UNFPA COUNTRY SUPPORT TEAM Office for the South PacificDiscussion Paper No. 18 |
William J. House
Adviser on Population Policies and Development Strategies
Introduction*
The total population of the Pacific island countries amounts to about 7 million persons. By world standards the absolute number is relatively small, but critical demographic factors, such as the rate of growth, distribution patterns, and migration and urbanisation, all have a direct impact on the potential for realising sustainable development and rising living standards in these islands. While investment in human capital, physical infrastructure and productive capacity are the key ingredients for attaining social and economic development, and has been quite respectable due to the scale of international donor support, significant population growth in some of these countries is adversely impacting on their potential for realising rising welfare levels for their citizens.
While rapid population growth in excess of, say 2% per annum, need not be a cause for concern if accompanied by commensurate levels of economic growth, in the Pacific island countries, with less than dynamic economies, high rates of population growth may result in declining or stagnating levels of gross domestic product (GDP) per capita and deteriorating social indicators. Indeed, evidence is emerging of growing poverty, environmental degradation, rapid urbanization and rising social problems that all reflect the consequences of high population growth (House and Lewis, 1998).
While health conditions have improved significantly due to a reduction in communicable diseases via improved water, sanitation and health services, some vulnerable groups suffer from high mortality risks. Where fertility remains high, in some Melanesian and Micronesian countries the total fertility rate is at least 4.5 children per woman, infant mortality rates exceed 40 per 1000 live births, an unacceptable situation. Maternal morbidity and mortality are also relatively high in these countries, especially in Papua New Guinea, where the rate of maternal mortality is 370 per 100,000 live births (PNG, 1997). No doubt, such mortality scenarios are often attributable to high parity, short birth intervals and pregnancy occurring to adolescents and to women over the age of 35 years. And malaria remains endemic in Papua New Guinea, Vanuatu and the Solomon Islands.
The result is that, for the Pacific region as a whole, influenced largely by PNG, the current annual rate of population growth is about 2.3%. In Polynesia, while natural growth rates exceed 2.5% per annum, large scale out-migration has reduced the realised inter-censal annual growth rates to less than 1%. Out-migration from Cook Islands, Niue, Samoa and Tonga to New Zealand, 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 the export of goods and services. Yet, as New Zealand and Australian immigration authorities tighten the conditions of entry for Tongans and Samoans, the mother countries are vulnerable in a 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 of out-migrants. After the political events of 1987 Fiji also lost, and continues to lose, some of its brightest and ablest citizens, mainly people of ethnic Indian origin.
Under the terms of the Compacts of Free Association with the United States signed by the Federated States of Micronesia, Marshall Islands and Palau since attaining independence in the 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 their countries of skilled labour. Palau has experienced a significant inflow of alien labour, mainly from the Philippines, to fill the skill gaps. Meanwhile, so far Marshall Islanders seem not to have out-migrated in significant numbers. However, as the national economy is depressed and experiencing major retrenchments in public service employment, it is likely that many more Marshallese will leave densely populated Majuro and Ebeye in search of greener pastures. They may also seek to leave before the expiry of the Compact in 2001, after which their current access to the US may be curtailed.
Urban populations are also rising in most of the Pacific Island countries. In some of them (Fiji, Kiribati, Marshall Islands, Nauru, Palau, Cook Islands, Tonga and Tuvalu) already one-third or more of the population lives in urban areas with rates of urbanisation far exceeding the 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 of primary and secondary school enrolments in education systems following largely developed country curricula. The consequences are that rural areas and outer islands have lost some of their ablest 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 and elsewhere, unemployment and underemployment is rising, population pressure is being exerted on an infrastructure constructed for much smaller populations, and unfulfilled aspirations and frustration 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 in Micronesia and the atoll countries, with deleterious consequences for the environment.
Even if total fertility rates were to continue to follow their recent downward trend the present age structure of the populations of most countries is broad at the base and through the child bearing years, ensuring that population growth will be substantial far into the future.
Against this background, the island countries were among the strongest supporters of the International Conference on Population and Development (ICPD), held in Cairo in 1994, and its Programme of Action (POA). Some had developed population policies aimed to address some of their demographic-related problems in the period before 1994. Since then a smaller number have begun to revise their policies to reflect the paradigm shift in population concerns contained in the Conference declarations.
The purpose of this paper is to reflect on the nature and content of population policies, worldwide, pre-Cairo, and to draw lessons from these experiences for the Pacific island countries. What were the principal objectives of these policies and how successfully were they implemented? The paper goes on to examine the challenge created for national population policies in the period since the ICPD in their attempts to incorporate the broader concerns with reproductive health, beyond family planning, into their policies. The Pacific island country experiences with population policy formulation and implementation are documented and suggestions are made as to how the commendable goals of the Cairo Conference could be addressed by the newer vintage of population policies in the island countries.
Population Policy: Theory and PracticePre-ICPD 1994
In the period leading up to the International Conference on Population and Development (ICPD), "population policy" might well have been defined as:
| "A deliberate attempt by government to influence one or more of the key demographic parameters, fertility, mortality and migration" (Isaacs, Cairns and Heckel, 1991). |
In theory, such an effort at social engineering might be attempted through a whole range of direct and indirect policy interventions which could impact on the demographic objectives of the government in a desirable way. For example, nutrition and health improvements could be expected to raise life expectancy and lower mortality, especially infant and child mortality; industrial, infrastructural and locational policies might be expected to change the set of constraints and incentives facing entrepreneurs and individuals and help to determine where they locate their businesses and families; and patterns of fertility could be influenced by efforts to change desired family size (through population education and information, education and communications interventions) and the establishment of family planning services to meet the contraceptive needs of individuals and couples wishing to space or limit the size of their families.
