Promoting Reproductive Health: Investing in Health for Development 9781685852009

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Promoting Reproductive Health

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CENTER ON INTERNATIONAL COOPERATION

Studies in Multilateralism

Promoting Reproductive Health Investing in Health for Development

edited by Shepard Forman Romita Ghosh

LYN N E RIENNER PUBLISHERS

B O U L D E R L O N D O N

Published in the United States of America in 2000 by Lynne Rienner Publishers, Inc. 1800 30th Street, Boulder, Colorado 80301 www.rienner.com and in the United Kingdom by Lynne Rienner Publishers, Inc. 3 Henrietta Street, Covent Garden, London WC2E 8LU © 2000 by Lynne Rienner Publishers, Inc. All rights reserved Library of Congress Cataloging-in-Publication Data Promoting reproductive health : investing in health for development / edited by Shepard Forman and Romita Ghosh. p. cm. — (Center on International Cooperation studies in multilateralism) Includes bibliographical references and index. ISBN 1-55587-877-6 (he : alk. paper) 1. Reproductive health—Developing countries. 2. Human reproduction—Social aspects—Developing countries. 3. Health promotion—Developing countries. I. Forman, Shepard, 1938— II. Ghosh, Romita. III. Series. RG103.P755 1999 362.1 '96692'0091724—dc21 99-36680 CIP British Cataloguing in Publication Data A Cataloguing in Publication record for this book is available from the British Library.

Printed and bound in the United States of America

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The paper used in this publication meets the requirements of the American National Standard for Permanence of Paper for Printed Library Materials Z39.48-1984. 5 4 3 2 1

Contents

Acknowledgments 1

Introduction Shepard Forman and Romita Ghosh

Part 1

2

3

4

5

6

7

vii

1

D e v e l o p i n g Country Studies: Policies, Programs, and Financing Since the International Conference on Population and Development

Bangladesh Simeen Mahmud and Wahiduddin Mahmud

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Egypt Hind A. S. Khattab, Lamia El-Fattal, Nadine Karraze Shorbagi

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and

Indonesia Terence H. Hull and Meiwita B. Iskandar

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Mexico Yolanda Palma and José Luis Palma

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South Africa Barbara Klugman, Marion Stevens, and Alex van den Heever

147

Tanzania Margaret Bangser

183 v

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Contents

Part 2 Donor Case Studies: Policies, Programs, and Financing Since the International Conference on Population and Development

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The United Kingdom Christopher J. Allison

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221

The United States Judith E. Jacobsen

Part 3

251

Conclusion

10 Lessons Learned: The Need to Invest in Reproductive Health Axel I. Mundigo

Acronyms and Abbreviations The Contributors Index About the Book

281

299 303 305 315

Acknowledgments

We are grateful to each of the contributing authors, to our advisers (the advisory committee was José Gomez de Leon Cruces, national coordinator, Program of Education, Health, and Nutrition, Mexico; John Hobcraft, London School of Economics and adviser to the Department for International Development, United Kingdom; Klaus M. Leisinger, executive director, Novartis Foundation for Sustainable Development, Switzerland; Florence Manguwu, M.D., Kenya; Axel I. Mundigo, director, International Programs, Center for Health and Social Policy, United States; Harriet Presser, director, Center on Population, Gender, and Social Inequality, University of Maryland, United States; Jay Satia, executive director, International Council on Population Programs, Malaysia; Susan Sechler, director, Global Stewardship Initiative, Aspen Institute, United States), and to the foundations that supported our efforts, including the Ford Foundation, the John T. and Catherine D. MacArthur Foundation, and the Rockefeller Foundation, for helping bring this undertaking to fruition. We would also like to thank Dierdre Wulf for her assistance in editing the case studies for inclusion in this volume, and Hyeyeon Park, research assistant, and Joyce Modabi Nduku, administrative aide, for their diligent assistance throughout this endeavor. —The

vii

Editors

1 Introduction Shepard Forman & Romita Ghosh

THE NATURE OF INTERNATIONAL COOPERATION IN SUPPORT OF sustainable development has evolved over time. Development cooperation and the flow of aid between developed and developing countries in the 1950s and 1960s were strongly influenced by the politics of the Cold War and emphasized the quantitative aspects of growth through investments in large-scale infrastructural projects and scientific advancements, which were thought to be the driving engines of modernization. Theorists and practitioners alike have since recognized that, in addition to capital growth and technological advancements, social, political, and cultural progress are essential to development. The 1970s and 1980s, therefore, saw a shift toward the qualitative aspects of growth, including investments in education, health care, clean water, and sanitation, in addition to microenterprise credits and human rights. The increasing role of civil society in setting standards for effective development cooperation and collaborating in its implementation accompanied these changes, resulting, in the 1990s and into the next century, in a renewed emphasis on partnerships between and among private and public sectors, both nationally and internationally. Several additional trends parallel these changes, including an increasing role for multilateral agencies, such as the United Nations Development Programme and other UN special agencies, the World Bank, and collaborative bilateral donor forums, such as the Development Assistance Committee of the Organization for Economic Cooperation and Development. As private-capital flows sharply outpaced bilateral and multilateral development assistance, poverty reduction replaced economic growth as the rationale for development assistance, and the needs and demands of individual clients became established as the driving force for all development activities. The UN-sponsored international conferences of the 1990s reflect and have helped to reinforce this evolution in development thinking. Through

1

2

Introduction

such conferences, UN member states—often pushed by nongovernmental organizations—have sought to create consensus around development goals and promote cooperation on a range of global issues. They include the well-being of children (1990), a clean, healthy, and sustainable environment (1992), universality of human rights (1993), reproductive health and population (1994), social development (1995), women's rights (1995), safe and productive habitats (1996), and food security (1996). 1 Together, they constitute a platform for sustainable development in the century to come. The UN's 1994 International Conference on Population and Development (ICPD), held in Cairo, Egypt, was a landmark in the field of population and development. The Programme of Action, which was agreed to by 180 countries represented at the conference, reaffirmed the importance of slowing population growth for social and economic development, but it also called for a significant shift in strategies to achieve this goal. Rather than continuing a supply-side and quantitative approach to achieving demographic targets, the ICPD endorsed a client-driven approach to meet reproductive health needs of individual women, men, and their families. Rejecting the concept of "population control," the Cairo conference recognized that smaller families and slower population growth can be achieved through free choice and by ensuring the conditions that encourage such choice. The reproductive health approach embodied in the ICPD Programme of Action emphasizes the interrelationships between population, human rights, and sustainable development. It stresses the importance of advancing gender equality, equity, and the empowerment of women, and emphasizes women's ability to control their own fertility. It promotes women's involvement in the planning, management, implementation, and evaluation of reproductive health programs, and emphasizes the role of men as active partners in family planning and family life. The ICPD Programme of Action also calls for an approach to reproductive health that is comprehensive, client-centered, and dependant on quality health care. To satisfy the reproductive health needs of individuals, couples, and families during all stages of the life cycle, it recommends that primary health care systems in all countries provide a range of reproductive health information and services, including but not limited to family planning. The ICPD built on the outcomes of previous international population conferences in Bucharest in 1974 and Mexico City in 1984, the Earth Summit in Rio de Janeiro in 1992, the Vienna World Conference on Human Rights in 1993, and decades of research and experience. In addition, the ICPD consensus exemplified years of work by women's rights advocates and health professionals to put women's needs and concerns at the center of population and development efforts, and to recognize the central role healthy and educated women can play in alleviating poverty and promoting

Introduction

3

sustainable development. Additionally, the devastation caused by HIV/ AIDS lent a sense of urgency for a reproductive health agenda that would place increased attention on sexually transmitted diseases (STDs) and on risk-free sexual behavior. Importantly, each of the UN conferences went beyond the interstate actions of most other international agreements to include representatives of nongovernmental organizations (NGOs) and other sectors of civil society in the run up to their deliberations. Indeed, it would not be going too far to declare that the conference outcomes were strongly influenced by research and advocacy carried out by such NGOs during the past several decades. In most cases the conferences also called for a strong role for independent actors in promoting and monitoring compliance with the commitments governments have made. It is in this spirit that the Center on International Cooperation (CIC) at New York University initiated a project to review progress made by developing and developed (donor) countries in advancing the reproductive health agenda endorsed at the 1994 ICPD. This volume contains case studies of six developing countries: Bangladesh, Egypt, Indonesia, Mexico, South Africa, and Tanzania; as well as two developed (donor) countries: the United Kingdom and the United States. The case studies were authored by an international team of experts working collaboratively with professionals at the CIC. The studies review progress made in advancing the reproductive health agenda of the ICPD Programme of Action, focusing on how each country acted on the endorsement of different elements of the reproductive health approach for which cost estimates are given in the Programme of Action: elements including family planning, reproductive health services, STD/HIV/AIDS prevention, and research, data collection, policy analysis, and formulation. Each author was asked to examine the state of policy and program development and financing related to the implementation and sustainability of the reproductive health approach. In addition, a CIC policy report, Paying for Essentials: The Reproductive Health Approach to Population and Development, synthesizes major findings of the studies presented here and provides recommendations on key issues affecting financing, implementation, and sustainability of the reproductive health approach advanced at the ICPD. The authors reviewed existing literature and data from government and nongovernmental sources,, and interviewed many individuals, including government officials, representatives of NGOs and international donor agencies, academics, and, in the case of the developing-country studies, health care providers and users of services. Although the studies were conducted within a common framework and methodology, CIC encouraged the authors to develop their research around sets of questions that were most appropriate to each case. The studies, therefore, exhibit a rich diversity of

4

Introduction

data, analysis, and perspectives. At the same time, they evidence many common themes. The reproductive health approach endorsed at the ICPD has permeated policies and programs to varying degrees in each of the countries studied here. Although the language of reproductive health has entered population and family planning discourse everywhere, in some countries it is still contested terrain, as overriding concerns with population growth continue to dominate population and family planning policy. In others, the integration of family planning and reproductive health envisioned in Cairo is slowly taking shape, though constrained by established patterns of funding, bureaucratic prerogatives, organizational barriers, lack of popular understanding of the reproductive health approach, and limited training opportunities for health service providers. In several cases, reproductive health inroads into the family planning agenda are due to the impetus of donor funding. Although formidable obstacles to the identification and tracking of financial components stand in the way of thorough analysis, two patterns in financing the ICPD Programme of Action seem to have emerged. First, despite an initial spike immediately following the ICPD, support from international donors has declined, making it virtually impossible to meet the financial goals set at the ICPD. Second, health-sector financing within the six developing countries studied here raises serious concerns about sustainability. In some countries health spending has been negatively impacted by economic conditions; in all of the countries studied, health and population spending represents a small portion of total public-sector expenditures. Current donor funding patterns suggest that even the modest, nearterm financial targets set for implementing the Programme of Action will not be met. In 1995, twenty bilateral donors contributed nearly $1.4 billion to population assistance, some $3.6 billion short of the total bilateral and multilateral targets projected for ICPD implementation by 2000. Furthermore, 73 percent of the bilateral funding was from just four countries: the United States, Germany, the United Kingdom, and Japan. 2 Although the United States continues to lead in the disbursement of funds for reproductive health and population, its actual dollar commitment has declined due to congressional cuts in the aid budget. For its part, the United Kingdom has significantly increased its contributions as part of a generalized overseas poverty reduction program. However, unless there is a major recommitment of funds by current donors or an increase in the number of donor countries, it is highly unlikely that the 2015 target of $21.7 billion (international and national) envisioned in the Programme of Action will be available over the next twenty years. Although international donors will continue to play an essential role, sustaining the reproductive health approach will depend in large part on political will and resource mobilization efforts within each country.

Introduction

5

In particular, the donor country studies underscore the importance of consistent and long-term commitment of political leadership to the reproductive health agenda, the need to base international funding firmly on the local needs and priorities of developing countries, the importance of donor coordination and partnerships in maximizing programmatic and regional coverage of programs and financial needs, and the need for careful monitoring and evaluation of efforts to integrate the reproductive health approach into development and poverty reduction programs. The developing country case studies reveal important advances in policy formulation, financing, and delivery of services in the health and population sectors. However, they underscore that more needs to be accomplished, especially in improving the reproductive health care of women, men, and adolescents, as well as improving access to information and quality health care services. In addition, the studies reveal important lessons about the way in which international assistance works and how it can be improved. Local ownership of the design and implementation of programs is a prerequisite to success. Many of the reproductive health programs initiated in developing countries have been strongly influenced by donors. To ensure long-lasting benefits, donor assistance should be supportive of local priorities and programs. The Programme of Action was not intended to be a one-size-fits-all solution; national plans of action were expected to develop policies and programs according to local needs and capabilities, consistent with the principles and goals of the ICPD. The will and capacity to implement and sustain policies and programs depends in large part on their appropriateness to local needs and aspirations. A complex set of internal and external factors affects that will and capacity. At the national level, dominant ideologies and prevailing economic conditions play a critical role. Where entrenched population programs are in place and there is little room for citizen action, little progress can be expected. Overriding debt burden and alternative claims on scarce resources for social programs and poverty alleviation also limit the scope for implementation. The financial crises now affecting Asia and threatening Latin America raise serious questions about the ability of countries in those regions to promote reproductive health and increase health-sector budgets in the short term. Several of the developing country case studies make clear that the prevailing financial crises, structural adjustment demands, and vagaries of external funding threaten the sustainability of the reproductive health approach. Everywhere, the long-term success of investments in reproductive health is embedded in the process of health-sector reform and decentralization currently under way in many developing countries, significantly affecting how health services are prioritized and delivered. These changes in the health sector overall affect the extent to which reproductive health care

6

Introduction

is implemented and how effectively considerations of cost reduction and organizational efficiency are balanced with those promoting quality and equity.

Highlights of Case Studies Simeen Mahmud and Wahiduddin Mahmud's assessment of the situation in Bangladesh (Chapter 2) is cautiously optimistic. During the decade preceding the ICPD there were visible improvements in both the demographic and health conditions of the Bangladeshi population; however, the status of women's reproductive health remains compromised, despite the fact that women's childbearing burden has been halved. The authors contend that although public expenditures to expand health facilities during the 1990s appeared impressive, the figures fail to reveal either the quality or the equity aspects of such expenditures, which largely remain dismal. Access to a range of reproductive health services, including prenatal care, clean and safe delivery, and essential obstetric care, remains inadequate. One distinctive feature of the existing health and family planning program in Bangladesh is the low utilization of most public health facilities at the community level, largely due to the widespread but unofficial collection of user fees. The family planning program's excessive reliance on external funds, and the artificial division of labor and authority between the health and family planning personnel, have also affected service utilization and the care-seeking behavior of the population. Most important, donor dependence has prevented program efforts at self-reliance in terms of resource mobilization, cost recovery, participation, ownership, and accountability and has reduced the potential for financial sustainability over the long term. Following the ICPD, Bangladesh adopted a national reproductive health strategy designed to integrate, for the first time, services for women's health and family planning under a single programmatic approach while recognizing such an approach would require wide-ranging reforms in the health and population sectors. The Health and Population Sector Programme, initiated in 1998 to implement these reforms and address the issue of financial sustainability over time, seeks to implement the reproductive health agenda of the ICPD and introduce program equity, cost-effectiveness, and improvements in service quality. The authors caution that the realization of these objectives will depend on significant increases in public spending in the health and population sectors given scarce resources and continued dependence on external donors. It will also require improved administrative effectiveness and reorganization of the service delivery system, which is part of the much broader problem of

Introduction

7

"good governance" challenging development efforts in Bangladesh. The authors recommend that priority areas for donor action include the training of service providers for a comprehensive reproductive health approach to services, improving the quality of care at public facilities, and improving management information systems for monitoring program performance. Public- and private-sector collaboration is encouraged, the authors suggesting that the private sector could play a crucial role in nonmedical services, social marketing of health and family planning commodities, and media awareness. In Chapter 3, Hind Khattab, Lamia El-Fattal, and Nadine Shorbagi point out that even though Egypt's concern with population growth goes back to the 1950s, population policy has oscillated between emphasis on family planning and the importance of socioeconomic development. Hosting the ICPD provided Egypt with the impetus to critically evaluate past policies and programs, enhance national awareness of women's problems, and encourage the government and private sector to strategize in a more cooperative and comprehensive manner. Although the government's family planning program has achieved commendable levels of contraceptive use, the quality of health care requires significant upgrading. Poor quality has often resulted in high discontinuation of contraceptive use, incorrect use of methods, high rates of medical complications, and women's unnecessary exposure to unwanted pregnancies and unsafe abortions. Overall, the Egyptian government has reacted favorably to many ICPD issues, and recent policies and programs reflect a commitment to integrating family planning and reproductive health services and to making services more gender-sensitive. As a result of the post-ICPD strategy, NGO cooperation with the government has also improved. At the governmental level, the Ministry of Health and Population was created in 1996 to centralize, upgrade, and integrate all population, family planning, and reproductive health services and activities. Following the ICPD, the government consciously developed a modified population and health strategy that placed greater emphasis on providing universal health coverage and reproductive health services of high quality, part of an overall effort to improve women's health and status, especially in poorer regions. However, the authors note that despite concerted efforts to implement the ICPD reproductive health agenda, important obstacles stand in the way. First, the government and donors appear to be concerned that reproductive health will replace family planning, with grave consequences for rates of population growth and overall development. The basis of such fear is predominantly an incomplete understanding of the concept of the reproductive health approach itself. Consequently, the implementation of reproductive health programs has been haphazard and lacking in direction. Second, since Egypt is in the process of structural adjustment and health

8

Introduction

reform policy development, it is not clear how and whether the perceived extra costs of reproductive health will be covered. National resource mobilization is still in its infancy. Public spending in the health and population sectors has increased since 1995 but remains low, and international donors contribute a significant portion of related costs. In Chapter 4, Terence Hull and Meiwita Iskandar report on the 1997 financial crisis that led to fears that two decades of progress in providing family planning services and reducing fertility could be reversed by economic depression and government upheaval. However, they assert that anxiety about the fate of the family planning program betrays a lack of concern over the broader program of action of reproductive health and social development formulated at the ICPD. The authors point out that serious policy discussions on the control of STDs is virtually nonexistent; that abortion continues to be a subject of acrimonious debate; that calls for male participation lack any practical content with regard to the use of contraceptives and the control of STDs; that adolescent sexuality issues are almost taboo; that opposition to sex education, counseling, and contraceptive services for unmarried people is widespread; and that even family planning programs have long been criticized on issues of quality of care, appropriateness of technologies, and failure to meet the needs of adolescents, men, and women experiencing side effects or contraceptive failure. The authors conclude that although Indonesia's reproductive health program was undoubtedly in serious trouble in 1998 its problems are rooted in factors that long predated the economic crisis. The division between the National Family Planning Coordinating Board and the Department of Health, the lack of systematic improvement of quality of services, and problems of health care financing are examples of structural and policy issues that need immediate resolution. The political and economic reforms called for by the newly activated public may lead to long-term improvements in the quality of health and family planning services, but there is no guarantee that they will foster efforts to seriously address the ICPD agenda. Yolanda Palma and José Luis Palma point out in Chapter 5 that Mexico, the country that hosted the aforementioned 1984 international population conference, had begun to incorporate aspects of reproductive health into family planning programs well before the 1994 ICPD. Since the ICPD, a new Reproductive Health and Family Planning Program, which incorporates most of the elements of the reproductive health agenda, has been adopted. Laws and standards were created or modified to implement that program, and the 1997 Health Law incorporated, for the first time, the concept of reproductive health. Running parallel to the health and family planning program is the national population program, a program to improve the status of women, and health-sector reform. The reform process

Introduction

9

is designed to improve the financial management of the health insurance system, improve efficiency, expand coverage, ensure greater transparency and accountability among service providers, improve service delivery through decentralization, and introduce a "basic" package of services to address family planning, maternal health, and cervical cancer. The study reveals that implementation of the reproductive health agenda has only just begun and that questions remain over how best to integrate reproductive health services at the operative level; how best to train health personnel in the reproductive health approach to service delivery; and how to strengthen state-level capacities to implement programs, a problem that is especially relevant to the ongoing process of decentralization. According to the authors, an anticipated risk in the implementation of the concept of reproductive health is the adoption of an interpretation that weakens the links between reproductive health and population policies and programs, thus attaching to the former a predominantly "medical approach" that fails to realize the full integration of social and demographic components of policies. The involvement of NGOs in official reproductive health activities has increased since the ICPD, yet the potential of NGOs to collaborate as effective partners with the government in implementing specific programs has not been sufficiently tapped. The authors conclude that Mexico's reproductive health program is largely sustainable through the mobilization of national resources; however, program areas substantially supported by international donors, such as the testing of innovative strategies, personnel training, program evaluation, information, education, communications, and mass-media campaigns, may suffer due to the decline in donor funds to Mexico. Barbara Klugman, Marion Stevens, and Alex van den Heever's review of South Africa in Chapter 6 shows how the overall political context shaped the development of a human rights and equity orientation toward population policy as well as health services. The key component of the new government policy in 1994 was the creation of a single health system, with equitable distribution of resources and provincial implementation seeking to bring primary health care services as close to the people as possible. Sexual and reproductive health care is integrated into primary health care, so that most clinics provide maternal health care, contraception, and STD services. Abortion services are slowly being introduced; cervical screening is on the agenda; counseling training is taking place, mostly initiated through the AIDS program; and there seems to be sufficient commitment to public education programs on health and human rights. The authors recognize that the primary challenge to providing sexual and reproductive health services relates to the weaknesses of South Africa's health systems. This arises partly from the process of integrating

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Introduction

different health authorities and restructuring the system—from an urbancentered system in which most funds went into tertiary care into a decentralized system with equitable distribution of resources across all regions—and partly from the lack of management capacity at the provincial level. The completion of the restructuring process and improvements in management are prerequisites for efficient delivery of services and for cost-saving that will facilitate better use of resources. The authors estimate that there is a substantial gap between financial resources required to provide a basic package of sexual and reproductive health services and those available nationally, yet they are optimistic that the current process of decentralization and shifting priorities toward primary health care will bring more resources to such services over time. Moreover, the government's approach to eschew international donor funds, despite immediate financial shortages, must be seen as positive in the long run. Donor assistance, however, continues to be critically needed for NGO activities supporting public health system development, community education and outreach services, policy advocacy, and monitoring and evaluation of government performance. In Chapter 7, Margaret Bangser questions the likelihood of implementing the ICPD's reproductive health agenda in Tanzania given several factors. They include the existing constraints posed by the tremendous burden of debt service that undermines the health sector and social sectors in general; extreme poverty; a deteriorating primary health care system; limited local capacities; and minimal commitment on the part of political leadership to invest in social services. The launching of the 1998 Reproductive Health and Child Survival Strategy, influenced by the principles of the ICPD, represented a new approach in a field that traditionally focused on family planning. It also legitimized the claims of health advocates seeking a more comprehensive, gender-oriented approach to reproductive health. However, Bangser is concerned that Tanzania's almost total reliance on international donor funds makes this strategy vulnerable to donor biases, changing donor priorities, and budgets, and raises questions about the extent to which Tanzanians can determine the agenda and sustainability of reproductive health programs. Although reproductive health is a growing priority on the donor agenda, it is only one among many priorities that vie for limited national resources. Moreover, it is not clear how the ongoing process of health-sector reform and decentralization will affect implementation of the reproductive health agenda. The author recommends that donors involved in reproductive health conditions in Tanzania must address the problem of international financial systems that compromise implementation of the health services; assist to strengthen the primary health care system; attempt to strengthen local ownership of the health sector through the current evolution of sectorwide

