|
and
Laurie Lewis
This Discussion Papers series has been initiated by the CST (Suva) in an attempt to establish a dialogue with and among national population programme personnel on the integrated and coordinated multidisciplinary approach to population. Hence, CST Discussion Papers are not particularly addressed to academic audiences but to practitioners.
In this paper, William House and Laurie Lewis have attempted to sketch out some of the implications of the Programme of Action adopted at the International Conference on Population and Development (ICPD) and they ask the question, "Can the Pacific Island Countries meet the challenge?"
We would like to hear from you.
28 February 1997
Stephen Chee
Director
Overview
The 15 countries of the South Pacific region face daunting challenges to their prevailing living conditions and lifestyle in the near future. Their remoteness from their principal markets (Australia, New Zealand and the Western USA), their limited range o f natural resources, narrowly specialised and small economies, primarily focused on traditional agriculture, with no economies of scale because of their small size, the narrow base of local skills and jobs, largely dominated by a bloated public sector, of ten exacerbated by an outflow of the more educated and younger persons overseas, and an endangered environment, all threaten existing levels of real welfare. In addition, high natural rates of population growth are exerting intense pressure on the social services and economic institutions of the region such that sustained economic growth and sustainable development will be extremely difficult to realise over the longer term without the implementation of major innovative population-related policies and programmes.
The demographic scenarios within the region vary quite dramatically. Fiji is well advanced on its demographic transition, exhibiting relatively low fertility and mortality; Papua New Guinea, Vanuatu, Solomon Islands , Marshall Islands, the Federated States of Micronesia and Kiribati maintain high but falling levels of fertility and mor tality, resulting in very significant natural rates of population growth; and the Polynesian countries, with somewhat lower levels of fertility and mortality whose not inconsiderable natural rates of population growth have been partially ameliorated by l arge scale out migration to the more development Pacific-rim countries. Cook Islands, Tonga and Western Samoa, on the one hand, have been the beneficiaries of the remittances sent home by these out migrants, but have lost the skills of these usually more educated and better trained citizens.
One general conclusion might be that the experience facing each and every country in the region is often very different and even a simplified classification of the nations into Melanesia, Micronesia and Polynesia hardly does justice to the social, economi c and demographic situations each of them faces. The implication is that, in the design and planning of intervention strategies to influence demographic and development outcomes, these differences must be recognised and country-specific strategies fine tu ned accordingly.
Meanwhile, with a less than dynamic national economy from which to derive tax revenue and dwindling sources of aid funding, many Governments are finding it extremely difficult to maintain, let alone expand, the quality and quantity of social services. Whi le social indicators have attained commendable levels in many countries of the sub-region, set beside rapidly growing populations, there will be an inevitable tendency to trade off quality improvements for quantity expansion in the education and health sy stems as a result of shrinking social sector budgets. Evidently, it will not be easy to improve the quality of social services, especially reproductive health and family planning services, under these conditions. This will endanger prospects for further improving the education and health status of women and children, a pre-requisite for inducing greater demographic behavioural change and producing further declines in the overall natural rates of population growth.
Demographic Dynamics
Currently, the share of the under 15 years age group in the total population exceeds one-third in all the countries and every 100 persons in the working age groups 15-64 is liable to support 50 or more dependents, those aged under 15 and 65 and over. Each of the census reports in our three illustrative countries projects the future size and structure of their national populations under various fertility and mortality scenarios, including one in which fertility and mortality continue a moderate decline. I gnoring international out-migration, which is only important in Samoa of these three countries, it is projected that Samoa's population would grow by 28% or 2.5% p.a. over the 1991-2001 period; Vanuatu's population would, rise by 68% over the period 1991-2009 or by 2.6% p.a.; and Marshall Islands' growth of population would, at the demographic rates prevailing in 1988, be 94% or 3.9% p.a. during the 17 years 1988 - 2005. Because of the delay of at least 15-20 years in any fertility decline affecting the number of new entrants to the labour force, the projected growth in these countries' labour forces over this period far exceeds the growth rate of their populations.
Other countries facing similar potential population growth in the region include Papua New Guinea, Solomon Islands, Federated States of Micronesia, Nauru, Cook Islands, Tuvalu and Tonga. The extent to which this potential growth materialises is criticall y dependent on the future rate of out-migration, particularly in the Micronesian and Polynesian countries, which cannot be foreseen with any clarity.
Meanwhile, planners and policy-makers must be prepared to implement policies and programmes which are "population accommodating", necessitating major investments in the health and education sectors just to maintain the far from satisfactory current provis ion of services. Such rapid population growth will also have major implications for the labour markets of the sub-Region, since the small formal sectors cannot hope to accommodate all the newcomers from the education system, particularly when economic growth and employment creation have stagnated for at least the past decade in most countries.
"Population influencing" policies need to be far-reaching. To induce change in demographic behaviour without coercion, particularly with regard to fertility and migration behaviour, comprehensive and holistic innovative programmes will require formulation and implementation. Rural development may well retard rural to urban and over seas migration; improving the quality and quantity of reproductive health and family planning information and services can induce couples to employ more effective contraceptive methods to ensure that their desired and achieved fertility levels are more in unison; raising the life-time opportunities of the girl child and improving the status of women in society can go a long way to empowering women to be able to determine their own fertility behaviour; and t he creation of a political, social and cultural environment in which the small family norm is widely accepted can induce demographic change.
A Development Profile
By some standards the Pacific islands might be regarded as quite well developed in that they are peaceful, politically independent and have social structures which are highly effective in meeting the basic needs of their populations. Pacific islander s have long been highly mobile, between the outer islands or remote and the capital town or city, between rural areas and between their home country and the more developed countries of the Pacific - rim. Fundamental to this system of movement is a society where the extended family and the local community are the primary units of social reference. "Subsistence affluence" in the agrarian based village economy, together with these strong community affiliations, has ensured that absolute poverty and deprivation, as found in other parts of the world, are unknown. The commitment to the core unit in the extended family is demonstrated and maintained by substantial remittance flows from those members who have left for employment in nearly urban area s or overseas. Such mobility has likely contributed to the slowly evolving acceptance of modern family planning methods to achieve a smaller family size norm as new ideas have infiltrated rural societies.
Customary systems are very strong in all the countries and are significant in the social organisation of the family and village. While Tonga has a monarchical system with a small group of noble families, the chiefly system maintains its control and influe nce in many of the countries.
Meanwhile, at the national level, Parliamentary democracy is widely practised and regular elections are hotly contested. At this level, a multitude of political parties has ensured that Governments are loose, frequently changing, fragmented coalitions, wh ere personalities tend to dominate over major policy issues. The result has been political instability and frequent changes of Government and Ministerial portfolios, hardly conducive to decisive policy-making addressing the substantive development challen ges. It is widely reported that such political instability retards development policy-making, in particular in Papua New Guinea, Fiji, Solomon Islands, Vanuatu, Cook Islands and Niue. In Fiji, for example, uncertainty over the renewal of long-term lease s of customary land to mainly Indian sugar farmers, and over the outcome of a Constitutional Review, are widely believed to be damaging local and overseas investor confidence and impeding economic growth.
Long time harmonious social conditions, however, are under threat as the traditional social fabric is challenged by modernising influences carried by formally educated youths, latter-day communications systems and visiting family members based overseas. The dominance of Parliament by the nobles in Tonga and the chiefly system elsewhere are under challenge by democratising activists; women's rights movements have grown to press for an improvement in the status of women and a reduction in overt discriminat ion; and recently educated youth are challenging traditional authority in the home and community. Symptoms of this confrontation between the traditional and the modern are found in rising urban shanty towns and concomitant increasing crime rates, particu larly in urban Fiji and Solomon Islands; the opening of women's crisis centres to deal more transparently with domestic violence inflicted on wives; significant adolescent fertility in Papua New Guinea, Fiji, Solomon Islands a! nd Marshall Islands as young unmarried girls become sexually active at an earlier age but fail to use a contraceptive method; an increasing number of reported STDs and the threat of an AIDS epidemic; a growing incidence of suicide, particularly among the urban youth; evident food insecurity in some rural areas as traditional social safety nets come under threat; and increasing o besity and associated non-communicable diseases as sedentary lifestyles and processed foods replace traditional diets. As population sizes grow and pressure on limited land intensifies, there are increasing cases of challenges to the traditional authorit ies over access to land and its uses. In matrilineal societies, such as the Marshall Islands, women's traditional claims to their land are being usurped while, in Fiji, there are frequent disputes between traditional land owners and those who have leased their land for modern sector uses.
Evidently, not all is well in the seemingly tranquil Pacific Island countries. At the risk of oversimplification, many of these social problems are attributable to the complex and largely unexplored interrelationships between the region's population dynam ics and its generally underdeveloped state.
Population Projections
Because of the young age structures of the populations of the countries in the sub-Region population growth will be significant well into the 21st Century regardless of the speed of behavioural change and the decline in rates of fertility. In many of the countries the share of the under 15 age group exceeds 35% and as this bulge in the population pyramid moves into its childbearing years, even if on-going behavioural change continues and the average woman bears fewer children than her mother, there will be many more Pacific islanders by the year 2010 than at present. Even the option of overseas migration as a means of shelving surplus population may be curtailed. The Australian and New Zealand door is felt to be closing on Samoan and Tongan immigrants and the end of the Compacts of Free Association with the United States may curtail the present migration option of people from Palau, FSM and the Marshall Islands.
Given the lack of dynamism in these economies, described as the "Pacific Paradox", the sustainability of present living standards, including the commendable health and education advances made, may be jeopardised.
ICPD Goals
The ICPD Programme of Action highlights a number of major concerns and recognises that population dynamics are inextricably linked to the full range of human development concerns. Demographic behaviour affects, and in turn is affected by, patterns of ove rall social and economic development, including poverty alleviation, women's empowerment and environmental protection.
Population, Sustained Economic Growth, and Sustainable Development
The prospects of initiating sustained economic growth and sustainable development in these countries do not appear promising as they suffer from the lack of natural resources, underdeveloped human resources with poor labour market skills, isolation, inade quate infrastructure, etc. Environmental degradation is evident in a number of countries, particularly in urban areas, as population growth exerts pressure on clean water, sanitation and coastal facilities. The drive to generate economic growth has led to the unsustainable depletion of natural resources, particularly fish stocks and forests. Some of the Polynesian countries have managed to relieve such population pressure in the past by off-loa ding some of their citizens to Pacific-Rim countries but this escape valve may be closing. Furthermore, large scale donor aid has supported infrastructural construction and operating costs but here too, donor fatigue has led to a downward trend in the su pply of this source of funding.
