| IMPLEMENTATION
ISSUES AND CHALLENGES
1. Population and development: policies and
strategies
Although not suggesting specific country targets,
the Bali Declaration urged governments to set achievable
population targets consistent with their level of
development. It was recommended that targets be attained
through "strategies to attain replacement level
fertility, equivalent to around 2.2 children per woman,
by the year 2010 or sooner" (section II, "Population
goals"). It also stressed the need for the integration
of population issues with those of poverty alleviation,
human resources development and sustainable development.
The Cairo Programme of Action reiterated the links
between the demographic process and general development
processes and provided some support for efforts to
lower population growth rates. It also stressed the
larger human rights and equity aspects of ensuring
health for all at all stages of the life cycle, and
placed empowerment of women at the centre stage of
social and economic development and planning.
Many countries of the ESCAP region had achieved impressive
progress in the reduction of fertility and mortality.
The regional rate of population growth was below 1.5
per cent and in some subregions well below 1 per cent.
Population was considered an integral component of
government planning efforts, and attempts had been
made to integrate population variables into the development
plans of most countries of the region.
However, implementation of the recommendations of
the Programme of Action and the Bali Declaration had
been hampered by a number of factors, including inadequate
political commitment, limited human and financial
resources, and uncertainty about the effectiveness
of some of the Programme's recommendations. The macroeconomic
and social context in which countries of the ESCAP
region were attempting to implement the recommendations
had changed, giving rise to new challenges and opportunities.
Two significant changes in the macroeconomic context
were increased interdependence among countries (globalization)
and an increased role for the market in providing
services. The need for governments to relegate many
activities to the market was recognized in the Programme
of Action. However, there were indications that the
move to market-based methods of service delivery must
be balanced by continued government involvement in
those areas where there were large externalities and
a need to ensure that marginalized and disadvantaged
groups of society were provided with access to quality
services.
The processes involved in globalization included
increased international flows of investment, people,
ideas and values. Those processes had major implications
for population and development. The "demonstration
effects" resulting from globalization might facilitate
acceptance of many of the ideals and goals of the
Programme of Action and the Bali Declaration by service
providers and those needing services. However, globalization
might also accentuate inequities. The challenge was
for governments to play a proactive role in planning
in order to anticipate and plan for the changes that
were associated with globalization.
Globalization, however, also reduced the ability
of governments acting alone to exert control over
development processes. That highlighted the need for
greater cooperation among governments, between governments
and international agencies, and between governments
and civil society in addressing emerging issues associated
with globalization. Some of the issues were a large
volume of international migration, both legal and
illegal, among countries of the region; increasing
economic disparity within and among countries of the
region; erosion of traditional cultural values, particularly
for groups such as adolescents; and changes in the
relationship between economic development and population
growth.
In that changing context, the diversity of circumstances
of the countries of the ESCAP region implied a diversity
of issues, and difficulties in applying specific policies
or programmes on a regionwide basis. The diversity
was clearly observed in the priority issues identified
by those countries. For some countries, the issue
of high fertility was paramount. For others, the issues
of changes in age structure, particularly reduced
numbers entering the labour force, were the priority.
Several countries gave priority to population distribution
and rural-urban migration, while others stressed socio-economic
disparities within their societies. The complexity
of population and development linkages and the diversity
of circumstances of member countries required the
formulation of country-specific approaches to population
and development problems.
A major constraint in shifting to the more holistic
approach to population and sustainable development
recommended in the Programme of Action had been the
difficulty of overcoming obstacles of a socio-cultural
context that mediated between the objectives of population
programmes and individual attitudes and behaviour.
Programme approaches that stressed targets and aggregate
population-development relationships focused on the
magnitude of demographic events. Services and policies
were adjusted to influence aggregate levels of the
targeted events. An emphasis on serving the existing
and emerging needs of individuals and couples required
a much greater understanding of what those needs were
and the socio-cultural factors that affected them.
An analysis of country responses concerning constraints
on the implementation of programmes and policies indicated
that in addition to programme operations, socio-cultural
factors were considered a major obstacle in pursuing
the approaches suggested in the Programme of Action.
That was associated with the move from an approach
that stressed family planning and fertility decline
to a more holistic approach to the relationship between
population and development.
An obstacle to developing programmes and policies
that overcame some of the constraints experienced
in implementing the Programme's recommendations, and
to meet new challenges that had arisen since the Fourth
Asian and Pacific Population Conference and the Cairo
Conference, was a shortage of appropriately trained
staff. Decentralization of programme activities had
highlighted the limited human resources available
at the local level. Training of local-level planners
was required to enable them to understand the emerging
issues in population and development.