In practice, however, a specific fertility goal – especially reduced fertility in order to lower the national population growth rate – invariably became the prime objective of early national population policies. Indeed, rapid population growth continues to be viewed by many political leaders and academics around the world as a serious impediment to the realisation of the goal of socio-economic and sustainable development and a national population policy has often evolved as a response to such conceived constraints. Such a reduced national population growth rate has become the overriding concern of many population policies. After early warnings from academics, a few politicians and otherwise concerned citizens about the likely deleterious consequences of rapid population increase for achieving socio-economic development, it often took years for a national population policy to be officially adopted and effectively implemented because key senior Government officials, principally the head of state or head of government, remained unconvinced.
Yet, Ibrahim and Ibrahim (1998) for Egypt, Visaria and Chari (1998) for India and Ajayi and Kekovole (1998) for Kenya have narrated how, even after the adoption of formal population policies, their effective implementation depended heavily on key political figures – Presidents and Prime Ministers – first becoming convinced that population growth presented a constraint on national development and then becoming pro-active to promote the implementation of the policy.
Thus, in a traditional, pro-natalist cultural environment, the launching of an anti-natalist, ‘top-down’ population policy took much courage and political conviction (Jain, 1998). Meanwhile, religious leaders, nationalists and traditionalists often could be relied upon to voice fierce opposition. The rationale for the policy was sometimes explained in terms of the aggregate benefits for the nation from having a lower dependency ratio, with a concomitant reduction in the need to cater for an ever-growing population demanding social services including education, health services and jobs. Such social investment could then be redirected to improve the quality of such services already provided as well as to raise the rate of economic growth via investment in directly productive activities. The health benefits accruing to the individual family, particularly the mother and her children, from better spacing of pregnancies and reducing the number of births, were highlighted as a means of rationalising the use of contraceptives and family planning.
Because of the emphasis given to the goal of reducing the national population growth rate, population policies invariably became identified with the provision of family planning services and responsibility for implementation vested in Ministries of Health. These policies, in turn, were ‘sold’ to a suspicious and skeptical public as part of a Maternal and Child Health (MCH) programme, whereby the use of contraceptives to space children – but not necessarily to limit childbearing – would have beneficial effects for the health of mothers and their children. Yet, couples who maintain strong desires to produce large families are unlikely to adopt family planning methods despite their ample provision. Thus, population policies incorporated activities to change family size attitudes through information dissemination to the public at large, stressing the health and economic benefits to the family from the adoption of family planning. The introduction of a population education syllabus in schools also attempted to form smaller-size family norms in children at an impressionable age. Trade unions, cooperatives, workplaces and women’s groups became the targets of IEC activities in many countries.
Meanwhile, progress in economic development, as reflected by such social indicators, as increased literacy, higher school enrolment rates, particularly for girls, resulting in a delayed age at first marriage, urbanisation, greater diversification in employment opportunities, again particularly for girls – as well as declining infant mortality and rising household incomes, all contributed to lowering desired family size and the greater likelihood of couples adopting family planning methods, especially the use of modern and effective contraceptives.
Much has been written about the relative importance of family planning service provision versus improvements in these development indicators in inducing a demographic transition and fertility decline (Mauldin and Ross, 1991; Pritchett, 1994 a and b; Knowles, Akin and Guilkey, 1994). We would argue that attributing the demographic transition solely to either family planning programmes or to socio-economic development is a pointless and trivial exercise. The shaping of fertility goals and the decision to adopt family planning and the use of contraceptives are highly complex human decisions and depend on a multitude of closely interrelated social, cultural and economic influences. Attempting to unravel the relative strength of demand and supply-side factors is a fruitless task.
The effective implementation of a comprehensive population policy, incorporating the priority objective of lowering fertility and reducing the national rate of population growth, clearly depends on successfully constructing an efficient family planning programme as well as making progress in many of the indicators of development that would serve as instruments to induce a change in the demand for children. For the effective implementation of such a broad-based policy, a government would need to mobilise a multi-sectoral, cross-ministerial, integrated population programme that would incorporate many of the essential policy instruments to be utilised to attain the desired national demographic goal. Worldwide, such integration and coordination in policy implementation has been extremely rare.