Gender Equality, Equity, and the Empowerment of Women
The need for women's equality is stressed throughout the Programme of Action, being viewed as an ethically mandated end in itself. The improvement of women's political, social and economic status, and improving women's health, are viewed as essential for slowing population growth and achieving sustainable development.
Women are grossly underrepresented in the political arena in all the countries of the sub-region. Indeed, it was only recently in Samoa, the passage of a Referendum providing a popular franchise that women were fairly represented in the election process. They have only nominal representation in the Parliaments of the sub-region and Ministerial portfolios for women are even rarer. Their economic status, as reflected in their occupational attainments and earnings levels, are distinctly inferior to men.
Great improvements have been made in the area of girls' educational attainment, promising that the current disparity in the rate of literacy between adult men and women, will be narrowed in the future.
Most of the countries have already met the quantitative goal of the ICPD of attaining universal primary education. Quantitative improvements at the secondary level are also likely to continue. The greatest concern, however, must be over the likely deter ioration in the quality of education as public sector budgets come under intense pressure during structural economic reform at the same time as burgeoning numbers of pupils reach school age. In addition, as formal sector employment opportunities stagnate or even contract, there could well be disillusionment with the formal education system, further impeding advancement of the demographic transition.
Reproductive Rights and Reproductive Health
The ICPD-POA argues that, if women are to realise their full potential as productive members of their communities, they must be able to manage their many roles, including motherhood. This means that they must have access to reliable information and quali ty reproductive health care, including family planning services.
Many of the island countries have adopted the primary health care approach of which reproductive health and family planning is an integral part. However, many of the current RH/FP programmes are still very much within the conventional Maternal and C hild Health and Family Planning (MCH/FP) framework, focussing mainly on pregnancy care and contraception and employing the pregnancy outcome as the main indicator of women's health. Indeed, MCH/FP services are often restricted only to married women, an approach which fails to meet the specific needs of special groups, such as teenagers and women over the age of 40. In addition, the conventional programmes hardly do justice to the rising concerns of advocates of RH/FP in the related areas of reproductive tract infections, sexually transmitted diseases, abortion and infertility. One issue raised in the paper concerns a possible trade-off between providing quality RH care for a few as opposed to servicing the basic contraceptive needs of the mass of Pacific island couples in situations where resource and budgetary constraints are tightening.
Most data on CPRs comes from reported visits to service facilities and under-records traditional methods and practices. The reported CPRs of Papua New Guinea, Vanuatu, Solomon Islands and Tokelau are quite low; the CPRs in Kiribati and Fiji have sta gnated for a decade or more.
The conclusion is that contraceptive use is still thought to be quite low and has stagnated in some countries, including Fiji, for reasons which have not been fully investigated. It may well be, however, that actual contraceptive use is greater than that which is currently reported. Much more research is required in these countries, starting with basic national KAP-type studies and increasing in complexity to address issues such as the qualitative assessment of service provision by both users and p roviders. This would allow programme planners to assess the reproductive goals and desires of couples and design interventions to meet their unmet needs, particularly addressing the special needs of adolescents and older men and women, particularly those in rural areas and on outer islands who are likely to be the most disadvantaged.
Without such basic information it will be impossible to assess the nature and size of gaps to be filled before the Pacific island countries can meet the qualitative and quantitative targets of the ICPD-POA.
Women's Health and Safe Motherhood
The ICPD-POA agreed on specific numerical goals to be reached by the years 2000, 2005 and 2015 in promoting women's health and safe motherhood. All countries are charged with reducing maternal morbidity and mortality to "levels where they no long er constitute a public health problem". Disparities in maternal illness and death rates should be narrowed both between countries and within countries between socio-economic groups.
The use of the maternal mortality rate as the principal health indicator has serious problems in the Pacific context. As already noted vital registration systems are grossly inadequate in the island countries. Deaths, in general and maternal, are u nder-reported because of the underdeveloped state of the civil registration systems, particularly in Papua New Guinea, Vanuatu and the Solomon Islands. More generally, because of the small size of these countries, and despite the relatively high fertility rates, the annual number of births occurring in many countries is very small, often less than 1000. Therefore, a maternal death is a rare event which can dramatically raise the calculated maternal mortality rate (MMR) in a particular year.
Pre-natal care coverage ranges from 52% in Tokelau, and possibly lower still in Papua New Guinea, to 100% in Fiji, Cook Islands, Niue, Palau and Tuvalu. Reported rates of delivery by health personnel are high in many of the countries, but low in Kir ibati, Papua New Guinea, Vanuatu and Solomon Islands. However, the reported rates in Appendix Table A are likely to be urban-biased and exaggerated. Women residing in rural areas and on outer islands are very likely to be without maternal care and to have been overlooked in these data.
One concern in the Pacific sub-region is the high rate of sexually transmitted diseases (STDs) which adversely affects women's reproductive health. They are also an important indicator of high-risk sexual behaviour and the potential danger of an HIV /AIDS epidemic in these countries.
In order to increase the financial allocations for population programmes greater politicalcommitment is essential. Without it, the profile of population programmes will remain fairly low and, at the same time as donor support is being curtailed and the domestic economies are stagnating, these programmes will suffer.
Population Policies and Strategies
Many Pacific countries have formulated or are in the process of revising explicitpopulation policies. In the post-ICPD era, a more holistic approach has been adopted, which isbeginning to produce very positive results. Under the auspices of the UNF PA and its CST,population awareness-raising workshops have been organized in various countries, serving toinitiate the process of designing a national policy and programme, where one does not already exist, identify population-related problems and formulating strategies to address them. Withgreater political commitment and improved institutional coordination a more comprehensiveapproach to developing an implementing a national population policy is evi dent. From the perspective of the authors, the concentration of technical support services, asembodied in the multi-disciplinary character of the TSS/CST system, appears as the optimal wayof ensuring success int he implementation of Pacific island programm es. Covering all thematicareas, the system is able to respond in full to the needs of priority countries. Even in lowerpriority countries, technical assistance is seen as a cost-effective way of strengthening nationalcapacities and for maintaining linka ges between UNFPA and member states. Conclusions This paper demonstrates that population-related programmes in the Pacific Islandcountries have made progress in recent years. Social indicators exceed expectations in many ofthe smaller countries at their stage of development but provide more patchy evidence of progressin much of Melanesia. However, overall progress has been made and the road ahead presentsnew and profound challenges. Success in promoting family planning and the use of contraceptionhas been achieved by persuading the urban, more e ducated residents to change their demographicbehaviour. The greatest challenge lies ahead in convincing rural couples that it is in their bestinterest to bear fewer, well-spaced children, concepts which may not be obvious in a largely agricultural-based, household economy. New and innovative methods are needed to disseminatethe population message via the influential traditional leadership and churches who, perhaps, havenot been fully utilised in the past but who are held in great este em by the local populace. Improvements in the provision of quality services, particularly in rural areas, are required to facilitate this process. New population-related problems are also presenting themselves in the form of risingrates of adolescent fertility, sexually transmitted diseases entailing the ever-present threat of anHIV/AIDS epidemic, and disenchantment with local, rural-based clin ics and health facilities. Rural-urban migration continues unabated and immense pressure is being exerted on urban infrastructure, the job market and the environment. As traditional authority breaks down thereis concern over rising substance abuse, crime, domestic violence and suicide in some countries. These challenges require innovative population-accommodating and population-influencing strategies to be incorporated into comprehensive national population anddevelopment policies and programmes. Such strategies need to go hand-in-hand with detaile dimplementation plans which have yet to be formulated in most of the island countries. Theseshould entail a detailed accounting of the financial and human resource costs of implementing the policies, including the resource requirements for meeting the goals and targets of the ICPD-POA. The paper concludes by offering some proposed strategies for the various programme areasto meet the profound challenges in the PICs in the remaining years of this century and beyond. Perhaps the greatest challenge will be to fully integrate population issues into thedevelopment planning process, particularly at the grass-roots level, at a time when nationaldevelopment policy options are quite limited and when public sector budget s are under intensepressure as rates of economic growth have been disappointing and donor support declining. The challenge to donors, including UNFPA, will be to ensure that past achievements aremaintained and the quality of life of Pacific Islanders continues to progress.
I. OVERVIEW II. DEMOGRAPHIC DYNAMICS AND THEIR IMPLICATIONS III. A DEVELOPMENT PROFILE IV. ICPD GOALS: HOW DO THE PACIFIC ISLAND COUNTRIES FARE? V. POPULATION POLICIES AND PROGRAMMES
VI. SUGGESTED FUTURE PROGRAMME STRATEGIES FOR THE SOUTH PACIFIC VII. CONCLUSIONS REFERENCES List of Tables Table 1:Selected Demographic Indicators for 14 Pacific Island Countries, 1995 Table 2: Population and Economic Growth Indicators for Selected Pacific Island Countries 1982- 92 Table 3: Patterns of Health Care Expenditures in a Sample of Pacific Island Economies Table 4: Status of Population Policy in the Countries of the South Pacific20 Figure 1: Population Pyramids of Vanuatu, Marshall Islands and Western Samoa from the Most Recent Census APPENDIX TABLE A: Development Indicators in the South Pacific Islands Countries APPENDIX TABLE B: Summary of RH/FP Situation in the Pacific Island Countries.
One general conclusion might be that the experience facing each and every country inthe region is often very different and even a simplified classification of the nations intoMelanesia, Micronesia and Polynesia hardly does justice to the socia l, economic anddemographic situations each of them faces. The implication is that, in the design and planningof interventionist strategies to influence demographic and development outcomes, thesedifferences must be recognised and country-specific strategi es fine tuned accordingly. One common factor, however, which all the countries suffer, is their exposure toexogenous forces beyond their control. This makes them extremely vulnerable, in varyingdegrees, to the vicissitudes affecting their economies and income levels, th eir ability to exportand import, to create employment opportunities for burgeoning numbers of new job seekers andto satisfy the increasing demands being placed on their social sectors, particularly the educationand health sectors. Their land and sea resou rces are also vulnerable to the over-exploitation of their scarce natural endowments by over-zealous, often foreign loggers, mining operators andfishermen. Population pressure, particularly in urban areas, has endangered the fresh watersupplies and sanita tion facilities and made segments of the population vulnerable to outbreaksof contagious diseases. And since many of the countries of the region remain heavily dependenton foreign aid flows to cover public sector budget and tr! ade deficits, including large differences between levels of domestic savings and investment, they remain vulnerable to the likely loss ofmuch for this aid support due to donor fatigue and the shift of the Western powers' interest to theemerging economies of Eastern Europe.