A great deal of applied research was needed to guide
effective development of programmes. Research was
necessary to address some of the fears of high-fertility
countries in the region about the possible adverse
consequences for fertility decline if a shift in emphasis
was made from a narrow focus on family planning programmes
to a broader focus on reproductive health. Innovative
research was also needed to clarify relationships
between socio-cultural factors and population processes.
A challenge for countries in the ESCAP region was
to develop their statistical systems in order to obtain
comprehensive data that could be used to monitor and
evaluate the relationships between population and
development. Core indicators that measured key aspects
of population programmes needed to be developed, tested
and implemented. Finally, current indicators for many
of the important concepts stressed in the Programme
of Action and the Bali Declaration, for example gender
equality and equity, needed to be adjusted to take
into account emerging concerns.
2. Gender equality, equity and the empowerment
of women
The Programme of Action included recommendations
aimed at increasing the participation of women in
employment and political life, promoting equality
and equity in education outcomes, and empowering women
in order that they could play a more active role in
decision-making both within and outside the family.
Consensus was established on two fundamental points:
empowering women was an important end in itself, not
only as a human right but one that had the potential
to enhance human well-being; and empowering women
and improving their status were essential ingredients
in realizing the full potential of economic, political
and social development and in ensuring sustainable
development.
Much of the rationale for promoting women's participation
in social and economic activities was the opportunity
which that provided to improve women's status in the
family and society. Greater levels of gender equality
and empowerment of women would lead to improved access
to and use of family planning, reduce the incidence
of induced abortion and also help the prevention of
sexually transmitted diseases (STDs) and the human
immunodeficiency virus (HIV). In addition, the use
of family planning would significantly improve the
health of mothers and children and reduce maternal
and infant mortality.
Most countries in the region were committed to promoting
gender equality. At the legal and institutional levels,
most countries had made efforts in that direction.
The survey of countries of the ESCAP region found
that almost all had legal or other provisions to promote
gender equality in the areas of education and employment.
However, there were a number of areas in which a significant
number of countries had no provisions, for example,
equal inheritance rights for women and protective
labour laws addressing the special needs of women.
Although there was considerable diversity among countries
in the region, significant progress had been made
in the areas of expanding women's educational and
occupational roles. There remained a gender gap in
education in most countries, but that had been reduced,
and in some countries eliminated at the primary school
level of education, although remaining at higher education
levels. There had also been a general trend towards
the increased involvement of women in employment,
especially urban and industrial employment and, in
some countries, in managerial and administrative positions.
However, in most countries women remained disproportionately
concentrated in those occupational sectors where wage
levels were low and opportunities for advancement
limited. The objective of gender equality in terms
of quality of outcomes, rather than in meeting numerical
targets, remained a challenge.
A pervasive constraint on achieving gender equality
and promoting the role of women in decision-making
was socio-cultural beliefs about the appropriate roles
of men and women. In many countries of the region
women had low autonomy and power vis-a-vis men and
were expected and even required to play a subordinate
role to men in the family and to restrict their participation
in public life. Those beliefs were difficult to change,
especially among those, both men and women, who had
been socialized into accepting the validity of those
beliefs. Opportunities must be sought to promote new
ways of thinking about gender relations and roles.
Development trends were associated with emerging
areas of concern in gender relations. Some of those
were the feminization of poverty and the increase
in numbers of female-headed households. Those new
concerns presented significant challenges to promoting
the advancement of women in the region. They indicated
the need to give more focused attention to areas in
which there were wide gender disparities and levels
of poverty were high.
A feature of recent development trends in the region
had been the increase in levels of female migration,
both within and among countries. Women now comprised
the majority of rural-urban migrants in a number of
countries of the region and, among a much smaller
number of countries, they comprised the majority of
international labour migrants. Although migration
had also been associated with increased trafficking
of women, both for the purposes of prostitution and
for forms of indentured labour, for the majority of
women migration appeared to have made a positive improvement
in their lives and contributed to greater gender equality
and equity. Policy initiatives were required in the
area of female migration, with policies that targeted
those practices and situations that increased the
physical, economic and social vulnerability of female
migrants.
A major obstacle to promoting gender equality was
the lack of suitable indicators available to monitor
levels of gender equality and equity. Most available
indicators were macro-level and the validity of some
of those measures, for example, the contribution of
women's economic activities to the gross national
product, was questionable. Micro-measures of gender
equality, for example, measures of the quality of
relationships between men and women, were usually
not available and needed to be developed.
Special concern was raised about practices that led
to excess mortality and morbidity of the girl child
and women. While examples abounded, special attention
was directed towards the occurrence of prenatal sex
selection and sex-selective abortion in some countries,
and the nutritional deficiencies faced by females
in many countries.