Indeed, nowhere has population policy implementation ever commanded such a high-profile campaign-like adherence across ministries and sectors, as well as involving some of the actors in civil society, such as NGOs. Perhaps a cause and a consequence of this non-collaboration has been the manner in which population-related issues have been conceived as the sole responsibility of the Ministry of Health or, in particular, of a vertically constructed, stand-alone family planning programme in the national Health Ministry. Yet, Governments have often attempted to create multi-sectoral National Coordinating Committees and at a higher level of seniority, National Population Councils, made up of Cabinet Ministers and/or Permanent Secretaries or their equivalents as Departmental Heads, to oversee and give direction to the implementation of the population policy. However, representatives of the Ministry of Finance, holding the purse-strings of any policy implementation plan, have been frequently overlooked as members of such coordinating bodies. The result has been that the Councils or Committees became ‘talking-shops’ and lacked the necessary teeth and spending authority to effectively implement the policy. Nor has membership of these coordinating bodies been at a consistently senior level to influence the patterns of investment in other ministries and sectors, which would have promoted the attainment of the goals of the population policy. Indeed, only if population policy were being implemented and monitored at the Cabinet level of Government could such intersectoral coordination of expenditure patterns have been realised. Again, this would require very senior political commitment to address national population issues and a bureaucratic mechanism to ensure consistency between population policies and other social and development policies.
Furthermore, linkages from the central policy coordinating body to the state, district and community level, where the practical implementation of policy is effected, have often remained weak. Local level officials have not been readily apprised of policy-decisions made at the centre, and data and information collected at the local level, which are essential for monitoring the progress made in policy implementation and for changing policy direction at the centre have been frequently sparse and inadequate. Failure to convince community and religious leaders of the significance of population-related problems at the national and local level has contributed to the relatively low profile of population issues and the slow rate of implementation of policy.
No doubt, the international climate for population policy formulation has had a significant impact on the evolution of national policy. At the 1974 World Population Conference in Bucharest some of the LDCs emphasized that economic development is "the best contraceptive" as opposed to the construction of family planning programmes. Yet, population policies continued to be centred in family planning programmes while interventions to improve health, education, the environment, and issues of employment generation, were espoused on their own merits and incorporated as goals of national development plans without articulating the linkages to population policy. Demographic dynamics and population policies were never adequately integrated into the national development planning process in most countries, reflecting the failure of population issues to rise to the top of the policy agenda.
The 1984 International Population Conference in Mexico endorsed the importance of family planning programmes to attain the goals of fertility reduction and a decline in the national rate of population growth. As fertility has declined in many parts of Asia and Latin America in the past 2-3 decades, and some countries in Africa are experiencing the onset of a demographic transition, family planning programmes have indeed registered considerable success according to this criterion. Yet, some programmes in Asia were criticised for introducing targets and quotas for individual service-providers which may have led to incidents of coercion in some cases, particularly in India. At the same time, socio-economic change has also contributed to changing fertility desires at the household level, resulting in reduced childbearing and falling population growth ratesa.
Post-ICPD 1994
The International Conference on Population and Development held in Cairo in 1994 and its Programme of Action (POA) is credited with marking a paradigm shift in the emphasis given by the international community and national governments to the importance of improving the state of individual well-being, especially women’s reproductive health. Although mention is made in the ICPD’s POA of "the crucial contribution that early stabilization of the world population would make towards the achievement of sustainable development" (UN, 1994 para. 1.11), reduced population growth does not feature as a major objective of the POA.
The result has been that the principal goal of population policies, at least for the principal UN population and development agencies, has now shifted to an enhancement of individual well-being. A reduced rate of population growth, perhaps induced through an improved reproductive health status of women, through greater gender equity, equality and the empowerment of women, and a wider, more informed choice and greater uptake of modern contraceptive methods, is conceived to be an intermediary objective, automatically following on from the attainment of these health and gender goals, all of which contribute to the overriding goal of improved individual well-beingb. And implementation of programmes to attain the latter – most notably reproductive health and family planning programmes, which may have the incidental effect of reducing rates of population growth – must respect basic human rights. Because reproductive health is conceived to be a basic human right, under no circumstances should quotas for service providers, demographic targets for policy makers and planners, and incentives for clients, be employed in population policies and reproductive health and family planning programmes.
The POA recognizes women’s education, equality and empowerment as paramount and family planning should be provided within the context of full sexual and reproductive health care. Coercion, violence against women and discrimination are to be eradicated. In addition, the POA recognises the central role of sexuality and gender relations in women’s health and rights. It assets that men should be fully involved, without veto powers, in decisions involving fertility, sexual behaviour, sexually transmitted disease prevention and the welfare of their partners and children, and recognises unsafe abortion as a major public health issue. The neglected sexual and reproductive health needs of adolescents must be rectified and they should become prime targets in reproductive health programmes.
Furthermore, population is conceived as part of the necessary investment in people, without which no solutions to development and environmental problems will be found. A clarion call is made for the education of girls, while women must be treated as equal partners in development. The reduction of infant and child mortality, the promotion of safe motherhood, the assurance of access to quality family planning services, tackling the problems of STDs, particularly HIV/AIDS, and the provision of clean water and adequate food and nutrition, are all related to improved reproductive health. Some critics, however, have argued that traditional family planning programmes were down-played and marginalised in the wider context of reproductive health by ICPD (Caldwell, 1996; Kane, 1999). They lament the seeming lack of attention to family planning by the POA since they argue that contraception is the major component of preventive health interventions and is worthy of greater recognition in strategies to improve reproductive health.
Can and should the newer vintage population policies incorporate such a worthy and ambitious agenda? And to what extent should a reproductive health programme actively encourage individuals to have fewer children in the context of improving their reproductive health status, rather than merely providing the services for birth control and informing them about the mechanics of safe and effective birth control?