In addition, the small but privileged formal sector workforces, largely dominated by thepublic sector, whose pay and conditions of work far exceed those available to the majority of thelabour force, are threatened by economic restructuring and retren chment of the Governmentworkforce. The trade advantages enjoyed by some island economies which have gained preferential access to developed country markets for some of their products (e.g. garments andsugar from Fiji; automotive wire harnesses from Samoa) are threatened by the move to make theinternational trading environment more competitive, thus endangering many jobs in the privateformal sector. And, under the pressure of population growth and the lack of buoyancy in the formal job market, the subsistence sector in many of the island countries is extremely vulnerablebecause of its role as the employer of last resort and the absorber of surplus labour in theeconomy. Diminishing returns of subsistence output per unit of la nd and human effort have setin, resulting in rising costs of agricultural output. Marketing infrastructure for surplus farmproducts remains grossly inadequate in all of the countries. As urban consumers switch away from traditional foods to a lower cost diet of imported canned and processed foods, the incidenceof non-communicable diseases - hypertension, obesity, diabetes - has risen dramatically in thePacific. Where good land is scarce, population pressure has also resulted in the adoption ofunsustainable farming practices, endangering the livelihood of future generations of islanders.
Meanwhile, with a less than dynamic national economy from which to derive tax revenue,and dwindling sources of aid funding, many Governments are finding it extremely difficult tomaintain, let alone expand, the quality and quantity of social servic es. While social indicatorshave attained commendable levels in many countries of the sub-region, set beside rapidlygrowing populations, there will be an inevitable tendency to trade off quality improvements forquantity expansion in the education and h ealth systems as a result of shrinking social sectorbudgets. Evidently, it will not be easy to improve the quality of social services, especiallyreproductive health and family planning services, under these conditions. This will endanger prospects for further improving the education and health status of women and children, a pre-requisite for inducing greater demographic behavioural change which is necessary to producefurther declines in the overall natural rates of population growth. As the ICPD recognises, earlystabilization of populations will contribute to the achievement of sustainable development (UN, ICPD, para 1.11, p.7).
The current population size of the 15 countries of the Pacific islands region isapproximately 6 million, with 90% located in Melanesia, 5% in Micronesia and 5% in Polynesia.Fertility and mortality are generally higher in the relatively larger Melanes ia and Micronesiagroupings, as reflected in Table 1. With the exception of Fiji, structural changes in theseeconomies, entailing a relative movement out of agriculture and into modern sector industry and services, has been quite limited, perhaps partly explaining why the demographic transition havingbegun, has a long way yet to run. While health conditions have improved significantly due to a reduction in communicablediseases via improved water, sanitation and health services, some vulnerable groups suffer fromhigh mortality risks. Where fertility remains exceptionally high, in some Melanesian andMicronesian countries, infant mortality rates exceed 40 per 1000 live births, an unacceptable situation. Maternal morbidity and mortality are also relatively high in these countries, especiallyin Papua New Guinea, with local reported rates of maternal mortality exceeding 400 per 100,000 live births, although hard data are difficult to find. No doubt, such mortality scenarios are oftenattributable to high parity, short birth intervals and pregnancy occurring to adolescents and towomen over the age of 35 years. And malaria remains endemic in Papua New Guinea, Vanuatuand the Solomon Islands. The result is that, for the Pacific region as a whole, influenced largely by PNG, thecurrent annual rate of population growth is about 2.3%. In Polynesia, while natural growth ratesexceed 2.5% per annum, large scale out-migration has reduced the realised inter-censal annualgrowth rates to less than 1%. Out-migration from Cook Islands, Niue, Samoa and Tonga to NewZealand, Australia and Hawaii has been important, serving as a barometer of economic conditions in both the sending and receiving countries. Remittance flows to families left behind far exceed the countries' earnings from theexport of goods and services. Yet, as New Zealand and Australian immigration authoritiestighten the conditions of entry for Tongans and Samoans, the mother countries are vulnerable ina number of ways, to a loss of overseas opportunities for their surplus labour, to a sudden surge in the number of return migrants, and to the loss of remittances from the overseas earnings ofout-migrants. After the political events of 1987 Fiji also lost, and continues to lose, some of itsbrightest and ablest citizens, mainly people of ethnic Indian origin. Under the terms of the Compacts of Free Association with the United States signed bythe Federated States of Micronesia, Marshall Islands and Palau since attaining independence inthe latter half of the 1980s, citizens of these countries have the right of free access to the USA.There is evidence that rising numbers of Micronesians and Palauans are taking advantage of this opportunity and migrating to the Northern Marianas, Guam and Hawaii and depleting theircountries of skilled labour. Palau has experienced a significant inflow of alien labour, mainlyfrom the Philippines, to fill the skill gaps. Meanwhile, so far Marshal l Islanders seem not to haveout-migrated in significant numbers. However, as the national economy is depressed and experiencing major retrenchments in public service employment, it is likely that many moreMarshallese will leave densely populated Majuro and Ebeye in search of greener pastures. Theymay also seek to leave before the expiry of the Compact in 2001, after w hich their current accessto the US may be curtailed. Urban populations are also rising in most of the Pacific Island countries. In some ofthem (Fiji, Kiribati, Marshall Islands, Nauru, Palau, Cook Islands, Tonga and Tuvalu) already one-third or more of the population lives in urban areas with r ates of urbanisation far exceedingthe general rates of population growth. This phenomenon is partly the result of rising aspirations for wage employment and disenchantment with a rural existence, following rising rates ofprimary and secondary school enrolments in education systems following largely developedcountry curricula. The consequences are that rural areas and outer islands have lost some of theirablest people while urban areas are incapable of absorbing all of them in productive employment. Squatter settlements have grown in Port Moresby, Suva, Honiara, Port Vila, Nuku'alofa andelsewhere, unemployment and underemployment is rising, population pressure is being exertedon an infrastructure constructed for much smaller populations, and unfulfil led aspirations andfrustration often find an outlet in anti-social behaviour, as reflected in rising rates of urban crime and domestic violence. Population densities are especially high in some of the urban centres inMicronesia and the atoll countries, with deleterious consequences for the environment. Even if total fertility rates were to continue to follow their recent downward trend thepresent age structure of the populations of most countries is broad at the base and through thechild bearing years, ensuring that population growth will be sub stantial far into the future. The population pyramids in Figure 1 illustrate the youthfulness of the present populations of Vanuatu, Marshall Islands and Western Samoa, representing the three ethnic divisions in the Region.
Selected Demographic Indicators for 14 Pacific Island Countries, 1995
| Year Last Census | Population | 1995 Est. Pop (000s) | Land Area sq. kms. | Pop per sq km. | Annual Growth Rate of Pop. (%) | Sex Ratio | Crude Birth Rate | Crude Death Rate | Total Fertility Rate (TFR) | Infant Mortality Rate (IMR) | % Pop. <15 | % Pop. 65+ | Dependency Ratio | Life Expectancy at birth in years | % Urban Population | Annual Growth in Urban Population | ||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Male | Female | |||||||||||||||||
| Melanesia | ||||||||||||||||||
| Fiji | 1986 | 715375 | 784 | 18272 | 43 | 1.5 | 103 | 23 | 5 | 2.9 | 13 | 35 | 4 | 62 | 70 | 74 | 41 | 2.4 |
| PNG | 1990 | 3762954 | 4250 | 462243 | 9 | 2.3 | 112 | 34 | 13 | 4.7 | 82 | 42 | 2 | 79 | 51 | 52 | 15 | 4.1 |
| Solomon Is. | 1986 | 285176 | 378 | 27556 | 14 | 3.3 | 108 | 37 | 4 | 5.2 | 46 | 47 | 3 | 90 | 69 | 73 | 17 | 6.4 |
| Vanuatu | 1989 | 142630 | 169 | 11880 | 14 | 2.8 | 106 | 38 | 9 | 5.3 | 58 | 44 | 4 | 90 | 62 | 64 | 18 | 4.9 |
| Micronesia | ||||||||||||||||||
| FSM | 1994 | 105506 | 108 | 701 | 154 | 2.1 | 105 | 33 | 8 | 4.7 | 46 | 44 | 4 | 89 | 64 | 68 | 28 | 4.3 |
| Kiribati | 1990 | 72335 | 82 | 811 | 89 | 2.5 | 98 | 37 | 12 | 4.5 | 65 | 40 | 4 | 79 | 61 | 66 | 36 | 2.7 |
| Marshall Is. | 1988 | 43380 | 55 | 181 | 304 | 3.5 | 105 | 34 | 9 | 5.5 | 63 | 50 | 3 | 113 | 60 | 63 | 69 | 4.0 |
| Nauru | 1983 | 8123 | 11 | 21 | 523 | 2.7 | - | 24 | 5 | 2.7 | 26 | - | - | - | - | - | 100 | 2.7 |
| Palau | 1990 | 15112 | 18 | 494 | 36 | 3.3 | 117 | 22 | 7 | 2.8 | 25 | 30 | 6 | 56 | 67 | 67 | 71 | 2.8 |
| Polynesia | ||||||||||||||||||
| Cook Is. | 1986 | 17455 | 19 | 240 | 79 | 1.1 | 109 | 30 | 6 | 3.7 | 25 | 34 | 8 | 72 | 70 | 70 | 60 | 2.0 |
| Niue | 1994 | 2321 | 2 | 259 | 9 | 1.0 | 100 | 17 | 5 | 3.5 | 12 | 38 | 7 | 82 | - | - | 29 | - |
| Tokelau | 1991 | 1577 | 1 | 10 | - | -6.7 | 96 | - | - | - | - | - | - | - | - | - | - | - |
| Tonga | 1986 | 94649 | 98 | 699 | 140 | 0.6 | 101 | 29 | 6 | 3.5 | 17 | 37 | 6 | 76 | 66 | 70 | 41 | 3.4 |
| Tuvalu | 1991 | 9043 | 10 | 26 | 372 | 1.7 | 100 | 30 | 9 | 3.4 | 41 | 34 | 5 | 64 | 65 | 71 | 46 | 4.0 |
| W. Samoa | 1991 | 161298 | 165 | 3935 | 42 | 0.5 | 110 | 36 | 5 | 4.8 | 22 | 41 | 4 | 82 | 67 | 70 | 21 | 1.7 |
Source: National Censuses, SPC (1995) and UNFPA CST estimates.
