United Nations

E/CN.9/1996/3


Economic and Social Council

 Distr. GENERAL
10 January 1996
ORIGINAL: ENGLISH


Commission on Population and Development
Twenty-ninth session
26 February-1 March 1996
Item 4 of the provisional agenda*

      FOLLOW-UP ACTIONS TO THE RECOMMENDATIONS OF THE INTERNATIONAL
                CONFERENCE ON POPULATION AND DEVELOPMENT:
               REPRODUCTIVE RIGHTS AND REPRODUCTIVE HEALTH

                   Monitoring of population programmes

                     Report of the Secretary-General




     The present report has been prepared in accordance with the
new terms of reference of the Commission on Population and
Development and its topic-oriented and prioritized multi-year work
programme, which were endorsed by the Economic and Social Council in
its resolution 1995/55.  The topic for 1996 is reproductive rights
and reproductive health.

     This report, which reflects the responses received from
representatives/country directors of the United Nations Population
Fund (UNFPA) in 78 countries, is intended to give a broad overview
of the range of activities that have been initiated in the aftermath
of the International Conference on Population and Development in the
areas of reproductive rights, reproductive health and population
information, education and communication.  It assesses the different
strategies and approaches that countries have adopted to implement
the recommendations in the Programme of Action of the International
Conference on Population and Development concerning reproductive
health and population information, education and communication.  It
also provides an analysis of the difficulties and constraints
encountered by countries in implementing reproductive health and
population information, education and communication programmes.


                        CONTENTS

                                                Paragraphs        Page

            INTRODUCTION                             1 - 5

  I.        INTEGRATION OF FAMILY PLANNING INTO
            REPRODUCTIVE HEALTH PROGRAMMES:
            CONCEPTUALIZATION AND OPERATIONALIZATION 6 - 14

 II.        QUALITY-OF-CARE ASPECTS OF REPRODUCTIVE
            HEALTH PROGRAMMES                       15 - 27

            A.      Human resource development,
                    including training              17 - 18
            B.      Infrastructure                  19 - 22
            C.      Medical protocols               23 - 24
            D.      Availability of reproductive    25 - 27
                    health services

III.        POPULATION INFORMATION, EDUCATION AND
            COMMUNICATION                           28 - 33

 IV.        FOCUS ON SPECIFIC GROUPS                34 - 47

            A.      Adolescents                     35 - 38
            B.      Women's participation           39 - 43
            C.      Role of men                     44 - 47

  V.        ROLE OF NON-GOVERNMENTAL ORGANIZATIONS  48 - 54

 VI.        PROGRAMMING IN REPRODUCTIVE HEALTH:
            CHALLENGES AND CONSTRAINTS              55 - 66

            A.      Sociocultural factors           57 - 58
            B.      Infrastructure and accessibility59 - 63
            C.      Economic and financial aspects  64 - 66

VII.        CONCLUSION                              67 - 75


                               Tables

 1.         Availability of reproductive health components

 2.         Countries with a national information,
            education and communication (IEC)
            strategies, by region or group

 3.         Special programmes to increase
            male involvement in reproductive
            health, by region or group .

 4.         Principal constraints faced
             in implementing reproductive
            health programmes, by region



                      INTRODUCTION

1.  The present report on the monitoring of population programmes has
been prepared in accordance with the new terms of reference of the
Commission on Population and Development and its topic-oriented and
prioritized multi-year work programme, which were endorsed by the
Economic and Social Council in its resolution 1995/55.  The theme for
1996 is reproductive rights and reproductive health, including
population information, education and communication.

2.  This report reviews progress with respect to population programmes
and related development activities at the country level.  It focuses
on programme experiences in the area of reproductive rights and
reproductive health and population information, education and
communication.  Since developed countries usually do not have
explicit population policies, but rather separate clusters of
policies, programmes and legislation, contrary to most developing
countries which have, over the years, adopted comprehensive
population policies and programmes, this report deals with the
programme experiences of developing countries as well as countries
with economies in transition.  Since the principal focus of the
report is the monitoring of population programmes, it primarily
addresses operational activities in the area of reproductive health
and related information, education and communication programmes and,
to a lesser extent, reproductive rights.

3.  In order to obtain the data and information necessary for the
preparation of this report, the United Nations Population Fund
(UNFPA) sent out a questionnaire to all its representatives and
country directors in the field.  The questionnaire was sent to 125
field representatives, covering more than 130 developing countries
and countries with economies in transition.  It contained questions
pertaining to the main subjects covered in chapter VII, Reproductive
rights and reproductive health, and chapter XI, Population,
development and education (part B) of the Programme of Action of the
International Conference on Population and Development. 1/  More
specifically, the questions referred to the following:

    (a)  Integration of family planning information and services into
the broader framework of reproductive health;

    (b)  Quality-of-care aspects of reproductive health programmes;

    (c)  Dissemination of the Programme of Action of the International
Conference on Population and Development and whether it was being
translated into the national language;

    (d)  Existence of a national information, education and
communication strategy for reproductive health;

    (e)  Reproductive health needs of adolescents;

    (f)  Extent of womenžs participation in the design and
implementation of reproductive health programmes;

    (g)  Initiatives under way to increase menžs participation in
reproductive health programmes;

    (h)  Role of non-governmental organizations in the formulation and
implementation of those programmes.


4.  This report is based on responses received from 78 countries. 2/
The breakdown according to the regions from which the responses were
received is as follows:


          Region or group                       No of Reports


     Sub-Saharan Africa (including Eastern, Middle, 
        Southern and Western Africa                          33

     Northern Africa and Western Asia                         8

     Asia (including Eastern, South-eastern and
     South-central Asia) and Oceania
     Latin America and the Caribbean                         17

     Countries with economies in transition                   3
       (including some countries
       in Eastern and Northern Europe)

     Total                                                   78


5.   This report is intended to give a broad overview of the range of
activities that have been initiated, since the International
Conference on Population and Development was held, in the areas of
reproductive rights, reproductive health and population information,
education and communication.  It is more qualitative than
quantitative in its approach.  The report assesses the different
strategies and approaches that countries have adopted to implement
the recommendations in the Programme of Action of the International
Conference on Population and Development concerning reproductive
health and population information, education and communication.  It
focuses on efforts to integrate family planning information and
services into reproductive health programmes; quality-of-care aspects
of those programmes; population information, education and
communication programmes; and initiatives undertaken to address
adolescent reproductive health needs and to increase women's
participation, and on strategies to involve men, as well as on the
role of the non-governmental sector.  The report also analyses the
difficulties and constraints encountered by countries in implementing
reproductive health and population information, education and
communication programmes.