3. Reproductive health, including family
planning and sexual health
Integration of reproductive health services
The Bali Declaration recommended that reproductive
health care "should be improved considerably
in the region. Policies and programmes should strive
to incorporate the totality of reproductive health
care and aim at reducing maternal morbidity and mortality,
induced abortion, sterility, childlessness, sexually
transmitted diseases (STDs) and spread of the human
immunodeficiency virus (HIV) and acquired immunodeficiency
syndrome (AIDS)" (recommendation (19)). In many
ways that anticipated the consensus arrived at in
Cairo two years later, where the Programme of Action
marked a conceptual shift from emphasizing fertility
reduction as a key end in itself and family planning
programmes as critical to achieving that, to articulating
the more holistic concept of reproductive health rights
and fertility regulation as one of many rights linked
to improving levels of reproductive health.
However, family planning remained central to reproductive
health, with the Programme of Action including the
recommendation that "countries should ... assess
the extent of national unmet need for good-quality
family planning services and its integration in the
reproductive health context, paying particular attention
to the most vulnerable and underserved groups in the
population" (paragraph 7.16).
Underlying the concept of reproductive health was
that individual choice was paramount and that human
development was a process of enlarging people's choices.
The Cairo Conference placed particular emphasis on
both the rationale for enhancing people's choices
and the probable ways of achieving that. The Programme
of Action defined reproductive health as "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 to its functions and processes" (paragraph
7.2). In that regard, reproductive health services
were seen as the crucial means through which people
could express their choices.
The operationalization of the concept of a holistic
approach to reproductive health was to be attained,
in part, through the integration of services. Most
countries in the ESCAP region stated that they had
made efforts to integrate their reproductive health
services. For example, in Bangladesh, drawing upon
operations research, an Essential Package of Services
(EPS) had been developed as part of a comprehensive
package of reproductive health services. A similar
exercise had been undertaken in India. In the Philippines,
the Task Force on Reproductive Health was reviewing
how to merge different elements of reproductive health
care, while in Thailand the Government had recently
announced the integration of reproductive health components
into one package of services. The Islamic Republic
of Iran had established a health network system that
integrated a number of reproductive health services,
including family planning, maternal and child health,
prevention and control of STDs, diagnosis and treatment
of infertility, and pre-marriage counselling. There
was a need to document the successes that had been
achieved in integrating services, and to disseminate
those results widely to countries that were attempting
to integrate their reproductive health services.
Although there was a clearly stated desire to provide
integrated reproductive health services, the experience
of countries in the region indicated that there were
certain critical issues that could help facilitate,
or alternatively hinder, the integration of reproductive
health components. Among those were management arrangements,
financial aspects, appropriate and integrated basic
and continuing training of reproductive health-care
providers, and logistic systems. In addition, the
policy environment was important with regard to awareness
of gender issues and a willingness to accept innovation
in the delivery of reproductive health services. A
major obstacle to the integration of services was
the perception among some governments, particularly
those where levels of contraceptive use were low,
that programmes were not ready to be integrated. In
those cases, there was a feeling that a move to reproductive
health programmes might dilute family planning efforts.
Countries varied in their reproductive health needs,
the existing organization of services available to
provide reproductive health needs, and resources.
Consequently, the emphasis given to particular components
of reproductive health and the way that they should
be provided would differ between and within countries.
Where fertility was high and maternal health poor,
more emphasis was being placed on the family planning
and maternal health components of reproductive health.
Where fertility levels were low, and where much progress
had been made in reducing child and maternal morbidity
and mortality, other components, such as the treatment
of STDs, might be given more emphasis. Wherever possible,
functional integration and harmonization at the primary
health-care level should be achieved as a priority.
The challenge was to maintain, and if possible improve,
the effectiveness of components of reproductive health
care, while achieving synergy and more cost-effective
provision of services through integration of the provision
of various components. Many of the issues related
to integrating component services into more comprehensive
reproductive health care had been concerned with setting
priorities within reproductive health care, consolidating
successful components and then extending the scope
of reproductive health care, making sure that services
were technically adequate and acceptable to clients;
and giving priority to underserved groups. Another
challenge was to convince policy makers that an emphasis
on the integration of family planning with other reproductive
health components would not result in failure to meet
population goals.
Many of the requirements for integrating reproductive
health services involved a renovation of delivery
systems. That would involve retraining of staff; decentralization
of management; increased community participation;
introduction of client-centred management systems;
improvement in logistical support; and new financing
strategies
The concept of integration of health services could
vary among countries. Some countries in the region
had integrated some health components, while others
had integrated different components. Still other countries
had also integrated non-health components into the
package. One challenge for successful integration
was the need to develop and test various integration
models in order to determine what strategy was best
for a particular context. Integration must also be
undertaken at the level of training if it was to be
successful in the field.