Currently, the share of the under 15 years age group in the total population exceeds one-third in all the countries and every 100 persons in the working age groups 15-64 is liable tosupport 50 or more dependents, those aged under 15 and 65 and over . Each of the census reports for these illustrative countries projects the future size and structure of their national populationsunder various fertility and mortality scenarios, including one in which fertility and mortalitycontinue a moderate decline. Ignoring international out-mi gration, (which among these countriesis already important in Samoa, and gaining importance in the Marshall Islands) it is projectedthat Samoa's population would grow by 28% or 2.5% p.a. over the 1991-2001 period; Vanuatu'spopulation would rise by 68% ov er the period 1991-2009 or by 2.6% p.a; and Marshall Islands'growth of population, at the prevailing 1988 demographic rates, would be 94% or 3.9% p.a.during the 17 years 1988 - 2005. Because of the delay of at least 15-20 years in any suchfertility dec line affecting the number of new entrants to the labour force, the projected growth in labour forces over this period far exceeds the growth rate of populations. In the case of theSolomon Islands, the outcome of a scenario with rising life expectancy and moderately decliningfertility suggests that the total population would grow from 28 4 thousand in 1986 to 456thousand, an increase of 61%, by 2001. This corresponds to an annual growth rate of 3.2%, a"best case" scenario. Other countries facing similar potential population growth in the Region include PapuaNew Guinea, Federated States of Micronesia, Nauru, Cook Islands, Tuvalu and Tonga. Theextent to which this potential growth materialises is critically dependent on the future rate of out-migration, particularly in the Micronesian and Polynesian countries, which cannot be foreseenwith any clarity. Meanwhile, planners and policy-makers must be prepared to implement policies andprogrammes which are "population accommodating", necessitating major investments in thehealth and education sectors just to maintain the far from satisfacto ry current provision ofservices. Such rapid population growth will also have major implications for the labour markets of the Region, since the small formal sectors cannot hope to accommodate all the newcomersfrom the education system, particularly when economic growth and employment creation havestagnated for at least the past decade in most countries. The pressure on land will intensify in situations where demarcation disputes overtraditional, communally-owned, unregistered land are growing rapidly in many of the countries. The situation is especially volatile in those countries, such as Cook Isla nds, Niue, Tonga andSamoa, where large numbers of overseas residents return to lay claim to parcels of land. National and household-level food security are also threatened in some cases as locally grown food pricesbecome uncompetitive with less nutritious but cheaper imported processed foods and where tastepatterns have been irrevocably changed. The foreign exchange cost s of imported foods are rising rapidly as populations grow yet, in most cases, export earnings with which to pay for these foodimports fail to respond. "Population influencing" policies need to be far-reaching. To induce change indemographic behaviour without coercion, particularly with regard to fertility and migrationbehaviour, comprehensive and holistic innovative programmes will require f ormulation andimplementation. Rural development may well retard rural to urban and overseas migration; improving the quality and quantity of reproductive health and family planning information andservices can induce couples to employ more effective contraceptive methods to ensure that theirdesired and achieved fertility levels are more in unison; raising t he life-time opportunities of the girl child and improving the status of women in society can go a long way to empowering womento be able to determine their own fertility behaviour; and the creation of a political, social andcultural environment in which the small family norm is widely ac cepted can induce demographic change. In the Pacific Region how do the prevailing set of policies and programmes, be theypopulation accommodating or population-influencing, sit alongside the current and prospectivedemographic situation portrayed above?
Since outright support for family planning interventions is still thought to be highly "sensitive", political commitment for these programmes remains lukewarm in most countries of the Region. No head of state, Prime Minister or senior Ministe r has been known to regularly and forthrightly address population issues in public statements.
All the countries of the Region are strongly Christian societies and various Church denominations, including the Catholic, Anglican and Methodist Churches, have wide networks into the local communities. Many of the churches have their own youth and women's organisations addressing a wide range of development-related concerns, including population issues. Yet, the tremendous potential to play a major advocacy role for population-related programmes has yet to be fully exploited.
There are a multitude of NGOs in the region promoting human resource development and many countries have an IPPF-affiliated Family Planning Association. Some of the better known NGOs include the Foundation of the Peoples of the South Pacific and Sav e the Children Fund which operate in various countries. The Solomon Islands Development Trust (SIDT) has a well-earned reputation for promoting rural development, including programmes on population and HIV/AIDS.
Long time harmonious social conditions, however, are under threat as the traditional social fabric is challenged by modernising influences carried by formally educated youths, latter-day communications systems and visiting family members based overse as. The dominance of Parliament by the nobles in Tonga and the chiefly system elsewhere are under challenge by democratising activists; women's rights movements have grown to press for an improvement in the status of women and a reduction in overt discrimination; and recently educated youth are challenging traditional authority in the home and community. Symptoms of this confrontationbetween the traditional and the modern are found in rising urban shanty towns and concomitant increasing crime rates, particularly in urban Papua New Guinea, Fiji and Solomon Islands; the opening of women's crisis centres to deal more transparently with domestic violence inflicted on wives; significant adolescent fertility in Fiji, Solomon Islands and Marshall Islands as young unmarried girls become sexually active at an earlier age but fail to use a contraceptive method; an increasing number of reported STDs and the threat of an AIDS epidemic especially in PNG; a growing incidence of suicide, particularly among the urban youth of Samoa; evident food insecurity in some rural areas as traditional social safety nets come under threat; and increasing obesity and associated non-communicable diseases as sedentary lifestyles and processed foods replace traditional diets. As population sizes grow and pressure on limited land intensifies, there are increasing cases of challenges to the traditional authori ties over access to land and its uses. In matrilineal societies, such as the Marshall Islands, women's traditional claims to their land are being usurped while, in Fiji, there are frequent disputes between traditional land owners and those who have lease d their land for modern sector uses.
Evidently, not all is well in the seemingly tranquil Pacific Island countries. At the risk of oversimplification, many of these social problems are attributable to the complex and largely unexplored interrelationships between the region's popu lation dynamics and its generally underdeveloped state.
The Economies
Reference has been already made to some of the major obstacles to sustained economic growth encountered by the Pacific Island economies, including their small size, dispersion andisolation, limited natural resources, low level of skills of the work f orce, narrow production base and underdeveloped infrastructure. Their exposure to climate change, particularly tropical cyclones which cause severe damage to crops and infrastructure, and their vulnerability to changes in the terms of trade over which th ey have little control, are severe impediments to economic growth and development. These fundamental constraints to development have neither changed nor been supplanted by new advantages in recent decades.Yet, these island economies enjoy a relatively high level of basic subsistence income without much physical effort due to the bounty of nature. To make good on their limited resources they have been supplied with substantial concessional aid flows by foreign donors andremittances from citizens working overseas. For the 8 countries included in Table 2 official development assistance amounted to almost 27% of GDP during 1980-92, although between - country variation is large. At one extreme, aid amounted to only about 3.3% of GDP in Fiji but, at the other extreme, it amounted to 56% for Kiribati. Thus, other tha n for Fiji, aid has been a major source of development finance. Such flows have permitted consumption levels to be maintained far in excess of what is domestically produced by covering large fiscal and current account deficits, to support large public sector bureaucracies, and the undertaking of major public sector investment programmes. Sound fiscal and monetary management has ensured relative exchange rate stability and low inflation. In spite of these favou rable factors significant economic growth has failed to materialise and has been surpassed by the substantial rate of population growth. As a result per capita income in most countries has stagnated or declined for the last decade and more, as illustrated in Table 2.
The World Bank (1993) has explained this "Pacific Paradox" - low level economic growth despite high levels of foreign resource inflows and high rates of investment - by the nature of such public investment, in long gestating infrastructure and social capital, but also its low efficiency because of both poor choice of projects and weaknesses in implementation.
As donors have been reducing aid flows in recent years, the prospects of realising a significant improvement in the rate of economic growth have dwindled. Evidently the current rate of population growth is not sustainable in the future at prevailing levels of real income.
Without growth in the national economy to generate tax revenues, and with declining sources of donor aid, it will become ever more difficult for Governments in the region to expand both the quantity and quality of social services, particularly health and education, which are, in turn, essential prerequisites for building the human capital base necessary to generate economic growth. In addition, structural changes in the economy, especially relative shifts out of the agricultural sector, often change traditional attitudes and the set of incentives and costs facing the individual household in its decision-making over the number of children to bear. Without further structural changes in these economies, the recent observed trend of declining fertility may well taper off.
It might be argued that recent fertility declines and greater use of modern contraception has occurred mainly among the more educated urban populations. Indeed, everywhere contraceptive prevalence rates are higher and fertility rates lower in urban areas. The greater challenge will come to lower fertility and raise contraceptive use in the more traditional rural areas. While knowledge of contraception is invariably very high in rural Pacific societies, reported adoption rates are still quite low. It seems that, without more intensive economic dynamism and development in these societies, including changes in the role and status of women, the set of incentives necessary to induce behavioural change will be slow moving.
Table 2
Population and Economic Growth Indicators for Selected Pacific Island Countries 1982-92
| GNP per Capita 1993 (US$) | GDP Growth Rate 1983-93 | Population Growth Rate 1983-93 | GDP per Capita Growth Rate 1983-93 | Gross Investment as % GDP 1983-93 | |
|---|---|---|---|---|---|
| Fiji | 2140 | 2.4 | 1.31 | 1.1 | 18.1 |
| FSM | 1554 (a) | 0.8 | 2.71 | -2.1 | - |
| Kiribati | 710 | 0.8 | 2.01 | -1.2 | 31.0 |
| Marshall Is. | 1610(a) | 0.8 | 3.99 | -3.1 | - |
| Solomon Is. | 750 | 3.2 | 3.00 | 0.2 | 30.7 |
| Tonga | 1610 | 2.1 | -0.18 | 2.3 | 30.0 |
| Vanuatu | 1230 | 2.8 | 2.71 | 0.1 | 32.4 |
| W.Samoa | 980 | 1.0 | 0.40 | 0.6 | 32.1 |
This section of the paper summarises the situation in the Pacific region countries vis-a-vis the following areas of concern in the Programme of Action of ICPD:
Population, Sustained Economic Growth, and Sustainable Development
As documented earlier, during the last 10-15 years the rate of population growth has exceeded the rate of economic growth in a majority of the island countries such that per capita income has declined. The lack of structural change, particularly in rural areas, has boosted rural-urban migration, perhaps stimulated by rising levels of education and increased job expectations, such that the speed of urban squatter settlements has become a problem in Port Moresby, Suva, Honiara, Port Vila, Nuku'alofa, Tarawa, Majuro and elsewhere. While absolute poverty and destitution - in the sense of severe malnutrition - is largely absent f rom these countries, there is concern over growing household inequality and relative poverty, including rising income disparities both between urban and rural areas and within urban areas.