        I.  INTEGRATION OF FAMILY PLANNING INTO REPRODUCTIVE
                          HEALTH PROGRAMMES:
            CONCEPTUALIZATION AND OPERATIONALIZATION


6.   Experiences over the past two decades have shown that family
planning programmes work best when they are part of, or linked to,
broader health-related initiatives that address closely related
health needs.  As a result of these experiences, there is an emphasis
on reproductive rights and reproductive health in the Programme of
Action of the International Conference on Population and Development
and on the need to integrate family planning information and services
into reproductive health programmes.  The Programme of Action of the
International Conference on Population and Development 2/ (para. 7.2)
states:

        "Reproductive health...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, when and how often to
     do so. Implicit in this last condition are the right of men and
     women to be informed and to have access to safe, effective,
     affordable and acceptable methods of family planning of their
     choice, as well as other methods of their choice for regulation
     of fertility which are not against the law, and the right of
     access to appropriate health-care services that will enable women
     to go safely through pregnancy and childbirth and provide couples
     with the best chance of having a healthy infant."

The Programme of Action of the International Conference on Population
and Development further calls for information and services to be made
accessible through the primary health-care system.

7.   In 1995, following the International Conference on Population and
Development, one of the first steps many countries took was to
address the conceptualization and operationalization of the
reproductive health approach in the particular context of their own
country.  Responding to the need for guidance, several United Nations
bodies produced materials aimed at assisting countries in
implementing reproductive health programmes.  For example, the World
Health Organization (WHO) issued several new publications on this
topic.  United Nations organizations and agencies also delineated
their objectives and activities in operationalizing reproductive
health.  UNFPA revised its guidelines on reproductive health, the
United Nations Childrenžs Fund (UNICEF) presented its plans in this
area to its Executive Board in 1995, and the World Bank issued a
policy document on its role in improving reproductive health.

8.   In an attempt to define the implications of the reproductive
health approach for their national policies and programmes, 18
countries--Bhutan, Burkina Faso, the Comoros, Costa Rica, El
Salvador, Ethiopia, India, the Islamic Republic of Iran, Jamaica,
Malawi, Mali, Mongolia, Nicaragua, the Niger, Peru, Turkey, Viet Nam
and Zambia--reported having organized workshops or seminars to
discuss the implications of the reproductive health approach for
their national population programmes.  Workshops were held to
familiarize planners and/or health-care workers concerning the new
concept of reproductive health and its implications for programmes.
In addition, medical associations in various countries organized
forums or symposia to inform their members about the reproductive
health concept and approach and to discuss ways of conceptualizing
and operationalizing the notion of reproductive health.

9.   Countries took up the challenge of the Conference to adopt a
reproductive health approach in many different ways.  Of the
countries responding to the survey, 50 (64 per cent of the
respondents) reported having taken initial steps to broaden their
existing family planning, maternal and child health (MCH), birth
spacing and/or safe motherhood programmes and to include in them
other reproductive health information and services.  In some
countries in Africa, Governments are in the process of integrating
reproductive health services into ongoing activities under the Bamako
Initiative.  This Initiative was set forth at a 1987 meeting of
ministers of health of countries in sub-Saharan Africa to develop a
strategy to revive, strengthen and extend basic health-care services.

10.  In more than 30 countries, including 17 in sub-Saharan Africa,
Governments reported having begun a process of reorientation and re-
examination of existing policies.  In Guinea, for example, the
Ministry of Health initiated a review of the current modalities of
its safe motherhood/family planning programme aimed at transforming
it into a reproductive health/family planning (RH/FP) programme.  In
Indonesia, where the shift from family planning to reproductive
health was initiated even before the Conference, the transition will
be accelerated in its current five-year programme (1995-1999).  This
programme addresses such critical areas as quality of care in
reproductive health services, the demand-fulfilment approach,
prevention of human immunodeficiency virus/acquired immunodeficiency
syndrome (HIV/AIDS) within the framework of RH/FP through a family-
centred approach, education of youth regarding reproductive health
and family well-being, research and data collection on reproductive
health and women, and promotion of womenžs empowerment.  The
Government of Paraguay decided to revise its national plan for
reproductive health and family planning, elaborated just before the
Conference, so as to adjust it to the new focus, principles and
recommendations of the Programme of Action of the International
Conference on Population and Development.

11.  The Programme of Action of the International Conference on
Population and Development (para. 7.9) calls upon Governments to
promote community participation in reproductive health care by
decentralizing the management of public health programmes.  In
several countries, Governments responded to this recommendation by
taking steps towards decentralizing public health services to lower
levels of administration.  In Cameroon, for example, a programme
aimed at strengthening and expanding RH/FP services within primary
health-care programmes includes a component for the decentralization
of RH/FP activities from the Ministry of Health to district and
provincial levels.

12.  The extent of integration of family planning into reproductive
health programmes appears to depend largely on the state of health-
care services and facilities.  Countries in which most essential
reproductive health services were already available to the majority
of the population initiated activities directed towards previously
unserved or underserved groups in society.  Some of these countries
focused instead, or in addition, on the introduction of more specific
reproductive health services, such as the prevention and proper
referral of infertility and the prevention and treatment of
reproductive tract infections, as well as sexually transmitted
diseases.  In countries with less well-developed health services, the
full integration of family planning into reproductive health
programmes was expected to take much more time.  In many of these
countries, Governments adopted an incremental approach to introduce
reproductive health services gradually within the primary health-care
system.

13.  As stated in the Programme of Action of the International
Conference on Population and Development (chap. VII) and reaffirmed
in the Platform for Action adopted at the Fourth World Conference on
Women held in September 1995, reproductive rights rest on the
recognition of the basic right of all couples and individuals to
decide freely and responsibly the number, spacing and timing of their
children and to have the information and means to do so, and on the
right to attain the highest standards of sexual and reproductive
health.  Reproductive rights also include the right to make decisions
concerning reproduction free of discrimination, coercion and violence
(para. 7.3).  The two main aspects of reproductive rights involve
information and services.  As described above, in most of the
countries responding to the inquiry, initiatives were under way to
increase the scope of reproductive health services.  The initial
steps taken by Governments to create awareness of reproductive health
are discussed below.

14.  Some countries framed the assurance of reproductive rights within
a larger approach to issues of reproductive health, population and
sustainable development.  For example, the Government of Bolivia
issued a Declaration of Principles on Population and Sustainable
Development, which states that žone crucial aspect of MCH is
reproductive health, and a key component of this reproductive health
is family planning, undertaken as the fundamental right of couples
and individuals to decide freely and responsibly the number of their
children and the spacing between themž.


II.  QUALITY-OF-CARE ASPECTS OF REPRODUCTIVE HEALTH PROGRAMMES

15.  The emphasis on a comprehensive reproductive health approach in
population programmes has led to increased attention to the quality
of care provided to clients.  The Programme of Action of the
International Conference on Population and Development stresses the
need to improve the quality of care of reproductive health and family
planning programmes as an effective way to address existing unmet
demands for reproductive health information and services (see the
Programme of Action, para. 7.23 (a)-(h)).  Of the countries
responding to the inquiry, 52 reported having initiated activities
to improve the quality of care provided:  24 from sub-Saharan Africa,
4 from Northern Africa and the Middle East, 13 from Asia and Oceania,
10 from Latin America and the Caribbean, and 1 from countries with
economies in transition.