Constraints on Population Policy Implementation
Jain (1998) has suggested that broader public policies to affect human behavioural change have generally not been very successful in developing countries. He suggests that this was often due to the absence of a charismatic leader who could generate public sympathy for unpopular causes. This was particularly pertinent for population policies in post-Independence Africa and, as we shall suggest later, in the Pacific Island countries. In Africa, ex-President Kenyatta in Kenya was openly pro-natalist despite his country having the highest population growth rate in the world and, at the same time, an explicit population policy which was being implemented in a lukewarm fashion by an indifferent bureaucracy. Elsewhere in Africa, Presidents Sadat, Nyerere, Nkrumah, Kaunda, Banda, Mobotu and Mugabe of Egypt, Tanzania, Ghana, Zambia, Malawi, Zaire and Zimbabwe, respectively, were never readily supportive of anti-natalist population policies and failed to utilize their own personal charisma and popularity to further the policy goal of lowering the national rate of population growth. In India, the opposite was the case to some extent, with the excesses of the Indira Ghandi administration of the late 1970s, including quotas and targets for service providers and often forced sterilization, retarding the long-term objectives of the policy. In the Pacific island countries no post-Independence political leader has publicly addressed population issues in a consistent and explicit manner.
Bureaucratic inefficiencies have also contributed to the failure of old-style population policies through the inadequate allocation of resources to the implementation of a policy, poor quality and inadequate access to resources, and the establishment of unrealistic goals. Only when a large majority of men and women want small families and the policy is efficiently implemented through the availability of fertility regulation mechanisms can a population policy which has a fertility-reducing objective be effectively implemented.
In contrast, the ICPD strategy implies the need for a more balanced, comprehensive, and humane approach to the reduction of fertility and population growth. At the heart of the strategy to ultimately stabilize the size of world population is the realisation of gender equality. Development policies which reduce gender disparities in the sectors of health, education and employment need to become the primary goal. But advocates of traditional population policy might ask: is this the most cost-effective way to reduce fertility and national population growth? Advocates of the ICPD POA would respond that gender equity and the empowerment of women must stand in their own right as desirable development objectives. At the same time, the ICPD emphasized the need to provide a wider choice of contraceptive methods within a broader range of reproductive health services. Yet, the ICPD POA stressed that public policies to establish gender equity and improved reproductive health services should be justified as basic human rights and desirable ends in themselves, and it did not directly link these goals to national and international concerns with reducing population growth.
One major problem with past population policy implementation around the world has been that the single agency most concerned with reducing the rate of population growth, usually a Population Planning Unit housed in the National Planning Office, has had neither the status, control nor influence over the development expenditures of the principal development-oriented Ministries and Departments that are supposedly responsible for implementing gender-sensitive social and economic policies. Nor do departments responsible for family planning have any leverage over the allocation of funds necessary for women to be empowered in order to exercise their reproductive choices voluntarily, in accordance with the goals of the ICPD. Unlocking these constraints would facilitate the implementation of newly conceived population policies in an effective manner.
| "Consequently, when discussion occurs between a donor and a government about issues related to population policy, it takes place between the department of family planning and the officer in charge of population within the donor organization. This limits the scope of discussion to the issues related to service delivery. The implementation of a broader population policy would require that such discussions take place between parties responsible for the entire development process. It would then be possible to place the need to implement gender-sensitive social and economic policies on the agenda of both groups – those interested in reducing population growth and those interested in economic development" (Jain, 1998, p.198). |
Unfortunately, no bureaucratic mechanism seems to exist in practice to ensure compatibility between the goals of population, health and reproductive health, and development policies. In theory, a truly multi-sectoral policy requires interventions by all the key players; in practice, ‘population’ has very often been identified with ‘family planning’ whose principal stakeholders and officials have only a mandate to implement a family planning programme, and not an all- embracing population policy as part of an overall development policy and programme.
Population Policy: Can and Should It Incorporate Fertility Reduction as well as Reproductive Health and be Part of a Development Policy?
In the post-ICPD era how might we conceive of the relationship between a national population policy, a family planning programme and an expanded and broadened reproductive health programme? As demonstrated earlier, a narrow traditional interpretation views population policy as a fertility reduction policy implemented via a family planning programme. Alternatively, according to the new paradigm, population policy should be broadened and equated with a reproductive health policy while the family planning programme is encompassed as just one of the various reproductive health services. An even more comprehensive interpretation equates population policy with development policy and further expands the arena of population activities to interact with all sectors of development.
Jain (1998) suggests that the direction and movement of a country’s population programme from the pre-ICPD period depends on how resources for the population sector are mobilised and the way the funds are allocated. If national governments and certain international donors continue to allocate funds to the population sector solely with the intention of reducing fertility and population growth, at the programme level it will be difficult to move beyond the pre-ICPD situation. For them, only if it were demonstrated that the provision of reproductive health services reduces fertility in a cost-efficient way could the reproductive health programme attract funding from the advocates of the conventional fertility-reducing programme agenda.On the other hand, the alternative of equating population policy with a reproductive health policy is likely to encounter issues of resource mobilisation and allocation. Which ministry should provide and pay for reproductive health services? How should it provide the services? And does this mean that reproductive health programmes would be equated with or replace traditional family planning programmes? Can poor, developing countries afford to expand their family planning programmes to embrace the broader and more clinical and expensive reproductive health services when their existing, more narrowly-focussed programmes already face severe financial and human resources constraint?