Introduction

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approaches to funding; and be more transparent and responsive to community needs and priorities; and the author underscores the need for highly accountable systems of tracking health financing for program and policy formulation, implementation, monitoring, and evaluation. Chris Allison's assessment of policy, program, and financial responses to the ICPD in the United Kingdom (Chapter 8) describes progress made by the Department for International Development (DFID) in aligning policy formulation, program design, appraisal, and monitoring with the ICPD agenda. He notes that the series of UN-sponsored international conferences in the 1990s prompted the British government to increase attention to the social sectors in development assistance, including health and population. The Children by Choice initiative was launched by the government in 1991 in preparation for the UN's 1992 conference in Rio de Janeiro. In May 1997, following the election of the Labor government, there was a move to modify both domestic and foreign policies. This process culminated in the publication of a 1997 white paper that reaffirms the importance of the reproductive health approach as envisaged in the ICPD and the need to build effective partnerships. DFID policy and program documents emphasize the importance of reproductive health goals, including reproductive rights, principles of choice, equity, and equality, which DFID recognizes as "common causes" to be shared with all of DFID's partners. DFID's 1997 maternal health strategy aims to reduce the dangers of pregnancy in poor societies and focuses on four essential areas: ensuring that women have sufficient information to make sound decisions about health; ensuring that quality services are provided and accessible at all times; ensuring that women receive emergency care; and ensuring that safe motherhood efforts are properly monitored at all levels. In general, DFID has increased expenditures on reproductive and sexual health and population activities and also has increased its health personnel at headquarters and at field offices. However, it remains to be seen how far such strategies and principles are effectively addressed and achieved in the health-sector reform processes that DFID is promoting in developing countries. The author recommends increased emphasis on partnership building; greater efforts to monitor and demonstrate the costeffectiveness of DFID assistance for reproductive health; and strengthening of the process of accountability among program partners, which should ideally extend to "outward" accountability to the public of both developed and developing countries. In Chapter 9, a study of policy, program, and financial commitments to the ICPD in the United States, Judith Jacobsen demonstrates in her study that implementation of the commitments has been dominated by contrasts between the actions of the administrative and legislative branches of the U.S. government. A Democratic administration helped shape the

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Introduction

ICPD consensus and was committed at the highest levels to the women's empowerment and reproductive health agendas central to the consensus. In fact, 1995 saw the highest budget ever for U.S. international population assistance. But the climate for ICPD implementation changed, just two months after the ICPD, due to the election of the 104 t h Congress in November 1994, a majority of whose members are averse to foreign assistance, in general, and family planning, in particular. U.S. assistance for population and reproductive health activities in developing countries has since declined. Despite this climate, the author asserts, the U.S. Agency for International Development (USAID) has made good progress in its population program in broadening its traditional emphasis on family planning into a more comprehensive reproductive health approach. Large portions of the budget of the Center for Population, Health, and Nutrition are devoted to implementing the ICPD, and aspects of reproductive health are laced throughout the programs of the Office of Health and Nutrition and the Office of Population. According to the author, however, concerns remain. USAID's efforts in the area of reproductive health still tend to add pieces of reproductive health to family planning programs rather than place family planning in a larger reproductive health context. In addition, in keeping with its history and authorizing legislation, USAID's strategic planning documents and indicators for success reflect a belief in providing family planning to reduce fertility and improve health conditions in order to achieve population stabilization. This is in contrast to the Cairo approach, which, according to Jacobsen, is a commitment to changing people's lives, especially the lives of women, so that lower fertility and a stable population follow. The author cautions that these are crucial details that make relatively little difference in how USAID implements the ICPD today, yet failing to make the transition to the "new" way of thinking could compromise the fuller implementation of the ICPD agenda that the future should bring. To help guard against the shifts of national politics and government leadership, she recommends that consensual agreements be grounded in grassroots political organization to buffer international development policies against the possible and often rapid consequences of political change.

Lessons Learned Axel Mundigo's assessment of the studies underscores an overarching lesson learned: the need to invest in reproductive health. He asserts that the Programme of Action calls for changes that require not only a réévaluation of existing population policies but also an unprecedented merger of demographic and health concerns. This implies a need to reassess institutional

Introduction

13

structures, including those of major divisions within ministries and the nature of their programs, while developing innovative strategies that service providers can apply in providing comprehensive reproductive health care to women, men, and their families. Also required is the urgent need to bring to the attention of government officials the message of Cairo and its significance to the process of health-sector reform. According to the author, studies show that those countries where implementation of the reproductive health agenda is more advanced are those where the government and nongovernmental sectors have collaborated and where open public debates have facilitated the input of civil society and influenced decisions and action at the policy level. Therefore, democratic processes favoring the development and participation of civil society should be strongly supported and sustained. Mundigo recognizes that the need to invest in reproductive health is unquestionably the duty of national governments, yet it is also the responsibility of the international community, which has a vital role in forging partnerships, mobilizing resources, and encouraging political leaders and decisionmakers to commit to enhancing human development. He draws attention to the dual responsibility of the research community, first of all in assessing the costs and human resource requirements of various service alternatives to implement the comprehensive reproductive health agenda in different scenarios, and second in understanding the determinants and motivations of sexual and reproductive behaviors. Research in several areas is recommended. They include the study of sensitive areas of reproductive health, such as unwanted adolescent pregnancy, infertility, and female genital mutilation, where issues of privacy and confidentiality present unusual challenges; the study of normative barriers to reproductive health and rights, including those affecting self-determination, ethics, and laws; and increased efforts to improve the financial database of resources available within each country facilitating donor allocations to those areas lacking in national resources.

The Implications for Public Policy The findings of each of these case studies have provided the basis for a set of policy recommendations, which the Center on International Cooperation has published in a policy report, Paying for Essentials: The Reproductive Health Approach to Population and Development. The report reflects a widely held concern that a concerted effort is needed to deepen and extend the reproductive health approach and realize its full promise. Although financing is a critical focal point, the recommendations reach beyond the question of resource mobilization into the political, institutional, and

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Introduction

human requirements for sustainability. Drawing on the eight country studies, the report recommends that in order to advance the goals established at the ICPD, the long-term vision of the reproductive health approach should be reaffirmed. Its capacity and appropriateness to address population growth concerns should be documented and made clear to policymakers and family planning practitioners. At the same time, local, national, and international NGOs should be supported in their roles as advocates and service providers. Reproductive health advocates should encourage governments to provide the legal framework to allow NGOs to have the freedom and financial means needed to carry out their work. National governments need to assume greater responsibility for resource mobilization and program implementation. Well-informed and strongly committed leaders should provide strong incentives, backed by budget line items, to firmly embed the reproductive health approach in the institutions responsible for health and family planning. Given resource constraints, alternative sources of finances and cost-sharing mechanisms should be further explored and tested to determine whether such mechanisms can operate without damaging the principles of equity and quality embodied in the reproductive health approach. Governments should also improve and extend training programs for field personnel and support outreach efforts to build knowledge of the reproductive health approach. The continuing support of international donors is essential. Donors should base funding on local needs and priorities, incorporating the reproductive health approach into all international health-financing activities and development aid. Efforts to shift from external funding to local sustainability should be done responsibly so that promising initiatives are not curtailed or abandoned prematurely. Transparency and accountability need to be established as key elements of international cooperation. Stakeholders from both developed and developing countries should establish common systems for tracking and monitoring bilateral and multilateral donor aid. Central and open sources for statistical information in each country should be created to track the allocation and use of donor funds and national expenditures for reproductive health care. Stakeholders should monitor and report on implementation at regular intervals according to agreed benchmarks, and also fund research to help develop indicators of client demand for reproductive health services, gender equity in health service provision, and quality of care. Finally, the global estimates of costs for reproductive health programs for the years 2000-2015 should be reviewed and revised in order to set realizable goals for both donor and developing countries. A great deal more needs to be learned about what works best in the structuring and delivery of reproductive health services and their impact

Introduction

15

on social and economic development. In addition to program and project evaluation, donor financing should include assessments of overall system performance and the impact of external funding. Operational and action research are needed to ensure that the administration and management of services contain costs but maximize quality. Knowledge of client needs and preferences is essential to fulfillment of the reproductive health approach. Research to develop innovative strategies for health delivery, to clarify and develop the role of the private sector, and to evaluate schemes such as user fees, social marketing, and insurance programs is vital and must ascertain that public resources reach those who cannot afford to pay. The policy report concludes that the reproductive health approach advanced at the ICPD holds promise to improve health care and quality of life for billions of people. It should and must be sustained. International donor support is critical to this effort. It also is imperative to view the ICPD Programme of Action as a long-term goal, achievable through diverse program strategies that are appropriate in different country contexts. Donors must exercise responsibility over the long term as well as flexibility in their funding in order to ensure that the reproductive health approach, which many donors so energetically promoted, is able to take root and become sustainable within developing countries. The developing countries themselves must exercise wisdom and foresight in balancing investments in social programs, such as reproductive health, against anticipated future gains. This is especially true in countries affected by severe economic crisis or under the strain of foreign debt. Good health is a prerequisite to development. The urgent need to maximize the effective use of scarce resources makes this an opportune time to press for greater integration across sectors and demonstrate the efficiencies that an integrated approach to development can bring about. NGOs can help ensure that the reproductive health approach is central to these development activities. Ultimately, however, consumers must create the demand that legitimizes public expenditures for the reproductive health approach and the combination of services recommended in the Programme of Action.

Notes 1. United Nations conferences: World Population Conference, Bucharest, Romania, 1974; International Conference on Population, Mexico City, Mexico, 1984; World Summit for Children, New York, USA, 1990; Conference on Environment and Development, Rio de Janeiro, Brazil, 1992; World Conference on Human Rights, Vienna, Austria, 1993; International Conference on Population and Development, Cairo, Egypt, 1994; World Summit for Social Development, Copenhagen, Denmark, 1995; The United Nations Fourth World Conference on Women, Beijing,

16

Introduction

China, 1995; World Food Summit, Rome, Italy, 1996; United Nations Conference on Human Settlements (Habitat II), Istanbul, Turkey, 1996. 2. Forman, Shepard, and Romita Ghosh (1999). Paying for Essentials: A Reproductive Health Approach to Population and Development. Policy Paper Series. New York: Center on International Cooperation, New York University.

Parti Developing Country Studies: Policies, Programs, and Financing Since the International Conference on Population and Development

2 Bangladesh Simeen Mahmud & Wahiduddin Mahmud

T H E 1994 INTERNATIONAL C O N F E R E N C E ON POPULATION AND Development (ICPD) has been described as a "watershed event" in conceptualizing a new approach to population policies and programs (CIC 1997). Like other developing countries with a large official family planning program, Bangladesh was a signatory to the ICPD Programme of Action, which required an explicit policy shift from the "exclusive focus on demographic concerns to one that holds the well-being of individual women and men at the center of sustainable development" (UN 1995). In practical terms, this shift consists of a conscious move from a purely contraceptive delivery approach to service provision to a reproductive health approach. For the Bangladesh government, trying to meet the health and family planning needs of a large and growing population living in endemic poverty, this shift has considerable implications for the future direction of its activities, in both the population and health sectors. It raises questions not only of a new approach to service delivery and what services to deliver but also of the institutional reforms and increased investments needed. Bangladesh's commitment to the ICPD Programme of Action calls for wide-ranging policy changes, a reorganization of the health and population infrastructure, and a reorientation of health- and population-sector functions. In addition, the significant resource requirements of such an agenda, including institutional and human resource commitments, enhanced budgetary allocations, and viable resource mobilization strategies, will have to be adequately addressed.

Health, Population, and Development Since the late 1970s, the government of Bangladesh has been implementing a series of development interventions aimed at more rapid economic

19

20

Developing Country Studies

growth and poverty reduction. It has also pursued social and human development interventions that have growth-enhancing and poverty-alleviating effects. Despite year-to-year fluctuations, the relative share of public spending in the health and population sectors has increased during the 1990s. One estimate shows that between 1983-1984 and 1993-1994, per capita public spending on health and family planning nearly doubled (Chowdhury and Sen 1997). The same study also estimates that in per capita terms the bottom 20 percent of rural households have access to nearly 22 percent of public expenditure on rural health, compared to 21 percent access by the top 20 percent of rural households. Thus, the distribution of public health expenditure in rural areas is less skewed than that of income, underscoring the importance of access to public health facilities for the rural poor. In that context, the expansion in health facilities during the last decade is quite significant. Between 1985 and 1994, the number of hospitals increased by 20 percent (with private hospitals growing faster than government hospitals), the number of doctors increased by 70 percent, and the number of nurses by 50 percent (see Table 2.1). However, none of these figures reveal the quality and equity aspects of such expenditures. For example, despite increases in the number of trained medical personnel, the ratio of doctors and nurses to population continues to be dismally low, and the imbalance in the availability of trained personnel is clear from the lopsided doctor-nurse ratio. In rural areas, there was not

Table 2.1 Availability of Health Facilities and Personnel, 1985-1994 Hospitals Year GOB 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994

596 600 608 608 608 608 610 611 611 693

Private 164 164 267 267 267 267 280 280 292 280

Registered Doctors Government (MBBS, Registered Dispensaries BDS) Nurses THCs 1,275 1,275 1,310 1,310 1,310 1,310 1,318 1,362 1,397 1,397

14,591 16,090 16,929 18,030 18,917 20,006 21,004 21,749 22,400 24,911

6,418 6,912 7,000 7,390 8,056 9,274 9,655 10,607 9,455 9,630

346 356 351 352 352 352 400 400 172 380

RHCs 12 12 12 12 12 12 12 12 12 14

Maternity and Child Welfare USCs Centers 1,275 1,275 1,275 1,275 1,275 1,275 1,310 1,362 1,362 1,362

91 91 91 91 96 96 96 96 96 96

Source: Abul Barkat et al., 1997. Notes: All figures are progressive totals. GOB = Government of Bangladesh; THC = Thana Health Complex; RHC = Rural Health Center; USC = Union Subcenter (under Health Directorate).

Bangladesh

21

much increase in thana (subdistrict)-level facilities, and only some increase in the number of union subcenters, indicating an urban and a secondarycare bias in health facility expansion. This is supported by evidence showing that within the health and population sector the share of investment in secondary health care increased at the expense of the share of primary health care during the early 1990s, whereas the share of investment in family planning actually declined slightly. Moreover, the low quality of service provision at public health facilities is commonly acknowledged. As a result, people of all socioeconomic classes, including the poor, tend to rely disproportionately on private health care facilities. At the household level, the proportion of total per capita health expenditure spent on public health facilities remains very low (13 percent) and has not shown any signs of increasing during the recent past (Chowdhury and Sen 1997). Although the aggregate pattern of public spending during the 1990s attests to the government's commitment to expand public health facilities, the nature of the expansion so far appears to be more in terms of quantity than quality. Some exceptions may be noted such as the high-impact Expanded Programme of Immunization (EPI) and, more recently, the TB and Leprosy Control Programme, both of which are aimed at controlling the prevalence of many highly communicable but preventable diseases. Demographic and Health Indicators There were notable improvements in both the demographic and the health situation of the Bangladesh population during the decade preceding the ICPD (see Table 2.2). Although the size of the population has nearly doubled since 1974, causing Bangladesh to be the most densely inhabited country in the world, both the crude death rates and birthrates have registered significant declines. Since the fall in mortality levels has been relatively greater, the desired negative impact on the population growth rate is apparent. The average annual growth rate of the population between 1981 and 1991 was estimated at 1.8 percent. Between 1975 and 1995, life expectancy at birth increased from forty-five to fifty-eight years (although with a persisting gender gap), the fertility rate dropped significantly (from a total fertility rate [TFR] of 6.3 to one of 3.3 children per woman), and child survival has improved visibly. Despite a fall in mortality levels, however, morbidity statistics from sample surveys show a continuing high disease burden from communicable diseases, which dominate the ten top causes of current illness in the population. Moreover, deaths of children under five still account for about

22

Developing Country Studies

Table 2.2 Health and Demographic Indicators, 1984-1996

Year 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996

Crude Contraceptive Birth Total Prevalence Rate Rate Fertility (eligible couples) (per Rate (per Modern 1,000 All population) woman) Methods Methods 34.8 34.6 34.4 33.3 33.2 33.0 32.8 31.6 30.8 28.8 27.8 26.5 25.6

4.83 4.71 4.70 4.42 4.39 4.35 4.33 — —

3.84 3.58 3.45 3.41

19.1 25.3

13.8 18.4

—

—

—

—

—

—

31.4

24.4

—

—

39.9

31.2

—

—

—

—

44.6

36.2

—

—

49.2

41.5

Infant Crude Mortality Death Rate Rate (per (per 1,000 live 1,000 population) births) 12.3 12.0 11.9 11.5 11.3 11.4 11.3 11.2 11.0 10.0 9.0 8.4 8.1

Child (1-4) Death Rate (per 1,000 live births)

Life Expectancy at Birth Male Female

—

—

—

—

—

—

— —

—

—

116 98 94 92 88 84 77 71 67

13.5 13.6 14.2 13.6 13.2 12.6 12.1 12.0 11.8

56.9 55.9 56.0 56.4 56.5 56.8 57.8 58.2 58.4 59.2

56.0 54.4 55.1 55.4 55.7 55.9 56.6 57.9 58.1 58.6

Source: Bangladesh Bureau of Statistics, Statistical Yearbook 1996.

half of all deaths. The main causes of child death are acute respiratory infections (ARIs), undernutrition, vitamin A deficiency, diarrheal disease, measles, neonatal tetanus, and injuries. Hence, if the population had access to certain curative and preventive services at convenient and practical locations, the majority of deaths in Bangladesh could be prevented. The reproductive health of women remains especially compromised, despite the fact that the childbearing burden has been halved. According to a World Health Organization (WHO)/UNICEF estimate, the maternal mortality ratio (MMR) is still at the unacceptably high level of 850 per 100,000 live births. The primary causes are believed to be poor maternal nutrition, harmful and unsafe practices during pregnancy and childbirth, lack of access to emergency obstetric care (EOC), and reproductive tract infections (RTIs). Thus, although access to family planning is widespread, access to the other three "pillars" of safe motherhood as defined by WHO—antenatal care, clean and safe delivery, and essential obstetric care—remain wholly inadequate. Almost three-quarters of women giving birth do not receive any antenatal care during pregnancy, and there are sharp differences in antenatal care coverage by subgroup. Moreover, 96 percent of all births are delivered at home, again with large socioeconomic and regional differences.

Bangladesh

23

For example, women living in urban areas and with some secondary schooling are significantly more likely to have received antenatal care and to have the birth in a health facility. Fewer than 10 percent of births are attended by trained personnel such as doctors, nurses, and family welfare visitors. The coverage of mothers for tetanus toxoid shows considerable improvement since 1989, rising from 26 percent to nearly three-quarters in 1996-1997 (Barkat et al. 1997). The improvement in child survival can be linked to the increased coverage of immunization under the EPI. The significant fall in the fertility level has been possible due to the tremendous increase in the use of modern methods of contraception, which rose from 5 percent of eligible couples in 1975 to nearly 42 percent in 1996-1997. Among the modern methods, pill use is the most popular, especially among women twenty to thirty-four. The use of traditional methods of family planning (abstinence and withdrawal) has remained fairly constant (8 percent) despite the implicit program bias against such methods. Nevertheless, 30 percent of users experience contraceptive complications, and the problems are more pronounced for clinical methods like IUDs and injectables. Effectiveness of use is less than adequate, resulting in many unwanted pregnancies. Women have only limited access to menstrual regulation services, despite the fact that menstrual regulation services have expanded significantly. Follow-up surveys show that two-fifths of rejected menstrual regulation clients try to get abortions elsewhere, and many of them suffer from complications that may be life-threatening at times (Kamal and Begum 1990). Women are also subject to high rates of RTIs, chronic and acute undernutrition, and postnatal complications.

Health and Family Planning Service Delivery Systems In Bangladesh, health care and family planning services are available from public and private facilities—including NGOs—at three levels: primary, secondary, and tertiary. The Ministry of Health and Family Welfare (MOHFW) has two divisions—health and family planning—deploying nearly 85,000 trained health staff and nearly 52,000 trained family planning staff to provide fixed and domiciliary services at the district, thana, union, and community levels in every region of the country. The two divisions and their directorate general are responsible for administrative direction, manpower management and development, budgetary control, provision of supplies and logistics, and the management information systems. The MOHFW provides the overall policy guidelines. Hence, there are well-entrenched, vertically segregated organizations for

24

Developing Country Studies

service delivery throughout the country. The division of labor and authority between these two divisions of the MOHFW at each level of service provision is parallel and complex, causing long-standing hostility between the personnel of the two wings. Earlier attempts at integrating service delivery in the field only resulted in a widening of the differences, the result of staff resistance, inadequate policy, and insufficient commitment of the government. The lowest-level fixed health facility is the outreach service at the union level in rural areas and the ward level in urban areas. Currently there are 2,988 union health and family welfare centers (UHFWCs), 1,362 rural dispensaries and union subcenters, and twelve Maternal and Child Welfare Centers (MCWCs) at the union level. The UHFWC, staffed by a family welfare visitor, provides limited curative, preventive, and promotive health and family planning services. Besides the fixed services, several preventive and promotive health and family planning services are also delivered by an army of field-workers providing domiciliary services through home visits. The Health Directorate employs three field-level health workers known as health assistants in each union (mostly very senior males) who are supposed to make home visits every two months for preventive health care services and immunization. Health assistants are also supposed to provide family planning motivation to the male population, but they usually refrain, as they view it as the responsibility of the family planning workers. Health assistants are supervised by health inspectors located at the thana. The Family Planning Directorate employs one family planning assistant (male) who supervises three family welfare assistants (female field-workers) at the union level. They supply condoms, oral pills, and injectables through home visits. The next tier of service provision is at the thana level. In 1995, there were 397 thana health centers (THCs), sixteen rural health centers, and twelve MCWCs covering nearly all thanas in Bangladesh. THCs are the first referral facility and provide curative, preventive, and surgical health services, including EOC and, in centers that have operating theaters, cesarean operations. The THC is supposed to be staffed by nine medical officers of various specialties, including one for family planning services. All these employees are supervised by the Thana Health and Family Planning Officer, who is also a medical doctor. The Thana Health and Family Planning Officer is also the overall supervisor of all health and family planning domiciliary field-workers. Thus, at the thana level, there is an attempt to unify the supervision of health and family planning services. The field operations of vertical projects like the EPI and TB and Leprosy Control are also directed from the THC.