16.  Most of these countries were pursuing the following similar paths
to increase or improve the quality of reproductive health services:
(a) developing human resources, including training of medical and/or
paramedical staff in reproductive health; (b) improving
infrastructure; (c) developing medical protocols for RH/FP services;
and (d) increasing the availability of reproductive health services.

A.  Human resource development, including training

17.  The training of health-care providers--doctors, nurses and
midwives--in reproductive health and family planning matters and/or
the review and revision of training materials seem to be standard
components of most of the reproductive health-care projects developed
in the countries responding after the Conference was held.  An often-
cited objective of training programmes is to increase the number of
service providers so as to expand service coverage, particularly in
rural areas.  Through such training, service providers and health-
care planners and supervisors are made aware of the latest
developments with regard to reproductive health issues, of the need
for clients to have the opportunity to make informed choices, and of
the need for honest and compassionate counselling of clients on
reproductive and sexual health matters.

18.  The Philippines reported, for example, having trained about 80
per cent of all governmental and non-governmental health workers in
basic and comprehensive family planning and interpersonal
communication skills.  Viet Nam reported that its programme included
the review and revision of training curricula and materials based on
findings from the assessment of quality of care of family planning
services in Viet Nam, the Rapid Evaluation Method (REM) survey, and
job descriptions and task analyses of the MCH/FP health personnel.
The Comoros reported that the manual for health-care providers was
being elaborated to include information, education and communication
aspects, the importance of client confidentiality and the need for
mechanisms for follow-up of contraceptive users.  The last mentioned
measure is in line with the recommendation in the Programme of Action
of the International Conference on Population and Development (para.
7.23), which states:  "In the coming years, all family-planning
programmes must make significant efforts to improve quality of care.
Among other measures, programmes should: ... (e) ensure appropriate
follow-up care, including treatment for side-effects of contraceptive
use".

B.  Infrastructure

19.   The increased attention to quality-of-care aspects of
reproductive health programmes appears to have led to increased
concern for the health-system infrastructure, particularly in terms
of the maintenance of health-care facilities and the availability of
sufficient supplies of medical equipment and drugs, including
contraceptives.  Of the countries responding, 20--Benin, Burkina
Faso, Cambodia, Cameroon, Cape Verde, Co“te d'Ivoire, Ecuador, the
Gambia, Guinea-Bissau, Guinea, Lao People's Democratic Republic,
Mexico, Myanmar, Namibia, Nicaragua, the Niger, Senegal, Sierra
Leone, the United Republic of Tanzania and Zimbabwe--reported having
undertaken initiatives aimed at improving the health-care
infrastructure and facilities.  In C“te d'Ivoire, for example,
beginning in 1993, health-care centres had been renovated and
equipped:  20 of those centres were already operational and another
20 were expected to have been renovated and equipped by the end of
1995.  Similarly, in Nicaragua, the Ministry of Health was working,
in cooperation with non-governmental organizations, on improving the
infrastructure and equipping primary health-care units.  In Cambodia,
the Government was addressing the quality of care through, inter
alia, the repair and rehabilitation of health-care facilities and the
provision of medical equipment.

20.   The Programme of Action of the International Conference on
Population and Development (para. 7.23 (a)) recommends that family
planning programmes "recognize that appropriate methods for couples
and individuals vary according to their age, parity, family-size
preference and other factors, and ensure that women and men have
information and access to the widest possible range of safe and
effective family planning methods in order to enable them to exercise
free and informed choice".  Governments, often with the assistance
of the international donor community, began to respond to the need
to expand the availability of different contraceptive methods by
increasing the method mix in health-care facilities.  Projects have
been formulated to introduce previously unavailable methods, while
at the same time strengthening the general supply of contraceptives.

21.   Some countries reviewed their organizational infrastructure with
the aim of assessing effectiveness and efficiency.  The Ministry of
Health in Peru, for instance, undertook an organizational
restructuring to facilitate the integration of MCH, adolescent
health, cancer detection and family planning programmes within the
Social Programmes Directorate of the Ministry of Health; doing so
allowed the Ministry to streamline its health policies and fostered
a more integrated approach to reproductive health.  The Government
of Mexico, in December 1994, merged its Directorate-General of Family
Planning and Directorate-General of Maternal and Child Health within
the Ministry of Health into one Directorate-General of Reproductive
Health, in an organizational change intended to strengthen both
components.

22.   To be able to meet the increased demands for contraceptives, 13
of the countries responding to the inquiry--Bangladesh, Burundi,
Ecuador, Ethiopia, the Lao People's Democratic Republic, Namibia,
Nicaragua, Panama, Togo, Uganda, the United Republic of Tanzania,
Viet Nam and Zambia--reported having programmes formulated since the
Conference to pay special attention to the need to improve the
national logistics management information systems (LMIS), which
enable countries to respond to declining stocks.  The Government of
Ecuador, for instance, initiated a project to strengthen the LMIS of
its national family planning programme.  In the United Republic of
Tanzania, a nationwide LMIS has been established to improve storage,
ordering and forecasting of family planning and AIDS-prevention
methods. A ll MCH coordinators and AIDS-prevention coordinators were
being trained in LMIS.  This training led to improvements in storage,
ordering and forecasting of commodities.  In Viet Nam, following the
Conference, the Government included the strengthening of its
logistics system, covering the distribution of contraceptives, as
well as the FP/MCH management information system (MIS), in the
current programme cycle.

C.  Medical protocols

23.   In a number of countries responding to the inquiry, initiatives
were under way to revise or update medical standards for RH/FP or
related programmes.  For example, the Ministry of Health of Ghana
developed safe motherhood clinical protocols aimed at standardizing
service delivery, as well as reorienting and enhancing the training
of service providers.  The major components of this protocol include
family planning, prenatal and postnatal services, supervised
delivery, the management of complications as a result of abortions,
and the prevention and treatment of sexually transmitted diseases and
HIV/AIDS.  In 1994, the Government of C“te d'Ivoire adopted a
national family planning policy, which sets the standards for health
professionals in providing family planning information and services
in the context of maternal and child health.

24.   In Pakistan, the Government published and disseminated to
health-care providers a Manual of National Standards for the Delivery
of Family Planning Services, which covers all contraceptive methods.
In Egypt, the Government undertook several initiatives to improve the
quality of RH/FP services.  One of them was the review and updating
of the National Clinical Guidelines to include the latest
developments in reproductive health and family planning.  In Nepal,
quality-assurance teams undertake regular field visits to ensure that
standards are being met.

D.  Availability of reproductive health services

25.   Although efforts are under way to improve the quality of
reproductive health and related services,  in the majority of
developing countries responding to the inquiry, the full range of
reproductive health services were either unavailable or inadequately
available to all eligible women and men.  Table 1 shows the number
of countries offering selected components of reproductive health by
degree of availability.