The ICPD POA justifies its concern for improving reproductive health status, especially that of women, on the basis of treating reproductive health as a basic human right and as a means of improving individual well-being. Yet, if governments are more concerned with fertility reduction and lowering the rate of population growth, they may only allocate scarce resources to reproductive health interventions if it can be demonstrated that they, indeed, will reduce fertility. But can we be sure that there is a causal link? The new orthodoxy of women’s reproductive health and reproductive and human rights has yet to pass the empirical test; does the evidence suggest that it will produce the desired demographic outcomes and will it result in healthier better-off individuals and families? To pass such a test evaluations of reproductive health programmes need to document any such fertility effect (Basu, 1997). Indeed, in poor Third World countries, where should government priorities lie? Can they afford the luxury of addressing the reproductive health needs of the current generation of women if these may not contribute to the reduction of their fertility which is necessary to prevent future generations being swamped by increased numbers of people? And if reproductive health is a basic human right, where should it lie in the scale of expenditure priorities in relation to other basic human rights? The answers to such profound questions need to be provided to overcome the prevailing skepticism of critics of the ICPD POA. Only then will the resource constraints presently impeding the full implementation of the POA be overcome.
Jain (1998) asks: "What is a practical strategy for the population field and, in particular, for those who remain interested in the reduction of population growth and fertility?" He argues that, at the policy level, it is essential to distinguish between ‘population’, ‘fertility-reduction’, ‘reproductive health’ and ‘family planning’ policies. At the programme level it is essential to recognise their interdependencies. For example, the family planning programme can contribute to improved reproductive health status as well as to reducing population growth and fertility by reducing unwanted childbearing. But this also entails the need to reduce gender and other disparities across the development sectors, in order to shape and reduce desired family size, and hence reduce the demand for children, and provoke a demand for family planning services and contraceptives.
Evidently, the higher authorities must recognise that the delivery of reproductive health services cannot be the sole responsibility of family planning programmes and that the health sector, more broadly defined, must be involved to ensure that a comprehensive package of reproductive health services is delivered. Financing of these services cannot be the sole responsibility of the family planning programme alone. Ministries of Finance must be brought into this policy dialogue to gain their sympathy and support for activities and interventions which further the commendable goals and objectives of the ICPD POA. To date, this has not happened in many countries, perhaps because UNFPA and other donors have been captivated by Ministries of Health and overlooked the strategic role of national exchequers in ensuring sustainability in programme efforts.
In line with the new paradigm espoused in the POA of the ICPD, advocates of a reformulated population policy need to highlight the importance of the overall goal of raising individuals’ well-being and the quality of their lives and to identify such issues as population size, the national population growth rate, reproductive health status, gender equality and the empowerment of women, and family planning, as instruments and interventions to promote individual welfare. This more comprehensive approach to population policy could then be identified as another very important component of the social reform movement which is concerned with improving the lives of individuals.
It is also important to attempt to embed and integrate such population-related concerns into overall development policies and strategies in line with the philosophy behind the ICPD which was, after all, the International Conference on Population and Development. Population policies, reproductive health programmes and family planning programmes cannot be implemented as distinct and separate programmes; they should be viewed as key ingredients and components of national development policies. Therefore, they should follow the holistic and comprehensive approach of the ICPD POA and address aspects of population dynamics and its interface with sustainable development, environmental change, poverty alleviation, employment creation, urban-rural population distribution, migration as well as population ageing. This would reinforce the POA’s holistic approach and strengthen aspects of reproductive health programmes as part of overall national development policies and help to enhance the implementation of other aspects of the ICPD POA. Of course, all are constrained by national development budgetary allocations but the comprehensive approach would ensure that the sum total of benefits from sectoral interventions exceeds the sum of the benefits of the individual parts. And reproductive health and family planning programmes would be the beneficiaries of this holistic approach.
What progress has been made in implementing the "Cairo agenda" and, in particular, reproductive health policies and programmes conceived as integral parts of national development programmes?
Reproductive Health Policies And Programmes: Progress Since Cairo
In a recent review of the extent of progress made since Cairo, Hardee et al (1999) presented eight country case studies to document their experiences in revising their reproductive health policies and implementing their programmes. These countries – Bangladesh, Ghana, India, Jamaica, Jordan, Nepal, Peru and Senegal – evidently span a wide and diverse range of cultural, social, economic and family planning programme contexts. From interviews with key stakeholders, the authors were able to assess progress made in implementing reproductive health policies and related programme activities, including each country’s definition of reproductive health and priorities, how policies have involved the participatory process in policy-making, the identity of supporting and opposing groups, how services are being implemented and the sources of funding for reproductive health.
Their survey suggests that from the eight countries, only Jordan and Peru had not adopted the Cairo definition of reproductive health verbatim i.e.
| "A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes" (United Nations, 1994). |
Some of the basic elements of a typical prescribed reproductive health programme entail: maternal health care including prenatal care, delivery and post-natal care, menstrual regulation and post-abortion complication care; adolescent health care; family planning; management and prevention of sexually transmitted diseases, including HIV, and reproductive tract infections; and child health care, including an expanded immunization programme, control of acute respiratory infections and diarrhoel diseases, and prevention of malnutrition.