Bangladesh

25

In addition, there are ninety MCWCs (some initiated in the early 1990s), of which fifty-five are located at district headquarters. These facilities aim to provide family planning (mostly clinical) services, antenatal and postnatal care, diagnosis and treatment of RTIs, normal delivery services, and some limited EOC. Health staff at present includes one medical officer and one family welfare visitor trained in safe delivery practices. More recently, the MOHFW has introduced a program of monthly satellite (mobile) clinics at different health facilities at the union level to provide family planning, antenatal care, immunization, and identification of communicable diseases, a step toward the gradual withdrawal of domiciliary services. Both field- and clinic-workers participate in service provision at the satellite clinics. All evidence points to the low level of utilization of most public health facilities at the community level. Utilization is not only very low but also unbalanced, with overutilization of facilities at the district and teaching hospitals and extreme underutilization at THCs and UHFWCs. These facilities are particularly notorious for the poor quality of services provided: inadequate attention given to patients by the doctors, shortages or absence of medicines and supplies, long waiting times, poor maintenance of equipment, unhygienic conditions, an overemphasis on contraceptive acceptance but neglect of follow-up care, widespread absenteeism of medical personnel, and inadequate training and knowledge among service providers (UBINIG 1998; BRAC 1991). Studies evaluating domiciliary family planning services have reported low contact with the households as the major reason for the ineffective service provision, leading to a large unmet need for family planning services and high discontinuation and method failure rates (Barkat et al. 1997; BRAC 1991; Khan 1988; Shuaib 1994). Little wonder, therefore, that only 12 percent of rural illnesses receive treatment at community-level facilities (Begum 1996). The existing belief about fixed services at the community level is that UHFWCs are intended only for the delivery of contraceptives, with some limited child health services, such as immunization and distribution of oral rehydration sachets (UBINIG 1998). Although routine and preventive maternal and child health services are supposed to be provided, very little attention is given by service providers to the health problems that women present and, indeed, to the whole range of common childhood diseases children suffer besides diarrhea. These negative perceptions are reinforced by the long-standing hostility between the medical (health) and the nonmedical (family planning) personnel. Another factor believed to be responsible for the low utilization rates of community-level facilities is the widespread practice of collecting unofficial

26

Developing Country Studies

user fees, or unauthorized payments that coexist alongside "free care" and formally approved service charges such as hospital admission (HEU 1997d). Official fees, which are levied primarily on commodities (medicines and surgical supplies), are collected by health facility staff, usually Class 3 and Class 4 employees. One study reports that unofficial fees represent as much as ten to twelve times the expected amount of official fees (HEU 1997d). Since poorer patients attending the THC are those most likely to pay unofficial fees, this works to their disadvantage. Unofficial fee collection takes place because the program fails to deliver required levels of services, commodities, and accessibility under "free care." Fee collectors take full advantage of information disparities between what they know and what the patient knows. In most facilities, fees are standardized, almost institutionalized, and linked in the patients' mind with low service quality (HEU 1997d). Hence, unofficial fees provide a built-in bias against the delivery of quality service and are likely to be an impediment to reforms aimed at raising the efficiency and quality of facilities. What's more, the family planning program's excessive reliance on external funds (on average, nearly 65 percent during the 1990s) has also adversely affected service utilization and the care-seeking behavior of the population. Heavy donor dependence has meant that service delivery has had to conform to donor priorities and donor beliefs, often imposed through tied loans and conditionalities. For example, donor pressure pushing for the delivery of modern contraceptives to curb the runaway population growth of poor nations led to the present supply-driven, capital-intensive, technologytransfer nature of the Bangladesh family planning program. The emphasis on door-to-door contraceptive delivery by poorly trained field-workers led to a passive demand for services, which encouraged the neglect of the health aspects of modern contraceptive use and legitimized the poor quality of service delivery. Door-to-door delivery was also seen as perpetuating and consolidating existing patriarchal norms that restrict women's mobility and prevent them from adapting their behavior to demand high-quality services. More important, donor dependence has prevented program efforts at self-reliance in terms of resource mobilization, cost recovery, community participation and ownership, community accountability, decentralized planning, and local authority. It has also reduced the potential for longterm financial sustainability by promoting the deployment of an unwieldy and increasingly expensive workforce and by allowing duplication and waste through mutually overlapping projects funded by different donors. The health and family planning programs currently offer contraceptive distribution from both clinical and community-based services; antenatal checkups at fixed facilities; iron and folic acid distribution at antenatal checkup facilities and during home visits; screening for high-risk pregnancy

Bangladesh

27

at static facilities and during home visits; immunization of pregnant mothers and children at outreach facilities; distribution of oral rehydration sachets and vitamin A capsules; referral of complicated pregnancies to appropriate facilities; referral of family planning clients with complications and side effects; menstrual regulation and treatment for incomplete abortions; safe delivery, at home through trained birth attendants and family welfare assistants, and at static facilities by medical officers and family welfare visitors; and EOC at selected facilities. To summarize, many of the service components of the ICPD reproductive health agenda are covered by Bangladesh's existing health system. The poor status of women's reproductive health in Bangladesh must therefore be linked to the ineffective delivery of these services and the fact that the majority of women have inadequate access to them. In other words, there are both formidable supply and demand barriers to service provision and utilization.

Financing for Health and Population Programs Since the early 1980s, fiscal as well as external deficits have had to be reduced to sustainable levels, whereas the developmental role of the government, as well as the priorities of public expenditures, have been redefined. As a result, patterns of public expenditure on health and population activities and their sources of funding have also undergone significant changes. Some of these changes in the government's fiscal management can be seen in Table 2.3. The budget deficit as a proportion of gross domestic product (GDP) has been declining since the early 1980s, following a similar decline in the availability of foreign aid. The extent of the decline in foreign aid, which finances most of the budget deficit in Bangladesh, is quite remarkable, going from 7.8 percent of GDP in 1984 to 3.5 percent in 1997. However, despite reduced aid availability, the level of public expenditures (current and capital expenditures combined) has remained more or less unchanged, roughly 17 percent of GDP. This has been made possible by increased revenue mobilization, particularly in the early 1990s, coupled with some increase in domestic borrowing in the very recent years. Expenditure on health and population activities has increased as a proportion of GDP and of total budget expenditures. The main structural budget shift has come about as a result of redefining the government's developmental role and the resulting changes in the composition of so-called development expenditure. Thus, the government has drastically reduced its role in direct investment in agriculture and manufacturing, whereas agricultural subsidies, previously accounting for a large share of development expenditure, have been virtually withdrawn. Future reallocation of expenditure to

28

Developing Country Studies

Table 2.3 Trends in Fiscal Balance and Public Expenditure on Health and Family Planning, 1984-1997" 1983/84 Fiscal Balances as % of GDP b Revenue 8.0 Expenditure 17.1 Budget deficit 9.1 (of which is foreign aid) (7.8) Expenditure on health and family planning As % of budget expenditure 4.8 As % of GDP 0.8 Per capita in 1987 taka c 72.0 (in 1987 d U.S.$ ) (1.69)

1985/86 1987/88 1989/90 1991/92 1993/94 1995/96 1997/98

9.1 16.6 7.5

9.0 16.1 7.1

9.3 17.2 7.9

10.9 15.9 5.9

12.1 18.1 6.0

11.4 17.1 5.7

12.0 17.4 5.4

(6.7)

(6.9)

(6.6)

(4.9)

(4.9)

(3.5)

(3.5)

3.4 0.9

5.5 0.9

5.5 0.9

5.8 0.9

7.0 1.3

6.4 1.1

7.3 1.3

50.9

80.7

85.3

86.9

125.7

120.8

142.4

(1.19)

(1.89)

(2.00)

(2.04)

(2.94)

(2.83)

(3.3;

Sources: Official fiscal statistics and data compiled in the annual Country Economic Memorandum of the World Bank. Notes: The estimates are based on actual income and expenditure of the central government and not on budget figures. a. Refers to fiscal years. b. GDP at market prices. c. At 1987 constant taka prices derived by using the consumer price index. d. Constant taka prices are converted to U.S. dollars at the 1987 exchange rate: U.S.S1.00 = Tk 42.7.

social sectors will require more difficult reforms, for example, in public administration and the state-owned enterprises. Table 2.3 also shows that per capita public spending in the health and population sectors has nearly doubled in real terms since the mid-1980s. Even so, the level remains pitifully low—only U.S.$3.33 per capita in 1997 (in constant 1987 prices). This is a reminder of the fact that the scarcity of resources, arising from low levels of per capita income and of public spending generally, is a major limiting factor in achieving population and health targets in Bangladesh. Table 2.4 attempts to provide a macro view of the flow of resources in the health and family welfare activities, including public and private sectors. By piecing together information from various sources for a recent financial year (1994-1995), the table identifies sources of funding as well as the various channels of service delivery. The picture that emerges is helpful for illuminating many policy issues. Combined public and private spending on health and family planning in 1994-1995 is estimated to be about U.S.$876 million, equivalent to U.S.$7.3 per capita, or 3.2 percent of GDP at market prices. This compares

Bangladesh

29

Table 2.4 Flow of Funds and Expenditure Patterns in Health and Population Activities, 1994/95 Sources of Funding

Providers

Government's Food and Total Local Commodity Project Foreign a Aid Resources Aid Aid Households

Public Sector Hospital PHC FP/MCH Other NGOs

246

40

135

174

7

61 78 61 47 2

10 14 11 4

7 14 96' 17

18 28 107 21 46

2 3 2 1 6

Private for Profit Medicine Qualified doctors Unqualified doctors Grand Total

NGOs

2

391

249 (28.4%)

319 24 48 404 (46.1%)

2

Total 428 (48.9%) 80 109 170 69 56 (6.4%) 391 (44.6%) 319 24 48 876 (100%)

Sources: Based on revised budget allocations, official data on NGO funding, and survey data on household health expenditure; see HEU (1997c). Notes: Due to rounding, rows and columns may not sum exactly to totals, a. Earmarked revenue generated from food and commodity aid.

poorly even with other South Asian countries. For example, per capita health expenditure in India, Sri Lanka, and Pakistan in 1990 was U.S.$21, U.S.$18, and U.S.$12, respectively. Table 2.4 also shows that households provided the largest source of funding, 46 percent, whereas the government provided 28 percent (from local resources) and donors a further 25 percent. Donor funding is heavily concentrated on project aid for the funding of family planning activities. In terms of delivery of services, the public sector's share is 49 percent, with a slightly lower share for the private sector providers (45 percent), whereas the NGO sector appears quite small (only 6 percent), though often it is highly effective. The overwhelming share of household expenditure (97 percent) is directed toward the private sector, which shows the extremely low level of cost recovery in the public sector (less than 4 percent according to the estimates in Table 2.4). Cost recovery in the case of services delivered by NGOs seems to be somewhat better, about 11 percent. The estimates also show a high propensity of households to seek the services of unqualified doctors, more so among poorer income groups, according to survey findings. Survey findings also show that the distribution of household health expenditures is highly skewed among income groups,

30

Developing Country Studies

more so than household income distribution. For example, the top 25 percent income bracket is found to account for 60 percent of household expenditure on health (HEU 1997c). Thus, even though an expansion of user fees may be necessary for funding a basic package of health services, it would be desirable to find mechanisms to protect the poor. Family planning and primary health care have accounted for an increasingly large share of total public spending in the health and population sectors. The family planning programs are estimated to have accounted for about 45 percent of this total spending during the first half of the 1990s. Although it is not possible to isolate expenditure on reproductive health care (not included in the family planning programs), some rough estimates can be made regarding the proportion of expenditure on primary health care out of the health sector's total spending. For fiscal year 1994-1995 this proportion is estimated to be about 55 percent. Moreover, this proportion appears to have increased significantly since the mid-1980s. Estimates for the first half of the 1990s show that donor financing accounted for about one-third of total budgetary allocations for the population and health sectors. It is noteworthy that this proportion has not fallen despite the decline in the overall aid-financing of the government's budget and the increase in budgetary allocations for the population and health sectors during this period (see Table 2.3). This reflects an overall trend in aid composition, namely, a marked shift toward the funding of social-sector projects. The increased allocation in the budget for the health and population sectors has not been due solely to the redirection of external funds; it is also due to increased funding by the government from its own domestic resources. It is, however, the overall allocation of resources, both external and domestic, that would better reflect the government's own priorities (assuming that the government could freely decide about the allocation of funds at the margin).

Developing a New National Reproductive Health Agenda A rapid rate of population growth has long been articulated as one of the major problems constraining economic development in Bangladesh. The major policy thrust of the government has, therefore, been the reduction of the population growth rate. Successive five-year plans have set time-bound targets to achieve replacement-level fertility through progressively higher levels of contraceptive prevalence. Thus, the need to increase contraceptive acceptance has traditionally driven program design and formulation, and the program structure believed to have the greatest impact in this respect was "a centralized, top-down bureaucracy for essentially transferring contraceptive technology," achieved typically "with the active encouragement

Bangladesh

31

and assistance of international agencies" (Demeny 1975). In fact it was believed that program effectiveness would be maximized if family planning activities were totally segregated from health activities, a structure that was also useful for attracting donor funds earmarked for population control. Historically, therefore, the demographic imperative of the family planning program has demanded a bifurcated program structure, with an artificial divide between family planning and health services. And despite a shift in recent years toward including maternal and child health under the purview of family planning services, this approach was largely adopted to broaden the clientele for the delivery of contraceptives. After the ICPD in 1994, the mandate of providing reproductive health services was added to this overriding demographic mandate. The primary government agency responsible for these new mandates (replacement-level fertility by 2005 and the provision of comprehensive reproductive health services) is the MOHFW and two of its directorates: Health Services and Family Planning. Reaching National

Consensus

In December 1993, the MOHFW issued a document "re-affirming the Government's commitment to solve the population problem." The report stated that despite the "impressive strides" made by the national family planning program, it still confronted "formidable challenges" (MOHFW 1994). In order to reach replacement-level fertility, the contraceptive prevalence rate (CPR) would have to be raised to 70-75 percent of couples of reproductive age. And even if fertility decline could be sustained to reach a net reproduction rate of 1 by the year 2005, the population would still exceed 139 million by that time. The five broad areas of activity identified as necessary to achieve a CPR of 75 percent were promotion of the small family norm; improvements in the quality of services; mobilization of resources for family planning-maternal and child health (MCH); strengthening of governmentNGO collaboration; and the financial sustainability of the family planning-MCH program. Some new strategies included involving the community to generate a sense of ownership of the program; focusing on underserved groups (young couples and men); increasing the choice of methods by expanding clinical services; strengthening the management information system (MIS); providing in-service training of family planning workers, the social marketing of family planning, and primary health care commodities; and increasing reliance on fixed and satellite clinics to replace door-to-door services. These priority activities appear to overlap with some elements of the ICPD Programme of Action, particularly those that could lead to an increase

32

Developing Country Studies

in the uptake of clinical contraceptives. However, the absence of any focus on the health of mothers, pregnant women, and contraceptive users suggests that women's health was still not a very high priority at that time. Moreover, although the service elements necessary to ensure high quality of care were recognized, they were seen primarily in the context of enhancing the use of clinical and surgical methods rather than to ensure that all family planning clients received high-quality service. Although representatives of the donor community (World Bank, the U.S. Agency for International Development [USAID], and the Population Council) agreed with the continued demographic imperative of the program, particularly the need to tackle population momentum and reduce fertility to replacement level, they also emphasized activities that could influence the demand for services, such as economic development, child survival, and girls' schooling. They also spoke of new approaches to service provision that would ensure couples the ability to freely determine their family size, a wider choice of contraceptive methods, better treatment and quality care at service centers, and access to a full range of reproductive health care. In January 1995, the MOHFW formed the Technical Review Committee to guide the strategic planning needs of the family planning program up to the year 2005. This activity, financed by USAID's Dhaka office, was undertaken in light of a growing awareness that each additional unit of increase in the CPR would be increasingly difficult and costly to achieve. The committee suggested a "Quality Strategy" focused on the needs of clients—both existing and future users—for family planning services and focusing on improving the quality of services available at that time. The major areas for action included transforming those who intended to practice family planning into users, raising continuation and effectiveness rates, and shifting contraceptive use toward longer-acting methods. Such a strategy, it was thought, would satisfy the client-based approach recommended in the ICPD Programme of Action, would improve the long-term financial sustainability of the program, and would help achieve replacement level fertility by 2005. However, how this exercise contributed to the process of reaching a national reproductive health agenda remains unclear. In August 1996, the MOHFW organized a national workshop—"Reproductive Health with a Gender Perspective"—in recognition of the 1995 Fourth World Conference on Women in Beijing, which had highlighted the gender perspective in the process of development (MOHFW 1996b). The objectives of that workshop were to arrive at a consensus on an appropriate definition of reproductive health in Bangladesh and to help government policymakers incorporate issues of gender equity within the fifth Health and Population Policy Project (HAPP5) to be implemented from 1998 to 2003. The sponsors were the Swedish International Development Agency (SIDA), the UN Population Fund (UNFPA), the UN Children's Fund (UNICEF), the World Health Organization (WHO), and the World Bank.

Bangladesh

33

Although the ICPD definition of reproductive health was thought generally appropriate, participants at the meeting expressed the need to place reproductive health care interventions within the wider social, cultural, and programmatic contexts of Bangladesh. They urged that the planning of reproductive health care services should take into account the underlying causes of women's poorer health status relative to men. These factors include gender-discriminatory sociocultural beliefs and practices (such as preference in the allocation of food, medical care, and schooling; harmful practices during pregnancy and childbirth; strong pronatalist norms like women's early marriage and first birth, the custom of marrying daughters outside the natal village, and large age difference between spouses) that lead to women's poorer nutritional status and greater exposure to violence relative to men; the legal system that reinforces women's low status by restricting abortion, promoting biased inheritance laws, and failing to prevent women's sexual and physical abuse; and the existing program structure, which fails to prevent women's unnecessary exposure to health hazards related to contraceptive use, abortion (because of inadequate menstrual regulation services), pregnancy, and delivery, as well as RTI/STDs. The workshop recommended the adoption of a life-cycle approach, whereby reproductive health services would be designed according to the needs of women throughout their entire lives according to the following stages: before sexual maturity, sexually mature, unmarried, sexually mature and married, and after the fertile period. It was also recommended that men and single adults who are widowed and divorced should come under the purview of such services. Hence, the workshop made a significant contribution by setting the concept of reproductive health in Bangladesh within a broader context and by incorporating into it the perspective of changing reproductive health needs over a woman's entire life, not just her childbearing years. In December 1996, a national Plan of Action to reflect the ICPD Programme of Action was finalized by a national committee convened by the MOHFW and funded by UNFPA. The action plan listed current government programs and suggested future programs for each of the broad themes articulated in the Cairo document. Under the theme of reproductive rights and reproductive health, for example, the action plan listed activities for safe motherhood, family planning, safe abortion, male participation, adolescents, infertility, RTI/STD and AIDS, and the like. As such, the national action plan reflected the ICPD Programme of Action almost in its totality yet appears to have been of little use in setting a specific national reproductive health agenda for Bangladesh. In the second half of 1996, a high-powered technical committee was formed by the MOHFW to develop the National Reproductive Health Strategy (MOHFW 1997a). The steering committee included top policymakers from both the Directorates of Family Planning and Health Services, as well

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Developing Country Studies

as representatives from the sponsors of the activity (World Bank, WHO, UNFPA, and UNICEF). Following the guidelines for UNFPA program support, the new reproductive health strategy identified four priority areas for service provision: maternal health; family planning; menstrual regulation and care of postabortion complications; and the management of RTIs/STDs. The resulting 1997 reproductive health strategy conceptualized, for the first time, integrated services for women's health (including safe motherhood, safe abortion, and RTIs) and family planning under a single programmatic approach. It was rightly felt that a program structure responsive to such integrated service provision would have to be flexible and clientcentered, rather than driven by a rigid demographic target, and would have to be staffed with personnel skilled in a wide range of services beyond family planning. Obviously, Bangladesh's existing program structure— with its well-entrenched vertical organizations delivering health and family planning services separately, weak accountability, centralized decisionmaking, and supply bias rather than client focus—would be inadequate in these respects. In addition, the strategy envisaged a more prominent role for NGOs, private-sector physicians and operations, and operations research organizations. Although reproductive health had become a fairly well accepted concept at government policymaking levels, understanding of the concept was believed to be almost nonexistent at the field-worker and service-provider levels, where reproductive health was still equated with MCH and family planning. It was believed, however, that the lack of comprehension about reproductive health care would not hamper implementation of the government's reproductive health agenda, since the essential services package (ESP) proposed under the Health and Population Sector Programme (HPSP) would be implemented in such a way that 40 percent of its components included reproductive health care elements. The official reproductive health agenda was seen to have only partially adopted the ICPD concept, since there was total silence on the issue of reproductive rights: the right of women over their bodies, and their right to decide the number of children and when to have them. Although, in principle, there was no visible opposition to the concept of reproductive rights, in practice this was difficult to ensure. For example, in the case of menstrual regulation and abortion, Bangladeshi women must obtain the consent of their husbands, and women seeking menstrual regulation at their own request are denied access to government facilities. The question of women's exposure to physical violence as a cause of their low health status was also glossed over, almost with tacit agreement from all quarters, including the government as well as donors. Despite the fact that rape and violence against women are becoming less taboo as topics for discussion, and despite general agreement on how widespread such

Bangladesh

35

practices are, the reproductive health strategy makes no official recognition of the problem. The MOHFW, therefore, found itself with two major mandates. The first was the challenge of attaining replacement-level fertility by significantly increasing contraceptive prevalence to around 70 percent of eligible couples. The second was implementation of an appropriate and contextually relevant reproductive health agenda through the government's health and family planning service delivery mechanism. Although these two mandates were not totally contradictory, each had the potential to undermine the other and to pull in opposing directions. Ultimately, such contradictions would have to be reconciled in the form of an implementable program structure and a deliverable and acceptable services package. The development of such a program proceeded over a period of two years, culminating in what is known as the Health and Population Sector Programme for 1998-2003.