26.   It is clear from table 1 that, of the various reproductive
health components, the most widely available were family planning
counselling, information, education and communication services, and
facilities for prenatal care, safe delivery and postnatal care.  In
one fourth of the countries responding to the inquiry, however,
family planning information and services were considered inadequately
available to all women and men.  Several reports mentioned that in
most cases, most, if not all, components of the reproductive-health
approach were available for middle- and higher-income groups in urban
areas, whereas those services were not available or inadequately
available to the majority of the urban and rural poor.

27.   Of the 78 countries responding, 10 (13 per cent) reported having
all seven components of reproductive health programmes, as described
in table 1, available to all women and men through the primary
health-care or other health-related system.  Thus, in the majority
of countries responding, the full range of reproductive health-care
services was either not yet available or inadequately available.

Table 1.  Availability of reproductive health components
------------------------------------------------------------------
Reproductive
health component               Available          Inadequately
                                                  available
                         -----------------------------------------
                         Number   Percentage    Number    Percentage
---------------------------------------------------------------------
Family planning
councilling,
information, education,
communication and
services                    49         63          19           24

Education and services
for prenatal care, safe
delivery and postnatal
care, especially
breast-feeeding and
infant and women's
health care                 55         71          11           14

Prevention and
appropriate treatment
of infertility              30         40          18           23

Abortion, as specified
in para, 8.25 of the
ICPD Programme of
Action of the
International
Conference on
Population and
Development, including
prevention of
abortion
and the management of
the consequences of
abortion                    25         32          16           21

 Treatment of
 reproductive tract
 infections                 30         38          17           22

 Sexually transmitted
 diseases and other
 reproductive health
 conditions, including
 cancers of the
 reproductive systems       38         49          19           24

 Information, education
 and counselling, as
 appropriate, on human
 sexuality, reproductive
 health and responsible
 parenthood                 35         45          15            19


------------------------------------------------------------------
Reproductive
health component           Not Available          Not ascertained
                         -----------------------------------------
                         Number   Percentage    Number    Percentage
---------------------------------------------------------------------
Family planning
councilling,
information, education,
communication and
services                     3          4           7            9

Education and services
for prenatal care, safe
delivery and postnatal
care, especially
breast-feeeding and
infant and women's
health care                  5          6           7            9

Prevention and
appropriate treatment
of infertility              23         30           7            9

Abortion, as specified
in para, 8.25 of the
ICPD Programme of
Action of the
International
Conference on
Population and
Development, including
prevention of
abortion
and the management of
the consequences of
abortion                    30         38           7            9

 Treatment of
 reproductive tract
 infections                 24         31           7            9

 Sexually transmitted
 diseases and other
 reproductive health
 conditions, including
 cancers of the
 reproductive systems       14         18           7            9

 Information, education
 and counselling, as
 appropriate, on human
 sexuality, reproductive
 health and responsible
 parenthood                 21         27           7            9
 ----------------------------------------------------------------------
   Source:  UNFPA inquiry, 1995.
   Note:  The subheading "Number" refers to number of countries
offering a given component by degree of availability; the
corresponding subheading "percentage" refers to the number as a
percentage of the total number of countries (78) responding to the
inquiry.


     III. POPULATION INFORMATION, EDUCATION AND COMMUNICATION

28.   Any new concept needs to be accompanied by an information,
education and communication (IEC) strategy to make people aware of
its content and implications--and all the more so if this new concept
involves, as does the concept of reproductive rights and reproductive
health, many aspects, ranging from sociocultural factors--cultural
beliefs and practices, status of women, overall health and well-
being, religious convictions and ethical values--to economic
conditions.

29.   Of the 78 countries responding to the inquiry, 25 (32 per cent)
reported having a national IEC strategy for reproductive health (see
table 2).  In most cases, these national strategies were closely
linked with service delivery.  Of the respondents, 16 countries (21
per cent) reported that efforts were under way to develop a national
IEC strategy for reproductive health.  Thus, a little more than 50
per cent of the countries from which information was received will
soon have a national IEC strategy focusing on reproductive health and
related subjects.  More than 50 per cent of the countries in sub-
Saharan Africa (18 out of 33 countries) for which information was
available had, or were in the process of developing, a national
information, education and communication strategy.  In Northern
Africa and Western Asia, 4 out of 8 countries had formulated, or were
in the process of formulating, a national policy.  In Asia and
Oceania, 10 out of 17 countries had, or were in the process of
developing, a national IEC strategy. In Latin America and the
Caribbean, 8 out of 17 countries had, or were in the process of
formulating, a national IEC policy.  In countries with economies in
transition, 1 country out of 3 had done so.

30.   The absence of a national IEC policy for reproductive health
does not necessarily mean, however, that no initiatives were under
way in those countries.  In nearly all countries from which
information was received, IEC activities were being carried out aimed
at increasing awareness of reproductive health and family planning.
Those activities were often part of larger RH/FP or related
programmes, using a  variety of communication channels (such as print
media, radio and television), interpersonal communication and
traditional communication techniques (such as drama, songs, dances
and the use of puppets, posters and leaflets).

31.   In some countries, it was felt that IEC activities were not yet
adequately linked with service delivery, and that this thereby
limited the impact of IEC programmes on RH/FP behaviour.  Other
obstacles were also observed in a number of countries, such as a
prevalence of a high illiteracy prevalence; the notion that
reproductive health matters were private and should therefore not be
discussed in public; lack of IEC materials; limited IEC skills of
health providers; cultural and traditional beliefs and values
preventing, for instance, awareness creation among youth; and lack
of an effective non-governmental sector, which hampered the
implementation of IEC activities and their intended impact.

32.   The international community considers generating greater public
awareness, understanding and commitment to be vital for the
successful implementation of reproductive health programmes.  The
Programme of Action of the International Conference on Population and
Development therefore calls onall parties concerned to strengthen existing 
IEC activities.  The first step after the Conference would have been to 
give wide dissemination to the Programme of Action of the International
Conference on


    Table 2.  Countries with a national information, education
         and communication (IEC) strategy, by region or group

 -----------------------------------------------------------------
                                        Number of       Number of
                           Number of    countries       countries
                           countries    having national developing
 Region or group           responding   IEC strategy    IEC stragey
--------------------------------------------------------------------
Sub-Saharan Africa            33             11             7
(including Eastern,
 Middle, Southern and
 Western Africa)

Nothern Africa and             8              2             2
Western Asia

Asia (including Eastern,      17              6             4
South-eastern and
Western Asia) and Oceania

Latin America and the         17              5             3
Caribbean

Countries with economies       3              1             0
in transition (including
some countries in
Eastern and Northern
Europe)

Total                          78            25            16
---------------------------------------------------------------
 Source:  UNFPA inquiry, 1995.