Quality of care
Until recently, organized large-scale government
family planning programmes in nearly all countries
in the Asian region had been based on the objective
of controlling population growth. The Programme of
Action resulted in a fundamental shift in the approach
to family planning services. Family planning was viewed
in terms of the needs of individuals and couples and
as part of the much broader concept of reproductive
health. Family planning was not de-emphasized in the
Programme, rather it was viewed as a fundamental human
right that couples and individuals should be provided
with access to, and information about, so that they
could make informed choices that were consistent with
their overall reproductive health needs.
Several countries in the region had made important
advances in promoting a quality-of-care approach to
providing reproductive health services. Indonesia
had developed a number of strategies to improve the
quality of care, including the provision of a broader
range of contraceptive choices and promoting the integration
of family planning and other reproductive health services.
Mongolia and the Republic of Korea were considering
similar approaches. Several countries, including the
Philippines, had undertaken needs assessment studies
to determine how the quality of care could be improved.
Although many countries in the region retained numerical
targets for family planning service providers, a number
had moved away from targets in response to recommendations
in the Programme of Action. For example, India had
now adopted a "target-free" approach to
family planning. It was important to note that the
move away from numerical targets was aimed at targets
that were fulfilled by service providers. At the aggregate
planning and management level, targets could be an
important tool used to assist in the efficient allocation
of resources.
The quality-of-care approach included six essential
elements: choice of methods, information given to
users, technical competence, interpersonal relations,
mechanisms to encourage continuity, and appropriate
constellation of services. Although the quality-of-care
framework had been developed in the context of family
planning, its principles were applicable on the broader
reproductive health spectrum.
Many of the obstacles that had been encountered in
the shift to a quality-of-care approach had involved
the lack of staff skills and understanding of client
needs, especially in the communication of the options
available to clients. Family planning programme personnel,
in some cases, believed that free choice of methods
might not be the best for clients, and therefore they
did not provide clients with all the necessary information
to enable them to make informed choices.
A barrier to informed and free choice was the use
of financial or material incentives to promote the
use of government-preferred methods of family planning.
Apart from being inconsistent with the human rights
focus of the Programme of Action, recent studies indicated
that those payments did not necessarily promote contraceptive
use. Free choice of contraceptives was more likely
to result in a more sustained use of contraceptives
and, thereby, the achievement of demographic goals,
as well as meeting individual needs.
However, given the experience of many Asian countries
during the 1970s and 1980s, where strong family programmes
with clearly defined targets were associated with
very rapid declines in fertility, it was difficult
to convince programme managers, especially at local
levels, of the benefits of a target-free, quality-of-care
approach to family planning. Therefore, an important
challenge was to convince governments, through advocacy
based on the research and experience of countries,
that needs-based family planning strategies were compatible
with population growth reduction policies.
As many countries, partly in response to the Programme
of Action, decentralized policy- making and programme
implementation activities, advocacy efforts were also
required at the subnational levels. At the same time,
there was a need to recognize that family planning
services were an essential and central component of
reproductive health programmes, and that in the process
of broadening the scope of support for reproductive
health services there was no reduction in commitment
to the focus and priority given to family planning.
In order to meet the objectives of the Programme's
recommendations related to the quality of care and
a target-free approach, much remained to be done.
Continuing efforts were needed to abolish all targets
and quotas, promote freedom of choice of contraceptives,
and discontinue the use of financial payments and
method-linked incentives.
To improve the quality of care of reproductive health
programmes, there was a need to pursue vigorously
the integration of components of the reproductive
health system in order to create a more user-friendly
environment; provide training in interpersonal communication
and counselling to service providers; and undertake
research into the needs of clients.
Training in quality-of-care approaches should cover
all components of a reproductive health programme.
Furthermore, the training should be integrated with
the technical and managerial aspect of providing services
in order that quality of care was considered to be
one of the necessary components of service delivery.
In order to both implement quality-of-care approaches
and improve the existing quality of care, a major
challenge was to develop indicators that could be
used to monitor and evaluate the quality-of-care components
of reproductive health programmes.
Adolescent reproductive health
In the Programme of Action it was stated that the
reproductive health needs of adolescents should be
addressed programmatically: "governments, in
collaboration with non-governmental organizations,
are urged to meet the special needs of adolescents
and to establish appropriate programmes to respond
those needs." (paragraph 7.47). Furthermore,
the Programme recommended that "Countries, with
the support of the international community, should
protect and promote the rights of adolescents to reproductive
health education, information and care and greatly
reduce the number of adolescent pregnancies."