The Health and Population Sector Programme The background for the preparation of the HPSP was provided by the experience gained during the implementation of the Fourth Population and Health Project (FPHP) and its two-year extension to mid-1997. From that experience there emerged a common donor-government concern, pointing to the urgent need to address the long-term financial sustainability of the program. Long-term financial sustainability was also particularly significant in the context of the ICPD Programme of Action, which required that developing countries contribute at least two-thirds of the new investments needed to implement the comprehensive reproductive health agenda. From the government's perspective, financial sustainability was seen as contingent upon rising program costs and a likely reduction in donor financing. Rising program costs were identified as a major constraint to future program implementation. For example, it was believed that the cost of simply maintaining the family planning program's current worker-client ratio would be doubled in a decade and that the doorstep contraceptive delivery system would become too expensive to continue (MOHFW 1997a). In fact the cost of the family planning program has been projected to reach $222 million by 2001-2002, of which 86 percent is expected to be raised from government taxes and revenues, food and commodity aid sales, and grants and loans from donors (HEU 1996a). In other words, a funding shortage of around $31 million has been projected, which will have to be met from other sources. From the donors' perspective, the long-term financial sustainability of the program was most strongly linked to the issue of resource management

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Developing Country Studies

and health-sector reform. Donors were particularly concerned with the fragmented implementation structure and dissociation of sectoral development projects from MOHFW line-managers. This led to the poor utilization and management of donor aid, causing the kind of waste and duplication of resources associated with implementation (or its lack) of a huge number of development projects. This concern coincided with strong pressure to shift from project aid to program aid, a concept emanating mainly from the World Bank, which headed the donor consortium for HAPP5. (The World Bank-IDA Consortium includes SIDA, the Canadian International Development Agency, the Department for International Development, the Netherlands, Norway, the European Union, and the German agencies for technical cooperation and financial cooperation.) The shift to the World Bank's sectorwide management approach was viewed as a way to reduce waste of human and material resources and promote more efficient service delivery. Additionally, it would to lead to better coordination among donors and better management of aid at the national level. Several crucial implementation issues were raised by the donors cofinancing the FPHP. These had to do with the existence of "free services" (believed to be undermining prospects for financial sustainability), the overall poor utilization of government services, and the related issues of cost-effectiveness and quality of service. However, the concerns of policymakers within the government came from a somewhat different perspective. These were how to incorporate the reproductive health agenda into the existing family planning program without compromising its "success" in contraceptive delivery; and how to prioritize interventions so as to achieve the maximum impact in terms of the population's overall health status (MOHFW 1997a). These concerns emerged because the family planning program was based largely on a system of doorstep service delivery, in which the program went to women in their homes. Wider reproductive health care services, as envisaged in the national reproductive health strategy, do not lend themselves to such a service delivery model and would have to be clinic-based in the future. Moreover, many of the service elements of reproductive health care would have to be directly under the purview of health personnel. Thus, knowing full well the barriers to such efforts, the MOHFW felt the need for a major reorganization of functions and personnel into a unified structure for service provision, supervision, and monitoring of results. Given this background, in consultation with UN agencies (UNDP, WHO, UNICEF, and UNFPA), the World Bank, and other important stakeholders, the government prepared the Health and Population Sector Strategy (HPSS). The final HPSP was the outcome of a two-year process in which ten specialized task forces developed and refined Bangladesh's health- and

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37

population-sector strategies. The program reforms were intended "to provide adequate basic health care for the people and slow population growth." Such "health care services should be responsive to clients' needs, especially those of children and women and the poor, and achieve quality of care with adequate delivery capacity and financial sustainability" (HPSS 1997). The strong donor influence on the functioning of the various task forces was reflected in the fact that although all were chaired by MOHFW staff from both the health and the population sectors, nine had secretaries who were located in donor and UN agencies. However, the process was seen to be fairly consultative and participatory, as was emphasized in the ICPD Programme of Action and by the donors. For example, the task force for community and stakeholder participation fulfilled its mandate through consultation with clients, participatory rural appraisal sessions with clients and field-workers at thana and district levels and in one urban slum, district workshops with all three types of stakeholders, and consultations with the media. The HPSP comprises six separate but interwoven components: an essential services package, reorganization of service delivery at the thana level, integrated support services, hospital-level services, sectorwide program management and policy, and regulatory action. The elements of the ESP are grouped into five major areas: reproductive health care, child health care, communicable disease control, limited curative care, and behavior change communication. The ESP is to be delivered through a unified structure at the thana level and below, with referral care at secondary and tertiary levels. The thana manager will be responsible for overall management and administration of all activities and for the supervision of all health and family planning workers. Existing family planning field staff will be shifted from the development to the revenue budget of the government in order to remove the existing pay anomalies between health and family planning workers. At the community level, the ESP will be provided from a fixed "community clinic" designed for easy access at the time of need, gradually moving away from the existing domiciliary service but continuing with the mobile service to ensure coverage of clients who may not have access to community clinics. Of the two core staff at the clinic, at least one will be a woman. To ensure community involvement and ownership, the clinics will be built, maintained, and secured by the community. Sectorwide management will allow the pooling of resources from various sources and their allocation to reflect sector priorities, the integrated management of activities under line managers rather than free-standing project directors, and common arrangements for reporting and performance monitoring. The HPSP identifies various activities to achieve this:

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Developing Country Studies

setting up procedures for disbursement, procurement, accounting, and reporting of pooled funds; development of annual operational plans; annual performance reviews; provisions for capacity development of managers at different levels; and transparency in financial procedures. The changes in the financial procedures will have to be far-reaching enough to gradually abolish the distinction between the MOHFW's development and revenue budgets, revise the internal procedures for authorization and release of funds, and establish centers of managerial accountability in terms of program outputs for the different components of the program. The HPSP was planned to begin on July 1, 1998, and all components will be gradually phased in. The cost of implementing the program has been estimated under different growth scenarios (HEU 1997a). Under the most optimistic scenario, the total estimated cost over five years will be U.S.$3.37 billion, reaching a per capita expenditure of U.S.$4.67 by 2 0 0 2 - 2 0 0 3 . It is expected that U.S.$2.47 billion, or 73 percent of the estimated cost, will be met from domestic sources, the rest coming from donor funding. The HPSP envisages that the horizontal integration of services will generate considerable economies of scale, leading to efficiency gains. Another proposed cost-saving measure is to discontinue the costly doorstep program for delivery of contraceptive devices. Despite such cost-saving measures, however, the resource implications of the program remain formidable because of the envisaged improvements in quality and coverage. How far the targets of cost-effectiveness and service quality improvements can be achieved will depend on how well the reorganized health system is administered. If sufficient resources cannot be mobilized in a timely fashion, such a large commitment from the government raises the question of the economic feasibility and financial sustainability of the HPSP. The HPSP and the National Reproductive Health

Agenda

It is clear that the essential services package forms the binding theme for the implementation of the HPSP, and all other components are conceptualized to support the delivery of the ESP. Although the design of the E S P was based on the concept of disability adjusted life years, the components of the national reproductive health agenda are all included in the ESP. For example, the emphasis on better delivery of EOC reflects the priorities of the national reproductive health strategy, and the maintenance of a flexible mix of both fixed and mobile clinics constitutes a safety net for the most vulnerable. The proposed expenditure pattern for E S P delivery during the first year reflects the government's commitment to provide comprehensive reproductive health care focused particularly on women, children, and the poor. The share of reproductive health care is almost half of the entire cost of delivering the ESP, and this share is double the level for the community

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39

facility as compared to union and thana facilities. Apparently, reproductive health services will be most accessible from the community clinic. However, a major part of the cost is likely to be due to the transfer of the salaries of family planning field-workers from the development to the revenue budget, so that a larger share may not necessarily indicate a qualitative improvement in services. The mechanism for assuring quality of service is to provide one doctor per union. A doctor's presence will be ensured by arranging for residential quarters. Obviously, the upgrading of medical skills and adequate supervision should play an important role in improving the quality of care. However, the indicators for monitoring service performance are still the conventional quantitative indicators, such as the CPR, discontinuation rates, the proportion of complicated pregnancies reaching first level of obstetric care, proportion of deliveries managed by trained personnel, and the like. Although such indicators say something about the aggregate level of performance, they do not indicate whether changes have taken place in the attitudes of service providers, in the client-centered focus of the facility, such as improved waiting times and privacy, in contraceptive side effects, in the demand for specific services, in the degree of choice in method, and in the level of information passed on. During 1998-1999, ESP delivery is estimated to cost U.S.$76.4 million, of which 49 percent is to be used for reproductive health care. The estimated cost of reproductive health care as a percentage of total estimated cost for ESP delivery will be 79 percent at the community level, 31 percent at the union level, and 34 percent at the thana level. The question remains whether health and family planning personnel will actually coordinate and integrate efforts for efficient provision of reproductive health care. Reorganization itself is unlikely to increase efficiency or cost-effectiveness—two concerns expressed in the ICPD Programme of Action—if realistic and "respectable" job descriptions and a system of incentives and disincentives for the performance of service providers are not put in place. The shift from the development to the revenue budget may be an incentive for family planning workers, but much more may be needed in terms of opportunities, not only for in-service training but also for training that can lead to upward mobility. Yet the shift may even induce poor performance since family planning workers' jobs are now secure. Hence, the connection between reorganization and improved quality of care is not immediately obvious. Gender Equality

and Women's

Empowerment

The ICPD concern with gender equity and women's empowerment has been articulated in the HPSP document as a cross-cutting issue. It is

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acknowledged that the implementation of activities to promote gender equity within the program (personnel placements, human resource development, staffing of the gender office within MOHFW, its access to planning and policymaking, etc.) has been difficult during the FPHP, limiting their effectiveness in reducing gender inequality. Therefore, the HPSP proposes to undertake a gender and institutional review at the start of the program. A proposed gender action plan will establish a mechanism for systematic analysis of demand and supply factors that lead to women's relatively lower health status compared to that of men and assist in evaluating inputs, outputs, and the impact of HPSP components in a gender-sensitive manner. The plan proposes actions in the following areas: the implementation of the E S P (awareness-raising with service providers, curricula and training plan development, training for management of violence victims, etc.); human resource development (increasing career opportunities for female staff, improving working conditions, gender training for all staff, etc.); sector management (assigning one person in the maternal and child unit to safeguard concerns with gender equality); and performance review (by developing gender-sensitive indicators and including relevant agencies in the review process). Local Resource Mobilization

Strategies

Concern with the financial sustainability (with respect to cost reduction and cost recovery) of the HPSP is articulated across the board. With regard to cost reduction, the HPSP is not forthcoming. The only component with a large potential for cost reduction is sectorwide management, which proposes to reduce waste of external resources by streamlining aid management and eliminating duplication of activities. The other potential costreduction component is the reorganization of service delivery. One analysis has shown that significant cost reduction in the delivery of specific services (such as IUD insertions) would be possible if field-workers and clinic-workers eliminated unauthorized leave, reduced unused time at work, and increased working time by one hour, from four to five hours per day (Janowitz et al. 1997). In fact, the projected demand for family planning services in the year 2004 could be met with the existing level of resources if service providers' working time could be made more productive. The need for increased reliance on cost-sharing strategies has received greater attention in the HPSP, given that the gap between the sectoral resource envelope and projected sectoral expenditures is quite wide. Under the HPSP, cost-recovery schemes would be initiated to meet some of this resource gap. Such schemes would have to take into account people's willingness and ability to pay. These will be assessed through cost-recovery experiments now being piloted. These studies will link revenue generation

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to revenue retention at participating facilities and to quality improvements. They will also identify avenues to generate local funds and the provision of safety nets for the vulnerable while ensuring administrative efficiency. Since the practice of unofficial user fees is widespread, most health activists and providers feel that the introduction of service charges would not adversely affect access to services. However, clients often associated unofficial user fees with poor quality of service. Hence, the introduction of user fees without an improvement in service quality and adequate availability of drugs and medicines may push clients away from public facilities toward private health care. Because the impact of user fees on the health status of the poor is not known sufficiently, the application of user fees should be viewed with some caution. The question of design and implementation also needs to be considered, as bad design and poor implementation may lead to a net loss of revenue as well as adverse impacts on the poor. The pilot study undertaken by the health economics unit of the MOHFW suggests that it is ultimately the response of the household to changing prices for health care that will determine the health impact of a resource mobilization strategy (HEU 1995a). Given the biased resource allocation pattern within households on the basis of age and gender, such fees may actually worsen the relative health status of women and children. Studies of NGO health programs that charge user fees show that the so-called flat pricing system (similar charges for doorstep and clinic-based services) does not encourage clients to seek clinic services. With a flat price there is also the chance of losing potential clients who cannot pay, so NGOs allow deferred payments. About half of the clients prefer to defer payment; of those, 25 percent do not pay at all (Streatfield et al. 1997). Hence, targeting may be required to identify vulnerable groups who may be adversely affected by the application of undifferentiated service charges. Providing the poor with safety nets is crucial and may be achieved through innovative self-selection and targeting strategies (HEU 1996c). Health insurance schemes constitute another approach for financing health care. Social health insurance is justified if it generates additional revenues, improves the efficiency of the system, improves the quality of service, and helps to establish the patient's rights as clients (HEU 1997a). The concept of social health insurance by not-for-profit providers, in combination with subsidized services, is not new in Bangladesh; indeed considerable experience already exists, primarily in the NGO health sector. The HPSP will support pilot studies on social health insurance in rural areas for possible replication and expansion. NGOs have been identified as the main vehicles for carrying such schemes because of their comparative advantages in organizing the rural poor and for introducing financial

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Developing Country Studies

discipline to the people, whereas the government will attempt to create the necessary enabling conditions. The experience with health insurance schemes so far has been positive. However, total coverage is not very wide, and the degree to which service provision costs are recovered varies. For example, the Grameen health program, a health insurance scheme for primary services, charges an annual premium ranging from Tk 50 (50 taka, or U.S.$1) to Tk 100 (U.S.$2), depending on the household's socioeconomic status. The consultation fee is minimal (Tk 2), and medicine is priced at cost. The Ganoshashthya Kendra (GK) health insurance scheme charges lower premiums—between Tk 5 and Tk 50—and also covers the costs of referral; pathology tests are priced at market value. It is reported that the subscription rates are 52 percent for the GK program and 27 percent for the Grameen program. The level of cost recovery is reported to be 45 percent of recurrent expenditures for Grameen and 20 percent for GK, so that actual cost recovery is likely to be lower when all components are expensed (HEU 1997a). The commercial marketing of contraceptives and primary health care products has been an important mechanism for financing distribution costs. The potential for social marketing for other commodities is substantial and will be explored under the HPSP. At present the Social Marketing Company in Bangladesh has one of the largest marketing systems in the world for the commercial distribution of health and family planning products. Until now that activity has been funded by USAID, which is outside the donor consortium for HAPP5.

NGO, Private-Sector, and Community Partnerships Successful implementation of the HPSP will require effective sectorwide partnership among the government and NGOs and the private sector. However, the need for delineation of roles and responsibilities and the basis for expanded collaboration have to be worked out. Stakeholder participation activities during the preparation of the HPSP demonstrated significant existing collaboration and potential for partnership between the government and NGOs. It is hoped that the partnership will promote service quality, encourage innovations, target underserved groups and inaccessible areas, and progressively take on subsectoral responsibility, like running clinics and hospitals. Several priority activities within the HPSP have been identified for NGOs: behavior change communication, training service providers, delivery of ESP, strengthening of referral systems, operations research, community information centers, advocacy for a Client's Bill of Rights, and the

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initiation of cost-sharing and health insurance schemes on an experimental basis. In policymaking, NGOs will be involved in a consultative process through a national policy committee. Mechanisms for the selection of NGOs, for contracting processes, for alternative funding mechanisms, and for monitoring and accountability will be instituted under the HPSP. The efforts of NGOs in the area of reproductive health care delivery preceded those of the government. For example, the health program of the Bangladesh Rural Advancement Committee (BRAC) has over twenty years' experience in implementing community-based health care programs focused on the needs of the poor, women, and children. BRAC started a Woman's Health and Development Programme in 1991 for its village organization members, mostly poor women, providing mainly primary health care and family planning services. In 1996, a reformulated Reproductive Health and Disease Control program was started experimentally in ten thanas. At present, it covers a population of more than 1.8 million (village organization members and nonmembers alike). The components of the service include a reproductive health care package, adolescent family life education, contraceptive information and services, antenatal and postnatal services, ARI, STD, and RTI, and HIV/AIDS awareness. The services are provided by domiciliary field-workers, all local women based at an area office, at mobile antenatal clinics and fixed health centers. The program also arranges monthly local antenatal clinics (ANCs). The service at these clinics includes neonatal checkups to identify highrisk pregnancies, immunization, health education, and the application of clinical contraceptives. High-risk pregnancy clients are encouraged to obtain hospital delivery, and other pregnant women are motivated to attend one of thirty-four BRAC health centers (BHCs), which are located all over the country. The ANCs request a service charge of Tk 5 - 6 (U.S.$.10), and clients have to pay for urine tests and iron tablets. However, the service charge is only collected from women who can afford to pay. To ensure quality of service there is regular monitoring of performance by the area office, by HQ staff, and by the monitoring office. There are service charges for outpatient consultations, for deliveries, and for family planning and other surgical services and pathological services provided at the BHC. Charges are 2 5 - 5 0 percent higher for non-village organization members. All drugs are charged at cost. It is estimated that an average outpatient visit at a BHC costs around Tk 70 (U.S.$1.25). Charges for ARI inpatient care are around Tk 100 (U.S.$2), excluding food and drug costs. Very rough estimates suggest that cost recovery at BHCs is quite substantial, around 6 0 - 8 0 percent on average. Although the private sector (physicians and pharmacies) now delivers the major portion of curative services, its role in the implementation of the HPSP is yet to be worked out. That the private-sector role should be

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Developing Country Studies

expanded is agreed, but the extent of service provision, the cost and quality of such service, and sources of financing are yet to be assessed. Based on this assessment a more effective involvement may be sought, but the principles for partnership with the private sector based on information on costs, efficiency, and capacity for ESP delivery will need to be worked out. It should be noted that health service provision in the private sector is subsidized to a large extent by the public sector, as government medical personnel provide the major part of the skills and manpower for private-sector health service provision. This may impede the institutionalization of private health services under the HPSP. In addition, there is an urgent need for a strong regulatory framework for the conduct of all practitioners and the protection of clients. The HPSP will carry out investigative studies and arrange to review the overall position with regard to the legal and regulatory framework that will regulate all providers under the HPSP. The HPSP seeks to develop sustainable processes for partnerships between the government and organized communities for achieving common goals. Local-level planning, community involvement in implementation, and monitoring of the ESP will be used as entry points for such partnerships. Local communities will also be involved in supervising the lower performance areas and in hospital management as they become more autonomous. However, such nontraditional activities will require training to develop necessary competencies (for example, in the use of participatory rural appraisal tools, planning, and monitoring) and foster needed attitudinal change both in the community and among government functionaries and program managers. NGOs may play a role in facilitating such training.

Conclusion The reduction in fertility levels since the mid-1980s is impressive given that the macroeconomic scenario in Bangladesh during the period was, at best, stagnant and that any reduction in poverty was slow. Moreover, fertility decline in Bangladesh has taken place in the face of little visible improvement in the conventional indicators of women's status, such as literacy and labor force participation rates, or indeed, even in the less traditional indicators of women's empowerment, such as decisionmaking and control over income. This has prompted the claim that lower fertility is a supply response, almost precluding any demand-side explanations (Cleland et al. 1996). Although the government family planning program has so far been able to deliver contraceptive services in a fairly extensive manner, it would be naive to ascribe the entire change in reproductive behavior to supplyside approaches and their cost-mitigating properties. Even if contraceptive delivery is seen as the only program objective, program success should be

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measured in terms of how far it has been able to satisfy unmet and new demand for family planning services among all subgroups of the population, not just among currently married women of reproductive age. In fact with a broadening of the agenda of the national family planning program to include reproductive health care services, success and its indicators will need to be entirely reformulated. The transition from exclusively family planning to a comprehensive reproductive health program, as envisaged in the ICPD Programme of Action, is yet to be realized. Nonetheless, notable progress has been achieved. First, there is a general acceptance among policymakers and implementers that the concept of reproductive health, rather than the traditional maternal/child health approach, is more efficient for providing family planning and health care. Moreover, the process of reaching consensus on a national reproductive health agenda has been fairly participatory. Although Bangladesh's Fifth Five Year Plan still emphasizes demographic targets, it plans to achieve these "within the framework of reproductive health care and a reorganized service delivery system." Emphasis on a "program" rather than a "project" approach to service delivery is also conducive to a reproductive health approach. Finally, the preparation of the HPSP itself, which incorporates the reforms needed to move toward a reproductive health approach, may be interpreted as the most positive indicator in this transition process. Several factors have contributed to the shift in policy and program design. One of the most pressing has been continued high maternal mortality, despite reductions in the pregnancy burden. The rising concern with STDs and AIDS and the need to move beyond family planning in order to increase the CPR have also been important. The feasibility of a comprehensive reproductive health care approach, as demonstrated by NGO programs, and the strong donor pressure to bring about health sector reform have also carried a lot of weight. However, the integration of a reproductive health agenda into the country's health services is fraught with problems. The most severe is the existence of vertically segregated service delivery structures, which have created two mutually exclusive and often hostile service provider cadres for health and family planning. Integration of the two systems implies that health personnel will require training in high-quality family planning service provision, and vice versa, entailing considerable training and reorientation costs. Insufficient accountability and inadequate supervision of service providers also pose formidable barriers. Integration is further impeded by the apprehension that the concern with reproductive health care delivery will undermine the "success" achieved in terms of levels of contraceptive use, and by the overriding policy mandate to achieve a CPR of 70 percent of eligible couples by 2002. Within the context of a sectorwide program, the role of donors, the private sector, and the NGOs achieve special significance. Recommended

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priority areas for donor action would be in the training of service providers for a comprehensive reproductive health approach to services; assistance to improve the quality of care at public facilities; and support in establishing mechanisms for monitoring and supervising service providers, and, in MIS, for the monitoring of program performance. The role of the private sector is more difficult to define because of the absence of a regulatory framework that could ensure proper monitoring of private services and providers. However, activities for which the private sector could be useful and complementary to the public sector are the provision of nonmedical services (cafeteria, ambulance, private nursing, etc.); high-cost tertiary services; urban service provision; social marketing of health and family planning commodities; and media-awareness services. The HPSP recognizes many of the constraints inherent in its health system and has provisions to address them. Among them, the ESP should provide integrated services at a one-stop clinic at the community level, with an effective referral system to higher levels of service provision. Ideally, such a system should facilitate the much-needed reorganization of the service infrastructure. Training in the provision of integrated and clientfocused services should improve the quality of care and reduce women's opportunity cost of visiting these community clinics. It is apparent, however, that future financing of the new reproductive health agenda has not been sufficiently comprehended. In the past, changes in the composition of public expenditure in favor of the social sectors, including health and population, occurred as a result of redefining the government's developmental role rather than a major policy shift. A sectorwide program will require a much greater shift in government expenditure to the health sector than in the past, a difficult policy decision at best. If sufficient funds are not available, then overly ambitious targets may face resource shortfalls in later years, causing unforeseen cuts that could threaten the entire program. There are also aid conditions regarding the level of local financing and the proportion going to the delivery of the ESP, which could prove counterproductive. If conditions are unrealistic, there may be noncompliance, leading to disruption in aid disbursement and constraints on program implementation. Although the HPSP fits well with the government's poverty reduction and human development strategy, its ultimate success depends upon how well "reorganization" is carried out. This, in fact, is part of the broader governance challenge facing Bangladesh.