The investigators found that most countries had set some priorities among the elements of reproductive health. Family planning seems to claim first place in all the countries, which should satisfy proponents of the traditional approach to population policy and the lowering of fertility, followed by maternal and child health care and by STD prevention and care. Therefore, the pre-Cairo priorities of the old MCH-FP programmes still seem to hold sway, although post-abortion care and adolescent reproductive health are gaining increasing emphasis in some countries. Reproductive tract cancers and infertility receive less attention while gender-based violence remains outside the scope of most programmes. The reproductive rights concerns of Cairo have been relegated below the more transparent aspects of health care (Hardee et al, 1999, p.58).
While the countries in this case-study had devoted considerable attention to formulating reproductive health policy in the post-Cairo period, implementation of the programmes is in its infancy. Perhaps this is partly because the ICPD POA provided no blueprint for implementation. The complexity of administrative and service integration, entailing careful planning from the national ministry down to the village health post, seems to be causing problems. Institutional constraints and coordination problems among organisational units have impeded progress while attempts at integrating reproductive health services concurrently with the decentralization of their management and finance has exacerbated the difficulties.
Most countries are experiencing staff shortages and work overload, as well as a lack of trained providers, particularly female providers. Improving the quality of care of reproductive health services remains a formidable and unsolved challenge.
In order to address these constraints additional financial and human resources are necessary, requirements which were fully recognized by the conference in Cairo. All the case study countries, except Bangladesh, admitted to experiencing funding constraints. While accepting that the role of most donors is positive, many of the countries fear that such donors promote their own priorities and agendas which may not be in accord with national priorities.
Half of the countries seem to be experiencing lukewarm participation and political support for reproductive health, such that progress to the implementation stage is being impeded. Continued efforts at advocacy and in extending participation through extended policy dialogue are required to facilitate a feeling of broad-based national ownership of reproductive health policy and its interventions. Yet, as the investigators conclude:
| "Blanket implementation of the constellation of services called for at the ICPD is unlikely to occur in the near future in most of these countries.… Budgeting, allocating resources to programs and financing additional reproductive health services cannot proceed effectively until the next initial stages take place – helping countries to set priorities for reproductive health interventions, increasing funds for services and developing workable implementation strategies" (Hardee et al 1999, p.59). |
In order to garner the necessary political and bureaucratic support, which is essential if international donors, national governments and their Ministries of Finance are to provide the essential financial budgets for the implementation of the ICPD POA agenda, some blending of the earlier demographic approach to population policy-making and the currently in vogue reproductive health approach seems essential. Many key decision-makers in government still view the reduction of fertility and rapid population growth as a major development policy priority, and do not see the linkage between a broadened reproductive health approach, with its constellation of service provision beyond family planning, and their concern with fertility behaviour. Evidently, much more advocacy and awareness-raising is required to bring together advocates of the demographic and reproductive health approaches. As long as the former hold the upper hand in budgetary allocations, reproductive health interventions beyond family planning are unlikely to receive the necessary additional financial and human resources to implement programmes effectively.
Hardee et al (1999) cite numerous examples of how the two sides are in apparent conflict in their country case studies. India’s population policy since the 1950s has been focussed on reducing fertility and population growth, often through method-specific targets. The elimination of such targets after Cairo was a positive move; unfortunately no alternative was planned or implemented and confusion has reigned as contraceptive prevalence has declined. An advocate of the demographic approach is quoted as saying:
| "The target-free approach was precipitated by Cairo. This approach is negative for India… which is still choking with population pressure"c. |
Meanwhile, a donor representative argued:
| "The government was unable to meet the needs even within family planning… and now the shift to broader reproductive health service provision. Is it feasible?" (Hardee et al 1999). |
Hardee et al (1999) predict that financial constraints will prevent the reproductive health approach being fully implemented in India, Nepal, Jordan, Ghana, Senegal, Jamaica and Peru, partly because of the environment in which donors are fatigued and partly because senior policy-makers remain unconvinced of the efficacy of reproductive health programmes.
Most of these countries, therefore, seem to have revised their policies to reflect the reproductive health messages from Cairo but have failed to find the human and financial resources, and, perhaps, the political will, to implement them effectively.
Population Policies in the Pacific Island Countries: What Have They Achieved and Where Lies Their Future?
Many of the Pacific island countries formulated population policies in the period before the ICPD, displaying a major concern for reducing their high fertility and retarding their high rates of population growth. For example, the first policy statement from the Republic of Marshall Islands (RMI) was published in 1990, at a time when the total fertility rate was thought to exceed 7 children per woman and the annual rate of population growth was in excess of 4%. The resulting policy document was far too long and overly academic and technical, and it did not contain any explicit demographic or other policy goals or objectives. Far too much space was spent elaborating on the deleterious consequences for the various social and economic sectors of continued rapid population growth. The "policy" did not contain any statements of official intent but was merely an elaborate justification for the need for Government, indeed, to formulate a policy. Not surprisingly, little of the document found its way into the National Development Plan for the period 1991/92 – 95/96.