The prospects of initiating sustained economic growth and sustainable development in these countries do not appear promising. Environmental degradation is evident in a number of countries. The drive to generate economic growth has led to the unsust ainable depletion of natural resources, particularly fish stocks and forests.
Meanwhile, economic restructuring and reform is curtailing the major source of public sector employment in these countries, with no obvious viable alternative. Income and employment prospects face a major crisis in Cook Islands and Marshall Islands as there is massive downsizing of the public sector. The other countries in Micronesia who also depend on Compacts of Free Association funding face an impending crisis as the end of the compacts draw near. Therefore, it is impossible to be anything but sceptical about the prospects for generating sustained economic growth and sustainable development in the Pacific region in the next decade. New sources of economic growth, including a rejuvenate d rural economy, have yet to emerge. Without economic growth, past advances made in human resources development, including improved health and women's status, will be much more difficult to maintain. As Appendix Table A illustrates, countries with the highest rates of population growth have the lowest per capita income, and perhaps, the poorest prospects for raising income l evels.
Narrowing Income Inequalities
Our knowledge of inter-household and inter-personal income inequality in the Region, which may be a determinant of demographic behavioural differences among socio-economic groups, is quite limited. Recent analysis of income inequality from a 1990-91 survey in Fiji found that between the late 1970s and early 1990s the distribution of income had become more unequal. In 1977, the bottom 20% of households received 5.4% of income per capita and the top 20% realised 43% of income. By 1990-91 these shares were 5% and 54% respectively. Average incomes and the degree of inequality were found to be highest in urb an Fiji and lowest in the villages. Between one-third and one-quarter were located below the nationally determined poverty line. This represents a significant increase in poverty over the estimates for the 1970s. Furthermore, while 9% of all households i n Fiji are headed by women, almost 20% of households with the lowest share of income are headed by women. Again, stagnation in the national economies seems to have damaged the prospects of improving women's economic and income status. Rapid population and labour force growth is likely to intensify future income inequalities and poverty by exerting downward pressure on modern sector real wages and labour productivity in the agricultural sector. Income inequality and poverty is often associated with the lowest income strata in society having high fertility norms, suggesting perhaps that more equal income distributions are needed to induce demographic behavioural changes. On the other hand, "subsistence affluence" in the PICs is believed to have significantly raised the supply price of labour to the modern sector, thus retarding investments in labour-intensive activities which are required to ensure that the p ositive benefits of development are widely dispersed. As the ICPD POA maintains, it is necessary to reduce inequality and poverty in order to lower birth rates. Thus, countries need to intensify efforts to promote rural development in order to diversify the village economy and raise the status of women as a means of inducing fertility decline. Gender Equality, Equity, and the Empowerment of Women The need for women's equality is stressed throughout the Programme of Action, being viewed as an ethically mandated end in itself. The improvement of women's political, social and economic status, and improving women's health, are viewed as essentia l for stabilizing population growth and achieving sustainable development. Women are grossly underrepresented in the political arena in all the countries of the region. Indeed, it was only recently that they received the franchise in Samoa. They have only nominal representation in the Parliaments of the Region and Ministe rial portfolios for women are even rarer. Their economic status, as reflected in their occupational attainments and earnings levels, are distinctly inferior to men. In some Polynesian and Micronesian countries, as reported in Appendix Table A, their recorded rate of labour force participation barely reaches one-third; in Melanesia, where women are more likely to be engaged in subsistence farming, their participation rates are higher.
Yet, we have little documented evidence that women are overtly discriminated against in the labour market. More research is needed on how labour markets operate in these countries, on the perceptions of employers about their work performance and productivity, and why women are largely absent from the higher echelons of the occupational structure.
To address women's issues most of the countries have created a National Women's Council or Association, often with Government financial support, and Governments have mandated an existing Ministry to be responsible for women's affairs. NGOs are often active in promoting women's income generating activities in rural areas.
Great improvements have been made in the area of girls' educational attainment, promising that the current disparity in the rate of literacy between adult men and women, will be narrowed in the future. As reflected in Appendix Table A female school enrolment reaches equality in many countries in primary and secondary school, but girls are more prone to drop out of the higher school streams. They are also disadvantaged in terms of their enrolment in vocational training.
Most of the countries have already met the quantitative goal of the ICPD of attaining universal primary education. Quantitative improvements at the secondary level are also likely to continue. The greatest concern, however, must be over the likely deterioration in the quality of education as public sector budgets come under intense pressure during structural economic reform at the same time as burgeoning numbers of pupils reach school age. In addition, as formal sector employment opportunities stagnate or even contract, there could well be disillusionment with the formal education system, further impeding advancement of the demographic transition.
Health, Reproductive Rights and Reproductive Health
One striking characteristic of health care systems in countries of the Region is the dominance of the public sector in the provision of services, organised typically around a first-line network of clinics and dispensaries that are meant to be referra l points for patients with complications to district or central hospitals. Other than in Papua New Guinea, Fiji, the number of private medical practitioners is negligible. While the public physical infrastructure for providing primary and preventive health care services has been constructed, many of the facilities are poorly maintained and inadequately staffed while the supply of medicines and other materials are often inadequate. Cost recovery rates for services pro vided are amongst the lowest in the world. Efficient health service delivery is impeded by numerous constraints including the geographically isolated populations located on remote islands, the severe shortage of indigenous doctors and trained nurses, gaining access to essential drugs is often difficult, and the knowledge base to promote healthy lifestyles is underdeveloped.
< /p> In many of the island countries the changing lifestyles are presenting health planners and policy makers with a policy dilemma as the "epidemiological transition" is underway. Recent years have seen a shift in the pattern of illness and death in these countries as modernisation and development occurs. Infections, communicable and parasitic diseases, including endemic malaria, are more common in the least developed countries such as Papua New Guinea, Vanuatu and the Solomon Islands who also ex hibit more diseases of infancy and maternal causes. Their higher rates of infant mortality are evidence of this problem. On the other hand, the richer, more developed and urbanised countries such as Fiji, Samoa and Tonga experience a greater incidence of "lifestyle diseases" which are non-communicable, such as heart disease and strokes, cancer, diabetes and accidents. Such diseases are associated with the shift away from traditional diets to imported convenience foods,! often low in nutrition and high in sugar and salt, sedentary lifestyles without much physical exercise, and excessive indulgence in tobacco and alcohol.
The consequence of this dichotomous transitional pattern of change has been the imposition of a major burden on health care resources. As a result a shift has occurred towardsmore expensive, hospital-based curative treatments such that funding for pr eventive and primary health care has suffered. The latter is known to generate more equitable and widespread improvements in infant and adult health via the control of infectious diseases for the great majority of the population, the bulk of whom are rural based. Scarce resources have been diverted to expensive curative care for the more affluent urban minority.
Table 3
Patterns of Health Care Expenditures in a Sample of Pacific Island Economies
| Country | Public Expenditure on Health as % of GNP | Recurrent Health Care Expenditure as a % of Public Expenditure | Curative Health Care Expenditure as a % of Public Expenditure |
|---|---|---|---|
| Cook Islands | 6.2 | n.a. | n.a. |
| FSM | 7.6 | n.a. | n.a. |
| Fiji | 1.7 | 8.0 | 86.7 |
| Kiribati | 5.9 | 14.6 | 80.6 |
| Marshall Is. | 10.0 | 16.4 | 74.7 |
| Niue | 10.6 | n.a. | n.a. |
| Palau | 1.3 | n.a. | n.a. |
| PNG | 9.3 | n.a. | n.a. |
| Samoa | 3.6 | 8.8 | 82.6 |
| Solomon Is. | 3.7 | 6.1 | n.a. |
| Tonga | 3.8 | 10.2 | 81.0 |
| Tuvalu | 5.1 | n.a. | n.a. |
| Vanuatu | 2.4 | 9.3 | 89.2 |
Even more concerns are raised over the sustainability of the health programmes generallywhen set aside current economic retrenchments and spending cuts and prospective populationgrowth. Problems in the delivery of primary health care seem to have multiplied in the region with budgetary cutbacks. Low utilisation rates of peripheral facilities are evident in Kiribati, WesternSamoa, Fiji and Tonga as rural patients bypass local health facilities and directly attend hospitals,often for simple curative care. Accompanying overcrowd ing in hospitals is attributable topatient-perceived gaps in the skills and attitude of nurses and medical assistants staffing the fieldfacilities. Reproductive health and family planning programmes have been constructed in all thecountries of the Region but with only limited success. As portrayed in Table 1 fertility and crudebirth rates remain high, reflecting perhaps, a lack of access to qual ity family planning servicesand a lack of conviction on the part of the population as to the health and livelihood benefits tobe derived from family planning and child spacing. On the other hand, while desired family sizehas no doubt fallen in past yea rs, the desire to bear four and more children is widespread. Nodoubt this is a reflection of the set of incentives facing the typical rural household, including theneed for adequate family farm labour, the benefits to be derived from numerous childre n, some of whom migrate out of the household but continue to contribute to its welfare through regularremittance flows, and in those countries where infant mortality rates continue to be high (Papua New Guinea, Solomon Islands, Vanuatu, Marshall Islands, Kiribati and FSM), the need to replacechildren who are anticipated to die. While demographic and KAP - type surveys have not been widely conducted in thePacific countries, it is believed that the great majority of couples will have received someinformation about contraceptive methods. Initial UNFPA CST analysis of a 1995 K AP surveyin Vanuatu, for example, suggests that 72% of eligible women had heard of family planning and91% of these said they were in favour of family planning; only 24% were currently practisingcontraception, and only 18% of them were using a modern metho d. Yet, 79% of allrespondents claimed to have "easy access" to services in their area. More investigation is needed of thereasons why they were not using the service. Such surveys need to be conducted more often and in more of the island countries iffertility rates are to be induced to decline from their present high levels and RH/FP services areto improve. Information also needs to be generated on the current quality of services providedboth from the providers' and users' perceptions. Indeed, basic information is lacking on the extent of service delivery since the modern contraceptive prevalence rate in most countries isknown only with great uncertainty and is estimated usually from poorly kept service statistics. Such guesstimates vary widely both between and within coun tries, ranging from a high of over 50% in Cook Islands and over 40% in Tuvalu to over 30% in Palau, Marshall Islands and Fiji, to a low of 18% in Vanuatu and only 9% in the Solomon Islands. However, it is worth reiteratingthat all these data are likely to contain a large margin of error, especially when we know withgreater certainty that rates of fertility have been falling, sug gesting greater use of moderncontraception. Family planning services have been integrated into the primary health care programmein most of the countries, but because of the constraints experienced by the front-line rural clinics,it is suspected that the quality of reproductive health service p rovision is low. In addition, therange of contraceptive choice is often extremely limited. Other areas of reproductive health for which information is generally lacking in thePacific is the prevalence of sexually transmitted diseases (STDs) and reproductive tract infections(RTIs). Levels of STDs are believed to be high and increasing, sig nificantly raising the risk ofHIV transmission and hence AIDS. The high prevalence of STDs indicates a fairly high levelof HIV risk behaviour in the region, particularly unprotected sex with several partners, which could easily fuel a future HIV epidemic in the Pacific (United Nations 1996). Indeed, relativeto nearby developed countries, reported rates of gonorrhea and syphilis are high in the region.Gonorrhea is common in Papua New Guinea, Cook Islands, Kiribati, Marshall Islands, SolomonIslands and Vanuatu while syphilis rates are high in Fiji and Marshall Islands. Yet, as with HIV infections, the data available include only cases reported to the Ministry of Health or viewed ingovernment clinics. As these reflect only a small fraction of the total number of STD cases,many others go untreated or self-treated or privately treated. O thers are often treated withtraditional medicine. More research is necessary in this whole area of reproductive health, the unmet need forFP services and the prevalence of STDs and RTIs in order to generate information and data todesign and improve services to address problems of which we hav e little current knowledge. Theoverall impression is, however, that the quality of services, especially on the outer islands and in rural areas, has much room for improvement. Meanwhile, many actors are involved in disseminating information to the general publicon many of the issues. IPPF affiliates are very active in Samoa, Tuvalu, Fiji, Solomon Islands,Tonga and Vanuatu with information campaigns and the provision of so me services while theMinistries of Health utilise their Health Education Units. NGOs are very active in many of thecountries with awareness campaigns and there are usually population-related subjects taught inthe (mainly secondary) school curricula.