(paragraph 7.46).
The attention given in the Programme of Action to
the reproductive health of adolescents showed a marked
shift from earlier approaches. For many years, the
needs of adolescents had largely been neglected in
population and reproductive health programmes, partly
owing to the sensitivity of issues relating to adolescent
sexuality and reproductive health. However, the growing
numbers of adolescents and the rapid social changes
affecting those groups and their exposure to high-risk
behaviour had made governments increasingly aware
of the need to address the issues of adolescent reproductive
health (ARH).
A number of factors had affected the sexual behaviour
and reproductive health-related risks of adolescents
in recent years. Those included a trend towards declining
age at menarche, an increase in age at marriage, improved
levels of literacy, and changes in socio-economic
and cultural values, including the globalization and
influence of the mass media, particularly the entertainment
media (e.g. MTV). The period between sexual maturity
and marriage had increased in most of the countries
in the region. In addition, traditional customs, which
often discouraged premarital sex, had started to erode.
As a consequence, the risk of unwanted pregnancy and
STDs, including HIV/AIDS, had increased significantly
for adolescents and youth. Furthermore, since large
proportions of pregnancies were unwanted, they were
more likely to end up as induced abortions, often
performed under unsafe conditions, with a high risk
of serious and long-term complications, and even death.
In response to the Programme of Action, countries
in the ESCAP region had made considerable efforts
to introduce ARH programmes. Several countries, such
as Malaysia, the Philippines and Thailand, had started
the process of developing a programme through an ARH
needs assessment. The advantage of that strategy had
been the ability to develop programmes that could
distinguish between the needs of various groups of
adolescents and youth. In some cases, innovative approaches
had been developed to reach some of the hard-to-reach
groups, such as out-of-school youth. A few countries,
for example Indonesia, Mongolia, the Republic of Korea
and Sri Lanka, had established a systematic policy
framework for considering ARH.
However, most countries in the ESCAP region either
had no such policy or ARH was part of several different
policies. Even among those countries with systematic
ARH policies, there were several important constraints
on meeting adolescent and youth health needs. Those
included lack of available data about adolescents,
and existing ideas and views, often misconceptions,
among adults, including parents, planners, policy
makers, teachers, religious leaders and health staff,
and adolescents themselves, about the actual sexual
behaviour, knowledge, views, needs and problems of
adolescents. Misconceptions often led to ignorance,
neglect of the real situation, inadequate approaches,
moral judgements and stereotyping. In many countries,
there were often legal and service obstacles to providing
adolescents with reproductive health services. For
example, unmarried adolescents and youths might not
be provided with access to contraceptives. Attempting
to integrate adolescent reproductive health services
into the existing system that provided services to
adults might not be a suitable way to meet the needs
of adolescents.
Major challenges remained to be overcome in the drive
towards providing adolescents and youths with reproductive
health services. In many countries, a policy framework
was needed for issues relevant to adolescents, including
legislation related to age at marriage; access to
reproductive information and services, including contraception
and pregnancy-related services; and child prostitution
and sexual abuse. To overcome barriers related to
lack of information, qualitative and quantitative
research to gain insights into young people's attitudes,
values and behaviour should be carried out. In that
regard, the participation of youth in the development
of ARH programmes would be beneficial. Intensive advocacy
aimed at influential people, including policy makers,
teachers, community leaders and parents, to sensitize
them to issues pertaining to adolescent reproductive
health, was required. In terms of improved service
delivery, there was a need to ensure that service
providers had the necessary communication and technical
skills, and that services were provided with full
protection of confidentiality.
Gender issues in reproductive health
The Programme of Action placed a great deal of emphasis
on gender relations and gender equity. An explicit
link was made in the Programme between greater gender
equity and improvements in the reproductive and sexual
health of women and men. To achieve that, both men
and women must play an active and responsible role
in reproductive and sexual behaviour. Recommendations
to achieve those goals were contained in both the
Programme of Action and the Bali Declaration.
The links between gender-based forms of discrimination
and poor reproductive health varied across the life
cycle of women. At childhood ages, those forms of
discrimination could manifest themselves in sexual
abuse. At adolescent ages, early marriage, lack of
access to sexual knowledge and restricted access to
reproductive health services became more important
as determinants of poor reproductive health. During
childbearing ages, sexual violence and limited access
to health services were related to gender discrimination
and resulted in low levels of reproductive health.