References Barkat, A., et al., 1997. Family Planning Unmet Need in Bangladesh. versity Research Corporation.

Dhaka: Uni-

Bangladesh

47

Begum, S., 1996. "Health Dimensions of Poverty," in H.Z. Rahman, M. Hossain and B. Sen (eds.), Dynamics of Rural Poverty in Bangladesh. Dhaka: Bangladesh Institute of Development Studies. BRAC (Bangladesh Rural Advancement Committee), 1991. A Tale of Two Wings. Rural Study Series. Dhaka: Bangladesh Rural Advancement Committee. Chowdhury, O.H., and B. Sen, 1997. "Role of Public Expenditure in Poverty Alleviation in Bangladesh." Draft. Dhaka: Bangladesh Institute of Development Studies. CIC (Center on International Cooperation), 1997. "Health, Population, and Development: Policies and Financing Post Cairo." Project Description. New York: Center on International Cooperation, New York University. Cleland, J., et al., 1996. The Determinants of Reproductive Change in Bangladesh. Washington, D.C.: World Bank. Demeny, P., 1975. "Observations on Population Policy and Population Programme in Bangladesh." Population and Development Review 1, no. 2. HEU (Health Economics Unit), 1995a. "A Pilot Programme for Resource Mobilization Through User Fees." Research Note 3. Dhaka: Health Economics Unit, Ministry of Health and Family Welfare. , 1995b. "A Public Expenditure Review of the Health and Population Sectors." Working Paper 1. Dhaka: Health Economics Unit, Ministry of Health and Family Welfare. , 1995c. "An Analysis of Recurrent Costs in GOB Health and Population Facilities." Working Paper 2. Dhaka: Health Economics Unit, Ministry of Health and Family Welfare. , 1996a. "Balancing Future Resources and Expenditures in the GOB Health and Population Sectors." Research Paper 3. Dhaka: Health Economics Unit, Ministry of Health and Family Welfare. , 1996b. "Key Issues in Costing an Essential Package of Health Services for Bangladesh." Research Note 4. Dhaka: Health Economics Unit, Ministry of Health and Family Welfare. , 1996c. "User Fees, Self-Selection, and the Poor in Bangladesh." Research Note 5. Dhaka: Health Economics Unit, Ministry of Health and Family Welfare. , 1997a. "A Pre-feasibility Analysis of Social Health Insurance in Rural Bangladesh: The NGO Model." Research Note 8. Dhaka: Health Economics Unit, Ministry of Health and Family Welfare. , 1997b. "Resource Envelope Estimation for HAPP-5." Research Note 10. Dhaka: Health Economics Unit, Ministry of Health and Family Welfare. , 1997c. "An Assessment of the Flow of Funds in the Health and Population Sector in Bangladesh." Research Paper 5. Dhaka: Health Economics Unit, Ministry of Health and Family Welfare. , 1997d. "Unofficial Fees at Health Care Facilities in Bangladesh: Price, Equity, and Institutional Issues." Research Paper 10. Dhaka: Health Economics Unit, Ministry of Health and Family Welfare. HPSS (Health and Population Sector Strategy), 1997. Government document. Dhaka: Ministry of Health and Family Welfare. Janowitz, B., et al., 1997. "Can the Bangladeshi Family Planning Programme Meet Rising Costs Without Raising Costs?" International Family Planning Perspectives 23, no. 3. Kamal, G.M., and S.F. Begum, 1990. Study on Interventions Necessary for Preventing Rejection of MR Clients. Dhaka: Bangladesh Association for the Prevention of Septic Abortion.

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Khan, M.R. (ed.), 1988. Evaluation of Primary Health Care and Family Planning Facilities in Rural Areas of Bangladesh. Research Monograph No. 7. Dhaka: Bangladesh Institute of Development Studies. , 1997. Bangladesh Health Finance and Expenditure Pattern. Research Monograph No. 14. Dhaka: Bangladesh Institute of Development Studies. Mahmud, W., 1998. "Bangladesh: Structural Adjustment and Beyond." Paper presented at the International Conference on Adjustment and Beyond. Dhaka: Bangladesh Economic Association and International Economic Association. M O H F W (Ministry of Health and Family Welfare), 1994. Future Challenges in Bangladesh Family Planning Programme: Policy Guidelines and Strategic Action. Dhaka: Ministry of Health and Family Welfare. , 1996a. Strategic Direction for the Bangladesh National Family Planning Programme, 1995-2005. Dhaka: Ministry of Health and Family Welfare. , 1996b. Report of the National Workshop on Reproductive Health with a Gender Perspective. Dhaka: Ministry of Health and Family Welfare. , 1997a. National Reproductive Health Strategy. Dhaka: Ministry of Health and Family Welfare. , 1997b. Health and Population Sector Strategy. Dhaka: Ministry of Health and Family Welfare. Shuaib, M., 1994. "Baseline Study on Combined Service Delivery in Manikgonj District." Dhaka: UNICEF. Streatfield, K., et al., 1997. Financial Sustainability of Family Planning Service Delivery in Bangladesh. Dhaka: Population Council. UBINIG (NGO, Bangladesh), 1998. "The Status of Health Services at the Union and Thana Levels." Dhaka: UBINIG. UN (United Nations), 1995. Population and Development, Volume 1. Programme of Action adopted at the International Conference on Population and Development, Cairo, September 5 - 1 3 . 1994. New York: Department of Economic and Social Information and Policy Analysis, United Nations. UNFPA (United Nations Population Fund), 1996a. Reproductive Health in Bangladesh: A Sectoral Review. Dhaka: UNFPA. , 1996b. Strengthening MCHlFamily Planning Services at MCWCs in Bangladesh. Dhaka: UNFPA. USAID (U.S. Agency for International Development), undated. National Integrated Population and Health Programme: Results Package, July 1997-June 2004. Dhaka: USAID.

3 Egypt Hind A. S. Khattab, Lamia El-Fattal & Nadine Karraze Shorbagi

T H E INTERNATIONAL C O N F E R E N C E ON POPULATION AND DEvelopment (ICPD), held in Cairo, Egypt, in September 1994, offered a new international understanding of population policies and programs. Rather than focus exclusively on population growth and family planning (FP) and their social and economic impact on national development, the new ICPD paradigm emphasized the reproductive health and well-being of individual women and men, and viewed that as a prerequisite for sustainable development. The ideological shift that resulted from the Cairo conference replaces the traditional approach, based on the assumption that limiting fertility through family planning programs produces slower population growth and that lower birthrates, in turn, have a positive impact on national development with a new, more comprehensive paradigm. This new approach defines reproductive health as "a state of complete physical, mental and social well-being and . . . is not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health, therefore, implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, and when and how often to do so" (United Nations Population Fund 1996, para. 7.2). This new multidisciplinary and holistic framework presupposes a greater sensitivity to gender differences in national policies and programs and encourages attention to both medical and social components in understanding reproductive health (Zurayk 1997b). However, it is important to note that although the focus of ICPD's reproductive health approach is on health, well-being, and the ability to satisfy reproductive intentions, it does not, by any means, exclude family planning. Indeed, as H. Zurayk (1997a: 5) points out, "one important notion to emphasize is that reproductive health is a concept much more acceptable to women than family planning,

49

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Developing Country Studies

as it addresses a wider circle of their needs. It is inclusive of family planning, and can actually have positive implications for healthy and continued use of modern contraceptives when contraindicated conditions are also taken care of in the process." Given that this new international understanding is now four years old and that governments, international donors, and nongovernmental organizations (NGOs) have had time to reflect on the issues and act on the ICPD Programme of Action, the two most pressing questions to ask in the case of Egypt are: 1. To what extent, if any, has ICPD's new reproductive health approach made its way into national policies and programs? 2. Is this new approach viable, financially feasible, and sustainable? The use of Egypt as a case study is interesting because of two features that distinguish it from other developing countries. First, Egypt's very high rate of population growth has been recognized as a problem for a long time. Indeed, as early as 1953, the population issue was brought to light by the Egyptian government. In the following years, extensive family planning policies and programs were instituted, using vast financial and human resources. Today, the government of Egypt still assigns the population problem high priority. Second, Egypt, to a large extent, has had considerable success in reducing population growth through family planning efforts. The main objective of this study is to examine the impact of ICPD on ideologies that are shaping health and population policies in Egypt. The study reviews the ICPD agenda and evaluates its appropriateness, viability, and sustainability in Egypt. It then analyzes national and international projects, programs, and policies in Egypt, with specific focus on financial sources and funding mechanisms. Finally, some recommendations for effective ICPD policy implementation are suggested. The documents examined include government reports in demography, health structure and infrastructure, policy, and government budget reports, as well as studies in reproductive health interventions and reproductive health rights and NGO and donor reports. In addition to the review of literature, the authors conducted extensive interviews with prominent individuals in the field: representatives of international donor agencies, government officials (policymakers and program planners), reproductive health and reproductive health rights advocates, and the staff of NGOs involved in population programs and reproductive health. Several follow-up consultations were held to augment the data already collected.

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51

The specific objectives of the study are to: • Examine the ideologies shaping health and population policies in Egypt. • Assess the influence of ICPD and the appropriateness, viability, and sustainability of the ICPD agenda in Egypt. • Review current and alternative sources and mechanisms for health financing at the national level. • Review the current role of the international community in providing population and health assistance to Egypt. • Assess changes and the direction of change in the role of donor agencies since ICPD. • Identify gaps in reproductive health implementation and provide some recommendations for developing a more realistic, dynamic, and sustainable course of action.

Population and Health Conditions Egypt's population is large and growing rapidly, having gone from 37 million people in 1976 to 59 million people in 1996 (CAPMAS 1996). The vast majority of the population lives in only 6 percent of Egypt's total land area, predominantly along the narrow stretch of the Nile Valley and the Delta (see Table 3.1). 1 There are significant regional disparities in terms of economic and health conditions, especially between Lower and Upper Egypt, and between urban and rural areas. Rural Upper Egypt fares worst: it is the least developed region in the country and adheres to strong traditional values and norms that favor high fertility rates. In Egypt, the burden of fertility control falls exclusively on women, and the methods they are most likely to use are modern—especially IUDs and the pill. On the whole, Egyptian women are familiar with and knowledgeable about modern contraceptive methods. The use of contraception increased from 40 percent in 1980 to 68 percent in 1995. Although these levels are relatively high, there is also a high rate of contraceptive discontinuation—about 30 percent after twelve months of use. 2 Poor compliance and misuse, especially among pill users, have also been recorded, probably as a result of poor counseling (Hassan and Fathallah 1995). In general, contraceptive users rely more heavily on the private sector than on the public sector to obtain their contraceptive methods. The public sector provides services predominantly in rural regions and to the urban poor, whereas private-sector use dominates in the urban community.

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Table 3.1 Demographic and Health Data, Egypt Births per year (1995) Fertility rate (1995) Crude birth rate (1995) % of average population growth rate (1960-1994) % of population under 15 years (1996)a % of population in urban areas (1996) % of population in rural areas (1996)b Under-5 mortality rate (1995) % of children under 5 vaccinated against major preventable childhood diseases (1995) % of contraception use (1995) % of contraception discontinuance after 12-month use (1995) % of FP users obtaining method from: public sector (1995) private sector (1995) % of births receiving antenatal care (1991-1995) % of births in which mothers received at least one Tetanus Toxoid vaccination (1995) Maternal mortality rate (1995) Average breast-feeding time (not exclusive) Illiteracy rates (1996)° (%): Men Women % of working women receiving cashd

1.6 million 3.6 births per woman 28 per 1,000 population 2.4 40.0 43.0 57.0 81 deaths per 1,000 births 79.0 68.0 30.0 35.7 62.7 39.0 49.0 174 deaths per 100,000 live births 8.9 months 34.6 61.2 15.0

Sources: DHS, 1995. a. Moreland, 1996. b. CAPMAS, 1996. c. INP, 1996. d. Zurayk, 1997a.

Although the government has helped people achieve commendable levels of contraceptive use, the quality of health care is in need of significant upgrading. Due to the low quality of services at public health facilities, research shows that 62 percent of clients utilize private clinics, pharmacies, and doctors to obtain contraceptive supplies. Furthermore, poor quality leads to high discontinuation of services, incorrect use of methods and medical complications, exposure to unwanted pregnancies, and unsafe abortions. Egypt's Demographic and Health Survey (EDHS) data applicable to the five years prior to 1995 indicate that only 39 percent of women giving birth received antenatal care. 3 The prenatal care provider was most often a doctor. Most Egyptian women deliver their children at home, and only one-third of deliveries occur in either private (15 percent) or public (18 percent) health facilities. Overall, less than half the births were assisted by doctors or trained nurses/midwives, and traditional birth attendants (dayas) provided assistance in 49 percent of deliveries.

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53

According to a study to examine the status of HIV and AIDS in Egypt conducted by C. Lenton and H. Khattab (1997) for the European Commission, the country is still at an early stage of an HIV epidemic, 4 and HIV and AIDS are not yet serious public health problems. Female circumcision is widely practiced in Egypt (97 percent of never-married women fifteen to forty-nine). Most circumcisions occur before puberty (median age: 9.8 years), with traditional practitioners performing the cutting in about eight in ten cases. Women in the EDHS-1995 survey practiced female circumcision because of tradition and their husbands' preference. Although data on reproductive morbidity is not yet part of the regular data collected in EDHS surveys, an in-depth field study among 509 women in the Giza Governorate in 1989-1990 conducted by the Reproductive Health Working Group showed that reproductive morbidity in this region is very high. Gynecological examinations showed that women carry a very heavy disease burden, which they tend to bear with silent endurance (Khattab 1992). Egyptian women place a high social value on marriage (almost universal), motherhood, and fertility. These provide women with social, emotional, and economic security. Pregnancy and childbirth are viewed as natural processes that reflect the competencies of a healthy mother. Such perceptions explain why marriage occurs relatively early, why fertility rates are high, and why both infertility and pregnancy often have tragic consequences for women (Zurayk 1997a). Despite insufficient research on the extent to which women make decisions at the household level, there is some evidence that many decisions are made jointly with the husband. However, the degree of shared decisionmaking depends on a woman's age, her position in the family, and her financial contribution to it. Women appear to make most decisions in family matters such as children's marriage and education, child care, and health care, as well as nutrition.

Population and Health Policies and Programs Egypt has been concerned about population growth for many years. As early as 1953, the National Commission for Population Matters was established, and in 1962, the country's charter referred to rapid population growth as a grave problem demanding prompt attention (Osheba and Sayed 1991; Moreland 1996). A historical review of population activities in Egypt shows that until 1994 population policy fluctuated between an emphasis on family planning and an emphasis on socioeconomic development. Many administrative

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changes during the earlier years led to confusion and bureaucratic inefficiencies and to an inability to meet program targets. In the period 1965-1973, efforts mainly concentrated on the provision of family planning services as a means of reducing fertility. 5 In 1973, after the first policy document was issued, there appeared to be a change in thinking about the country's population problem. The improvement of socioeconomic conditions, especially education and income levels, rather than exclusive focus on the provision of family planning services, was seen as a way to reduce fertility growth. 6 In fact Egypt has seen an increase in the enrollment of girls in primary schools. According to EDHS (1995), the proportion of girls in primary education increased from 38 percent in 1972-1973 to 45.7 percent in 1994-1995. Between 1975 and 1994, armed with substantial donor funding and technical assistance, principally from the U.S. Agency for International Development (USAID), Egypt adopted a more comprehensive approach toward population policy. This involved upgrading the "quality" of the population (e.g., education, health) as well as improving socioeconomic conditions. Toward this goal, the Population and Development Project, initiated in 1977 to serve rural areas, sought to reduce fertility by upgrading the quality of health and family planning services; improving the status of women through literacy and economic participation; promoting smallscale economic activity; facilitating access to urban areas; promoting information and communication through community institutions; mobilizing community participation; and upgrading the managerial capabilities of local councils and officials responsible for project activities. The National Population Council (NPC) was established in 1985. Headed by the prime minister, this semiautonomous government unit was assigned responsibility for population policy. The National Family Planning Project replaced the Population and Family Planning Board (PFPB) and was charged with all family planning activities in Egypt. In 1994, Cairo hosted the ICPD. The Cairo conference itself had an enormous impact on population and health policies and programs in Egypt. It provided the impetus for a critical evaluation of past policies and programs, as well as the chance to increase national awareness of women's problems and encourage mobilization of all the parties involved and strategize in a more cooperative and comprehensive manner. In 1996, the Ministry of Health and Population (MOHP) was created in an attempt to centralize, upgrade, and integrate all population, family planning, and reproductive health services and activities into one government agency. MOHP is currently the largest supplier of health and family planning services in Egypt. The two other government agencies currently involved in population and reproductive health/family planning are the Ministry of Social Affairs, which supervises NGO activity, and the NPC, responsible for research and coordinating activities.

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55

Until recently, the main thrust of Egypt's government population policy was to bring down growth rates through reducing fertility (Ibrahim 1995), and the major strategy to achieve this was by increasing the use of contraception. Because reduced growth in population is linked to reduced government expenditures in education, health, food subsidies, housing, water, and sewage treatment, this policy was seen as a "sound investment" (NPC and RAPID IV 1994). A highly publicized cost-benefit analysis of Egypt's family planning program (Moreland 1996: 173) concluded that the "benefits of increased family planning far exceed the extra investment costs . . . [and] over the period between 1993 and 2 0 1 5 , the savings due to higher family planning in the health sector would be 1,034 million L E " (£E, about U.S.$305 million). The policy is exemplified by the national goal of achieving a twochild family by the year 2 0 1 5 , a replacement-level fertility of approximately 2.1, and a contraceptive prevalence rate of 74 percent by the year 2015. This policy is consistent with ICPD's goal of eliminating all unmet need for family planning (Moreland 1996: 6). In terms of reducing fertility through the increased use of modern contraceptive methods, the government's efforts are widely considered successful. Indeed, measuring by various indicators, most experts believe that a reproductive revolution is under way in Egypt (Osheba 1996). Between 1980 and 1995, for example, the total fertility rate fell by 1.7 births, from 5.3 to 3.6 per woman (DHS 1997). In 1995, the crude birth rate was estimated to be 28 per 1,000 population, compared to 38.6 in 1986 (DHS 1995). Factors other than the increased use of contraception have also been responsible for reducing fertility rates in Egypt. They include significant increases in age at first marriage, as well as attitudinal change, reflected in the expressed desire of women to have fewer children. Yet it is important to note that fertility in Egypt is not declining as fast as did in the past, and the demand for family planning services is not growing as rapidly. Government

Programs After

ICPD

After the Cairo conference, the government of Egypt revised its population and health strategy, placing greater emphasis on providing universal health coverage and high-quality reproductive health and family planning services and giving greater support to NGOs in the development of local communities. The new strategy also includes efforts to improve women's education and increase their employment opportunities. Three divisions of MOHP provide reproductive health programs in Egypt: the Maternal and Child Health Care Division (with 140 childbirth centers and hospitals); the Primary Health Care Division (which runs a nationwide network of more than 3,800 primary, secondary, and tertiary health care units providing health services), and the Population and Family

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Planning Division. All government health services are offered at little or no cost to users, and all contraceptives supplied to users are at minimum cost. In fact, women report that cost of service and supplies are not restraints on their use. 7 In light of improved transportation facilities and roads, this means that all Egyptians are within thirty minutes of a health facility. Given the fact that responsibility for health services is shared by three of its divisions, MOHP's mandate following ICPD was to centralize all family planning, maternal and child health (MCH), and health (including reproductive health) activities and to develop a comprehensive approach that would combine all such services into a broad women's health program. Particular attention was to be given to disadvantaged, resource-poor regions (i.e., rural Upper Egypt and poor urban areas). Special programs addressed child mortality and its causes, safe delivery and obstetric care, neonatal care, the counseling of pregnant women, and breast-feeding. Pilot projects that use this integrated approach are already under way in some regions, and standard treatment protocols, training guidelines, and materials are being developed by technical task forces under MOHP. For example, the Reproductive Health Working Group (RHWG), with funding from the UN Population Fund (UNFPA), is currently designing, implementing, and evaluating the feasibility of integrated reproductive health services at three primary-level ministry clinics in Giza Governorate. Working closely with MOHP policymakers, RHWG is helping to expand services to include essential preventive, diagnostic, and curative care for gynecological and related conditions; strengthen family planning, MCH, outreach, and referral services; train service providers; offer health education directed at both men and women; upgrade the physical condition of basic, low-cost clinics; improve internal organization and management; and develop indicators to monitor and evaluate progress and ensure the feasibility and sustainability of upscaling to a national level in the future (RHWG 1998). MOHP is also focusing on improving maternal health through integrated reproductive health programs and in reducing neonatal mortality by increasing the quality of care given to newborns at home and in health facilities. In 1996, MOHP abolished the practice of female circumcision in any of its premises. Furthermore, with assistance from USAID, the Gold Star Quality Improvement Program, based on clearly defined standards of clinical practice, service, and training, was initiated to provide quality family planning services at all 3,975 MOHP family planning units. That program seeks to expand the range and variety of family planning services and methods; improve clinical performance and physical conditions in family planning clinics; provide commitment to client satisfaction, effective management systems, and teamwork; and introduce monitoring systems to

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measure compliance with standards. The program also includes some reproductive health components, such as diagnosis and treatment of reproductive tract infections, postabortion care, postpartum problems, urinary tract infections, screening for breast and cervical cancer, and premarital and adolescent health promotion. MOHP has announced a major objective—"Health for all by the year 2 0 0 0 " — w i t h an emphasis on healthy children. To realize this objective, President Hosni Mubarak declared 1 9 8 9 - 1 9 9 9 as the "Decade for the Protection and Development of the Egyptian Child." The National Council of Childhood and Motherhood, set up to coordinate activities among ministries, was cochaired by the first lady and the prime minister. High-Level Political Support for the ICPD

Agenda

The president and the first lady have both been active and vocal on women's issues, especially health and reproductive rights. In addition to numerous public statements in support of reproductive health, President Mubarak was awarded the United Nations Population Prize in recognition of his efforts in population affairs in Egypt. The first lady also heads two NGOs that are active in reproductive health: the Integrated Care Society and the Egyptian Red Crescent. In 1998, both the president and the first lady were presented with commemorative awards by the intergovernmental organization Partners for Population and Development. The president was commended for his support of the country's population program and of the ICPD Programme of Action, as well as for his efforts in bringing population and health to the forefront of public awareness and national policy attention. The first lady was honored for her support of NGOs, maternal and child health care, and the education of girls. Minister of Health and Population Dr. Ismail Salam is a vocal and dedicated advocate of women's rights, health, and reproductive health and is a strong supporter of grassroots movements, women's clubs, and increased attention by service providers and policymakers to women's perceptions about health and population issues. Since taking office in 1996, Dr. Salam has supervised the integration of health and population activities into a single ministry, and he has mobilized a huge increase in government funding. He has also made regular public statements in the media supporting the integration of reproductive health care services. Documentation A procedure manual issued by MOHP in March 1998 defines a set of practice standards for service providers in reproductive health and family planning. It

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covers such topics as sexually transmitted diseases, postnatal and postabortion infections, and counseling in family planning options. 8 MOHP has issued well-written pamphlets on various reproductive health topics. Examples include "Reproductive Health Problems During Adolescence"; "Caring for Women Before and After Pregnancy"; "The Reproductive Health of Women and Family Planning"; "Early Detection of Breast Cancer"; "Female Circumcision"; and "The Role of Men in Using Reproductive Health Services and Family Planning." Clearly, the Egyptian government has made significant progress in addressing many of the important issues included in the ICPD Programme of Action. However, two very important ICPD concerns have received little or no attention from the Egyptian government, even though a few NGOs in Egypt have exerted efforts to research these two areas: violence against women and abortion. 9 The Health-Sector

Reform

Program

Egypt, assisted by World Bank, USAID, the European Commission, and the Danish International Development Agency, has just embarked on the Health Sector Reform Program. The reform program aims primarily at reducing the significant financial burden incurred by the health care system with privatization. Health services will be funded by a national social health insurance scheme, financed with government contributions and premiums from the population. Those who can afford to pay will be covered by private insurance, whereas the poor will be provided insurance by the government. The reform program seeks to "provide universal coverage of a basic level of care including preventive, curative and rehabilitative services that utilize cost-effective interventions to maximize well being, address priority community health problems and reduce significantly mortality and morbidity." Through a decentralized health care delivery system, health units will become financially self-sufficient and operate independently from the government. Physicians will be contracted by insurance companies and be awarded nonfinancial compensation in the form of a title (zamalah) after three years of satisfactory service. Contract renewals of physicians will be based on the quality of services provided and user satisfaction. A household survey is currently being conducted by MOHP to identify households and household members who will be eligible for coverage by the national insurance scheme, as set up by the Health Sector Reform Program, which is currently being piloted in three Governates: Alexandria (Urban), Menoufiyeh (Lower Egypt), and Sohag (Upper Egypt). Unfortunately, reproductive health is not a major theme in the program, although maternal and child care is listed as an independent theme

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within the overall reform effort. The program addresses mother and child as a unit. Specifically, efforts will focus on reducing infant mortality, mortality under the age of five, and maternal mortality. It will also contribute to reducing population growth and will address major causes of adult and overall mortality and morbidity (personal lecture notes from a presentation on the Health Sector Reform Program). In light of this program, as well as the fact that Egypt is in the middle of implementing structural adjustment programs, it is impossible to predict what lies ahead for reproductive health and family planning policies and programs, especially given that donor contributions to health and population are expected to decline. The government's privatization and national health insurance scheme to institute higher user fees, from a highly subsidized cost of £E0.50 per visit (U.S.$0.15) at public health centers to £E3 per visit (U.S.$0.9), may cover some of the incurred costs. And parents of newborns would be provided with the necessary care (including incubators for premature babies) and immunization for a lump sum of only £E50. Privatization would relieve the ministry from paying approximately 70 percent of its current salary bill, which would release considerable resources to finance upgrading. Thus the government and the MOHP are hoping that a degree of privatization will relieve them, to a great extent, from the financial burden they currently bear. If so, MOHP budgets will be redirected to upgrade health center services.