The ICPD-POA argues that, if women are to realise their full potential as productivemembers of their communities, they must be able to manage their many roles, includingmotherhood. This means that they must have access to reliable information and qualityreproductive health care, including family planning services. What is the situation in the PacificRegion? Many of the island countries have adopted the primary health care approach of whichreproductive health and family planning is an integral part. However, many of the current RH/FPprogrammes are still very much within the conventional Maternal and Chi ld Health and FamilyPlanning (MCH/FP) framework, focussing mainly on pregnancy care and contraception and employing the pregnancy outcome as the main indicator of women's health. Indeed, MCH/FPservices are often restricted only to married women, an approach which fails to meet the specificneeds of special groups, such as teenagers and women over the age of 4 0. In addition, theconventional programmes hardly do justice to the rising concerns of advocates of RH/FP in therelated areas of reproductive tract infections, sexually transmitted diseases, abortion andinfertility (Lee, 1995). As noted in Table 1 the level of fertility in some of the island countries remains high,exceeding 5 children per women in some cases. While the TFR is a useful aggregate measure,fertility patterns of high reproductive health risk groups need separat e monitoring. For example,adolescent pregnancy is an emerging problem area and deserves special concern since it is associated with curtailed education, impeded job prospects and raised health risks. As AppendixTable A illustrates the share of total births to teenage mothers is quite significant, approaching10% and over, in a number of countries. Yet, without more ca reful research, we cannotdetermine the proportion of these births attributable to unmarried teenagers. Women aged 35 andover also have special needs. Both groups of women exhibit relatively high levels of fertility inMarshall Islands, Solomon Islands, FS M and Vanuatu. Urban-rural differentials among thosegroups are also important. While FP services are everywhere integrated with MCH services, ICPD emphasiseswidening the available choice of contraceptive methods. The range of contraceptive choice isgreatest in Fiji, Marshall Islands and Palau. Other countries do not always of fer subdermalimplants (Norplant), or female or male sterilization. The data in Appendix Table A illustrate thewide differences in contraceptive prevalence between countries and the poor quality of data in some cases leads to the rather imprecise estimates. Reliable CPRs for sexually active teenagers as a measure of their access to RH/FPservices is even more difficult to come by. Among all 15-19 year olds in Marshall Islands in1994 a CPR of 11% was reported, compared with 45% for all adult women (Lee, 1995). On-going analysis at the UNFPA CST of a 1995 KAP survey in Vanuatu shows that only 50% of 15-19 year olds girls had heard of family planning and only 9% were currently using a method. Among 20-24 year olds the corresponding proportions were 70% an d 28% respectively.
A survey on youth carried out in Marshall Islands, Fiji and Western Samoa (Jenkins,1996) found that 58 percent of respondents had ever used a condom. In some Pacific islandcultures, access to reproductive health services by the young is constrained, exemplified inWestern Samoa where more than half the survey respondents claimed it was difficult to obtaincondoms. Yet, Lee (1995) has concluded that a wide choice of contraceptive methods is availablein these countries although there seems to be an over-reliance on a single method, with onemethod accounting for over 40% of all reported users in Solomon Islands, Palau, Tokelau, Vanuatu, Kiribati and Samoa. However, we cannot identify without further in-depth research,the main reasons for the over-reliance on one method. What is evident, however, is thatwidening the choice of methods does not guarantee that women will use contr aception. Evenwhere the supply side of the equation is adequately addressed the demand for family needs to beattended to, including the dissemination of information about the benefits to be derived from asmaller, well-spaced family size via the use of co ntraception. Male participation in family planning is low in the Pacific, being limited to condom use,with some small acceptance of sterilization. The conclusion must be that contraceptive use is still relatively low and may havestagnated in some countries, including Papua New Guinea and Fiji, for reasons which have notbeen fully investigated. Much more research is required in these countri es, starting with basicnational KAP-type studies and increasing in complexity to address issues such as the qualitative assessment of service provision by both users and providers. This would allow programmeplanners to assess the reproductive goals and desires of couples and design interventions to meettheir unmet needs, particularly addressing the special needs of ad olescents and older men and women, especially those in rural areas and on outer islands who are likely to be the mostdisadvantaged. Without such basic information it will be impossible to assess the nature and size of gapsto be filled before the Pacific island countries can meet the qualitative and quantitative targetsof the ICPD-POA. Women's Health and Safe Motherhood
The ICPD-POA agreed on specific numerical goals to be reached by the years 2000, 2005and 2015 in promoting women's health and safe motherhood. All countries are charged withreducing maternal morbidity and mortality to "levels where they no longer co nstitute a publichealth problem". Disparities in maternal illness and death rates should be narrowed both betweencountries and within countries between socio-economic groups. The use of the maternal mortality rate as the principal health indicator has seriousproblems in the Pacific context. As already noted vital registration systems are grosslyinadequate in the island countries. Deaths in general, and maternal and othe r cause-specificdeaths in particular, are under-reported because of the underdeveloped state of the civilregistration system, particularly in Papua New Guinea, Vanuatu and the Solomon Islands. More generally, because of the small size of these countries, and despite the relatively high fertilityrates, the annual number of births occurring in many countries is very small, or lower than 1000. Therefore, a maternal death is an even more rare event for which random variation candramatically raise the calculated maternal mortality rate (MMR) in a particular year. Appendix Table A reports the recently recorded MMRs for the countries of the region. For the reasons stated above these data should be interpreted with caution. Compared with thereported MMRs for UNDP's "Low" and "Medium" Human Develop ment countries of 590 and170 per 100,000 live births respectively, the Pacific island countries perform relatively well (UNDP, 1993). Even compared with the MMR of "High" Human Development countries of 120,these island countries do quite well. In this case the ICPD quantitative goals of achieving anMMR of below 60 by the year 2000 seems entirely feasible. Pre-natal care coverage ranges from 52% in Tokelau to 100% in Fiji, Cook Islands, Niue,Palau and Tuvalu (Lee, 1995). Reported rates of delivery by health personnel are high in manyof the countries, but low in Kiribati, Vanuatu and Solomon Islands. However, the reported ratesin Appendix Table A are likely to be urban-biased and exaggerated. Women residing in rural areas and on outer islands are very likely to be without maternal care and to have beenoverlooked in these data. The ICPD-POA sets a goal for all countries to achieve an infant mortality rate (IMR) ofbelow 35 per 1000 live births by 2015. Table 1 and Appendix Table A show that this objectiveis entirely feasible in the island countries, given the current respec table levels compared with the1991 levels of 96 and 42 in "Low" and "Medium" Human Development countries. Again,countries in Melanesia where malaria is endemic have the most ground to make up. Currently reported levels of female life expectancy in Table 1 and Appendix Table A inthe island countries are relatively high and made significant progress in recent years. There isevery chance that a life expectancy at birth of at least 75 years c an be achieved by 2015, in orderto meet the ICPD target. One concern in the Pacific region is the high rate of sexually transmitted diseases (STDs)which adversely affects women's reproductive health. They are also an important indicator ofhigh-risk sexual behaviour and the potential danger of an HI V/AIDS epidemic in these countries. As reported in Appendix Table A the incidence rates for gonorrhea in Papua New Guinea, FSM, Fiji, Kiribati and Vanuatu raise concern while syphilis rates for Papua New Guinea, MarshallIslands, Fiji and Solomon Islands are at least four times greater than that in Australia (15 per100,000). Lee (1995) summarises the status of each island country in the main areas of reproductivehealth and family planning and her table is reproduced as Appendix Table B. While the attainedCPRs are still quite low it is anticipated that the large and grow ing young age groups in thepopulation will raise the demand for RH/FP services. However, success in expanding thedemand for FP services will crucially depend on better quality of service provision via an increased number of well-stocked clinics with well-trained, sympathetic service providers. Thiswill inevitably raise the demand for budgetary allocations at a time when health budgets havebeen declining in these countries. In order to increase the financial allocations for population programmes greater politicalcommitment is essential. Without it, the profile of population programmes will remain fairly lowand, at the same time as donor support is being curtaile d and the domestic economies arestagnating, these programmes will suffer. Population Policies
The ICPD POA underlines the importance of dealing with population-related problemsin an integrated fashion. Economic restructuring to promote sustainable growth, innovativedevelopment strategies and population policies are not dichotomous options but integral partsof an essential comprehensive strategy to address profound development problems. As the ICPD POA states:
| "At the international, regional, national and local levels, population issues should be integrated into the formulation, implementation, monitoring and evaluation of all policies and programmes relating to sustainable development. Development strategies must realistically reflect the short-, medium- and long-term implications of, and consequences for, population dynamics as well as patterns of production and consumption.... Governments should establish the requisite internal institutional mechanisms and enabling environment, at all levels of society, to ensure that population factors are appropriately addressed within the decision-making and administrative processes of all relevant government agencies responsible for economic, environmental and social policies and programmes... Political commitment to integrated population and development strategies should be strengthened by public education and information programmes and by increased resource allocation through cooperation among Governments, non-governmental organizations and the private sector, and by improvement of the knowledge base through research and national and local capacity building" (ICPD POA, 1994, para. 3.5, 3.7, 3.8). |