Population and Development.  From information obtained from responses
to the inquiry, it is clear that the Programme of Action of the
International Conference on Population and Development has been
widely disseminated (75 out of 78 countries responding).  In most
cases, both Governments and UNFPA field offices were responsible for
the dissemination of the document.  Copies were sent to ministries,
project staff, the media, non-governmental organizations,
universities and other interested organizations and individuals.
Seminars, workshops and media briefings were held in many countries
to spread news on the Conference and its implications.  In almost all
the 78 countries that responded to the inquiry, newspapers, radio and
television programmes reported on the Conference.

33.   In terms of translation of the Programme of Action of the
International Conference on Population and Development into national
languages, the picture is quite different.  In less than 50 per cent
of the countries responding (38 out of 78 countries) was the
Programme of Action of the International Conference on Population and
Development translated into the national language, and the figures
being even this high was owing partly to the fact that the national
language happened to be one of the six official languages of the
United Nations (Arabic, Chinese, English, French, Russian and
Spanish) in which the document had been published.  In most countries
in sub-Saharan Africa and Asia and Oceania, apart from those
countries where Arabic, English or French is the official national
language, the document has not yet been translated into the national
language.  In some countries, however, translation activities are
under way.  Many countries in Africa have several official national
languages; thus, it has been reported that translation into all of
those languages seems to be almost impossible to achieve in a short
time.  As of this writing, the Programme of Action of the
International Conference on Population and Development has been
translated into Amharic, Bahasa Indonesia, Farsi, Mongolian and
Vietnamese.

                  IV.  FOCUS ON SPECIFIC GROUPS


34.   The Programme of Action of the International Conference on
Population and Development recognized that certain groups, including
adolescents, women and men, are in need of special attention as
specific audiences for reproductive health information and services.

                  A.  Adolescents

35.   The Programme of Action of the International Conference on
Population and Development encourages Governments to address
adolescent sexual and reproductive health issues through, inter alia,
the provision of appropriate services and counselling (see the
Programme of Action, para. 7.44 (a)).  From the responses received,
it seems that, in many countries, the International Conference on
Population and Development clearly triggered a process aimed at
giving far greater attention than ever before to the needs and
problems of adolescents in the field of sexual and reproductive
health.  Nearly two thirds of the countries responding to the
questionnaire reported having undertaken initiatives to address
adolescents' reproductive rights and reproductive health and to put
their needs in the political agenda.  In some cases, these
initiatives were undertaken by Governments; in others, in cooperation
with, or solely by, non-governmental organizations.

36.   Many Governments are taking various steps to address the special
needs of adolescents.  The Government of Cambodia, for example,
issued guidelines for service providers on taking special care of
adolescents and unmarried clients and not discouraging them from
coming to service delivery points.  In Ghana, the Government
established a National Steering Committee on Adolescent Reproductive
Health aimed at strengthening coordination and providing a forum for
planning and executing activities of the Committee in the country.
In C“te d'Ivoire, special plays directed at youth and adolescents
were being written and performed.  In Uganda, a participatory process
was set in motion which resulted in the formation of the Programme
for Enhancing Adolescent Reproductive Life.  The programme aims at
enhancing the reproductive health of Ugandan adolescents through the
provision of appropriate counselling and services.  To ensure
sustainability, the Programme calls for young people and community
leaders to take a leading role in implementation efforts.

37.   Often, Governments and non-governmental organizations were
working hand in hand to address adolescent reproductive health
issues. In Mexico, even before the International Conference on
Population and Development, a national-level meeting attended by
governmental and non-governmental organization representatives issued
the Declaration of Monterrey, which recognizes the needs and demands
of adolescents.  At the time of the UNFPA inquiry, there were 78
reproductive health-care units for adolescents installed in health-
care facilities throughout the country, where information and advice
were given and where reproductive health services and family planning
were promoted.  By the end of November 1995, it was expected that the
entire country would be covered by the adolescent-care programme and
that each State would have a minimum of two units, one in an urban
health centre and another in a general hospital.  A similar form of
cooperation between Government and non-governmental organizations
took place in Morocco, where the Ministry of Youth and Sports and the
Moroccan Family Planning Association developed an innovative approach
to young peopležs needs.  Five regions of Morocco were being covered
by a programme to educate youth about reproductive and sexual health
through the so-called youth clubs.  In those clubs, adolescents
create their own materials such as songs, drama and puppet shows, the
best of which are shown at national festivals.  The projects cover
such topics as family planning, sexually transmitted diseases and
HIV/AIDS, communication and family life, and sex education.

38.   In countries where adolescent reproductive health issues were
not being addressed by governmental or other programmes for a variety
of reasons, religious and/or cultural factors were most frequently
mentioned as reasons for not addressing the reproductive health needs
of this age group.  The responses to the inquiry revealed that in
many countries where Governments were reluctant to address adolescent
sexuality and reproductive health needs of adolescents, non-
governmental organizations were filling the gap and undertaking
activities for adolescents.  Often, non-governmental organizations
and other local or community-based organizations were in a unique
position to work in this area.  In line with aspects of the
recommendation contained in the Programme of Action (para. 7.48),
many non-governmental organizations were training peer groups in
counselling techniques to provide guidance to adolescents in matters
related to responsible sexual and reproductive behaviour.


                   B.  Women's participation

39.   A crucial aspect for the introduction of a reproductive health
approach in any country is the level of womenžs participation in
decision-making processes.  Paragraph 7.7 of the Programme of Action
states, inter alia that:

      "Reproductive health-care programmes...must involve women in the
    leadership, planning, decision-making, management,
    implementation, organization and evaluation of services.
    Governments and other organizations should take positive steps to
    include women at all levels of the health-care system."

From that perspective, it might be useful to see whether the level
of women's effective participation in the design and implementation
of reproductive health programmes changed after the Conference.

40.   The information received indicates that the level of
participation differed considerably from country to country.  A total
of 41 countries reported having women in decision-making positions
in the health-care system.  The information received does not permit
quantification of the proportion of the positions held by women, nor
does it permit the delineation of trends. However, examples were
given of women's decision-making roles and impact.  In El Salvador,
for instance, it was reported  that women in decision-making
positions in the health-care system and in the National Assembly were
speaking out on issues related to women's health and well-being.  It
was reported that the Government of Togo recently changed the
organizational structure of the Family Health Division in its
Ministry of Health, with women occupying 8 of the 17 decision-making
positions, inter alia, as heads of the Departments of Information,
Education and Communication, Safe Motherhood, and Child Nutrition,
the National Contraceptive Depot and Supervision of RH/FP in the Lom‚
district.

41.   Information gathered from the responses received illustrates
that the health sector is quite vulnerable to economic and social
crisis.  Since women make up most of the workforce in this sector,
womenžs participation in health care in general, and reproductive
health care in particular, is often hardest hit in times of economic
hardship.