Women's problems in reproductive health and reproductive
rights reflected deep-rooted beliefs about gender
relations and gender roles. The poor general health
of women (malnutrition, anaemia), the larger share
they adopted in the burden of family planning, their
greater exposure to sexual health risks (reproductive
tract infections, STDs, HIV/AIDS), and gender-based
maltreatment (sex selection, domestic violence, rape
and forced prostitution) reflected the lower status
accorded to women in many societies.
Countries in the ESCAP region were undertaking a
range of activities to overcome gender-based forms
of discrimination that affected reproductive health.
To overcome obstacles related to male participation
in reproductive health, a number of innovative programmes
had been established. For example, in the Philippines,
a new reproductive health centre for men was trying
to involve them in reproductive health programmes.
Indonesia had expanded its counselling programme to
include training materials on male participation in
reproductive health, including family planning.
Because of the cultural and social roots of issues
related to gender equality, there were many constraints
to change. Many of the approaches that had been used
to attempt to promote gender equality and to increase
male participation in reproductive health programmes
did not deal, on the one hand, with the underlying
problem - cultural and institutional support for unequal
gender relations - and on the other hand, provided
limited short-term improvement because they often
aimed to reverse, through superficial means, deeply
held beliefs about gender roles.
A further constraint was that in several countries
there was a perception that gender discrimination
did not exist and that adequate legal mechanisms were
in place to protect and promote the rights of women.
In other countries, significant changes were still
required to achieve legal equality between men and
women.
The major challenge to be faced in implementing the
recommendations contained within the Programme of
Action and the Bali Declaration was to design programmes
that effectively overcame the social and cultural
barriers that sustained gender inequality and that
supported the limited responsibility of men in matters
related to reproductive health.
What were needed were programmatic strategies to
target youth in programmes of education about the
practice of responsible sexual relations and male
participation in family planning. Another strategy
might be to include fathers in all programmes that
were concerned with the family, including those relating
to pregnancy support, post-partum care and child welfare.
Finally, the bond between fathers and their children,
and hence a greater commitment to the family by men,
could be strengthened by the removal of legislative
and other barriers that supported gender-based roles.
Monitoring and evaluation
The holistic focus on reproductive health that underlay
the recommendations of the Programme of Action required
new directions in applied research. The costs and
benefits of alternative modes of service delivery
needed to be assessed on a broader understanding of
desired outcomes. Operations research, assessment
of content and delivery of information, education
and communication (IEC) messages, and programme evaluation
techniques all needed to be pressed into service to
achieve that task. Of particular importance was the
need to use effective performance monitoring and evaluation
to ensure that the design and implementation of essential
packages of reproductive health services were cost-effective.
The selection of appropriate indicators, the levels
of the system to apply them, and the frequency of
measurement, were essential parts of the design of
a strategy.
Countries in the region continued to strengthen their
management information systems so that the quality
and coverage of reproductive health programmes could
be monitored. However, as the programmes changed,
and a new focus was applied, there was the need to
obtain a core set of indicators that were consistent
with the new objectives of reproductive health programmes.
Indicators had to be relevant to the needs of a programme,
and in particular those of programme managers; the
set of indicators should not be so extensive that
the task of obtaining the information became onerous
and/or too expensive; the indicators should allow
for monitoring, evaluation and impact assessment;
and indicators should relate both to reproductive
health programmes in general and to assessing the
progress towards meeting the goals of the Programme
of Action.
The United Nations Population Fund (UNFPA) had developed
a set of indicators covering three principal thematic
programme priority areas: reproductive health, population
development strategies, and advocacy. However, the
shift away from indicators that measured outcomes
to those that tracked progress in programme implementation
(process indicators), had been constrained because
few established data sources existed. Indicators for
measuring quality of care had not been well developed
and, even when they were available, were not recorded
in existing databases. Other evaluation tools were
being developed, such as Jains's HARI index, the COPE
model of the Association for Voluntary Contraception
and indicators developed by the World Health Organization
(WHO).
There had been limited applications of those tools.
The HARI index, which was based on the percentage
of women who were able to succeed in avoiding unintended
pregnancies and who did not experience maternal morbidity
in a 24-month period, had been used in the analysis
of secondary data that are available from a number
of countries in the ESCAP region, and preliminary
use indicated significant benefits in assisting in
the development of reproductive health strategies.
The development, implementation and use of monitoring
and evaluation methods for reproductive health faced
many difficulties because the new assessment procedures
stressed different factors from those traditionally
used to measure the productivity of family planning
programmes and of individual workers. For example,
the new methods required accountability measures of
how well client needs were met, including client satisfaction
and unmet needs. Results from the survey of countries
participating in the Meeting indicated that few of
those new types of measures were available. But the
need for such measures was pressing, particularly
in programmes where rigid target-based criteria had
been used in the past. A major constraint on the use
of the emerging monitoring and evaluation tools was
that much of the data required were not collected,
or if collected were not readily available in a standardized
form.