Many of the countries of the Region have formulated explicit population policies in therecent past while others are currently in the process of revising policies. A status appraisal of thissituation is portrayed in Table 4 for all the countries, exc luding Tokelau. Table 4
Status of Population Policy in the Countries of the South Pacific
| Country | Status of Population Policy | Principal Demographic Concerns |
|---|---|---|
| Cook Islands | None | - |
| Fiji | Implicit Policy in Development Plan | Limit population growth |
| Kiribati | In preparation | - |
| Marshall Islands | Revised and Endorsed | Lower fertility |
| FSM | To be revised | Reduce fertility: health oriented improvements |
| Nauru | None | - |
| Niue | In preparation | To promote return migation and repopulate |
| Palau | In preparation | Reduce out-migration |
| PNG | Policy exists but implementation poor | Lower fertility, reduce urbanisation |
| Samoa | In preparation | - |
| Solomon Islands | Revision in preparation | Lower fertility |
| Tonga | In preparation | - |
| Tuvalu | In preparationn | Lower fertility; reduce urbanisation |
| Vanuatu | In preparation | - |
More recently, a new more holistic and comprehensive approach has been takenthroughout the Region which is beginning to produce very positive results. Under the auspeciesof the UNFPA, and its CST, population awareness-raising workshops and seminars have beenorganised in various countries including Kiribati, Marshall Islands, Solomon Islands, Tonga and Tuvalu and informal sessions have been held in FSM, Kiribati, Niue, Palau and Vanuatu. Suchmeetings have served important purposes in initiating the complex process of designing anational population policy and programme and of helping to identify the nat ure of population-related problems, formulating broad-based strategies to address them, and establishing theinstitutional and other requirements for drafting formal population policies. As a result many of the countries are now preparing to draft policy statements to be endorsed by the politicalleadership. These include Kiribati, Niue, Palau, Samoa, Tonga and Tuvalu while others, RMI,FSM and Solomons, have identified the need to revise their existing policy statements. In some cases a formal institutional structure or Population Focal Point has beenidentified to coordinate and monitor the implementation of the policy. In the Marshall Islandsa National Population Council has been convened, comprising of senior civi l servants and NGOrepresentatives and which is served by a more technical multi-sectoral National Population Policy Coordination Committee. This Committee has its Secretariat in the form of a Population FocalPoint in the Office of Planning and Statistics. A UNFPA project has provided financial andtechnical support to this structure by way of training and national capa city building for thePopulation Focal Point. Despite the severe financial and human resource constraints in the Marshall Islands,including the dearth of officials with any technical background in population and developmentplanning, much progress has been made in raising political commitment and formalising theinstitutional structure for monitoring the population programme. Indeed this approach couldwell be the model to be adopted in those countries which are about to embark on implementing a population programme. Its major benefit is t hat a comprehensive programming approach canbe readily adopted rather than the ad hoc, sectoral approach which has been elsewhere in vogueto date.
Much more effort will also be required to assist countries design integrated and consistentpolicy implementation plans for their population programmes. Past experience has been that theprincipal interventions in these programmes have been uncoordina ted. For example, in simpleterms, demand creators for FP services have been out of unison with the providers of services. Gender issues have either been neglected or have not been perceived as central to the planningand implementation of the national prog ramme. PDS and PAIEC strategies for the UNFPACycle need to address the area of policy coordination and implementation and create and supportthose institutions responsible for implementing the national population programme, which should be seen as a key and integral part of the process of identifying and implementing nationaldevelopment goals and policies. Meanwhile, much of the binding of the various strands of society to convert disparateprojects into a national programme is the task of PAIEC. Implementation and the focus offinancial support are largely in the domain of RH/FP-SH. But we are wedded to the UNFPA view that the synergy created by the coexistence of all core programme areas, together with thecrosscutting elements, including effective information systems and concern for gender equality,is essential for the success of the regional Programme. Thus, we again stress our belief that anefficient programme in a high priority country must involve substantive (though not necessarily expensive) investment in each of the sectors. Population and Development Strategies
As illustrated earlier the ICPD POA fully recognises that a regional or country populationprogramme must be viewed as an integral part of a holistic and comprehensive developmentstrategy. While formal, explicit population policies are not considered essential, UNFPA shouldassist national governments to draft or revise such policies where they request assistance. Indeed,the PROCESS of developing a population policy is viewed by the authors as much moreimportant than the finished document since it is this process that should promote the importantpolicy dialogue between political and traditional leaders, policy-makers and planners, the mediaand the ordinary citizenry. The building of political and community commitment to implement key population policy goals and objectives - including RH/FP goals and government commitmentto the programme's resource implications - via this process of awareness-raising and policy-dialogue should continue to be a key programme strategy. Given its rece nt success in stimulatingsuch a dialogue in a few countries the UNFPA CST should be encouraged to continue this process.
UNFPA should persist in promoting awareness-raising through the sponsorship ofnational and local-level awareness raising seminars and workshops. In addition, the UNFPACST has a comparative advantage in being able to provide region-wide technical tra ining to acadre of planners in techniques of population integration. Such training could be provided via one or two regional training workshops demonstrating the practical use of various softwares tobe followed by two to three annual CST missions to a select group of priority countries to workon important sectoral planning problems in which demographic proje ctions are explicitly accounted for in these exercises. Attachment training of national planners at the CST Office inSuva could also be employed as a training device.
Thus, UNFPA CST provision of such technical assistance in the areas of programmecoordination, advocacy, awareness raising, policy development and revisions, and more technicalwork at the regional and country level in population integration, is viewed as a strategiccomponent of a holistic and multidisciplinary approach to programme implementation. Research, Data Collection and Analysis The Prevailing Situation To implement policies and programmes to influence demographic outcomes (populationinfluencing policies - reproductive health/family planning programmes, IEC/FLE, raisingwomen's status including education etc.) or to accommodate increasing numbers of people(population accommodating policies - increased health and education services, employment opportunities, food provision etc) an essential prerequisite is a sound research and database. Such data should be timely and current, reliable, divisible by gender, geographic area and socio-economic group, and amenable to in-depth analysis. To be utili sed effectively in policyformulation and planning exercises it is inadequate simply to collect demographic data, e.g. point estimates of fertility, mortality and migration. To explain inter-geographic area or inter-socio-economic status differentials in behavioural patterns is the raison d'etre of the study of population-development interrelationships. Thus, such demographic data must be accompaniedby information on the socio-economic variables relating to the same unit of observation. Suchhousehold-based data must include:
Civil Registration: Since this provides the most basic information for monitoringchanges in the health and demographic situation, it is essential that coverage be improved. Inmany of the Micronesian and Polynesian countries where coverage is already reasonably high,such as in Tonga or Samoa, it should be feasible to extend it. What is required is the political will to create viable systems and the willing cooperation of agencies who could make them work. In many of these countries, village chiefs or councils, women's groups, district education andhealth staff, police, NGOs, Churches and other groups could all b e involved in encouraging theregistration of births, deaths and marriages. With a strong commitment, a series of national and district seminars would be required to provide information on how the system might work. Insome cases, modifications to the basic system might be required, but these would be slight. Thekey is commitment and involvement at the grassroots level.
For countries in Melanesia with virtually no registration systems, the same involvementat the grassroots is essential, but the achievement of full coverage is more ambitious. Costswould be far higher as the administrative and legal machinery would n eed to be established orstrengthened. The strategy in these cases might be to focus on a few sample areas at the outset. These experiments would help to identify the more important constraints or influences onimproving registration. In time they would s erve to demonstrate the requirements for success ofthe system as it is extended to other areas.
Migration, Health and Other Administrative Records: Users need to recognise thepotential usefulness of these records and the relative ease with which they might be compiled intostatistics. National statistical offices need to work with the s ubstantive agency in improving baserecord systems, including forms and information flows. In many cases it might be possible tonetwork processing systems to transfer raw or processed data directly to the statistics offices for further processing and publication. Population Censuses: Further encouragement is needed to promote national capabilitiesin the skilled areas of design, mapping, data processing and analysis. The key is training in-country where it is feasible, overseas where it is not. Great er interaction is required between producers and users of data, formally at seminars, less formally in open discussion, of what isneeded and how it can be produced. Sample Surveys: These are almost certainly grossly under-utilised in the Region. Theycan potentially help to explain more complex behaviour related to family formation andmigration than any other source. Recent experience in other countries has shown that evenrelatively small samples can produce valuable results, so long as the methodology is sound, andtraining is appropriate and field control is effective. They also require far closer cooperationbetween statisticians and users in defining the scope of a survey and in guiding the analysis. Technical requirements for designing, selecting and controlling samples are more demandingand require special training. The technical assistance that might be needed to develop surveycapabilities might justify a regional rather than country approach to survey taking.
