• Cohen J E 1995 How Many People can the Earth Support? W W Norton, New York
• Brown L R 1995 Who Will Feed China: Wake-up Call for a Small Planet. W W Norton, New York
• Erlich P R 1968 The Population Bomb. Ballantine, New York
• Gulhati K, Bates L M 1994 Developing countries and the international population debate: Politics and pragmatism. In: Cassens (ed.) Population and Development: Old Debates, New Conclusions. Overseas Development Council, Washington, DC, and Transaction Publishers, New Brunswick, NJ
• Jain A (ed.) 1998 Do Population Policies Matter? (Fertility and Politics in Egypt, India, Kenya and Mexico). Population Council, New York
• JeJeebhoy S J 1995 Women’s Education, Autonomy, and Reproductive Behaviour. Clarendon Press, Oxford, UK
• Malthus T R 1798 An Essay on the Principle of Population. J. Johnson, London
• Myers N 1995 Environmental Exodus: An Emergent Crisis in the Global Arena. The Climate Institute, Washington, DC
• Sen G, Germain A, Chen L C (eds.) 1994 Population Policies Reconsidered: Health, Empowerment, and Rights. Harvard University Press, Boston
• Simon J L 1977 The Economics of Population Growth. Princeton University Press, Princeton, NJ
• Sinding S W, Ross J A, Rosenfield A 1994 Seeking common ground: Unmet need and demographic goals. International Family Planning Perspectives 20: 23–7, 32. Reprinted in Mazur LA (ed.) 1994 Beyond the Numbers: A Reader on Population, Consumption and the Environment. Island Press, Washington, DC
• United Nations Flows of Financial Resources in International Assistance for Population

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Why BlackRock’s C.E.O. Wants to Rethink Retirement

Larry Fink, who leads the world’s biggest asset manager, warns in his annual investor letter that an aging population will soon pose huge economic troubles.

By Andrew Ross Sorkin ,  Ravi Mattu ,  Bernhard Warner ,  Sarah Kessler ,  Michael J. de la Merced ,  Lauren Hirsch and Ephrat Livni

BlackRock’s chief wants to rethink a fiscal time bomb

As the chairman and C.E.O. of the asset management giant BlackRock, Larry Fink commands attention from companies and governments, helping spearhead movements like socially driven business and the need for companies to fight climate change.

In his latest letter to investors, published on Tuesday, Fink weighs in on a new topic: a looming global retirement crisis, and what can be done to address it.

The way retirement is handled around the world needs to change, Fink writes. Many countries will hit an aging tipping point within the next 20 years, according to his letter, but most people aren’t saving enough for when they stop working.

In the U.S. in particular, people are living longer, a trend that’s likely to grow given the advent of weight loss drugs like Wegovy, Fink writes. But he adds that four in 10 Americans don’t have $400 in emergency savings, let alone proper retirement funds.

“America needs an organized, high-level effort to ensure that future generations can live out their final years with dignity,” he writes, much as tech C.E.O.s and Washington banded together to shore up U.S. semiconductor manufacturing. Fink adds that he has a good vantage point for the problem, given that over half of BlackRock’s $10 trillion in assets are for retirement.

Fink said he wanted to kick off some hard conversations , and offered some initial suggestions:

Setting up retirement systems to cover all workers, even gig and part-time laborers, as 20 states have done;

Encouraging more employers to offer incentives like matching funds and making it easier to transfer 401(k) savings;

Creating systems that allow for 401(k)-like plans that provide pension-like predictable income streams, to reverse what Fink called a historical shift “from financial certainty to financial uncertainty.”

Fink also raises a politically fraught idea: raising the retirement age. The Social Security Administration has said that by 2034, it won’t be able to pay out full benefits, he notes:

No one should have to work longer than they want to. But I do think it’s a bit crazy that our anchor idea for the right retirement age — 65 years old — originates from the time of the Ottoman Empire.