42.   Based on the responses received, it would appear that gender
concerns are increasingly being taken into account in programme
design and implementation.  In many reproductive health programmes,
gender issues are already included. For example, the Government of
Mexico set aside a special unit within the Directorate-General of
Reproductive Health to advise  on the inclusion of gender in the
programme.  In a large number of countries, gender training has
become a standard  component in many projects.  Also, female
consultants are being used for project formulation, implementation,
monitoring and evaluation.  In Costa Rica, for example, more than
half of the reproductive health projects that were being implemented
or prepared had women consultants and decision makers actively
participating in project formulation and implementation.

43.   One of the more visible signs of women's involvement in the
planning, formulation and implementation of reproductive health
programmes is through the rapidly growing number of non-governmental
organizations dealing with reproductive health care.  Often, these
non-governmental organizations are headed by women, and the majority,
if not all, of their staff are women.  As a result of the Conference,
Governments have become increasingly inclined to collaborate with
national and/or local non-governmental organizations and other grass-
roots or community-based organizations.  Thus, given the growing
importance of those organizations in project execution, the role of
women in decision-making should steadily increase in the coming
years.

                      C.  Role of men

44.   In many of the 78 countries responding to the inquiry, there
seems to be awareness of the need to integrate men into all aspects
of reproductive health programmes.  Of the countries responding, 36
(46 per cent) reported having started programmes specifically
directed at male involvement in reproductive health programmes (see
table 3).

 Table 3.  Special programmes to increase male involvement
           in reproductive health, by region or group

------------------------------------------------------------
                              Number of      Number of
                              countries      countries
    Region or group           responding     with special
                                             programmes
------------------------------------------------------------
 Sub-Saharan Africa               33            20

 Northern Africa and               8             2
      Western Asia

 Asia and Oceania                 17             9

 Latin America and the            17             4
  Caribbean

 Countries with economies          3             1
  in transition
                                  78            36
 Total
 -----------------------------------------------------------
    Source:  UNFPA inquiry, 1995.


45.   In some countries, this has resulted in innovative interventions
aimed at reaching out to men so as to involve them in issues related
to reproductive and sexual health, family planning and their
responsibility in these areas.  In C“te d'Ivoire, for example, male
nurses were being trained in order to reduce the barriers against
men's making use of health-care facilities.  In addition, an IEC
project was backing the reproductive health programme by producing
flip charts addressing male heads of families.  Similar programmes
were being implemented in other countries.  In the Philippines, male
peer counsellors were being trained to convince married men to
practise or support family planning.  This approach had been adopted
in response to the finding that many women refused to practise family
planning, not because they themselves did not want to but because
their husbands prevented them from doing so.  A similar approach was
being followed in a number of other countries as well.  Another
innovative approach being implemented in the Philippines was the
establishment of the first male reproductive health centre, catering
to the specific (reproductive) health needs of men.  In Sierra Leone,
a non-governmental organization was running a similar exclusively
male clinic.

46.   In other countries, plays were developed specifically for men as
a way to stimulate discussion among them on the use of family
planning and their responsibility in this area.  In Ghana, for
example, a series of community-based seminars and drama performances
had been organized for both male and female audiences to educate and
counsel them on issues concerning population and reproductive health.

47.   Another initiative in reaching out to men was under way in
Nepal.  In order to increase male participation in reproductive
health and family planning, condom boxes were being placed in almost
all the health facilities of the country, thereby providing free and
unhindered access to condoms by all.  In Peru, vasectomy was
officially approved by the Government as a method of family planning.
The Government of Indonesia recognized the need to develop and expand
the current counselling programme to include and improve the existing
training programmes and to develop training materials that focused
on male participation in family planning.


          V.  ROLE OF NON-GOVERNMENTAL ORGANIZATIONS


48.   The Programme of Action of the International Conference on
Population and Development (para. 7.9) calls for a broad and
effective partnership between Governments and the non-governmental
sector in delivering reproductive health information and services.
Governments are encouraged to promote much greater community
participation in reproductive health-care services by decentralizing
the management of public-health programmes and by forming
partnerships in cooperation with local non-governmental organizations
and private health-care providers.  The inquiry attempted to
ascertain whether, one year after and as a result of the Conference
in Cairo, the role of non-governmental organizations in the
development, implementation, monitoring and evaluation of national
reproductive health programmes had increased.


49.   From the information received from 78 countries, it is clear
that the involvement of non-governmental organizations differed
greatly from country to country.  The trend seemed to be towards more
involvement of those organizations, even in those countries where
they had been practically non-existent before the Conference.  In
several countries, international non-governmental organizations were
also working in the field of reproductive health, thereby
complementing or supplementing services provided by government
facilities and/or through national non-governmental organizations.

50.   In many of the countries responding to the inquiry, non-
governmental organizations provided and continue to provide a large
volume of reproductive health services, and information and
education, thereby increasing both the demand for and the access to
those services.  The Togolese Family Welfare Association was
operating a model clinic to demonstrate the integrated approach to
reproductive-health and family planning services, through service
delivery, training and research, and it planned to establish regional
model clinics in four more districts of the country.  In Maldives,
the first family planning clinic in the country was established by
a national non-governmental organization in January 1995.

51.   From the information received, it appeared that non-governmental
organizations had become effective partners for Governments through
their involvement in follow-up mechanisms, such as national
committees or councils, set up in several countries to coordinate the
national implementation of the Programme of Action.  At the same
time, non-governmental organizations had also been increasingly
collaborating and networking in order to expand their influence in
project formulation and execution.  One example was in Ethiopia,
where 11 non-governmental organizations had established a Consortium
of Non-Governmental Organizations in Family Planning.

52.   Traditionally, non-governmental organizations have played an
important role by providing information and services to those
segments of society not addressed by official governmental
programmes, such as the poor, adolescents, commercial sex workers,
unmarried couples, and men, or by focusing on sensitive or
controversial issues, such as traditional harmful practices against
women, violence against women and abortion.  The non-governmental
sector has often been a front runner in innovative approaches to
issues related to women's health, reproduction and family planning.

53.   In times of dwindling public resources for investments in the
social sector, including the health sector, the role of the non-
governmental and private sectors becomes more important.  However,
some countries reported that the increased demands placed on non-
governmental organizations to be full partners in the implementation
of reproductive health programmes have led to an overburdening of
those organizations.  Also, some countries reported that, as a result
of worsening economic conditions, the services provided by non-
governmental organizations had been negatively affected.  In other
countries, the non-governmental organizations, owing to financial
constraints, had been unable to reach large segments of society,
particularly in the rural areas.  In addition, financial difficulties
had led some non-governmental organizations to shift their focus from
low- to middle-income target groups.

54.   Based on the responses received, there is reason to believe that
the Conference has influenced the work of non-governmental
organizations.  As a result of the emphasis placed by the Conference
on a holistic and comprehensive approach to reproductive health,
traditional family planning-type non-governmental organizations are
increasingly broadening their services to include other reproductive-
health services in their clinics, and their staff are being trained
with respect to the implications of this new concept of reproductive
health.


