This article examines the relationship between female schooling and two behaviors-cumulative fertility and contraceptive use-in fourteen Sub-Saharan African countries where Demographic and Health Surveys (DHS) have been conducted since the mid-1980s. Average levels of schooling among women of reproductive age are very low, from less than two years to six. Controlling for background variables, the last years of female primary schooling have a negative relation with fertility in about half the countries, while secondary schooling is associated with substantially lower fertility in all countries. Female schooling has a positive relationship with contraceptive use at all levels. Among ever-married women, husband's schooling exerts a smaller effect than does female schooling on contraceptive use and, in almost all cases, on fertility. Although the results suggest commonalities among these Sub-Saharan countries, they also reveal intriguing international differences in the impact of female schooling, which might reflect differences in the quality of schooling, labor markets, and family planning programs, among others. There is considerable debate in the literature as to whether high fertility and high desired family size in Africa are caused by low levels of economic development that favor large families (see World Bank 1984, 1986), or by unique cultural features (see Caldwell and Caldwell 1987, 1990). Without denying the possibility that cultural traits may contribute to higher demand for children in Africa than in other developing regions, most studies have found differentials in current or total fertility by socioeconomic class, even in high-fertility countries

T'he AIDS epidemic is dramatically increasing mortality measles, oral rehydration salts, and access to health cate of adults in many Sub-Saharan African countries, with can do to nmitigate the impact of adu]t mor tality. potentially severe consequences for surviving family These programs disproportionately improve health members. Until now, most of these impacts had not been outcomes among the poorest children and, within that quantified.group, among children affected by adult mortality. Ainsworth and Semali examine the impact of adultIn Tanzania there is so much poverty and child health mortaLity in Tanzania on three measures of health amrong indicators are so low that these interventions should be chiidren under five: morbidity, height for age, and targeted as much as possible to the poorest households, weight for height. The children hit hardest by the death whlere the children bit hardest by adult mortality are of a parent or other adult are those in the poorest most likely to be found. (Conceivably, the targeting households, those with uneducated parents, and those strategy for middle-income countries with severe AIDS with the least access to health care.ep.demics, such as Thailand, or countries with less Ainsworth and Semali also show how much three poverty and better child health indicators might be important health interventionsimmunization against different.

Nigeria has experienced high fertility and rapid population growth for at least the past thirty years. Only recently have public authorities launched efforts to promote contraceptive use. In this article, individual women are linked to the characteristics of the nearest health facility, pharmacy, and source of family planning to assess the relative importance of women's socioeconomic background and the characteristics of nearby services on contraceptive use. The results suggest that the limited levels of female schooling (and probably other factors affecting women's opportunity cost of time) are constraining contraceptive use, especially in rural areas. Another major constraint to increased contraceptive use is the low availability of family planning services in Nigeria. Broader availability of the pill and other methods in pharmacies and of injectables and intrauterine devices (lUDs) in health facilities is likely to raise contraceptive use. Outpatient or consultation fees at nearby health facilities do not appear to be constraining demand for modern contraceptive methods. With a total population of nearly 100 million inhabitants, Nigeria is home to about one in every five Sub-Saharan Africans (World Bank 1992). Although there are indications of a fertility decline in southwest Nigeria (Caldwell, Orubuloye, and Caldwell 1992), the country as a whole has experienced high fertility and rapid population growth for at least the past thirty years. Only relatively recently have public authorities become interested in affecting these trends and promoted contraceptive use. Among those involved in the delivery of family planning services, there is a broadly held conviction that improved availability of contraceptives and higher quality of services will result in greater contraceptive use. At the same time, even the most recent surveys indicate that Nigerians often prefer large families. In the 1990 Nigeria Demographic and Health Survey (NDHS), for example, the mean desired family size among the 40

There is a need to better understand the effectiveness of HIV-prevention programs. Cluster randomized designs have major limitations to evaluate such complex large-scale combination programs. To close the prevention evaluation gap, alternative evaluation designs are needed, but also better articulation of the program impact pathways and proper documentation of program implementation. Building a plausible case using mixed methods and modeling can provide a valid alternative to probability evidence. HIV prevention policies should not be limited to evidences from randomized designs only.

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The Bank Group now funds a smaller share of global support for health, nutrition, and population (HNP) than it did a decade ago, but its support remains significant-$17 billion in countrylevel project financing, in addition to policy advice, analytic work, and engagement in global partnerships by the World Bank and $873 million in private health and pharmaceutical investments by IFC from 1997 to mid-2008. The Bank Group continues to play an important role and add value in HNP. ♦ About two-thirds of the Bank's HNP projects show satisfactory outcomes. Performance can be substantially improved by reducing project complexity, strengthening risk assessment and mitigation, conducting more up-front institutional analysis, and incorporating more evaluation to promote evidence-based decisions. The performance of IFC health investments, mainly hospitals, has improved markedly, but IFC has had limited success at diversifying its health portfolio. ♦ The accountability of Bank Group investments for demonstrating results for the poor has been weak. The Bank's investments often have a pro-poor focus, but their objectives need to address the poor explicitly and outcomes among the poor need to be monitored. Importantly, the Bank needs to increase support to reduce high fertility and malnutrition among the poor and ensure discussion of HNP in poverty assessments. IFC-financed hospitals mainly benefit the non-poor; IFC needs to support more activities that both make business sense and yield broader benefits for the poor. ♦ The Bank Group has an important role in helping countries to improve the efficiency of health systems. The Bank needs to better define efficiency objectives, track efficiency outcomes, and support better information and vigorous evaluation of reforms. IFC needs to enhance support to public-private partnerships and improve collaboration and joint sector work with the Bank. ♦ The potential for improving HNP outcomes through actions by non-health sectors is great, but incentives to deliver them are weak. Adding HNP objectives to Bank projects in other sectors, such as water supply and sanitation, raises the incentive to deliver health benefits. Strengthening the complementarity of investments in HNP and other sectors can also improve outcomes. In IFC, incentives, institutional mechanisms, and an integrated approach to health are needed to improve coordination across units.

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