While the policy statement demonstrated the need for population-responsive policies in various other social and economic sectors, their policy goals, which could have been incorporated into the population policy, were already in existence. Environment policy was incorporated in a National Environmental Management Strategy while the family planning programme was quite active and there were formal policies both for women and for youth. Yet, attempts at coordination of the various policies through the formation of a high-level National Population Council and a multi-sectoral coordinating committee were not very effective. The principal role of the latter seems to have been to respond to the criticism levelled at the first policy statement by revising and publishing a second policy document in 1994, before the ICPD. The result was that the revised document was much more explicit about policy interventions to address demographic change. Since it pre-dates the Cairo conference and was very much driven by demographic concerns, it failed to introduce the ICPD concepts of reproductive rights and reproductive health.
A 5-page population policy for the Federated States of Micronesia was published in the early 1990s and appears to be still in effect. It is very much an anti-natalist statement with its overall goal "to reduce the present population growth rate". To achieve this goal, strategies included reliance on an extended family planning programme and the implementation of population education programmes in schools. Again, the ICPD concerns with reproductive rights and the empowerment of women are totally absent from the document.
Papua New Guinea’s 1991 population policy’s principal goal was to promote sustainable development through, inter alia, reduced population growth, enhanced primary health care services, including family planning, expanded rural development and educational and literacy improvements. The demographic targets of the policy, e.g. to reduce the TFR from 5.4 to 3.2 in the space of 8 years, were totally unrealistic. As a result the policy had little impact and a revised policy is currently being written.
Perhaps the country which has made the greatest progress in reducing its population growth rate has been Fiji, whereby the total fertility rate fell from 3.6 in the period 1975-80 to 2.7 by the first half of the 1990s. Yet, the country’s explicit policy goals are summarised in a 5-paragraph statement in its Development Plan, the principal of which "is to maintain a population growth rate below 2 percent per year" and "to limit the rate of population growth to that which is compatible with sustained improvements in standards of living" (Republic of Fiji, 1993). To attain this goal reliance was placed on an efficient service delivery programme while NGOs were encouraged to assist in demand-creation through IEC programmes. Broad social programmes were to be established to raise the status of women through increasing education and employment opportunities. Since this document was published in 1993 and pre-dates the ICPD, it does not carry the changes incorporated in the POA with its emphasis on reproductive health. Despite this, Fiji has been successful in raising employment and educational opportunities for women, as well as reducing infant mortality below 20 per 1000 live births, all of which have helped to create conditions conducive for fertility decline.
The result of this review would suggest that the anti-natalist, narrowly focussed formal population policies of the island countries in the pre-ICPD era had limited impact. Despite this, family planning programmes have made commendable progress in many countries by offsetting to some extent various constraints such as shortages of finances, skilled service providers and counsellors, contraceptives, infrastructure and management skills. But the family planning programmes generally did not rely on the national population policy for their rationale and justification and tended to be vested in the Ministry of Health. The multi-sectoral approach to population policy, which was meant to be reflected in the operations of the Population Policy Coordinating Committee, was never very effective and proved incapable of taking a leading policy-making role in the implementation of the policy. Family planning units in Ministries of Health persevered without any major moral or vocal support for population policy from Heads of State and Government, Cabinets or Ministries of Finance.
No doubt this failure to galvanise the support of the national political leadership, particularly the civil and religious leaders, as well as officials in the National Treasury, impeded the implementation of the MCH-oriented family planning programme as well as the multi-sectoral population policy. Nor has population and population-related issues been adequately integrated into the national development planning process, partly because of the failure to raise population concerns high enough on the policy-agenda. The result is that population policy has continued to be largely identified with the Ministry of Health and its family planning programme.
Post-ICPD
Pacific island countries were well represented at the ICPD in Cairo. In the period following, advocacy has been undertaken, often with the involvement of the UNFPA Country Support Team based in Suva, to reorient policy makers, programme managers and project personnel towards a better understanding of the concept and scope of reproductive health and to assist countries to move towards comprehensive reproductive health, including family planning and sexual health services (RH/FP-SH). Reorientation sessions have sought to enable an appreciation of the paradigm shift from MCH/FP to RH/FP-SH, to the emphasis on promoting choice, the focus on well-being objectives rather than demographic targets, and the stress on integrated quality of care and service.
After five years of advocacy efforts, the concept has been accepted by all island countries and the operational implications are well understood by national programme managers and service providers. The integration of reproductive health is already occurring in the practical stages in varying degrees at the primary care level, but more needs to be done at the secondary and tertiary or national levels. To this end, increasing elements of the reproductive health concept are being incorporated into the new cycle of various donor projects. However, most countries need financial and technical assistance from their development partners in the interpretation and implementation of the ICPD POA to meet local conditions.
Of the population policies which have been designed in the post-ICPD era, perhaps the draft policy for Vanuatu comes closest to reflecting the philosophy of the ICPD’s POAd. For example, the draft document is explicit in upholding the principles of the ICPD POA and confirms the inalienable rights of women to equality and equity, their right to determine their own fertility, as well as the elimination of violence against women. However, the draft policy is still anti-natalist in tone and wishes to lower the national rate of population growth as well as fertility and mortality. The extended provision of quality reproductive health and family planning services, including IEC, are identified to be a worthy end, in and of themselves, as well as the means to reduce fertility and the rate of population growth. However, the policy has yet to be endorsed by Government.
The recently circulated 6-page draft population policy for the Solomon Islands is significant for highlighting the goal of reduced population growth and the absence of any semblance to the philosophy of ICPD. It is very much pre-ICPD in its tone and rationale despite its very recent preparation.