              VI.  PROGRAMMING IN REPRODUCTIVE HEALTH:
                   CHALLENGES AND CONSTRAINTS


55.   While a number of impressive initiatives are under way,
responses to the inquiry show that many countries still face
formidable obstacles or challenges which need to be addressed so that
those countries can fully implement the recommendations in the
Programme of Action in the area of reproductive health.  In general,
these obstacles can be classified using three categories:  (a)
sociocultural factors; (b) infrastructure and accessibility; and (c)
economic and financial aspects.

56.   As is shown in table 4, sociocultural factors, such as lack of
awareness among the public as well as among health professionals and
planners, and cultural and traditional values, were the most
frequently mentioned constraints with respect to implementing
reproductive health programmes.  Infrastructural constraints, such
as poor coordination between ministries, the complexity of health-
system structures, and the quality and skills of health
professionals, were also often reported as constituting important
obstacles to appropriate implementation of reproductive health
programmes.  Limited financial resources for the health sector was
also cited in a large number of reports as a factor affecting those
programmes.

                   A.  Sociocultural factors

57.   Low levels of education often contribute to low awareness as
regards reproductive health.  Illiteracy  and the low status of women
were frequently mentioned as inhibiting factors in raising awareness
with respect to the reproductive health concept.  Also, based on
information received, there is reason to believe that not only
institutions and organizations find it difficult to react promptly
and adequately to changes in health approaches but the public as
well, in part because of the frequency with which new terms and
health concepts are introduced.

58.   Cultural factors can have a profound impact on the availability
of reproductive health information and services.  Pronatalist
sentiments in parts of the world have impeded or limited concerted
and decisive actions by Governments to increase the availability of
such information and services since the Conference.  Male attitudes
and men's opposition to reproductive health and family planning
constituted another factor in limiting service delivery in this area.
Male opposition, often in combination with religious objections, was
frequently given as a reason for the reluctance of Governments to
plan interventions.  Formal opposition or outright resistance from
the religious hierarchy or establishment was a powerful factor in a
number of countries.  This resistance to reproductive health
sometimes stems from misconceptions about the actual meaning of the
concept or from misrepresentations of religious positions regarding
different dimensions of population.  Finally, the absence of female
physicians, particularly in rural areas, has caused women to refrain
from seeking reproductive health information and services in several
developing countries.



Table 4.  Principal constraints faced in implementing reproductive
                health programmes, by region or group
------------------------------------------------------------------------------

                                           Constraints
                     ---------------------------------------------------------
                      Number of                 Infrastructure    Economic
    Region or       of countries  Sociocultural      and        and financial
     group           responding      factors      accessibility     aspects
-------------------------------------------------------------------------------
Sub-Saharan  Africa a/   33            29             26           21

Northern Africa and       8             4              4            3
 Western Asia

Asia and Oceania b/      17            13             17            8

Latin America and        17            12             10            6
 the Caribbean

Countries with economies  3             2              -            1
in transition c/

Total                    78            60             57           39

Total as percentage
of total number of
countries responding    100            77             73           50
------------------------------------------------------------------------------
    Source:  UNFPA inquiry, 1995.
    a/ Including Eastern, Middle, Southern and Western Africa.
    b/ Including Eastern, South-eastern and South-central Asia.
    c/ Including some countries in Eastern and Northern Europe.


                B.  Infrastructure and accessibility

59.   In many of the countries responding to the inquiry, Governments
faced structural obstacles or difficulties which hampered their
ability to implement reproductive health programmes.  Because the
reproductive health concept requires a holistic and comprehensive
approach, cooperation and collaboration among sectoral ministries are
a necessity.  Lack of coordination among the responsible ministries
was one of the most frequently cited obstacles to the creation and
implementation of a comprehensive reproductive health policy.  Donor
coordination was reportedly limited or weak in several countries, and
in many, Government decision-making was still highly centralized.
This often inhibited the involvement of government officials at lower
levels, such as those at regional or district levels, as well as the
involvement of the non-governmental sector.

60.   Sometimes, the structure of a responsible ministry, often a
ministry of health, is not conducive to effective management and
coordination of national reproductive health programmes.  In many
ministries of health, management information systems are weak or are
not functioning adequately, and this leads to poor logistics and data
collection and analysis.  The organization of the health system may
itself become an obstacle to the implementation of reproductive
health programmes.  The existence of several vertical health
programmes (for instance, MCH, primary health care, HIV/AIDS
prevention), each with its own institutional compartments within
health ministries, can impede the integration of reproductive health
services.

61.   The limited coverage of health facilities, particularly in rural
areas, poor referral or inadequate service delivery systems and the
lack of human resources play further major roles in terms of limited
access to reproductive health services and the quality of care
provided in those facilities.  In addition, the low level of staff
motivation, frequent replacements and/or the mobility of health
personnel and lack of technical skills were frequently cited as
barriers to the implementation of a comprehensive reproductive health
approach.

62.   Some reports mentioned discrimination against women or youth as
a factor limiting their ability to participate in reproductive health
care.  Sometimes, health-care providers were reluctant to address
women's or adolescents' (reproductive) health needs.  Also, the
reportedly improper treatment of clients in health facilities in a
number of countries demonstrates the lack of respect for women's
needs and perspectives.  The respectful treatment of clients in
health facilities is regarded as an important element of high quality
of care.  Lack of such treatment reduces people's willingness to use
the available services.

63.   The geographical situation of some of the developing countries
responding to the inquiry places an additional burden on their
ability to provide reproductive health services, particularly to the
more remote areas.  Island States, such as the Philippines, along
with countries covering vast areas of land, such as Namibia, and
mountainous countries, such as Nepal, reported lacking the
infrastructure to cover their entire territory.

                C.  Economic and financial aspects

64.   Insufficient domestic financial resources to provide for
adequate reproductive health services were frequently mentioned as
affecting Governments' abilities to intervene in the health sector
in general, and in reproductive health in particular.  In several
countries, economic hardship prevented Governments from allocating
the necessary resources for reproductive health programmes.  This,
in turn, had detrimental effects on the provision of and access to
services, most visibly in shortages of staff, supplies and other
materials needed in health facilities and poor accessibility of
services due to limited coverage of health services throughout the
country concerned.

65.   The lack of domestic resources is, in several countries, further
affected by the allocation of large proportions of the Government's
budget for the health sector to spending on salaries.  As much as 80
per cent of the health budget may be spent on staff salaries, leaving
20 per cent for programme-related activities.  Many developing
countries remain to a large extent donor-dependent and therefore
vulnerable to changes in donor policies or priorities, as well as to
the political, social and economic situation in donor countries.

66.   Other economic obstacles, in particular, poverty and its
manifestation at the household level, have inhibited access to
reproductive health services.  Poverty has a profound impact on
people's ability to receive reproductive health information and
services.  Poverty not only hampers people's (financially related)
access to such information and services but also limits their access
to education, thereby contributing to a low awareness of the
reproductive health concept in many developing countries.