Financing for the Health and Population Sectors Population and health activities in Egypt are financially and technically dependent on a relatively large number of bilateral, multilateral, international, and private foundation donors. It has been estimated that donors support 43 percent of Egypt's family planning program (Moreland 1996). Collecting data on the financing of Egypt's health services is extremely difficult. It was not possible to determine with any accuracy where financial resources originate and how they are spent. Especially lacking is financial data at the MOHP, which made it impossible to disaggregate with any accuracy MOHP's budgetary allocations to family planning and reproductive health, and the exact contributions of donors to the ministry and the various activities it supports. The data provided in this section, therefore, are by no means comprehensive, but they are useful in giving a general idea of the financial aspects related to health and population activities in Egypt. Egypt currently has a dual health financing system, that is, health services are financed predominantly through government budgets or by

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patients themselves, who pay out of their own pockets. In 1995, households accounted for 51 percent of revenues for the health sector, whereas the Ministry of Finance, social insurance, firms, and donors accounted for the remaining half (31 percent, 10 percent, 5 percent, and 3 percent, respectively) (personal communication with MOHP). Estimated total health care spending in 1995 was U.S.$2,217 million, or $38 per capita, the equivalent of 3.7 percent of gross domestic product (GDP). This compares with an average of $54 per capita for the Middle East and North Africa, or an equivalent of 4.8 percent of GDP. All in all, government spending on health (including donor expenditure) accounted for less than 3 percent of total government spending. Although the impact of structural adjustment programs has been to reduce government spending in areas such as government administration and salaries as a proportion of GDP, as well as in food and energy subsidies, structural adjustment has not had a similar impact on government spending in the health sector. In fact since structural adjustment policies were adopted, government spending in health has been on the rise. Compared to other public health facilities, such as teaching hospitals, pharmacies, and health insurance organizations, MOHP receives only modest funding from the government—only 19 percent of total financial resources invested in the health sector. A survey of expenditure patterns at MOHP units in selected governorates provides a breakdown of MOHP spending (see Table 3.2). The data show that the level of MOHP spending on family planning, primary care/MCH, and preventive care is low (1.3 percent, 5.2 percent, and 14.3 percent, respectively), compared to 45.7 percent spent on curative functions and 33 percent on administration. Table 3.3 provides data on domestic spending and foreign grants since 1986 at MOHP. Although the data should be interpreted with care, it is safe to conclude that between 1986 and 1991 the relative share of domestic spending versus foreign grants remained constant (although in absolute terms they both increased), with foreign spending constituting up to 90 percent of total spending on family planning. However, by 1996, this trend

Table 3.2 Expenditure Patterns Within Ministry of Health and Population Function Curative Preventive Primary care/MCH Family planning Administration Total Source: Informal personal communication.

Percentage 45.7 14.3 5.2 1.3 33.0 100.0

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Table 3.3 Ministry of Health and Population Spending and Donor Assistance (in U.S.$) Year 1985—1986a 1986-1987 3 1989-1990 a 1990-199l a 1995-1996 a 1996-1997 b 1997-1998 b

Domestic % of Total Foreign Spending Domestic Spending Grants 262,000 160,000 244,000 210,000 738,000 75,604,000 38,666,000

10.0 27.3 10.5 10.0 64.1 96.2 88.5

2,353,000 428,000 2,088,000 1,891,000 413,000 2,952,000 5,018,000

% of Total Total Foreign Grants Spending 90.0 72.7 89.5 90.0 35.9 3.8 11.5

2,615,000 588,000 2,332,000 2,101,000 1,151,000 78,556,000 43,684,000

Source: Communication from MOHP. Notes: a. Domestic and foreign spending for these years covers spending in FP at MOHP headquarters only. b. Domestic and foreign spending for these years covers spending in FP, women's health, RH, and the cost of FP units in governorates and mobile units.

had changed substantially, with the relative share of domestic spending increasing to 64 percent of total spending, as a result of a dramatic increase in domestic spending from U.S.$210,000 in 1991 to U.S.$738,000 in 1996. This significant increase is largely attributed to a positive political environment supported by the president and the first lady, as well as to a change in the executive power at MOHP, with the appointment of the new health and population minister. After 1996, when reproductive health expenditures were included in the budget, in addition to MOHP expenditures at headquarters, mobile units, and the governorates, domestic spending (based on this expanded definition) reached a peak of more than U.S.$75 million in 1996-1997, then decreased to a little more than half that amount (U.S.$39 million) in 1997-1998. Foreign grants increased from U.S.$3 million to U.S.$5 million but constituted only 4 percent and 11.5 percent of total spending during the same period. To conclude, accurate and reliable data on health expenditure in Egypt are currently unavailable, and caution is advised in data analysis and interpretation. Nevertheless, what is clear is that total health expenditure is low. Efforts by the government must go toward devising an accurate and useful financial system for evaluation and planning purposes, as well as in increasing its health budget, especially in light of reduced donor support. The government must be able, financially and technically, to sustain and enlarge its family planning program, continue to improve the quality of care, and integrate reproductive health and other health and population concerns, as well as implement the Health Sector Reform Program. Although the government has already increased its share of public spending

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in these areas, considerably larger expenditures are required for there to be an effective health and population program in Egypt. MOHP's share of financial resources is particularly low, and the Health Sector Reform Program aims to provide MOHP with a larger share. Within MOHP itself, reform efforts will also work toward reducing administrative spending and increasing spending in reproductive health and family planning. Donor

Assistance

The donor community is influential in Egypt's health and population efforts, contributing both substantial financial and technical assistance. Given that there is no accurate official estimate of overall foreign aid to Egypt's health sector, it has been estimated that donors contribute about 3 percent of the total. For example, the public-sector costs of family planning in 1993 were about U.S.$20 million. The Egyptian government contributed less than half of this cost (43 percent), with 57 percent provided by international donors (NPC and RAPID 1994; Moreland and MulcahyDunn 1996: 174). USAID and UNFPA are the largest donors in the fields of health and population in Egypt. Since 1975, USAID, the principal donor in Egypt for population and health, has assisted in institutional capacity-building by training thousands of service providers, upgrading facilities, and providing improvements in quality of care and management systems. USAID's assistance in reproductive health and family planning totals U.S.$190 million since 1975. UNFPA, the second largest donor in this area, has been active in Egypt since 1969. From 1992 to 1996, UNFPA committed approximately U.S.$15 million in reproductive health/family planning, population and development, and information, education, and communication (IEC)/advocacy. Other important donors include World Bank, the World Health Organization, the International Planned Parenthood Federation (IPPF), and the Ford Foundation. Bilateral aid is also received from the Dutch government, the Canadian International Development Agency, and the Japan International Cooperation Agency, and multilateral aid is received from the European Union. Because of the size of the donor community and its high level of activity in health and population, several informal donor groups have been set up, some more active than others. For example, a health donor working committee meets monthly to discuss issues of common concern to donors (currently, the main topic of discussion is health-sector reform). There is also a population donor group, which appears to be less active. These donor committees are in addition to the formal meeting held annually by the Organization for Economic Cooperation and Development for donors

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and representatives of the Egyptian government. Despite these donor committees, there does not appear to be real collaboration and coordination among donors to fund and implement post-ICPD policies. Following are brief summaries of the type of programs funded by the prominent donors in Egypt, including funding levels. US AID. USAID is the largest single donor to family planning in Egypt. It is estimated that approximately 75 percent of all donor assistance comes from USAID, which since 1975 has allocated about U.S.$190 million to the family planning program, predominantly to the public sector, with some assistance to NGOs and private-sector activities. Initially, USAID funding was used to assist in expanding access to family planning and health services (training health personnel, upgrading physical infrastructure). This was followed by a period of national institutional strengthening. Current efforts are now aimed at improving the quality of services and in the eventual phasing-out of USAID assistance in 2006. Cost-effective programs and financial and institutional sustainability (capacity-building; improving health-sector efficiency; broadening and diversifying approaches for financing personal health services) are being promoted, and the Egyptian government is being assisted in implementing health policy reforms. An analysis of USAID assistance also shows efforts in reproductive health. Earlier work involved widespread training of 9,000 traditional attendants in safe delivery techniques and upgrading knowledge of infant and maternal care in Upper Egypt. Current reproductive health efforts are being implemented within the Healthy Mother/Healthy Child Project (see Table 3.4). UNFPA. UNFPA has been active in Egypt since 1969 and is the second largest donor to population programs in that country after USAID. From 1992 to 1996, UNFPA committed approximately U.S.$15 million in reproductive health/family planning, population, and development and IEC/advocacy. Egypt is currently designated as category "A" under UNFPA's resource allocation system. A new, five-year assistance program has just begun whereby U.S.$20 million will be committed to innovative reproductive health and family planning (expanded coverage and access to quality reproductive health, family planning, and MCH services; reproductive health services for adolescents; improved access to STD and HIV/AIDS quality services; capacity-building and enhanced reproductive health planning and management at MOHP; and IEC/advocacy). Table 3.5 provides a brief description of some UNFPA projects. Besides USAID and UNFPA, important financial and technical assistance is provided by other donors. Table 3.6 summarizes some of the more important projects.

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Table 3.4 US AID Projects in Egypt Project POP/FP III (1994-1997) Healthy Mother/Healthy Child (1995-2001) POPIV phase 1 (1997-2001)

POPIV phase 2 (2002-2006)

Objectives

Funding (U.S.S millions)

8 subprojects to provide quality FP services. Over 3,800 service sites were set up throughout the country. Provide a cost-effective essential minimum package to improve the quality, effectiveness, and use of child and RH services in public and private facilities. Increase the use and supply of FP services, improve sustainability of FP systems, support national FP system toward financial selfsufficiency, strengthen institutional and human resource capacity, and support policy research. Eliminate dependency of RH/FP sector on USAID by establishing a permanent and sustainable FP national program.

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90

n.a.

Sources: Various USAID published and unpublished documents.

To conclude, donor assistance for population and health activities in Egypt is substantial, not only in the large number of donors operating in the country but also in the level and extent of technical and financial contributions. An analysis of donor projects shows that even though activities in health and population focused predominantly on increasing accessibility to family planning services prior to ICPD, most post-ICDP efforts have gone toward assisting the public sector (with some support to NGOs) in reproductive health integration, quality service improvement, institutional capacity-building, and policy reform. Some efforts, notably by USAID, have focused on encouraging financial and institutional sustainability. Although available information does not allow for the detection of clear trends in donor funding (particularly post-ICPD), funding in the long term will likely decline, given that USAID—by far the largest funder of health and population—is planning to phase out its assistance by 2006. NGO Involvement in the ICPD Programme of Action

NGOs in Egypt have been active for many years in family planning efforts. NGO funding must receive prior approval from the Ministry of Social Affairs, which also audits NGO budgets. Although some tension exists regarding funding logistics, all in all NGOs appear to have a good working relationship with MOHP, which provides technical assistance and financial subsidies. Some level of coordination also exists, mainly to avoid duplication of activities.

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Table 3.5 UNFPA Projects in Egypt Project Upper Egypt communitybased FP project (1994) Community-based FP in CEOSS communities in 6 governorates (1994) Support to FP activities of the Egyptian Red Crescent Society (1995) Upgrading and expanding of training of nurses in interpersonal communication and counseling skills (1995) Upgrading and expanding of training of nurses in interpersonal communication and counseling skills (1995) Establishing and upgrading of reproductive health services in deprived areas (1997) Pilot implementation and evaluation of RH framework (1997) Reproductive health (1997)

Reproductive health (1998) planned

Objectives Upgrade FP services in outreach programs in Upper Egypt and open 3 new centers. Recruit new FP acceptors, create 10 new family health clinics, improve quality of FP services, and conduct operations research. Establish and equip 2 social and health services complexes to provide quality MCH/FP services and renovate and equip 21 FP clinics and 5 hospitals. Upgrade MCH/FP in formal nursing education and nursing performance with Assiut Health Directorate.

Funding (U.S.$) 323,855 408,855 393,560 235,176

Upgrade RH/FP/SH in formal nursing education at Menoufiya University.

183,425

Renovate and rent 15 RH and primary health units in Upper Egypt to provide services, create mobile units, and train service providers.

943,500

Develop and implement RH intervention framework 145,874 based on RH needs identified in an earlier baseline study in project area, and identify feasibility for scaling up. Innovative FP and RH (expanded coverage and 20,000,000 access to quality RH, FP and MCH services; RH services for adolescents; improved access to quality STD, HIV/AIDS services; capacity building and enhanced RH planning and management at MOHP; as well as IEC/advocacy). 9,000,000 requested

Sources: UNFPA, miscellaneous project documents.

As a result of ICPD, NGOs have gained increased influence and increased attention from the Egyptian government. NGOs are currently viewed as partners in population and health activities, and cooperation between NGOs and the government has increased. NGOs are viewed as capable of filling important gaps in health education and in the more sensitive issues of ICPD, such as policy reform, women's rights, and female circumcision, as well as in wider community outreach and participation. 10 NGOs are currently actively involved in research, training, provision of services (opening of clinics and provision of equipment and contraceptives),

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Table 3.6 Other Donor Projects in Egypt Project The Royal Government of the Netherlands (1996-2000) CIDA Japanese International Cooperation Agency European Union 3

IPPF (1997) WHO World Bank Ford Foundation

Objectives Fund the Fayoum Rural Health and FP project. Project involved local outreach workers in health, education, credit, and WID. Supported applied research by NPC. Supported RH Service Delivery Project in Qena Govemorate (1994). Established, equipped, and provided operating costs of 19 FP clinics in Qena and 1 master clinic (1992); support to population program in Upper Egypt to improve access to health care and increase contraception prevalence and human resource development (1997). Support to NGOs. Supports RH research of some NGOs and other research centers. Credit agreement to support a 5-year population project aimed at capacity-building at MOHP in policy and program development. Provided grants to stimulate RH debate and RH priorities, promote interdisciplinary research to address conceptual basis of RH, and sensitive RH issues. Provided RH education to youth groups and established an AIDS Hot Line for information and counseling.

Funding (U.S.S) 8.3 million 527,000 n.a. 2.7 million 18 million

611,000 n.a. 20.7 million n.a.

Note: a. Other small-scale projects have been funded by the European Union, notably one to support NCPD for the implementation of ICPD in 1995 at the cost of ECU 395,021.

information dissemination, increasing public awareness and c o m m u n i t y participation, and holding of seminars and workshops. B e l o w w e survey s o m e of the major nongovernmental organizations working in Egypt. National Commission for Population and Development. The National Commission for Population and Development ( N C P D ) is an umbrella organization set up originally to assist N G O s working in population and development to participate more effectively at ICPD. N C P D continues to work with local N G O s toward implementing the ICPD Programme of Action. N C P D holds workshops to link N G O s and the government, to exchange information, and to facilitate cooperation. S p e c i f i c activities include technical, managerial, and logistical support to N G O s , as well as assistance in program planning, management, and fund-raising (personal communication). N C P D has a budget of about U . S . $ 3 million, half of which c o m e s from international donors ( U N F P A , the European Union, the royal government of the Netherlands, and the Ford Foundation), the other half from local

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fund-raising efforts. NCPD's 1996 budget for a five-year period is presented in Table 3.7. Egyptian Fertility Care Society. The Egyptian Fertility Care Society (EFCS) is a research-oriented NGO, one of the more active in the area of reproductive health and family planning. Established in 1974, EFCS's mandate is to "promote family health through the conduct of research on family planning methods and maternal health care in Egypt, and then to disseminate this information" (EFCS nd: 2). EFCS is also active in training and information dissemination. Research projects conducted by EFCS have been funded by WHO, USAID, the Ford Foundation, the National Population Council, UNFPA, and the Egyptian government, among others (EFCS 1993, 1995a). More recent research appears to have incorporated a reproductive health approach. For example, EFCS conducted a study in 1994 to promote more effective use of IUDs by enhancing service providers' knowledge and improving their practices (EFCS 1995b: 1; 1994). EFCS has also invested substantial effort to institutionalize and integrate postabortion care services, family planning, and other reproductive health services at the national level (EFCS 1995c, 1997a, 1997b). Other current major research activities are in the areas of maternal morbidity, anemia in reproductive-age women, and infertility. Until 1991, EFCS's funding from international donors was quite large, with minimum restriction. Since then, EFCS has suffered major financial cuts and has had to limit its activities to small grants (U.S.$50,000100,000); as a result, its research and dissemination activities have been severely limited. Funding levels did not improve after ICPD. The Egyptian Family Planning Society. Established in 1958, the Egyptian Family Planning Society (EFPS), 11 an affiliate of the International Planned Parenthood Federation, is concerned with population and family planning

Table 3.7 National Commission for Population and Development Budget International Contributions UNFPA European Union Royal Government of the Netherlands Ford Foundation Subtotal NCPD's contribution Total budget Source: Personal communication.

U.S.$ 422,137 503,703 495,270 75,000 1,496,110 1,500,000 2,996,110

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issues at the national level. The voluntary organization has twenty-five regional offices throughout the country and supervises activities in 457 centers in urban, rural, and desert areas, in addition to medical mobile units targeted at marginal areas (EFPS 1987). Activities include information dissemination among women and youth, development, and environmental issues (predominantly in the context of family planning), with some work in reproductive health, reproductive health rights, and sexual health. Although EFPS was at first almost totally dependent on IPPF for financial support, a review of EFPS annual reports for the years 1991, 1996, and 1997 shows that external donor support has declined relative to domestic funding. There was also a significant increase in total revenues between 1991 and 1997, mainly as a result of increases in domestic funding, as well as an increase in revenue generation (see Table 3.8). IPPF funding reached a peak of U.S.$888,000 in 1996 (with other donors contributing $270,000), then declined to $611,000 in 1997 (with other donors contributing more than $1.5 million). Coptic Evangelical Organization for Social Services. Founded in 1950, the Coptic Evangelical Organization for Social Services (CEOSS) has worked in many regions to improve the status of rural women (both Christian and Muslim), focusing predominantly on women's education, health, nutrition, family planning, and employment. Since the ICPD, CEOSS has also focused its efforts on young women to improve their knowledge of reproductive health issues, violence against women, and economic security (personal communication). CEOSS's reproductive health activities to abolish female circumcision, early marriage, and bridal deflowerment ceremonies appear to have had a positive impact at the community level. According to an evaluation of their work by the Centre for Development and Population Activities, CEOSS's work reduced the rate of female circumcision by 70 percent in eight villages in the Minya Governorate.

Table 3.8 Egyptian Family Planning Society Sources of Revenues (selected years, U.S.$)

Total revenues External donors IPPF Others Government sources Revenue generation Other domestic sources

1991

1996

1997

689,000

2,620,000

4,784,000

500,000

888,000 270,000 303,000 733,000 426,000

611,000 1,567,000 1,017,000 803,000 786,000

44,000 108,000 37,000

Sources: EFPS Annual Reports for 1991, 1996, and 1997.