A challenge in the development of indicators for
monitoring and evaluation was how to balance the need
for comprehensiveness, consistency and relevance with
some of the technical and cost constraints. However,
meeting that challenge had been hampered by the lack
of resources. For example, many on the list of the
120 indicators developed by UNFPA had not been field-tested,
evaluated and used for programmatic purposes. That
difficult and expensive, but invaluable, exercise
could only be implemented through systematic efforts,
nationally, regionally and globally.
4. Role of civil society
The Programme of Action called on governments and
international agencies to "promote an effective
partnership between all levels of government and the
full range of non-governmental organizations and local
community groups, in the discussion and decisions
on the design, implementation, coordination, monitoring
and evaluation of programmes relating to population,
development and environment in accordance with the
general policy framework of governments, taking duly
into account the responsibilities and roles of the
respective partners." (paragraph 15.7).
At the national level, the non-governmental sector
of society was generally referred to as "civil
society". Civil society might be understood to
consist of most of the non-governmental sector in
a society, including NGOs, professional or ethnic
group associations, religious groups, academic institutions,
labour unions, political parties, community groups,
and the private sector. In all countries of the ESCAP
region, civil society played an important role in
assisting governments in the population field.
Considerable progress had been made since the Cairo
Conference in forging effective partnerships between
groups in civil society and governments, international
agencies and in bilateral and multilateral cooperation.
Among the many examples of expanded areas of cooperation
and increased responsibilities were: (i) the European
Community/UNFPA special programme on reproductive
health in selected countries in the Asian and Pacific
region, undertaken with the involvement of the International
Planned Parenthood Federation and member family planning
associations, with the aim of strengthening reproductive
health activities and services; (ii) participation
in organizing South- South cooperation programmes,
for example, the training for reproductive health
programme managers recently organized by the Government
of Thailand in cooperation with an NGO; (iii) advocacy
for legislation on aspects of reproductive health,
such as the Pregnancy Protection Bill, 1996 in Nepal,
and the Maternal and Child Health Law in the Republic
of Korea; and (iv) the establishment of formal and
informal networks linking civil society, governments
and international agencies.
The involvement of civil society in service implementation
and delivery had been particularly effective in accessing
disadvantaged and marginalized groups in society.
Many of the population challenges that had developed
during the past five years involved issues of a sensitive
nature. Those issues included the sexual behaviour
of adolescents, the spread of HIV/AIDS, abortion,
child labour and prostitution, abuses of human rights
of illegal migrants etc. It was often difficult for
governments to address those issues effectively .
Because of their community links and institutional
flexibility, NGOs had a comparative advantage in dealing
with them. Notable examples of work in that area included
the Red Cross Society of Thailand and the Planned
Parenthood Association of Thailand, working with marginalized
groups such as commercial sex workers and hill tribes
in HIV/AIDS prevention programmes, and the Indonesian
Planned Parenthood Association, through its Lentera
Youth Project, establishing a sexual and reproductive
health model.
However, experience from the countries in the ESCAP
region indicated that there remained many obstacles
to forging a more effective partnership between the
non-governmental sector and government. Constraints
for groups in civil society in taking advantage of
expanded opportunities also existed. Some of those
constraints were related to the perceptions of governments
about the appropriate roles for institutions of civil
society. Other obstacles were related to the underdeveloped
nature of civil society in many countries of the region,
and human and financial ALIGN="JUSTIFY">constraints.
In many countries, there were literally thousands
of NGOs and community groups, both national and international,
working in the field of population. Even though there
had been progress in avoiding duplication and maximizing
available resources through the establishment of networks,
a major obstacle to effective use of the limited available
resources had been the lack of coordination among
the different groups in civil society.
Much of the increased involvement of civil society
had been in implementation of programmes. Most countries
did not provide civil society with a formal role in
policy-making, although there were usually informal
mechanisms through which its views could enter the
policy debate. Without formal participation in policy
formulation, the ability of civil society to help
influence the direction of policy was hampered.
The limited availability of resources, both human
and financial, played a major role in inhibiting the
expansion of civil society activities. On the one
hand, there was increasing need for non-governmental
groups to obtain government and international funding
to undertake many of the new tasks entrusted to them
by governments, while on the other hand there had
been little increase in available funds. Many governments
in the region viewed the dependence of civil society
organizations on government and international donor
funding as a major constraint on their development
of significant roles in the population field.
