II. THE BALI DECLARATION AND THE PROGRAMME OF ACTION OF THE INTERNATIONAL CONFERENCE ON POPULATION AND DEVELOPMENT IN THE CONTEXT OF THE POPULATION DYNAMICS OF THE ASIAN AND PACIFIC REGION

Gavin Jones*

A. Changing perceptions of population policy issues: Bali, Cairo and beyond

It is clear that the International Conference on Population and Development, held at Cairo in 1994, in some respects represented a major break with prior emphases on population programmes. But the break was not as sudden as it appeared to many observers. By placing emphasis on women's empowerment, reproductive health and reproductive rights it represented the culmination of a movement critical of traditional approaches to population policy emphasizing family planning programmes as the key mechanism for achieving reduction in high rates of fertility while ignoring the welfare of women. The intellectual roots of this new approach had actually been building for some time and can be traced in studies such as those by Rosenfield and Maine, 1985 (from a public health perspective) and by Germain, 1987, Dixon-Mueller, 1993 and Sen, Germain and Chen, 1994 (from a feminist perspective). And there had long been many insiders in the family planning movement who, while stressing the importance of lowering fertility rates, also stressed the benefits of family planning to women's welfare and the need to respect women's rights and dignity in the approaches taken in family planning programmes.

One of the criticisms frequently expressed about the Programme of Action of the Conference is that despite the emphasis in the title of the Conference, in fact it had very little to say about population and development. Indeed, scant attention is paid to aggregate population-development relationships, notwithstanding the considerable preparatory work carried out in expert group meetings and intergovernmental conferences prior to the Conference. Comparison of the Programme of Action of the Conference with the Bali Declaration on Population and Sustainable Development reveals a striking change of emphasis. The Bali Declaration, in its preamble, expressed concern that population issues remained among the most pressing challenges facing the region and urged that all members and associate members of ESCAP make a firm political and financial commitment to incorporate population and environmental concerns fully in all national efforts to achieve sustainable development. The concern with the implications of aggregate population trends was clear. The Bali Declaration went on to urge that all members and associate members of ESCAP establish a set of population targets in line with sustainable development goals, and initiate and implement policies and programmes to achieve those targets. The targets were spelled out in section II, "Population goals", as follows:

To help reduce high rates of population growth, countries and areas should adopt strategies to attain replacement level fertility, equivalent to around 2.2 children per woman, by the year 2010 or sooner. Countries and areas should also strive to reduce the level of infant mortality to 40 per 1,000 live births or lower during the same period. In countries and areas in which maternal mortality is high, efforts should be made to reduce it by at least half by the year 2010.

This kind of approach, which was also reflected in the recommendations of the African Population Conference, held in 1992, came under attack from various sources in Cairo. The emphasis on aggregate demographic goals was anathema to many feminists, who argued that programes which were intended to act directly on fertility were inherently coercive and abusive of women's right to choose the number and timing of their children (McIntosh and Finkle, 1995:227). (Even the use of the term "women's" rather than "couples'" in this context reflected a hard-fought change from earlier World Population Conference documents).

It would be mischievous, however, to play up inconsistencies between the Bali and Cairo documents. The Bali Conference was part of a process of building up to the Conference in Cairo, and the Cairo Conference itself must be seen as part of a process within the United Nations system of considering human welfare from different perspectives, including that of the Rio earth summit (the United Nations Conference on Environment and Development, held at Rio de Janerio in 1992), the women's summit in Beijing (the Fourth World Conference on Women, held at Beijing in 1995) and the World Summit for Social Development held at Copenhagen in 1995. The Cairo document, in paragraphs 3.14, 3.25, 3.26, 3.28, 6.3 and 6.4, does give muted support to the need to reduce population growth rates. But the main thrust of the document lies elsewhere. Its paradigm of development emphasizes broad social policy in addressing population issues and stresses sustainability, poverty alleviation, and promotion of human rights and women's empowerment. "Population policy becomes a welfarist activity, seeking especially to benefit women. Effects on birth rates are not so much seen as secondary, but as an inevitable - and desired - consequence of women's empowerment" (McNicoll, 1995: 334).

Nevertheless, much post-Cairo discussion has focused on the demographic implications of the reproductive health approach. Arguments range from the view that by diluting family planning resources, the impacts on fertility will weaken, to the following upbeat assessment.