Fink also defended climate-minded investing. His firm has become a target for conservatives for embracing the approach known as E.S.G. But the BlackRock chief said that the transition to green energy was inevitable. “It’s a mega force, a major economic trend being driven by nations representing 90 percent of the world’s G.D.P.,” he writes. (That said, he said he had stopped using the term “E.S.G.” because of its political toxicity.)

He is embracing what he calls “energy pragmatism.” That involves acknowledging the need for energy security, which for many countries will involve relying on hydrocarbons for years, along with cleaner energy sources. “Nobody will support decarbonization if it means giving up heating their home in the winter or cooling it in the summer,” he wrote. “Or if the cost of doing so is prohibitive.”

Fink added that BlackRock hasn’t advocated divesting from traditional energy companies, in part because some are investing in next-generation green tech like capturing carbon from the air.

HERE’S WHAT’S HAPPENING

The U.S. and Britain impose sanctions on elite Chinese hackers. The countries accused Beijing’s top spy agency of putting malware in key American infrastructure, including electrical grids and defense systems, and of stealing voting rolls for millions of British citizens. The moves represent an escalation of cyberconflict between Western powers and China.

Adam Neumann reportedly makes a formal bid for WeWork. The bankrupt co-working company’s former C.E.O. has offered more than $500 million to buy the business, according to The Wall Street Journal. It isn’t clear how Neumann will finance the proposal — Third Point, a hedge fund his lawyers had cited as a potential partner , isn’t involved — or whether WeWork’s management team will accept his approach.

A lawsuit by Elon Musk’s X against a research group is dismissed. A federal judge rejected claims that the Center for Countering Digital Hate , which published reports finding a rise in hate speech on the platform X since Musk took it over, had violated X’s terms of service. The lawsuit, the judge said, was “about punishing the defendants for their speech.”

The Francis Scott Key Bridge in Baltimore collapses. It was not immediately clear how many vehicles were on the bridge when a cargo ship rammed into the structure early on Tuesday. A White House official told Bloomberg that there was no indication of nefarious intent.

The Trump stock winners and losers

Meme-stock mania is back, and this time it has a political spin.

Investors and Donald Trump’s supporters are piling into Trump Media & Technology Group ahead of its first day of trading, extending a torrid rally that has bolstered the former president’s net worth on paper by roughly $4 billion .

Trump Media is the parent company of Trump’s social media platform, Truth Social. It closed its merger on Monday with a listed shell company, Digital World Acquisition Corp., creating a kind of proxy for investors to back a digital media business bearing his name as he runs for president.

“At some level, I’ve thought that many of the holders of D.W.A.C. viewed the stock as something akin to a call option on MAGA,” Steve Sosnick, the chief strategist at Interactive Brokers, told DealBook.

The rally has transformed Trump’s finances at a time when his business empire remains under threat from multiple legal troubles. The stock price of the loss-making company in its final day trading as D.W.A.C. spiked on Monday after a New York appeals court gave Trump a lifeline : It reduced the bond he needs to pay to protect his business interests while he appeals a civil fraud case to $175 million.

Trump has a big say in what happens next at Trump Media. He holds a class of shares that give him at least 55 percent voting power on some key board decisions. One question: Would Trump cash out — either to pay his legal bills, top up his campaign war chest or bank his return — once the lockup period expires in September? Or, would he lean on the board to waive the traditional six-month lockout period?

The board is filled with loyalists, including his elder son, Donald Trump Jr.; Devin Nunes, a Republican former representative of California; and Linda McMahon and Robert Lighthizer, who both served during the Trump administration.

Trump’s next move could move the market. He holds about 60 percent of Trump Media’s stock. Selling all or some of that stake could torpedo the stock, leaving its large band of retail investors on the hook.

Even if that gets regulators’ attention, pro-Trump shareholders may not care. “I can’t recall any company so driven by external political factors, certainly not in the U.S.,” Sosnick notes. “So even though allowing an early termination of the lockup would be counter to many shareholders’ financial best interests, they might not mind it anyway.”