                VII.  CONCLUSIONS


67.   This report has reviewed the implementation of population
programmes in the field of reproductive rights and reproductive
health one year after the International Conference on Population and
Development and the adoption of the Programme of Action.  The
information received revealed that many Governments of developing
countries and countries with economies in transition had taken
significant steps in responding to the call for action in this area
by the Programme of Action.  In almost two thirds of the countries
responding to the inquiry, initiatives are under way to broaden
family planning information and services to include other
reproductive health elements in their programmes.

68.   The Conference has already helped crystalize issues and acted as
a catalyst.  Subjects previously ignored or simply overlooked have
come to the fore as a direct result of the Conference and the
Programme of Action.  For instance, the needs and perspectives of
adolescents are apparently receiving markedly increased attention.
Nevertheless, those needs remain a sensitive issue in many countries.
Non-governmental and youth organizations are apparently filling the
gap left by Governments of countries where adolescent reproductive
health is still a controversial issue.

69.   Another issue that many countries now recognize as being
important for an effective implementation of reproductive health
programmes is the role and responsibility of men in matters related
to sexuality, family planning, parenting, family life and gender
equality.  As mentioned earlier, numerous initiatives are under way
to involve men in existing programmes or to formulate special
programmes for them.  It is too early to assess the successes of
those programmes, but the increased attention to this issue attests
testimony to the serious commitment that many Governments have made
to the implementation of the recommendations of the Conference.  The
fact that negative male attitudes towards reproductive health and
related issues, as indicated in many country reports, still exist and
are often difficult to overcome justifies even more the need to
address male involvement in this matter.

70.   A third subject that is increasingly being addressed is the
issue of quality of care in RH/FP programmes.  Countries have begun
taking steps to improve or measure the quality of care provided to
clients and have been paying increased attention to the physical
state of health-care facilities.  In a large number of countries,
health-care providers are being trained in client-oriented service
delivery and the importance of confidentiality.  Governments are also
more responsive to expanding the availability of a variety of
contraceptives so as to address the different contraceptive needs of
clients.

71.   The non-governmental sector is playing an important role in the
implementation of reproductive health programmes.  Governments seem
to be more convinced of the potential and competence of community-
based organizations in supplementing or complementing their own
efforts in reaching unserved or underserved population.  In addition,
the Conference itself also had a positive impact on the non-
governmental sector, with non-governmental organizations redefining
their own role, policies and programmes.  The increased demand on the
non-governmental sector may lead to overburdening of non-governmental
organizations.  In many countries responding to the inquiry, national
non-governmental organizations were still weak in terms of resources,
skills and experience of their staff, and expertise, and their
ability to be involved in national execution of reproductive health
programmes was hampered thereby.  In some countries, Governments have
already experienced the limitations of non-governmental
organizations.  There is a general need for a critical assessment of
the potential of national non-governmental organizations to be
partners in development in general and reproductive health in
particular.

72.   Despite encouraging signs of commitment and dedication to the
implementation or strengthening of reproductive health programmes,
the socio-economic and cultural environment is not always conducive
to change.  On a national level, widespread poverty severely hampers
the abilities of Governments to fully implement reproductive health
programmes and, at the individual level, limits people's access to
basic social services, including reproductive health care.  Many
obstacles still need to be overcome, and countries need assistance
from the international community, in terms of both human and
financial resources to deal with those constraints.  Many constraints
have their roots in the unfavourable economic environment that most
developing countries face.  There are also constraints from within.
As the reports from a number of countries indicate, massive
bureaucracies hamper the implementation of the recommendations in the
Programme of Action.

73.   Likewise, accountability needs to be improved.  The
implementation of reproductive health programmes requires sectoral
coordination at the central governmental level.  It is clear that the
difficult, and at times unfavourable, economic situation faced by
many developing countries and countries with economies in transition,
the dwindling resources allocated by the international donor
community for official development assistance (ODA), and the
unfavourable internal conditions need to be fully addressed in order
to successfully implement reproductive health programmes and to reach
the goal of reproductive health by the year 2015.

74.   Monitoring population programmes in general, and measuring
progress in the implementation of reproductive health programmes in
particular, are difficult in the absence of clear indicators.  There
is a strong need for the development of indicators in such areas as
gender equality, reproductive health, womenžs participation, male
involvement and resource mobilization.

75.   The Programme of Action encourages Governments to commit
themselves at the highest political level to achieving the goals and
objectives of the Programme of Action and to take a lead role in
coordinating the implementation, monitoring and evaluation of follow-
up actions (para. 16.7).  Earlier studies undertaken by the United
Nations have underscored the importance of political commitment in
successful population and development interventions. 4/  Because of
the importance of sustaining political commitment at all levels of
society for the implementation of reproductive health programmes, it
should be extended to include not only the central government but
also government officials at various levels as well as
parliamentarians, local and community leaders, unions and the media.
Successful implementation of the recommendations in the Programme of
Action depends on the commitment of all groups in civil society.



                        Notes

     1/  Report of the International Conference on Population and
Development, Cairo, 5-13 September 1994 (United Nations publication,
Sales No. E.95.XIII.18), chap. I, resolution 1, annex.

     2/  Reports from the following 78 countries were received by 1
December 1995:  Algeria, Argentina, Bangladesh, Benin, Bhutan,
Bolivia, Brazil, Burkina Faso, Burundi, Cambodia, Cameroon, Cape
Verde, China, the Comoros, Costa Rica, C“te d'Ivoire, Cuba, Cyprus,
Ecuador, Egypt, El Salvador, Equatorial Guinea, Ethiopia, Fiji, the
Gambia, Ghana, Guatemala, Guinea, Guinea-Bissau, Haiti, Honduras,
India, Indonesia, the Islamic Republic of Iran, Iraq, Jamaica,
Jordan, Kenya, Lao People's Democratic Republic, Lithuania,
Madagascar, Malawi, Maldives, Mali, Mauritania, Mauritius, Mexico,
Mongolia, Morocco, Mozambique, Myanmar, Namibia, Nepal, Nicaragua,
the Niger, Pakistan, Panama, Papua New Guinea, Paraguay, Peru, the
Philippines, Romania, Senegal, Seychelles, Sierra Leone, South
Africa, Sudan, the United Republic of Tanzania, Togo, Tunisia,
Turkey, Turkmenistan, Uganda, Uruguay, Viet Nam, Zaire, Zambia and
Zimbabwe.

     3/  Report of the Fourth World Conference on Women, Beijing, 4-15
September 1995 (A/CONF.177/20), chap. I, resolution 1, annex II.

     4/  The national reports on population and development submitted
to the secretariat of the International Conference on Population and
Development showed that such commitment had expanded remarkably over
the past 20 years.  At the same time, most of the national reports
stressed the need for even greater political support to population
concerns, particularly in terms of raising social-sector public
expenditures (see report of the Secretary-General of the
International Conference on Population and Development on synthesis
of national reports on population and development (A/49/482, para.
57).                    

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