A reproductive health approach will be more cost-effective in meeting demographic goals in at least two ways: first by reducing contraceptive drop-out and failure rates, and second by appealing to the younger individuals and couples who, in demographic terms, need to delay sexual initiation and marriage, and contracept earlier and longer. Proponents of the International Conference on Population and Development also look to broad `social engineering', rather than fertility-centred propaganda or incentives to counter what Judith Blake called the 'coercive pronatalism' of everyday life (Germain, 1997:33).

There is a strong belief in the Asian region, reflected in the Bali Declaration and continuing to the present time, that population-development relationships are very important. This belief underlines the strong continuing emphasis on family planning in the largest countries of the region, Bangladesh, China, India and Indonesia, and an apparently increasing emphasis in Pakistan. While the direct family welfare implications of contraceptive practice are stressed in these and other family planning programmes, there is little doubt that they, and other strong programmes that have wound down because fertility has fallen to low levels (for example, Republic of Korea, Singapore and Thailand) received their key impetus from a belief that rapid population growth is a heavy drain on national development. And if the "national development" goal was criticized as dealing with aggregate matters and lacking a focus on individual welfare, the response was that individual and family welfare is the ultimate goal of such development and cannot be raised very much without it. The strong belief that rapid population growth is a drain on development was the reason why targets for fertility reduction, long an important feature of many individual country population programmes in the region, were adopted in the Bali Declaration. It should be stressed, however, that the targets espoused in Bali were general ones - for reductions in fertility and mortality rates, and certainly not for recruitment of acceptors by individual family planning workers.

Targets were effectively put off limits by the Cairo Conference, and since then, even the most ardent family planning programmes have learned either to eschew them, downplay them or call them something else. In the context of the present Meeting, the key issue in relation to targets may be whether they are generically a bad thing, or whether general targets for fertility reduction still have a useful role to play in countries where fertility is still high, by keeping the need for slower population growth in the public eye. A key contribution of the Cairo Conference was to re-emphasize that a wide range of social and economic policies can be expected to act on fertility. This point had already been strongly developed in the implementation strategies and recommendations for action adopted by the Senior Officials Meeting held at Bangkok in 1994 to discuss implementation strategy for the Bali Declaration (ESCAP, 1994), and in the background paper for that Meeting (Jones, 1994). The implication is that it is impossible to specify in isolation just what kind of family planning programme inputs will have particular impacts on fertility, because it all depends on the broader policy and programmatic context in which family planning programmes are embedded. But this is not to deny the validity of the objective of lowering fertility rates.

The kinds of targets most heavily criticized are those that translate the overall goals for fertility reduction, through some formula or other, down to the provincial, district and local levels, to provide targets for recruitment of acceptors by family planning workers. Such targets are rightly criticized, not only on the grounds that they can lead to human rights abuses, but also on the grounds that they reflect a mindset which gives a false picture of the primacy of family planning programmes in reducing fertility, and divert attention from the complex range of policies that can be expected to act on fertility, albeit with results that nobody pretends can be converted into precise forecasts of fertility trends.

The Cairo Programme of Action gives strong emphasis to gender relations, reproductive rights and reproductive health and poverty alleviation. A human rights approach is actually the hallmark of the new paradigm; all the above three emphases can be viewed through a human rights lens, and can make a major contribution to the welfare of women, families and society at large. A little more "gender balance" in its discussion of rights and responsibilities would have been desirable, however. "How can one make men more responsible for their own fertility if one denies them rights in reproductive decision-making, which is what the female autonomy and empowerment model [of the Conference] in effect implies?" (Basu, 1996). The pervasive emphasis in the Programme of Action on women's empowerment also leads to myopia with respect to barriers to improved welfare of the poor, of both sexes. Thus, instead of targeting the striking inequity in access to education by socio-economic status, the Programme chooses to stress inequitable access by gender, a much lesser problem, albeit still very important in South Asia (Knodel and Jones, 1996). Similarly, in relation to child mortality: "the gender difference in child mortality is seen as much more crucial than the high level of child mortality, male and female, in poor societies across the world" (Basu, 1997: 226).