Meanwhile, bets against Trump have soured. Traders who have shorted D.W.A.C.’s stock have racked up mark-to-market losses of about $96 million this year, Ihor Dusaniwsky, managing director of S3 Partners, a data firm, told DealBook. The recent rally, he said, “will definitely squeeze” them further.

“There’s no accountability on who has access to it and how it’s being used.”

— Emma Shortis, a senior researcher in international and security affairs at the Australia Institute, on SpaceX’s Starlink system. A Bloomberg investigation found a robust black market trade in service for the satellite internet system in countries where its use isn’t authorized.

What would fix Boeing?

Boeing finally buckled. Its C.E.O., Dave Calhoun, is planning to leave . The news came almost three months after a panel blew off a 737 Max jet and airlines, regulators and investors largely turned on the company.

But is a leadership shake-up enough to fix America’s aerospace leader after years of problems?

Boeing hopes that cleaning house will draw a line under the crisis. The company said on Monday that Calhoun — who took over in 2020 after a different safety crisis and vowed to fix the company — will be gone by the end of the year. The company chairman, Larry Kellner, will leave the board in May once his term expires, and its C.O.O., Stephanie Pope, will immediately replace Stan Deal, who is retiring, as head of the commercial airplane division.

Investors sent Boeing’s stock up on Tuesday, despite the company losing market share to a rival, Airbus, in recent years.

But its problems run deep. Lina Khan, the F.T.C. chair, wrote recently in Foreign Policy magazine that the decision to allow Boeing to become a “de facto national champion” by buying McDonnell Douglas in 1997 was “catastrophic.”

The deal slowed innovation, with R&D spending consistently below Airbus. Engineers came to be seen as “a cost, not an asset,” and too much work was outsourced or sent offshore. Boeing became too big to fail and vulnerable to foreign influence, she said.

Critics say fundamental changes are needed. Boeing demonstrates “the curse of bigness,” Tim Wu, a former antitrust official in the Biden administration now at Columbia Law School, told DealBook.

Boeing’s shortcomings are akin to the monopoly concerns in Big Tech and the telecoms sector, and regulators should consider a breakup, he added, pointing to the split of AT&T in 1984 as a precedent. “I wonder if Boeing would do it itself in light of its inefficiencies,” Wu said.

The U.S. is still highly reliant upon Boeing. More than a third of the company’s revenues comes from government contracts, Richard Loeb, an expert on government contracting law and a former government official, told DealBook. “They’re a sole-source supplier,” he said.

Such a deep relationship is problematic, with too much oversight ceded to the company over decades of deregulation.

What’s next? Pope was once seen as Calhoun’s heir apparent , but analysts now say that the company may need to look externally. General Electric , Calhoun’s onetime employer that’s gone through its own split, could be a model.

THE SPEED READ

The bankrupt crypto exchange FTX agreed to sell most of its stake in Anthropic , the artificial intelligence start-up, for $884 million to several buyers, including an Abu Dhabi investor. (WSJ)

The electric vehicle maker Fisker said talks for an investment from another manufacturer had ended, putting its future in doubt. Meanwhile, shares in a rival, Lucid , jumped after an affiliate of Saudi Arabia’s sovereign wealth fund agreed to another $1 billion investment. (Bloomberg)

Gov. Ron DeSantis of Florida signed into law a bill that would effectively bar some social media accounts for children under 14. (NYT)

“Russia has finally admitted Western sanctions are hitting its oil exports ” (Business Insider)

Best of the rest

Meta’s efforts to compete for artificial intelligence researchers reportedly include extending job offers without an interview and Mark Zuckerberg personally writing emails to employees of rivals. (The Information)

“Inside a C.E.O.’s Bold Claims About Her Hot Fintech Start-Up ” (NYT)

Federal agents raided homes tied to the hip-hop mogul Sean Combs , who faces lawsuits accusing him of sexual assault and sex trafficking. (NYT)

We’d like your feedback! Please email thoughts and suggestions to [email protected] .