With shift in emphasis to reproductive health services, which include family planning,it becomes important to evaluate the quality and quantity of such services. What better way todo this than to select random samples of both service users - adolesc ents and adults, males andfemales - and providers in order to gauge their perceptions of the adequacy of present servicesand how they might be improved? Such an approach has yet to be employed in the Pacific. Gender Issues: As the concerns for women's status become more widespread there isa growing demand for gender sensitive statistics that reflect changing situations and roles. Unfortunately, in many Pacific island countries there is a dearth of relevant data. Whilepopulation censuses and surveys can be more fully tabulated to provide information by sex for all major variables, the statistical offices have been accused of a lack of urgency in developingnew statistical instruments to address issues of critical concern to women. Thus, data relatingto the perceptions of women as victims of crime and aggression , combatting stereotype attitudes to changing roles at home and in the work place, are for the most part non-existent. Surely, if acompleted demographic transition in the South Pacific is to be promoted and realised, we mustknow much more about the roles and activities of women. Such information is the fundamentalprerequisite for designing policies to redress their inferior situation and to raise their status. Again, this deficit should be addressed in the near future to meet the goals of the ICPD POA. Population Advocacy, Information, Education and Communication (PAIEC) To reiterate once again, there is an urgent need to provide awareness and orientationprogrammes for political, cultural and religious leaders via a strategy to utilise themultidisciplinary composition of the UNFPA CST. In addition, numerous activiti es are requiredto support a training strategy in population education including the various types of courses forpre- and in-service teachers and curriculum developers. Another strategy calls for support to the establishment and functioning of inter-departmental and NGO PAIEC coordinating committees where experiences and materials areexchanged and properly planned. Pleas must be made to ensure technical and financi al supportto separate population education sections in curriculum development units, responsible forintegrating population education in educational and communication programmes. There needsto be greater targeting of audience groups - men, youths and adol escents - to provide greaterinformation about RH/FP and to encourage more responsible behaviour. In the field of population education, new areas must be included in the curricula such assexuality education, HIV/AIDS and the environment. And a strategy to promote research andevaluation of population education in both the formal and informal secto rs is recommended. In particular, PAIEC strategies must be formulated to help improve RH/FP services by:
Social indicators provide a mixed story, exceeding expectations in many of the smallercountries at their stage of development, but emphasising the uncertainties and developmentproblems for the larger Melanesian countries. Yet during recent years, th roughout the sub-region,improvements in life expectancy, health and education reveal how much progress has been made. However, the road ahead presents new and profound challenges. Success in promoting familyplanning and the use of contraception has been achieved by persuading the urban, more educatedresidents to change their demographic behaviour. The greatest challen ge lies ahead in convincing rural couples that it is in their best interest to bear fewer, well-spaced children, concepts whichmay not be obvious in a largely agricultural-based, household economy. New and innovativemethods are needed to disseminate the population message via t he influential traditionalleadership and churches who, perhaps have not been fully utilised in the past but who are heldin great esteem by the local populace. Improvements in the provision of quality services,particularly in rural areas are required to f acilitate this process.
New population-related problems are also presenting themselves in the form of risingrates of adolescent fertility, sexually transmitted diseases entailing the ever-present threat of anHIV/AIDS epidemic, and disenchantment with local, rural-based clin ics and health facilities. Rural-urban migration continues unabated and immense pressure is being exerted on urban infrastructure, the job market and the environment. As traditional authority breaks down thereis concern over rising substance abuse, crime, domestic violence and suicide in some countries. These challenges require innovative population-accommodating and population-influencing policies to be incorporated into comprehensive national population and development policies and programmes. Such policies need to go hand-in-hand with deta iled implementationplans which have yet to be formulated in most of the island countries. These should entail a detailed accounting of the financial and human resource costs of implementing the policies,including the resource requirements for meeting the goals and targets of the ICPD-POA,particularly those relating to new interventions in the sector of reproductive health. Anyway the greatest challenges will be to fully integrate population issues into thedevelopment planning process, particularly at the grass-roots level, at a time when nationaldevelopment policy options are quite limited and when public sector budgets are under intensepressure as rates of economic growth have been disappointing and donor support declining. The challenge to donors, including UNFPA, will be to ensure that past achievements aremaintained and the quality of life of Pacific Islanders continues to progress.
Katoanga, S (1996), Reproductive Health and Family Planning, Thematic Consolidated Report,UNFPA Country Support Team, Suva Kondo, A. and Paramanathan, K. (1996), A Review of the PAIEC Sector in the South Pacific, Thematic Consolidated Report, UNFPA Country Support Team, Suva Lee, Sun-Hee (1995), Reproductive Health and Family Planning in the Pacific: CurrentSituation and the Way Forward, UNFPA CST Discussion Paper No. 14 P.T. Insetra Konsultana, (1995), The Solomon Islands Population and Development Programme,1995-2000, Final Report to the Government of the Solomon Islands and Asian DevelopmentBank, Manila South Pacific Commission (1995), Demographic Estimates for Asian and Pacific Countries and Areas, Noumea
Taverner (1990), Results of the Household Income and Expenditure Survey in the Federated States of Micronesia 1988-1989: Final Report, UNDP Project TTP/86/203, mimeographed UNDP (1993), Human Development Report, 1993, New York United Nations (1994), Population and Development: Programme of Action Adopted at theInternational Conference on Population and Development, New York UNDP (1994), Pacific Human Development Report, Suva United Nations (1996), Time to Act: The Pacific Response to HIV and AIDS, Suva United Nations (1996), A Revised Approach for the Allocation of UNFPA Resources to Country Programmes, UNPFA, New York World Bank (1992), Pacific Regional Post-Secondary Education Study, Washington, D.C. World Bank (1993), Pacific Island Economies: Toward Efficient and Sustainable Growth,Vol.1, Overview, Washington, D.C.
Development Indicators in the South Pacific Islands Countries
| GDP per capita US$ | (%) share of Women in Labour force | Literacy | Rate (%) | Primary School Enrolment (%) | % Who are Females | Life Expectancy | at Birth | Infant Mortality Rate (IMR) | Maternal Mortality Rate per 100,000 births | Contraceptive Prevalence Rate (%) CPR | Reliance on One Method (% of Users) | % Share of Teenage Births in Total | % Attended Delivery | Incidence per | Rates 100,000 | Access to Safe Water % of Pop. | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Male | Female | Male | Female | Gonorrhea | Syphilis | ||||||||||||
| Cook Is. | 3416 | - | 99 | 99 | - | - | 70 | 70 | 25 | 46 | 47-50 | Pill(62) | 18(1991) | 99 | 42('92) | 0('92) | - |
| FSM | 1474 | 28 | 83 | 79 | 93 | 48 | 64 | 48 | 46 | 83 | 25 | Ster-F(37) | 13(1993) | 90 | 160('91) | 0('91) | - |
| Fiji | 1991 | 21 | 90 | 84 | 125 | 47 | 70 | 74 | 13 | 68 | 36 | Pill(26) | - | 98 | 152('92) | 75('92) | 79 |
| Kiribati | 461 | 46 | 94 | 92 | 84 | 49 | 61 | 66 | 65 | 127 | 26 | Injec (40) | 6(1990) | 59 | 164('91) | - | 73 |
| Marshall Is. | 4576 | 27 | 91 | 90 | 97 | 49 | 60 | 63 | 63 | 109 | 37 | Ster-F(41) | 21(1994) | 87 | 80('92) | 123('92) | - |
| Nauru | - | - | 90 | 89 | - | - | - | - | 26 | - | - | - | - | - | - | - | - |
| Niue | 3051 | - | 99 | 99 | - | - | - | - | 12 | 0 | 24 | Pill(11) | 9(1994) | 99 | - | - | - |
| Palau | 3289 | - | 98 | 97 | - | - | 67 | 67 | 25 | 267 | 38 | Pill(69) | 9(1994) | 99 | - | - | - |
| PNG | 1120 | 41.5 | 65 | 39 | 73 | 48 | 56 | 58 | 65 | 800 | 33 | n.a. | n.a. | 50 | 331('91) | 97('91) | 23 |
| Solomon Is. | 529 | 25 | 27 | 17 | 103 | 44 | 69 | 73 | 46 | 549 | 11-35 | Injec(72) | - | 87 | 120('92) | 62('88) | 61 |
| Tokelau | - | - | 99 | 98 | - | - | - | - | - | - | 9 | Injec(63) | 2(1994) | 100 | - | - | - |
| Tonga | 1396 | 21 | 99 | 99 | 133 | 47 | 66 | 70 | 17 | 70-80 | 39 | Injec(32) | 4(1994) | 92 | 39('91) | - | 96 |
| Tuvalu | 1068 | - | 99 | 99 | - | - | 65 | 71 | 41 | 0 | 45 | Injec(18) | 4(1994) | 100 | - | 13('89) | - |
| Vanuatu | 1020 | 47 | 68 | 60 | 94 | 47 | 62 | 64 | 58 | 92-138 | 15-25 | Pill(57) | 7(1993) | 75 | 182('92) | 1('88) | 61 |
| W. Samoa | 722 | 19 | 98 | 98 | 99 | 49 | 67 | 70 | 22 | 50 | 31 | Injec(47) | 5(1994) | 76 | 69('92) | 0('89) | 69 |
Source: World Bank (1993), SPC (1993), Lee (1995) and UNFPA CST estimates
Summary of RH/FP Situation in the Pacific Island Countries
| Country |
| High Teen fert. | High fert. women 40-49 | Low contraceptive use | Little change in contraceptive use | Available method limited | Over reliance on single method | Low male parti- cipation |
Low prenatal coverage | Low attended delivery | High MMR | Anaemia | High IMR (40+) | Low Birth Weight | High abortion | Chly- media |
Gono- rrheoa |
Syph- ilis |
|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Cook Is. | x | x | x | x | |||||||||||||
| FSM | x | x | x | x | x | x | x | ||||||||||
| Fiji | x | x | x | x | |||||||||||||
| Kiribati | x | x | x | x | x | ||||||||||||
| Marshall Is. | x | x | x | x | x | x | x | x | |||||||||
| Nauru | x | x | |||||||||||||||
| Niue | x | x | x | x | |||||||||||||
| Palau | x | x | |||||||||||||||
| PNG | x | x | x | x | x | x | x | x | x | x | x | ||||||
| Solomon Is. | x | x | x | x | x | x | x | ||||||||||
| Tokelau | x | x | x | x | x | ||||||||||||
| Tonga | x | x | x | ||||||||||||||
| Tuvalu | x | x | |||||||||||||||
| Vanuatu | x | x | x | x | x | x | x | x | x | x | |||||||
| W. Samoa | x | x | x | x |