Finally, Samoa has recently drafted a population policy which largely follows pre-ICPD concerns, including the impact of population growth on the social and economic sectors. Only scant reference is made to reproductive health issues while the focus of its attention seems to be on improving the efficiency of its family planning programme.
The challenge for advocacy and awareness raising will be to design a broad strategy that clearly defines the key targets and develops culturally sensitive approaches using appropriate media and tools to reach policy makers, planners and community leaders. This requires a supportive advocacy and IEC strategy to ensure that policies translate into actions and behaviour change at community, family and individual levels.
Two regional initiatives to support such a strategy are being implemented by the Secretariat of the South Pacific Community (SPC) with financial contributions by UNFPA in excess of US$1 million over four years. They aim to create national capacity in countries to advocate for reproductive health programmes, and to galvanise the support of the Pacific Parliamentarians Assembly for Population and Development (PPAPD) and other national leaders, including religious and community leaders. The support of the mass media is to be garnered to promote issues relating to reproductive health. The key targets of the IEC sister-project will be service providers, adolescents, youth and men.
The development of new reproductive health programmes provides an opportunity to infuse individual countries with a stronger focus on adolescent sexual and reproductive health concerns. While the introduction of sexuality education in schools is sorely needed, sensitivity is strong among some national traditional and religious leaders, and the educational authorities oppose discussions of sexuality topics perceived to be ‘too open’. Some Pacific governments are not in favour of setting up separate reproductive health services for adolescents within the existing health services infrastructure. Thus, the strategy should be to involve NGOs, such as the family planning or reproductive health associations which exist in many island countries, in partnership with the government in providing special services for adolescents. Other groups which have been identified to undertake advocacy/IEC activities, including counselling and peer education, are the Youth-to-Youth-in-Health organisation in the Marshall Islands and Wan Smol Bag, a well known community theatre group, in Vanuatu. There is likely to be greater involvement of young people in the design and implementation of activities organised by these less conventional groups.
Improving managerial and leadership knowledge and skills at all levels are an essential ingredient for the success of the new generation of reproductive health programmes. Indeed, the ICPD POA recognises the critical nature of the management dimension in effective programme performance and delivery of quality care and services. Yet, the problem of management deficiency in the Pacific Islands remains endemic.
Conclusions
With the new emphasis on reproductive health, where does that leave the demographic concerns of the earlier versions of population policy? Will the purveyors of the new reproductive health approach be able to galvanise the support of national political and religious leaders and policy makers in the Pacific island countries in order to attract their blessing and financial and moral commitment, when the earlier and narrower family planning programmes failed to do so? If their principal concern remains too rapid population growth – but not all political leaders have identified this as a national problem – in relation to natural and other resources, then the reproductive health agenda emanating from the Cairo POA must be shown to have a significant demographic effect. But can this linkage be adequately demonstrated to the political leadership which may still treat the too rapid growth in numbers as the priority concern for development expenditure and planning?
This writer would propose that high and middle level political and bureaucratic commitment to address national population-related problems, including extensive reproductive health concerns, are more likely to be attained if broad-based national population problems and multi-sectoral strategies to deal with them are expressed in a national population policy. To the political elite, seemingly esoteric reproductive health and gender concerns will not be adequately appreciated if they are treated as independent health issues. They are much more likely to receive the support and expanded budgetary allocations of national exchequers and international donors if they are conceived to be integral parts of broad-based national efforts to deal with population and development problems in a holistic manner.
Already the enthusiasm surrounding the new concepts arising from the ICPD has been dampened by the hard reality of having to compete with other interested parties for the national purse strings. The international donor community has fallen way behind in meeting the projected financial needs for implementing the reproductive health programmes identified in the ICPD. One way to arouse renewed interest would be to incorporate the linkages between interventions to promote improved reproductive health status, fertility decline and reduced population growth in the form of national population policies, conceived as integral parts of national development programmes. Meanwhile, if this approach is accepted, the Pacific island countries will be in dire need of technical support to undertake this task.
As Bongaarts and Bruce (1999) have recently advocated:
"Well-designed population policies are broad in scope, socially desirable and ethically sound. They appeal to a variety of constituencies, including those seeking to eliminate discrimination against women and improve the lives of children and those seeking to reduce fertility and population growth. Mutually reinforcing investments in family planning, reproductive health and a range of socioeconomic measures operate beneficially at both the macro and micro levels: the same measures will slow population growth, increase productivity and improve individual health and welfare."
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* The author wishes to thank Stephen Chee, Director, UNFPA Country Support Team, Suva, for comments on an earlier draft.
a Even though fertility is failing it is possible for national population growth rates to remain high for some time because of "population momentum", whereby past high fertility has resulted in a large sized cohort of women of reproductive age.
b Not all critics are convinced that the recent emphasis given to reproductive health as a means to attain individual well-being is such an innovation. "The reproductive health approach, however, is not as new as some would claim - particularly those who insist that all early family planning programmes were totally and blindly demographically driven. Some elements of reproductive health were included in earlier formulation of population policies" (Catley - Carlson, 1998).
c Some respondents in Senegal showed concern that the importnace of lowering the high level of fertility might be lost by focussing on reproductive health.
d The UNFPA Country Support Team based in Fiji has provided significant technical guidance in the preparatory activities and the drafting of the policy.