B. The diverse conditions of countries of the ESCAP region

ESCAP members are characterized by an extraordinary diversity, which complicates the task of providing a consistent set of policy recommendations applicable to all of them. Other background papers document and discuss this diversity. It will suffice here to note that the diversity covers a number of matters, notably population size, levels and trends in fertility and mortality, levels and rates of economic development and differences in approaches to development planning. If anything, the diversity has widened since the Bali Conference in 1992; certainly, evidence of the diversity has strengthened. Fertility rates have sunk very low in countries or areas such as Hong Kong, China and the Republic of Korea, whereas they have remained very high in Afghanistan and fallen little in Nepal and Pakistan. Differences in female ages at marriage, however, appear to be lessening, with encouraging increases in South Asian countries (Jones, 1997:9-11; Shaikh, 1997), although knowledge of recent trends is restricted by lack of data. Age differences between spouses are also tending to narrow in countries where they were previously very wide. These trends reflect important effects of education and other influences on gender relations. They raise many important policy issues, stemming from increasing intervals between attainment of puberty and marriage, and from the increasing autonomy of young people during those intervals.

Death rates continue to show an extraordinary diversity. The difference is most striking with regard to the maternal mortality ratio, which ranges from less than 10 per 100,000 live births in Australia and Hong Kong, China to well over 1,000 per 100,000 live births in Afghanistan, Bhutan and Nepal - more than 100 times as high. Diversity is also evident in levels of urbanization and in patterns of internal and international migration. Some countries and areas, such as the Philippines, are essentially countries of out-migration; others, like Thailand, have substantial labour migration flows both in and out; still others, such as Japan and Taiwan Province of China, attract workers from many countries.

One implication of wide differences in fertility and mortality (especially of fertility) is that the ageing of the population, though increasing throughout the ESCAP region, is proceeding much more rapidly in some regions and countries than in others. The proportion of older persons in the population will remain lower in South and South-West Asia and also in South-East Asia than elsewhere in the region.

The diversity of circumstances implies a diversity of issues, and difficulties of generalizing on an ESCAP-wide basis. On the topic just mentioned, ageing, for example, although all countries of the ESCAP region need to be taking steps to prepare for an ageing population, the nature and timing of these steps may differ. On another crucial matter, for many ESCAP members, the issue of whether family planning programmes should have a fertility reduction target has no further relevance. Countries with below-replacement fertility - and there are now a considerable number of them in the region - are normally interested in forestalling further fertility decline rather than promoting it. In such countries, an approach to the provision of family planning services that stresses reproductive health should raise no concerns at all. There are many other countries in which fertility is sinking towards replacement level, and although population momentum ensures a considerable further increase in their populations, there is no longer a feeling of urgency about reducing fertility rates. In such countries, the reproductive health approach should also prove acceptable. But there are other countries in which fertility remains high and governments have adjudged that rapid population growth is hindering development efforts. It is in such countries that the issues in moving to a reproductive health approach need further discussion. Planners in such countries may need to be convinced that an emphasis on reproductive health rather than fertility reduction per se will nevertheless have desired effects on fertility.

The literature on the "unmet need for family planning" suggests a serendipitous relationship between a reproductive health approach to family planning and the need to reduce fertility. By indicating a substantial level of "unmet need" in those countries where fertility remains high, it suggests that serious efforts to improve the provision of reproductive health services in a way that respects clients, recognizes their individual needs and their right to full information about matters influencing their reproductive health, will contribute substantially to bringing down fertility. Hard-nosed protagonists of demographic targeting may respond by arguing that while a reproductive health approach should have fertility-reducing spin-offs, these will be less than in the traditional family planning programme. This claim, however, remains to be proved, and in any case it begs the question of the extent to which fertility reduction needs to be prioritized. Another background paper1 deals in more detail with current thinking about the relationship between population growth and economic and social development. Suffice it to say here that while the case for lowering high population growth rates in the interests of more rapid social and economic development and a sustainable future remains strong, there are many means to this end. There is certainly no compelling evidence that the end requires family planning programmes that fail to respect fully the reproductive rights of individuals and couples.

The recent economic crisis confronting a number of countries of East and South-East Asia may provide a context of greater pessimism for this Meeting than prevailed at the time of either the Bali or Cairo conferences. Resources will be scarce and this will make it hard to fund new initiatives in implementing population programmes. On the positive side, the countries worst affected, Indonesia, the Republic of Korea and Thailand, have all succeeded in lowering fertility - to replacement level or below in the Republic of Korea and Thailand - and in providing wide-ranging family planning services. In a situation of economic crisis, fertility levels are unlikely to rise. What is likely to happen, unfortunately, is for layoffs to occur and for unemployment rates to rise sharply. This has already led to calls to repatriate foreign workers from Malaysia and Thailand.