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Family Planning and Reproductive Health Research Egypt has had a well-developed system for collecting demographic data for quite some time. Currently, the Demographic and Health Survey is conducted every four to five years, providing up-to-date regional and national data. The EDHS is increasingly comprehensive in its approach to health conditions and more sensitive to gender issues than in the past. The chapter in the survey dedicated to women's status (Chap. 14, pp. 185-206) covers information on household decisionmaking, financial empowerment, the treatment of women at home, women's participation in the labor force, how they dispose of their earnings, their workload, and attitudes toward gender roles and divorce. Similarly, an evaluation of research papers presented at the Cairo Demographic Center's annual seminars since ICPD shows a greater focus than before on gender issues, gender analysis, and issues of reproductive health. Papers presented in 1995 include articles on women's autonomy and gender roles in the family; women's participation in family-planning decisionmaking; the status of women in Egypt; and attitudes of Egyptian women toward female circumcision, among others (Cairo Demographic Center 1995). The Research Management Unit at the National Population Council documents, reviews, classifies, updates, and disseminates population research findings at regular intervals. In a volume entitled Egypt Population Abstracts (1983-1995), M. Khalifa (1997) reviews Egyptian population research and finds a great deal of data on family planning, some of which was gender-sensitive. She also finds research aimed at improving the quality of family planning and MCH programs, as well as other work aimed at understanding fertility preferences and contraceptive use. Furthermore, a review of reproductive health research in two of the leading population and health databases (POPLINE and MEDLINE) during the period 1990 and 1996 finds an increase in the number of published papers and unpublished reports on reproductive health in Egypt, especially studies on maternal health and child health topics and those addressing policy issues and medical studies (Zurayk 1997a). An analysis of the abstracts shows that the majority of the studies in Egypt are based on surveys using quantitative analysis, but very few qualitative in-depth studies are conducted. An assessment of gender in this body of literature suggests that it is not considered a key component of the research included in the databases. The Reproductive Health Working Group sponsored by the Population Council uses a reproductive health approach as a framework to conduct research and contribute to a better understanding and conceptualization of reproductive health in the Arab region. In its rethinking of issues, the group has incorporated nonmedical aspects and issues related to dignity, comfort, happiness, and sexual fulfillment. It has produced its own definition of

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reproductive health to mean "the ability of women to live from adolescence or marriage with reproductive choice, dignity and successful childbearing and to be free of gynecological disease and risk." This definition not only incorporates ICPD concepts (gender, reproductive choice, health, etc.) but goes beyond it, by understanding the priority that women in the region place on childbearing. Research conducted by RHWG, which aims for a better understanding of women's perspectives on their needs and problems, focuses on women and children's health within the context of family, community, and position in society (Zurayk et al. 1994; Zurayk 1997a). As a follow-up to the Giza reproductive morbidity study, a pioneer study conducted in 1996 looked into perceptions of sexuality among forty-one women in rural Giza (Khattab 1996). In-depth interviews show that women share and discuss their experiences and beliefs in matters of sexuality. This finding runs somewhat contrary to the notion that women of Muslim tradition and culture do not discuss such private and delicate matters and that their perceptions of sexuality and sex behavior are repressed. Al-Azhar University, the leading Islamic academic institution in the world, wields significant political power and influence in Egypt. By holding national and international conferences (many on matters of ethics and bioethics), Al-Azhar sets the official position and practice of Islam vis-àvis many areas, including health, population, and women's issues. In 1998, Al-Azhar University held the International Conference on Population and Reproductive Health in the Muslim World in Cairo, under the auspices of the Grand Imam. The conference brought together Muslim scholars and policymakers from forty-two Muslim countries. Among its main objectives was to evaluate progress achieved in the area of population in the Islamic world in light of ICPD. Among its many recommendations, the conference highlighted the importance of women's health and family planning and reaffirmed a large portion of ICPD's Programme of Action and twenty-three principles it termed consistent with the Shariah. Governments were encouraged to ensure equal rights to men and women within the context of Islamic teachings and were called upon to remove all obstacles to women's participation in political life and in the formulation of integrated and high-quality health and reproductive health services and programs. The conference supported women's universal right of access to reproductive health services, education, employment, and safe motherhood. Genital mutilation was discouraged, and countries were encouraged to end all violence against women (United Nations Population Fund 1998; Al-Azhar; 1998). At the same time, Al-Azhar reaffirmed its position on prohibiting abortion (particularly as a family planning method), unless the mother's life was endangered.

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Although difficult to evaluate at this point in time, Al-Azhar's overall positive response to ICPD is bound to have a significant impact on advocacy and NGO activity at the community level.

Recommendations Given that donor support is on the decline, the Health Sector Reform Program has just been approved, and the population and health sector is currently in transformation, the following is a list of recommendations that may be used to fill in the gaps in implementation of ICPD's Programme of Action and to develop a more comprehensive and dynamic course of action. • Set up a strategic planning task force responsible for looking into various policy actions to support the allocation of adequate financial resources and cost recovery mechanisms as a means to achieve a viable and sustainable integrated reproductive health program. • Carry out operations research to suggest feasible, cost-effective mechanisms for integrating reproductive health programs at the national level consistent with the realities of Egypt's health care system. Concurrently, efforts are needed to monitor the impact of reproductive health programs and policies. • Conduct more gender-sensitive and in-depth quality research (quantitative and qualitative), especially multidisciplinary diagnostic research on medico-social realities and reproductive health problems particular to Egypt. • Improve the quality of health care, especially with regard to screening of reproductive morbidity conditions, monitoring, and supervision, as well as better client-provider interaction. • Undertake mass training in reproductive health components for service providers, especially in the area of gender sensitization. • Encourage health care utilization by all segments of society, especially women outside reproductive age. Encourage family planning use in a positive way, stressing women's well-being rather than contraceptive use as a duty. • Incorporate STD and HIV/AIDS services in the context of integrated reproductive health services. • Intensify efforts in poorer regions and disadvantaged segments of society, where health and population efforts can have an important overall impact. • Increase the types of modern contraceptives available to users and provide users with information, options, counseling, and referral.

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Conclusion The Egyptian government, NGOs, and donors appear to have reacted positively to the ICPD Programme of Action, and impressive efforts are being made to integrate several aspects and dimensions of reproductive health into government policies and programs. Much of Egypt's positive response to reproductive health probably stems from the fact that ICPD was hosted by Egypt and was successful in mobilizing a range of participants to achieve consensus on an issue of significant international concern. Egypt has also made commendable efforts in training service providers in reproductive health; improving child health care; encouraging girls' education and employment opportunities; and raising the practice of female circumcision as an issue for public debate. There is also little doubt that the 1994 ICPD and the 1995 Fourth World Conference on Women in Beijing helped translate some of the stale and oft-repeated rhetoric in Egypt (especially vis-à-vis women) into concrete action. Egypt, along with most other countries in the world, is enthusiastic about being part of a global consensus and has been positively affected by the momentum generated from participating in a universal collective endeavor. This enthusiasm is exemplified by the follow-up conferences being held nationally, regionally, and internationally to ensure that the programs of action are being implemented.

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Health and family planning services in Egypt are available, accessible, and affordable, but the quality of service is questionable, especially in light of the fact that public expectations have risen and people are demanding more specialized and better quality health care. Although MOHP is working toward quality improvement and even though service providers are being trained in quality care, greater effort is needed in three important areas: • Educating the public is of the utmost importance. Women's knowledge about health services must be improved. They must be able to know where and when to seek health care and what services to ask for. • Improvements are needed in the technical and communication skills of service providers. • Improvements must be made in health premises, their physical structure, and their upkeep. 12 Reproductive health integration in Egypt is not occurring independent of, but rather within, the already well established framework of family planning and primary health care. Family planning and primary health care systems, facilities, and human resources are being adapted to address reproductive health concerns. Because the concept of reproductive health itself is not yet well developed and understood, its implementation has been haphazard and lacking in direction. More concerted and focused programs are also needed in the provision of information, counseling, referral, follow-up, community awareness, gender sensitization, and health education, although the government and some NGOs have done some scattered work to improve these areas. Efforts have also focused almost exclusively on women of reproductive age. Work should be expanded to reach younger and older women and men in future reproductive health/family planning activities. More work is also needed in identifying and treating diseases related to the use of family planning methods as well as other reproductive morbidity conditions. Despite universal access to basic health services in Egypt, the quality of reproductive health care still needs considerable improvement. Generally speaking, poor quality leads to a low utilization of services, high levels of contraceptive discontinuation, incorrect use of methods and medical complications, exposure to unwanted pregnancies and unsafe abortions, and widespread misinformation, fear, dissatisfaction, and a poor image of family planning in general. Quality improvement is currently MOHP's top priority in health and population-related activities, a task that is technically and financially supported by US AID and other donors.

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Part of this problem is attributed to the way in which family planning is presented to women. Instead of stressing the importance of population control, family planning should be introduced as a concept related to women's health, well-being, and rights. This latter approach is more likely to pay off and create loyalty and trust between women and service providers. Although there appears to be no serious opposition to the concept of reproductive health in Egypt, setting family planning targets still remains the government's top priority. The government and donors appear to be concerned that reproductive health will eventually replace family planning, thus losing all the momentum gained so far in limiting population growth. However, since Egyptian culture places a high social value on marriage, motherhood, and fertility, the reproductive health approach in Egypt has a good chance, at least from the demand side, of succeeding. Nevertheless, the understanding of reproductive health in Egypt is still limited to a biomedical-disease framework, embracing maternal and perinatal mortality and infant deaths. It still does not include important reproductive health social concepts such as sexual health and dignity, women's perceptions, reproductive health rights, and other nonmedical aspects. However, some efforts, notably those of the RHWG working in collaboration with MOHP, are working to conceptualize reproductive health within an Egyptian social context, and some attempts have been made at multidisciplinary diagnostic research to clarify the sociomedical realities underlying reproductive health problems in Egypt. In addition, the country still lacks a holistic, methodological approach for integrating various reproductive health dimensions and components. In our view, this is the only way in which reproductive health can successfully become the umbrella under which family planning, MCH, gynecological care, and prenatal care can all be integrated. Part of the problem is that reproductive health is still a new approach, lacking maturation worldwide, even on the part of the donors themselves. Consequently, time is needed for the accumulation of research, experience, and knowledge in reproductive health. Unfortunately, however, just when research is sorely needed, organizations involved in fertility and population issues have had their research budgets reduced to the point where they are no longer able to provide the data needed. In order to improve health in general, and reproductive health in particular, research is needed at the very least to evaluate the feasibility and practicality of various services. Identifying problems and their most appropriate solutions can best be achieved through research on how best to develop and upgrade health care services and which services have priority. Research is also needed to indicate not only the feasibility but also the effectiveness and sustainability of specific service interventions. This is especially relevant at a time of change, like the present, when reproductive

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health is being integrated into health services for women and when MOHP is beginning a major process of reform. Given that no formal mechanism (or indicators) has been set up to evaluate NGO work in Egypt, it is impossible at this stage to measure the impact of NGOs on reproductive health and family planning. What appears to be true, however, is that a considerable amount of their work remains in training and research, which to a large extent is similar to the work of the government in these areas. NGOs, therefore, should be encouraged to work in other areas, such as community outreach and awareness programs and advocacy. It is also impossible to quantify recent NGO funding trends in population and health by using the data generated for this study. However, based on the limited data available and on discussions with NGOs, the general feeling is that with the exception of NGOs that focus primarily on research, all other NGOs are receiving more funding than before, although the relative share of donor funding compared to domestic sources of funding appears to be on the decline. For instance, in the case of EFPS, the relative share of donor funding declined from 72.5 percent of the total budget in 1991 to 44.2 percent in 1996, although in absolute terms it actually increased by 280 percent during that period. For the entire NGO sector, however, insufficient data are available to show whether donor funding has actually declined in absolute terms following ICPD. Also, revenue generation appears to have become a more important source of funding in the case of EFPS and may ultimately constitute a more sustainable source in the future. If NGOs are expected to play a more significant role in population and health activities once the Health Sector Reform Program is in place, donors, the government, and the private sector must step in, at least initially, to provide financial and technical assistance to sustain momentum and allow NGOs to establish their new role as partners. Given that Egypt is in the process of structural adjustment and health reform, it is not clear how and whether the perceived extra costs of reproductive health will be covered.

Notes 1. Unless otherwise stated, data given in Table 3.1 and in this section are extracted from Demographic and Health Survey (1995). Cairo: National Population Council. 2. Health concerns and side effects were the main reasons given by women for discontinuing FP methods (NPC and DHS, 1997). 3. Defined by DHS (1995) as at least one visit to a provider prior to birth. Many women who sought antenatal care did so because of pregnancy complications, not because they viewed regular medical checkups during pregnancy as a monitoring process to reduce the likelihood of illness and death.

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4. Of 250,000 blood units donated voluntarily in 1996, only three tested positive for HIV. 5. To implement such a program, the Supreme Council for Family Planning (SCFP) was set up in 1965 to coordinate FP efforts among the various ministries. This was followed by the establishment of the Executive Board of Family Planning (EBEP) in 1966 to assist in the organization and delivery of FP services within the government's health and social services facilities (Osheba and Sayed, 1991). 6. This period also saw some organizational restructuring, with EBEP becoming a planning, coordinating, monitoring, and evaluating agency rather than an executive one. The SCFP was dissolved and replaced by the Supreme Council for Population and Family Planning (SCPFP); the EBFP replaced the Population and Family Planning Board. 7. The mean price for a pill cycle was P83 (83 piasters, or U.S.$0.24) in 1995, whereas the mean cost for the IUD was £E16.3 (U.S.$4.8). The cost of a visit to a public FP clinic is currently £E3 (U.S.$0.9). 8. Examples of MOHP training materials in reproductive health (in Arabic) evaluated by this study included the following: MOHP (Population and Family Planning Division): Trainer's manual for a course given to unit managers entitled "Upgrading Standards of Family Planning and Reproductive Health Services to Unit Administrators"; "Female Circumcision," by Dr. Murad Hassanien; "Early Detection of Breast Cancer," by Dr. Magdi Khaled; "Women's Health, Reproductive Health and Family Planning," by Dr. Izzeddin Osman; "Health Care for Women Prior to Marriage and Pregnancy," by Dr. Murad Hassanien; "Reproductive Health Problems During Adolescence, by Dr. Izzeddin Osman; "The Role of Men in Improving the Use of Reproductive Health and Family Planning Services," by Dr. Izzeddin Osman; "Advice to Men in the Area of Reproductive Health," by Dr. Nabil Younis; "Advice to Married Couples on Sterility and Basic Health Care," by Dr. Izzeddin Osman; "Non-use of Reproductive Health and Family Planning Services," by Dr. Nabil Younis. 9. Violence against women is an ICPD concern and that of the Nadim Center for the Rehabilitation of Victims of Violence and Torture. 10. For example, the Female Genital Mutilation Task Force was set up in 1994 to tackle the issue of female circumcision and to coordinate NGO activities in this domain. A recent activity of the task force was to document the experiences of NGOs working toward the elimination of FGM and access their impact (El-Katsha, et al„ 1997). 11. Information collected from EFPS Annual Reports (1987, 1991, 1996, 1997). 12. In this regard, MOHP is encouraging community participation in improving premises and physical structures, as well as in the supervision of work done in health centers.

References Al-Azhar, 1998. "Conference on Population and Reproductive Health in the Muslim World: Final Communique." Cairo: Al-Azhar University. Cairo Demographic Center, 1995. "Population Issues in the Middle East, Africa, and Asia: CDC Annual Seminar." Monograph no. 25. Cairo: Cairo Demographic Centre. CAPMAS (Central Agency for Public Mobilization and Statistics), 1996. "Summary Results of Population, Housing, and Structures" (Arabic). Cairo: Central

Egypt

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Agency for Public Mobilization and Statistics. DHS (Demographic and Health Survey), 1995. "Egypt Demographic and Health Survey." Cairo: National Population Council. , 1997. "Trends in Demographic and Health Indicators." Cairo: National Population Council. EFCS (Egyptian Fertility Care Society), 1993. "A Comparative Clinical Test of Two Once-a-Month Injectable Contraceptives: Cyclofem and Mesigyna in Egypt (February 1993)." Cairo: The Egyptian Fertility Care Society. , 1994. "Study on the Use of the IUD in Egypt: Final Report." Cairo: The Egyptian Fertility Care Society. , 1995a. "Pre-Introductory Clinical Trial of Norplant Contraceptive Subdermal Implants in Egypt." Cairo: The Egyptian Fertility Care Society. , 1995b. "Study on the Use of IUDs in Egypt: Project Summary Report." Cairo: The Egyptian Fertility Care Society. , 1995c. "Improving the Counselling and Medical Care of Post-Abortion Patients in Egypt: Final Report." Cairo: The Egyptian Fertility Care Society. , 1997a. "Counselling Husbands of Post-Abortion Patients in Egypt: Effect of Husband Involvement on Patient Recovery and Contraceptive Use." Cairo: The Egyptian Fertility Care Society. , 1997b. "Scaling-Up Improved Post-Abortion Care in Egypt: Introduction to University and Ministry of Health and Population Hospitals." Cairo: The Egyptian Fertility Care Society. , no date. "EFCS: Two Decades of Family Health Promotion." Cairo: The Egyptian Fertility Care Society. EFPS (Egyptian Family Planning Society), 1987, 1991, 1996, and 1997. "Annual Report of EFPS Activities." Cairo: The Egyptian Family Planning Society. El-Katsha, S., S. Ibrahim, and N. Sedky, 1997. "Experiences of Non-Governmental Organizations Working Towards the Elimination of Female Genital Mutilation in Egypt." Cairo: The Centre for Development and Population Activities and The Egyptian Society for Population and Development. Hassan, E.O., and M.F. Fathallah, 1995. "Broadening Contraceptive Choice: Lessons from Egypt," in Family, Gender, and Population in the Middle East: Policies in Context, C. Makhlouf-Obermeyer (ed.). Cairo: American University of Cairo Press, pp. 216-231. Ibrahim, S.E., 1995. "State, Women, and Civil Society: An Evaluation of Egypt's Population Policy," in Family, Gender, and Population in the Middle East: Policies in Context, C. Makhlouf-Obermeyer (ed.). Cairo: American University of Cairo Press, pp. 57-79. INP (Institute of National Planning), 1996. "Egypt: Human Development Report." Cairo: Institute of National Planning. Khalifa, M„ 1997. "Egypt Population Abstracts: 1983-1995." Cairo: The National Population Council. Khattab, H., 1992. "The Silent Endurance: Social Conditions of Women's Reproductive Health in Rural Egypt." Amman: UNICEF; and Cairo: The Population Council. , 1996. "Women's Perceptions of Sexuality in Rural Giza." Monographs in Reproductive Health no. 1. Cairo: Working Group on Reproductive Health, Population Council Regional Office for West Asia and North Africa. • , 1997. "An Interview-Questionnaire on Reproductive Morbidity: The Experience of the Giza Morbidity Study." Policy Series in Reproductive Health no. 4. Cairo: Working Group on Reproductive Health, Population Council Regional Office for West Asia and North Africa.

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Lenton, C., and H. Khattab, 1997. "Controlling HIV and AIDS in Egypt: Recommendations to the European Commission: Final Report." Paper presented to the European Commission. Cairo. MOHP/USAID (Ministry of Health and Population/U.S. Agency for International Development), no date: "Healthy Mother/Healthy Child Project." Brochure. Cairo: MOHP/USAID. Moreland, R.S., 1996. "Introduction," in Investing in Egypt's Future: The Costs and Benefits of Family Planning in Egypt, R. Scott Moreland (ed.). Cairo: Resources for the Awareness of Population Impacts on Development (RAPID), pp. 1-10. Moreland, R.S., and A.D. Mulcahy-Dunn, 1996. "Cost-Benefit Analysis of Egypt's Family Planning Program," in Investing in Egypt's Future: The Costs and Benefits of Family Planning in Egypt, R. Scott Moreland (ed.). Cairo: Resources for the Awareness of Population Impacts on Development (RAPID), pp. 143-166. NPC and DHS (National Population Council and Demographic Health Surveys), 1997. "Egypt In-Depth Study on Reasons for the Nonuse of Family Planning: Preliminary Report." Cairo: National Population Council and Demographic Health Surveys. NPC and RAPID IV (Resources for the Awareness of Population Impacts on Development), 1994. "The Cost-Benefit Study of Family Planning in Egypt: Summary Report." Cairo: National Population Council and RAPID IV. Osheba, I.K.T., and H.A. Sayed, 1991. "The Fertility Impact of Contraceptive Use in Egypt: An Aggregate Analysis." Working paper no. 23. Cairo: Cairo Demographic Center. Osheba, I.K.T., 1996. "Fertility Behavior in Egypt (1980-1992): An Analysis of the Direct and Indirect Determinants," in Investing in Egypt's Future: The Costs and Benefits of Family Planning in Egypt, R. Scott Moreland (ed.). Cairo: Resources for the Awareness of Population Impacts on Development (RAPID), pp. 11-38. RHWG (Reproductive Health Working Group), 1998. "Concept Paper for Third Phase of Project: Pilot Implementation and Evaluation of a Reproductive Health Framework: Preparation for Scaling Up." Cairo: Working Group on Reproductive Health, Population Council Regional Office for West Asia and North Africa. United Nations Population Fund, 1996. "Program of Action Adopted at the International Conference on Population and Development, Cairo, September 5-13, 1994." , 1998. Dispatches: News from UNFPA, no. 22 (May). USAID (U.S. Agency for International Development), no date: "USAID Assistance to Egypt's Family Planning Effort." Brochure. Cairo: USAID. USAID/Egypt, 1997. "Population, Family Planning, and Reproductive Health (POPIV): Results Package." No. 263-0267 (July 1997). Cairo: USAID. Zurayk, H., et al., 1994. "Rethinking Family Planning Policy in Light of Reproductive Health Research." Policy Series in Reproductive Health no. 1. Cairo: Working Group on Reproductive Health, Population Council Regional Office for West Asia and North Africa. Zurayk, H., 1997a. "Reproductive Health Research in the Eastern Mediterranean Region: Concepts and Conditions." Background Paper for the WHO/HRP Meeting on Women's and Gender Perspectives in Reproductive Health in the Eastern Mediterranean Region, Casablanca, Morocco, November 10-13, 1997. , 1997b. "Reproductive Health in Population Policy: A Review and a Look Ahead." Paper presented at the IUSSP General Conference, China, 1997.

4 Indonesia Terence H. Hull & Meiwita B. Iskandar

WHEN G O V E R N M E N T REPRESENTATIVES M E T IN CAIRO AT THE 1994 International Conference on Population and Development (ICPD) to review and reconsider issues of population and development, Indonesia was cited as a country with one of the most successful organized family planning programs in the developing world. Fertility had nearly halved between 1968 and 1992, and the proportion of married women of childbearing age who were using modern contraceptives had risen from less than one in twenty to nearly one-half. How did this happen, and what factors account for these dramatic changes in reproductive behavior? Certainly, the rapidly growing Indonesian economy and the attainment of near universal primary schooling— equal for girls and boys—could be identified as major factors contributing to a reduced demand for children. In addition, the government's role in making contraceptive information and services available to virtually all married women across the sprawling archipelago was seen as key to the widespread adoption of family planning by the population. This study examines that government role for a period of roughly thirty years and discusses the consequences of the political-economic crisis of the late 1990s for the future of reproductive health programs in Indonesia.