Andrew Ross Sorkin is a columnist and the founder and editor at large of DealBook. He is a co-anchor of CNBC’s "Squawk Box" and the author of “Too Big to Fail.” He is also a co-creator of the Showtime drama series "Billions." More about Andrew Ross Sorkin

Ravi Mattu is the managing editor of DealBook, based in London. He joined The New York Times in 2022 from the Financial Times, where he held a number of senior roles in Hong Kong and London. More about Ravi Mattu

Bernhard Warner is a senior editor for DealBook, a newsletter from The Times, covering business trends, the economy and the markets. More about Bernhard Warner

Sarah Kessler is an editor for the DealBook newsletter and writes features on business and how workplaces are changing. More about Sarah Kessler

Michael de la Merced joined The Times as a reporter in 2006, covering Wall Street and finance. Among his main coverage areas are mergers and acquisitions, bankruptcies and the private equity industry. More about Michael J. de la Merced

Lauren Hirsch joined The Times from CNBC in 2020, covering deals and the biggest stories on Wall Street. More about Lauren Hirsch

Ephrat Livni reports from Washington on the intersection of business and policy for DealBook. Previously, she was a senior reporter at Quartz, covering law and politics, and has practiced law in the public and private sectors.   More about Ephrat Livni

Read our research on: Abortion | Podcasts | Election 2024

Regions & Countries

Most americans favor legalizing marijuana for medical, recreational use, legalizing recreational marijuana viewed as good for local economies; mixed views of impact on drug use, community safety.

Pew Research Center conducted this study to understand the public’s views about the legalization of marijuana in the United States. For this analysis, we surveyed 5,140 adults from Jan. 16 to Jan. 21, 2024. Everyone who took part in this survey is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the ATP’s methodology .

Here are the questions used for the report and its methodology .

As more states pass laws legalizing marijuana for recreational use , Americans continue to favor legalization of both medical and recreational use of the drug.

An overwhelming share of U.S. adults (88%) say marijuana should be legal for medical or recreational use.

Nearly six-in-ten Americans (57%) say that marijuana should be legal for medical and recreational purposes, while roughly a third (32%) say that marijuana should be legal for medical use only.

Just 11% of Americans say that the drug should not be legal at all.

Opinions about marijuana legalization have changed little over the past five years, according to the Pew Research Center survey, conducted Jan. 16-21, 2024, among 5,14o adults.

The impact of legalizing marijuana for recreational use

While a majority of Americans continue to say marijuana should be legal , there are varying views about the impacts of recreational legalization.

About half of Americans (52%) say that legalizing the recreational use of marijuana is good for local economies; just 17% think it is bad and 29% say it has no impact.

More adults also say legalizing marijuana for recreational use makes the criminal justice system more fair (42%) than less fair (18%); 38% say it has no impact.

However, Americans have mixed views on the impact of legalizing marijuana for recreational use on:

• Use of other drugs: About as many say it increases (29%) as say it decreases (27%) the use of other drugs, like heroin, fentanyl and cocaine (42% say it has no impact).
• Community safety: More Americans say legalizing recreational marijuana makes communities less safe (34%) than say it makes them safer (21%); 44% say it has no impact.

Partisan differences on impact of recreational use of marijuana

There are deep partisan divisions regarding the impact of marijuana legalization for recreational use.

Majorities of Democrats and Democratic-leaning independents say legalizing recreational marijuana is good for local economies (64% say this) and makes the criminal justice system fairer (58%).

Fewer Republicans and Republican leaners say legalization for recreational use has a positive effect on local economies (41%) and the criminal justice system (27%).

Republicans are more likely than Democrats to cite downsides from legalizing recreational marijuana:

• 42% of Republicans say it increases the use of other drugs, like heroin, fentanyl and cocaine, compared with just 17% of Democrats.
• 48% of Republicans say it makes communities less safe, more than double the share of Democrats (21%) who say this.

Demographic, partisan differences in views of marijuana legalization

Sizable age and partisan differences persist on the issue of marijuana legalization though small shares of adults across demographic groups are completely opposed to it.

Older adults are far less likely than younger adults to favor marijuana legalization.

This is particularly the case among adults ages 75 and older: 31% say marijuana should be legal for both medical and recreational use.