To achieve the objectives of the Programme of Action
and the Bali Declaration, the constraints mentioned
above needed to be overcome. Challenges existed for
all actors. Governments needed to create the environment,
and assist in providing the support, to allow groups
in civil society the freedom to work on issues. That
environment should include creating institutional
mechanisms that allowed actors in civil society a
formal role in policy formulation. A greater share
of government resources directed to civil society
groups was also required in order to allow them to
operate effectively in implementing programmes.
Groups in civil society also needed to adjust their
strategies in order to operate in a changing environment
of increased responsibility. Within the limits imposed
by the development context, they faced the challenge
of developing strategies to tap community resources
more fully in order to ensure the implementation and
sustainability of their programmes. The programmes
of civil society organizations should also be monitored
and evaluated using acceptable international practices
in order to ensure that resources were being used
effectively.
The improvement of human resources required the cooperation
of national groups of civil society so that skills
and experience could be transferred through training,
and also required more cooperative training alliances
between international NGOs and agencies, governments
and national NGOs, and other actors in civil society.
5. Resource mobilization
The Bali Declaration urged "all governments,
intergovernmental and non-governmental organizations,
the private sector and external donors to make every
effort possible to increase, on a regular basis, their
financial commitment so as to attain their targets
by the year 2000" (recommendation (65)).
Likewise, the Programme of Action called upon the
international community to "achieve an adequate
level of resource mobilization and allocation, at
the community, national and international levels,
for population programmes and for other related programmes"
(paragraph 13.21).
It was estimated that the annual resource requirements
for implementing the Programme of Action would be
$17 billion by 2000, rising to $21.7 billion by 2015,
of which two thirds would be expected to come from
domestic sources and the remaining third from the
international donor community. Of the $17 billion
needed in 2000, it was estimated that $10.2 billion
would be needed for family planning, $5.0 billion
for additional reproductive health components, $1.3
billion for STDs/HIV/AIDS programmes and $500 million
for research, data and policy analysis. It was estimated
that countries of the ESCAP region would need approximately
$11.0 billion in 2000.
Preliminary analysis undertaken by UNFPA indicated
that (i) while there had been a significant increase
in donor contributions immediately before and after
the Cairo Conference, reaching $2 billion globally
in 1995, such contributions had since remained stagnant
at that level; (ii) while domestic resources constituted
a substantial portion of the funding for population
programmes in some countries, in others there was
heavy reliance on donor support; (iii) the region's
least developed and poorer countries would be unable
to mobilize adequate financial resources domestically;
(iv) the current economic downturn in some of the
fast-growing economies would also cause difficulties
for those countries in meeting the goals of the Conference,
and (v) NGO contributions to the programme resources
in the ESCAP region remained a modest 2 per cent of
the total needed.
Such shortfalls in funding had severe adverse consequences,
such as increases in unwanted pregnancies and abortions,
and higher levels of maternal mortality and infant
and child deaths. They also had an adverse effect
on the promotion of South-South cooperation in population
programmes.
In order to attain the goals of the Cairo Conference,
the levels of funding allocated to population activities
must increase. Governments faced the challenge of
obtaining new resources and ensuring that available
resources were used more effectively.
Countries in the developing world were more than
meeting their agreed share of funding required to
meet the goals and objectives of the Programme of
Action. For 1996, UNFPA estimated that domestic resource
flows accounted for 80 per cent of the almost $10
billion in total global population-related expenditure
and allocations. While some countries in the ESCAP
region still relied heavily on donor contributions
to fund their population activities, others reported
that the majority of population expenditure was domestic.
For example, in 1996, government funding covered over
90 per cent of the cost of the Indonesian population
programme. The current economic crisis being felt
by a number of countries in the region was placing
very heavy pressure on the resources available for
population activities.
Many countries in the region were actively exploring
ways to maintain continuity of domestic resource mobilization
and make more efficient use of available resources.
The Islamic Republic of Iran reported three strategies
that were employed in that country: intensive advocacy
to ensure political commitment to population activities;
reliance on operations research to plan cost-effective
service delivery; and increasing reliance on community
participation to assist in providing some services.
However, it was the shortfall in the agreed resources
to be made available from the international community
that was most responsible for the shortage of resources
necessary to carry out the objectives of the Programme
of Action. Therefore, the international community
had an important role to play. It should strive to
achieve the agreed targets for population assistance.
Further, the demonstrated availability of human resources
and accumulated experience in many of the developing
countries of the ESCAP region should be drawn upon
through South- South cooperation.
The situation of the Asian and Pacific region was
of particular concern in relation to the resource
shortfall. The region contained approximately 60 per
cent of the population of the world and 65 per cent
of its poor. Yet, relative to other regions, the share
of international resources flowing to the Asian and
Pacific region was declining. The challenge was how
greater equity in global resource allocations to population
could be achieved.
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