Indonesia's Family Planning Program: From Maternal Welfare to Population Control During the first half of the twentieth century, there was strong state and religious opposition to fertility control in Indonesia (a predominantly Muslim country). Small groups of middle- and upper-class activists campaigned for birth control on the grounds of women's health needs, to reduce the huge burdens of frequent and many births, and to prevent maternal deaths. B y

79

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the 1950s, medical professionals and some outspoken government officials had begun to promote the ideas and techniques of modern birth control in urban areas of the newly independent nation. From the late 1930s, upperclass women had obtained diaphragms and caps through private clinics, and after the formation of the Indonesian Planned Parenthood Association in 1957, services were increasingly available for middle-class urban women. Thus, although the main justification for contraceptive services was maternal welfare, the services were available to only a small minority of women. Conservatives of many religions and political persuasions publicly condemned the practice of contraception on the grounds that it was conducive to immorality (Hull 1994). In 1965-1966, political upheaval saw the overthrow of the Sukarno regime and the development of the New Order regime under President Suharto. In the New Order, pragmatic, foreign-trained technocrats were placed in key policymaking positions, and foreign aid was welcomed into the country. Family planning was high on the agenda of the new policymakers. The primary objective was the reduction of rates of population growth and the stabilization of population numbers. To achieve this objective (which was presumed to indirectly support the preexisting objective of women's welfare), family planning was included in the First Five-Year Development Plan of the New Order Government (known as "REPELITAI"), and a national program was designed to promote contraceptive use. One of the keys to the early success of Indonesia's family planning program was the broad and deep support the government received from international donors willing to provide money, supplies, and technical assistance. From a crucial World Bank report in 1969 suggesting the development of an autonomous coordinating board to organize policy, funding, and logistics, through close collaborative projects with the Ford Foundation and the U.S. Agency for International Development (USAID), to the systematic development of initiatives funded by the UN Population Fund (UNFPA), the program received a large amount of assistance in areas where the government had often been weak: planning, research and development, logistics, and training. Over time the financial role of donors declined relative to the growing government commitment to a very large bureaucracy established in the National Family Planning Coordinating Board (BKKBN). The devotion of substantial government resources to family planning, as well as a tenacious public information campaign to promote acceptance of contraception, totally changed public attitudes toward birth control and family size aspirations and totally changed actual family planning practice. Although there are no data on contraceptive use in the 1960s, it is likely that fewer than 5 percent of women were using any form of modern birth control prior to 1968. By 1976, surveys show, that had risen to 18

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percent. By 1997, more than half of currently married Indonesian women were reported to be using family planning—mostly modern methods. The proportion of the population of childbearing age reported to be using contraception appears to have plateaued in the 1990s, but in absolute terms this still represents a huge population of over 24 million (mostly women) family planning clients (see Table 4.1). Since 1968, the methods of birth control available in Indonesia have changed dramatically, as they have in the rest of the world. The adoption of modern contraceptive methods served in part to substitute for traditional practices of abstinence, for the use of herbal and other traditional remedies to bring on miscarriage, and for clandestine resort to surgical abortion. However, the switch away from traditional methods toward modern methods is not fully evident in Table 4.1. Survey questions have been inadequate in recording traditional practices. In part this is because Indonesian

Table 4.1 Use of Methods of Birth Control, Indonesia, 1976-1997 (% of currently married w o m e n aged 15-49) 1976

1987

1991

1993a

1994

1997

Official program methods, total 17.2 4.1 IUD Pill 11.6 — Injectables — Implant Condom 1.5 Program promoted but nonofficial methods, total 0.1 Female sterilization 0.1 Male sterilization 0.0 Widely available but programdiscouraged methods Medical abortion Traditional and folkloric methods, total 1.0 Rhythm 0.8 Withdrawal 0.1 Traditional (herbs or massage) 0.1 — Other methods Reported use of any method of birth control 18.3 No method being used at time of 81.7 survey

40.7 13.2 16.1 9.4 0.4 1.6

43.7 13.3 14.8 11.7 3.1 0.8

48.6 12.0 17.5 15.5 3.0 0.6

48.4 10.3 17.1 15.2 4.9 0.9

51.3 8.1 15.4 21.1 6.0 0.7

3.3 3.1 0.2

3.3 2.7 0.6

3.0 2.3 0.7

3.8 3.1 0.7

3.4 3.0 0.4

6.0 1.2 1.3 2.3 1.2

2.7 1.1 0.7 0.8 0.1

1.4b

2.7 1.1 0.8 0.6 0.2

2.7 1.1 0.8

49.8

49.7

53.1

54.7

54.7

52.3

50.3

46.9

45.3

42.6

— —

— —

—

0.8

Sources: 1976 SUPAS, 1987 CPS, 1991, 1994, and 1997 IDHS, and 1993 SUSENAS, all tabulated and published by the Central Bureau of Statistics. Notes: — indicates that data are not available in the particular surveys reviewed to compile this table. a. Data from the large-scale SUSENAS Social and Economic Survey conducted annually by the Central Bureau of Statistics. b. Includes categories of "other methods" and "traditional methods."

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women sometimes followed practices such as postpartum abstinence or abstinence during the time of ceremonial cycles, as part of an overall notion of "good behavior," rather than as an overt means to prevent conception. More important is the fact that when the official government program appropriated the terms "fertility control" and "family planning" in propaganda and campaigns for modern contraceptives, researchers found it increasingly difficult to frame survey questions about rhythm, withdrawal, and other contraceptive practices. The respondents' understanding of the term "family planning" no longer included traditional practices of fertilityregulating behavior still common in the community. The data in Table 4.1 also point to some of the political and cultural issues that determine the foundations of a reproductive health program. For instance, whereas the government family planning program subsidized the cost of sterilization operations, it was politically unable to recognize sterilization as an "official" method because of a lack of support for this practice from Muslim religious leaders. As a result, the use of sterilization never grew as it did in India, Bangladesh, and China. Similarly, program planners resolutely rejected abortion on the grounds that it was culturally and religiously unacceptable, even though resort to abortion, using both traditional and modern methods, is widespread (Hull 1993), albeit unrecorded. Limitations in access to sterilization and abortion aside, the substantial program effort orchestrated by the BKKBN and implemented by the Ministry of Health made Indonesia world-famous. The program ranked extremely high on the scale of composite indices of family planning effectiveness devised by experts, and its impact on life in Indonesia has been obvious to even the most casual observer traveling through the archipelago. During the early years of the program, government family planning initiatives were based within public maternal and child health services. The reasons for this were obvious: the existence of trained staff, clinic facilities, and complementary activities all promised appropriate backup for methods of contraception needing medical expertise for diagnosis, prescriptions, fitting, and monitoring. However, by 1970, it had become apparent that there was a massive imbalance between the numbers of potential clients and the facilities available to serve them. As a result, early program planners made two important decisions for the direction of the program. First, the standards of medical care presumed to be necessary for contraceptive provision were reviewed and modified so as to reduce the requirement that potential clients should receive thorough medical examinations. The logic used in this decision was based on relative risk assessments. Although less stringent standards of contraceptive care (IUD insertion or provision of pills) might constitute a slight risk to women's health and well-being, the risk was considered to be more than outweighed

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by the much higher risks associated with unwanted pregnancy and childbirth in the same environment. Second, the fact that most potential clients lived long distances from the health posts that were supposed to be providing contraceptive services constituted a major barrier to the acceptance of birth control. By the mid1970s, program planners had adopted a variety of strategies designed to take contraceptives straight to clients in their neighborhoods. These strategies included traveling medical teams, village contraceptive distribution posts, and mass treatment campaigns and camps (safaris). In addition, the process mobilized vast numbers of volunteers to promote family planning at the grassroots. The impact of these innovations was clear: millions of women were able to receive birth control services at affordable prices, generally within easy travel distance of their homes. In the process they largely came into contact with their peers, rather than with medical professionals, and these program volunteers supported and encouraged them in their contraceptive choices. The unforeseen consequence of this popularization of contraceptive technology was the marginalization of the clinical settings and clinical procedures that might have guaranteed high standards of medical care and a more comprehensive range of reproductive health services. By the mid1980s, the number of clinics, subclinics, and integrated service posts had multiplied, and staff numbers had expanded. But observers were discovering that the quality of contraceptive services remained problematic and that the range of maternal and gynecological services provided was limited. The goal of the family planning program had shifted from maternal health to population control. In the process, the program had moved from having a clinical focus to being dependent on a mass mobilization service strategy. The institutionalization of family planning by a government that was rapidly developing authoritarian mechanisms of social mobilization, populist approaches to health and education services, and a centralist direction of policy design constituted the organizational foundation within which a critique and discussion of broad reproductive health issues would take place in the 1990s. During the two decades before the ICPD, the Indonesian family planning program clearly had a number of weaknesses. However, it also developed some important innovations, of which the government was very proud. Nevertheless, the twin factors of a population control objective and an authoritarian approach to implementation troubled experts both within and outside Indonesia. There were accusations of coercive tactics being applied to force people to comply with government family planning policy and targets. And as disturbing reports emerged of forced abortions in

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China and forced sterilizations in India, some foreign commentators assumed that certain practices in Indonesia were similarly coercive and abusive of individual rights. Instead, the record shows, the Indonesian program never resorted to physical coercion. Rather, it manipulated a unique blend of indirect community, social, and cultural pressures, particularly among the populations of Java and Bali, to create widespread compliance in the uptake of modern contraceptive methods. We . . . are obliged to submit to (tunduk) and obey (patuh) all the regulations that emanate from the legitimate government. We are convinced that the purpose of the Government with all its regulations is to improve the life of its nationals. —From the Pancasila Morality Training manual used in schools

Very often, charges of coercion are based on "incidents" reported in newspapers and later found to have been exaggerated or even untrue. Nonetheless, every serious field-researcher in Indonesia has come across complaints that cannot be easily dismissed. More often than not, these relate to what can only be described as misconduct by the two pillars of the New Order: the military and the bureaucracy. Even these issues of misconduct seem to be rare when compared to the more common "coercive" use of peer pressures, group mobilization, and persistent low-level influence to create an environment in which a woman who does not use contraception is regarded as deviant. Personal choice is not accepted as a valid reason for nonuse. The military and the bureaucracy are the institutional units through which such an environment could be created. The New Order government of President Suharto came to power dedicated to creating public stability and harmony, and in fact this is what has characterized government activity in all areas, including family planning, for the last quarter of the twentieth century. The key element required to enforce such stability was the overt commitment of the armed forces to play dual roles (dwi-fungsi) as "stabilizers" and "mobilizers" in the military and civilian realms. Military officers were frequently appointed to leadership positions in the civilian bureaucracy, and civilian bureaucrats were given military and ideological training as a condition for promotion. From the outset, the military was active in the promotion of the family planning program, first through its own extensive network of hospitals and clinics, and, over time, as a mobilizer of mass participation through "special drives" and safaris. To outside observers, the experience of seeing military personnel rounding up women to be taken to have IUDs or implants inserted might appear both frightening and offensive. It is also a powerful image in support of charges of coercive practices. But as with so many other aspects of Indonesia, the starkness of the image is complicated by the realities of culture. An important influence modifying the role of the

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military in Indonesian society is the respect traditionally accorded traditional authority structures: aristocrats (in Javanese, the priyayi), intellectuals, religious leaders (of all faiths), and the nouveau riche all are perceived to merit such respect, as is a range of egalitarian, but essentially traditional and religious, values. No doubt some very serious coercive practices have characterized some military campaigns in support of family planning, but in general such tendencies are kept in check by these countervailing influences. It is not surprising to hear in interviews with villagers that they appreciate the role of the military in promoting family planning. After all, some say ironically, it is the only time you don't have to pay for the "free" services offered by the government. Over three decades, the New Order government achieved a major reconstruction of state and civil institutional structures in ways that increased central government control while promoting decentralized responsibilities. In the constitution, the executive branch of government is dominant, and under President Suharto it was domineering. The nonelected ministers in the executive branch took responsibility for framing the budget, for the design and implementation of policies and programs, and for the conduct of all foreign affairs and economic regulation. They also drafted laws submitted to parliament for discussion and ratification. The minister for home affairs is responsible for the structure of regional and local governments, through provincial governors, district and subdistrict heads, to village chiefs. This line of authority is used in the implementation of all development activities, including family planning and health. There was little scope for independent action outside the bureaucracy (without the ubiquitous izin, or permission), even less scope for independent monitoring or criticism of the exercise of bureaucratic power. One of the unique characteristics of the Indonesian government structure was the development of a "shadow" structure of organizations, composed of the wives of soldiers and officials. Women in the Dharma Wanita group hold positions parallel to those of their husbands in the government bureaucracy. These women's groups organized a wide range of community and social activities as a means of mobilizing "voluntary" support in the name of the government agency. Family planning was one of the frequent objects of such activity, and mass mobilizations of clinical or information, education, and communication services for the community were seldom undertaken without the active participation of large numbers of such women's organizations. Participation was maximized because the chief's wife could count on the wives of her husband's underlings to contribute to, and work for, the group. In addition, these women's groups themselves became an organized target for family planning services, thus ensuring a degree of egalitarianism in the efforts to meet the program targets.

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The Gradual Withdrawal of USAID Family Planning Assistance from Indonesia When former U.S. Ambassador for Population Marshall Green visited Indonesia in March 1988, he could point proudly to the government family planning program as a successful and lasting legacy of his influence on the first years of the New Order government. As U.S. ambassador to Indonesia in the 1960s, Green had tried to convince the novice President Suharto that investment in population control through contraception was much more efficient and effective in dealing with rapid population growth than the resettlement of Javanese to the Outer Islands of the nation. At the time, Suharto was still placing emphasis on transmigration, as the resettlement scheme was called, but he shifted his thinking and began, instead, to see that the widespread use of contraception would bring about small family sizes and a reduction in population growth rates. Returning two decades later, Green met with Suharto and learned that the proud "father of family planning" was anticipating a shift in responsibility for financing contraceptive services from the government to the consumer. The president's reasoning was that this was the only way to make the program self-sufficient and sustainable. The initiative designed to accomplish this development was the "Blue Circle" social marketing strategy, which would distribute partially subsidized contraceptive supplies for sale at low cost. Over time, people would move from dependence on the Blue Circle to the Gold Circle, where full cost recovery was the goal. Green saw this as a healthy development and commended the plan to the local USAID mission. USAID had been one of the largest donors to the Indonesian family planning effort for the previous twenty years, providing contraceptive supplies, training, and a wide variety of technical support to the BKKBN. But with growing self-sufficiency and a rapidly growing economy, the USAID mission in Jakarta began to plan for the closure of its population section. Rumors abounded in BKKBN concerning the exact date of closure and the impact it might have on the program. Many people pointed to a continuing need for support in the areas of research and training, but overall the mood during the period 1990-1997 was one of growing confidence in the government organization. There was the expectation that BKKBN would soon be able to make up for the resources previously coming from USAID. BKKBN also set up the International Training Program to provide courses to officials from around the world on the methods and strategies of running a successful family planning and family welfare program. This initiative promised both to raise the profile of Indonesia on the world stage, as a key player in regional organizations and the nonaligned movement, and to attract income from fee-paying participants. By 1993, the

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pride and the ambition of the BKKBN were at an all-time high, and there was serious discussion about the possible responsibility Indonesia might be assigned to provide assistance to poor countries in Asia and Africa.

Indonesia and the ICPD The Indonesian delegation to the 1994 Cairo conference played a prominent role in fashioning changes to the International Conference on Population and Development Programme of Action. Upon returning from the conference to Jakarta, Minister for Population Haryono Suyono was proud to announce that the world had looked with favor on the family planning movement in Indonesia. He particularly noted the interest in approaches that stressed and strengthened family values. The Indonesian delegation and the Indonesian press paid less attention to what the UNFPA saw as the major breakthrough of Cairo—endorsement of a more comprehensive "reproductive health" approach to family planning issues: helping couples and individuals meet their reproductive goals; the need for men to take a more active role in promoting reproductive health; the prevention of unwanted pregnancies and reductions in high-risk pregnancies and in maternal morbidity and mortality; making quality reproductive health services affordable, acceptable, and accessible to all; and government action to empower women, promote the interests of the girl child, and face the reproductive health needs of adolescents. Some news reports in the English-language press wrote of these themes in a global context, but few reports of the ICPD originating in Indonesia had anything to say on these topics in terms of their relevance or challenges for Indonesia. The politics of family planning in Indonesia inhibited any debate on nonmarital sex and nonprogram methods of birth control, and the bureaucratic culture muted any expressions of criticism of government activities. When women's groups and nongovernmental organizations (NGOs) had raised questions about voluntarism and about the quality of family planning services in the early 1990s, the central government had responded with statements that it was probably time to move from the stage of program outreach to consolidation of better approaches to patient care and safety. Nonetheless, when it was time to turn words into action, hesitancy replaced support. Change was seen as involving a trade-off between coverage—and hence impacts on fertility—and quality of care. Some senior officials and important donors assumed that this would involve greater cost per patient and would thus lead to reduced capacity to ensure universal accessibility. They also expressed concern that patient complacency might result from any pressure to ensure informed choice, and this

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would also reduce overall levels of use. When faced with such a choice, the government seemed to fear that investments in improving service quality would imply the sacrifice of hard-won achievements. If that were the whole story it might have been possible for the Indonesian women's groups and NGOs to address the family planning qualityquantity trade-off with well-designed research into the operations of the family planning program in the field. Around the world, governments were thinking about ways to meet the reproductive health needs of poor women through family planning and health programs that were chronically short of financial support. Research designed and carried out in a variety of poor settings pointed to the need for more support from rich countries, and this call was registered clearly in the Cairo document. But beyond that was the need for nations to mobilize domestic resources—both financial and human—to achieve better quality in the contraceptive services and options their family planning programs were offering. From this perspective, quality was not defined as an air-conditioned clinic so much as a truly caring physician making assessments and providing information on the basis of the patient's overall health and economic situation. Although expensive contraceptive technologies might be useful, they should only be considered with full awareness of the complementary resources, checkups, and services required to ensure their safe and effective use. Moreover, the basis of quality reproductive health was to be found in an attitude of respect for the patient, irrespective of sex, marital status, and personal reproductive goals. Creating such quality in service delivery programs is more a matter of changing attitudes and behavior of service providers and policymakers than of purchasing technologies and equipment. Unfortunately, these insights did not inform the Indonesian family planning movement in the mid-1990s, so the women's groups and NGOs found themselves arguing with the voluntarily deaf. But why was the program deaf to such issues? Essentially, discussion about reproductive health in Indonesia took two forms. These can be characterized as a debate over the BKKBN versus the Department of Health (DEPKES) and a debate over central versus provincial administration. The first argument was the result of the longstanding competition that had existed between the BKKBN and the DEPKES. The former was officially responsible for coordinating the activities of other government and nongovernmental institutions charged with providing family planning services. However, over time, coordination expanded into actual program implementation. By the 1990s, the BKKBN had a huge network of paid and volunteer workers engaged in motivating people to use family planning, as well as organizing a wide variety of welfare activities that were presumed to have some influence in motivating contraceptive use. In contrast, DEPKES, through its hospitals, clinics, and subclinics, provided the actual contraceptive services.

Indonesia

89

At the central level, DEPKES planners were often apathetic about family planning, as planning responsibility and donor funds were monopolized by BKKBN. Short of staff and famously overcommitted at the grassroots level, clinic personnel were resentful that the "family planning success" tag was applied to what they regarded as the public-relations side of the program rather than to the actual services being provided. This bureaucratic split meant that neither organization had much motivation to raise quality of care. For the BKKBN, this would mean focusing attention on health services outside its administrative control; for DEPKES, it would mean self-criticism of activities that formed only a small portion of its agenda. The second split developed during the 1980s and became more obvious as Indonesia embarked on an attempt to change policies in response to international comment and criticism. In the early 1990s, at the level of the central government agencies, the rhetoric of personal choice, client rights, and improved quality of care gained prominence in workshops, seminars, and research projects. In early 1993, the BKKBN's chair announced that the "target" system of chasing after "family planning acceptors" was being abandoned in favor of a service delivery approach designed to fulfill client demands for contraception. In practical terms, this meant that program officials would no longer be rewarded on the basis of the number of people cajoled into using contraception, and special weight would no longer be given to the promotion of program-preferred methods of contraception. Targets had also been a major consideration in the appointment and promotion of senior government officials, so in the long run the implication was that political pressures on family planning implementation would be relaxed as administrators paid more attention to what women wanted rather than to what bureaucrats contrived. Over the next few years, senior bureaucrats in the central offices of the BKKBN struggled to reform the program, changing the documentation of recording systems and expunging the Indonesianized English-word target from reports. It was replaced by the awkward acronym perkiraan permintaan masjarakat, or "estimates of community demand." At the provincial and local levels, however, such linguistic gymnastics took a long time to result in any real change. Officials charged with the task of implementing the program at regency and subdistrict levels found it easier to explain the estimates of community demand as a "new name for targets." They were also remarkably forthright in explaining that the various sanctions and incentives of the old target system were essentially still in force under the new names. Ironically, the central office's calculation of "community demand" in the annual estimates of community demand figures was not based on any empirical assessment of women's desires with regard to either the methods or associated services for family planning. Instead, the initial estimates of community demand figures for each province and regency

90

Developing Country Studies

were based on a computer program ( T A B R A P - C O N V E R S E ) developed in the 1970s to calculate the numbers of contraceptive users needed to meet specified birthrate targets. Because of these persistent conflicts within the Indonesian family planning movement, attempts to promote quality of care and to monitor patient services were chronically handicapped. Within the central bureaucracy, the officers involved in service provision in the Ministry of Health had limited ability to monitor and respond to complaints about family planning service, since that would be seen as interfering with the responsibilities of the B K K B N . Rhetoric concerning quality of services in the statements at the central bureaucratic level could not be effectively transmitted to local levels without a major overhaul of the administrative goals and operating procedures linking the national and local governments. The result was that the illusion of success created through statistics on fertility decline and the reported use of methods served to distract attention from severe systematic weaknesses in the family planning and health programs. These were ignored in discussions surrounding the 1994 ICPD and thus persisted until 1997, when Indonesia began to face calamitous political and economic crises.

Recent Trends in Reproductive Health Services and

Financing

Although the Cairo conference called upon all countries to pay attention to issues of reproductive health beyond the promotion of contraceptive use, there was little doubt among feminists and family planners alike that contraception is a central issue of reproductive health service delivery. The reason for this is a consideration of scale. Contraception is relevant to virtually all women and men at some point in their lives, and it is particularly relevant when they are under pressure to make decisions that will affect their ability to complete their education and participate in the workforce. In contrast, not all individuals experience many of the other issues of reproductive health, such as reproductive tract infections (RTIs), infertility, cancers, and unsafe abortion. Even though it is almost universally relevant, contraception is often very problematic because of the wide range of medical, religious, and economic constraints surrounding the selection and use of any method. In Indonesia, under religious teachings, there has been persistent concern over the acceptability of intrauterine devices, sterilization, and abortion. Nonetheless, Indonesia has a wide range of contraceptive options available to married women (see Table 4.2). Table 4.2 shows the average monthly number of women adopting various methods of contraception nationwide. The coefficient of variation measures the monthly swings of numbers, reflecting the relative gap between the highest and lowest monthly figures in each year. This figure is

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