By comparison, half of adults between the ages of 65 and 74 say marijuana should be legal for medical and recreational use, and larger shares in younger age groups say the same.

Republicans continue to be less supportive than Democrats of legalizing marijuana for both legal and recreational use: 42% of Republicans favor legalizing marijuana for both purposes, compared with 72% of Democrats.

There continue to be ideological differences within each party:

• 34% of conservative Republicans say marijuana should be legal for medical and recreational use, compared with a 57% majority of moderate and liberal Republicans.
• 62% of conservative and moderate Democrats say marijuana should be legal for medical and recreational use, while an overwhelming majority of liberal Democrats (84%) say this.

Views of marijuana legalization vary by age within both parties

Along with differences by party and age, there are also age differences within each party on the issue.

A 57% majority of Republicans ages 18 to 29 favor making marijuana legal for medical and recreational use, compared with 52% among those ages 30 to 49 and much smaller shares of older Republicans.

Still, wide majorities of Republicans in all age groups favor legalizing marijuana at least for medical use. Among those ages 65 and older, just 20% say marijuana should not be legal even for medical purposes.

While majorities of Democrats across all age groups support legalizing marijuana for medical and recreational use, older Democrats are less likely to say this.

About half of Democrats ages 75 and older (53%) say marijuana should be legal for both purposes, but much larger shares of younger Democrats say the same (including 81% of Democrats ages 18 to 29). Still, only 7% of Democrats ages 65 and older think marijuana should not be legalized even for medical use, similar to the share of all other Democrats who say this.

Views of the effects of legalizing recreational marijuana among racial and ethnic groups

Substantial shares of Americans across racial and ethnic groups say when marijuana is legal for recreational use, it has a more positive than negative impact on the economy and criminal justice system.

About half of White (52%), Black (53%) and Hispanic (51%) adults say legalizing recreational marijuana is good for local economies. A slightly smaller share of Asian adults (46%) say the same.

Criminal justice

Across racial and ethnic groups, about four-in-ten say that recreational marijuana being legal makes the criminal justice system fairer, with smaller shares saying it would make it less fair.

However, there are wider racial differences on questions regarding the impact of recreational marijuana on the use of other drugs and the safety of communities.

Use of other drugs

Nearly half of Black adults (48%) say recreational marijuana legalization doesn’t have an effect on the use of drugs like heroin, fentanyl and cocaine. Another 32% in this group say it decreases the use of these drugs and 18% say it increases their use.

In contrast, Hispanic adults are slightly more likely to say legal marijuana increases the use of these other drugs (39%) than to say it decreases this use (30%); 29% say it has no impact.

Among White adults, the balance of opinion is mixed: 28% say marijuana legalization increases the use of other drugs and 25% say it decreases their use (45% say it has no impact). Views among Asian adults are also mixed, though a smaller share (31%) say legalization has no impact on the use of other drugs.

Community safety

Hispanic and Asian adults also are more likely to say marijuana’s legalization makes communities less safe: 41% of Hispanic adults and 46% of Asian adults say this, compared with 34% of White adults and 24% of Black adults.

Wide age gap on views of impact of legalizing recreational marijuana

Young Americans view the legalization of marijuana for recreational use in more positive terms compared with their older counterparts.

Clear majorities of adults under 30 say it is good for local economies (71%) and that it makes the criminal justice system fairer (59%).

By comparison, a third of Americans ages 65 and older say legalizing the recreational use of marijuana is good for local economies; about as many (32%) say it makes the criminal justice system more fair.

There also are sizable differences in opinion by age about how legalizing recreational marijuana affects the use of other drugs and the safety of communities.

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Table of contents, most americans now live in a legal marijuana state – and most have at least one dispensary in their county, 7 facts about americans and marijuana, americans overwhelmingly say marijuana should be legal for medical or recreational use, clear majorities of black americans favor marijuana legalization, easing of criminal penalties, religious americans are less likely to endorse legal marijuana for recreational use, most popular.

About Pew Research Center Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of The Pew Charitable Trusts .