One important point to remember in this context is that the situation would be much worse had it not been for fertility reductions over the past three decades. These have muted the increase in the number of young people entering the labour market at present, as well as facilitating the rise in educational levels of those now entering the workforce. One example will suffice: if the fertility rate in Thailand had not fallen from the levels prevailing in the late 1960s, the number of young people reaching the workforce ages would have been rising by about 3 per cent every year at present: instead, it is actually decreasing by about half a per cent each year. Not only this, but entry into the labour force is delayed by the progressively longer time young people are continuing their education.

C. Post-Cairo developments in donor approaches to population policy

Donor agencies have been greatly affected by the Cairo agenda and have moved quickly to adapt their programmes and their rhetoric.

1. United Nations Population Fund

UNFPA has produced a new set of guidelines for its support of programmes. The guidelines focus on three core programme areas: reproductive health, including family planning and sexual health, population and development strategies, and advocacy. Advocacy means much more than the old "IEC" (information, education and communication) did. Advocacy is seen to include a whole range of efforts to influence public opinion and the opinion of government leaders and planners towards support for goals of gender equity and women's empowerment, reproductive health, expansion of educational opportunities, especially for females, and other elements of the Cairo package. The UNFPA post-Cairo documents have focused on how well the Programme of Action is being implemented. Given the magnitude and complexity of the task of implementing the new approaches, such a positivist approach was to be expected. But with the passage of time, progress in implementation both requires and provides the basis for a continuing reassessment of approaches and underlying rationale.

2. World Bank

The World Bank sees three sets of issues as important in the post-Cairo Conference world: (i) how to deal with population as a multisectoral policy issue; (ii) what role the public sector should play in reproductive health; and (iii) how to move programmes supported by the World Bank from the pre-Cairo to a post-Cairo approach. On the first, by de-linking population policy from family planning, the Conference is forcing governments and donors to rethink how they can deal with population at the level of broad social and economic policy. On the second, with the removal of the "population crisis" justification for population programmes, and justification for public sector and donor intervention needs to be on the basis of externalities and market failures; but there is argument over the extent to which these exist. On the third, the World Bank sees the need to identify reproductive health needs and priorities; devise delivery strategies for an essential package of reproductive health services and to find ways to finance and mobilize resources for the package; improve organization and management of the public health system; and induce behaviour change and community participation.

3. Asian Development Bank approaches

ADB has taken serious steps in its population programme to adhere to the reproductive health approach in its new initiatives. A good example is the reproductive health project developed with the Government of Indonesia, requiring close cooperation between the Ministry of Health and the Family Planning Coordinating Board. (Demographic Institute, 1997). This project attempts to go to the heart of three complex issues: clinical quality, comprehensive maternal care, and mass education in appropriate reproductive health behaviour.

4. World Health Organization and United Nations Children's Fund

WHO has helped to identify the various elements that should go into a reproductive health programme and have started popularizing this. Based on WHO assessments, the main concerns of reproductive health pertain to family planning needs, maternal and new-born health and management of reproductive tract infections. WHO sees its role in the transition from family planning to reproductive health as developing methodologies for assessing reproductive health needs and establishing priorities; defining reproductive health indicators; supporting research to determine the most effective service configurations in diverse settings; and setting norms and standards (ECO/UNFPA, 1996: 12-13). UNICEF has become involved in safe motherhood and birth spacing, probably largely because of the shift in thinking generated by the Cairo Conference (Sai, 1997:4).

D. Post-Cairo developments in ESCAP member country approaches

Most members of ESCAP have modified their overall population policy or their specific approaches to family planning programmes in the post-Cairo period. While countries represented at the Meeting will be able to document these changes more fully and accurately, here mention will simply be made of realignments of policy that have taken place in five large countries of the region, Bangladesh, China, India, Indonesia and Pakistan.

In India, a "target-free approach" was announced in April 1996. However, considerable scepticism was expressed in many quarters. Would "target-free" mean "responsibility-free"? Was it now all right to ignore family planning? How would worker performance be evaluated? Would family planning performance decline? Many States continued to impose targets. Further moves towards a reproductive health approach include encouraging States to remove incentive payments to both providers and acceptors of certain family planning methods, and closer collaboration with NGOs. Changing mindsets and entrenched ways of doing things, and the high costs of a quality reproductive health programme are major challenges to the new approaches (Visaria, Jejeebhoy and Merrick, 1997).

Bangladesh has framed a national health and population sector strategy, taking the Cairo agenda as its starting point and refining it to suit Bangladeshi conditions (Germain, 1997). This is in recognition that although Bangladesh is often cited as a case of success in family planning in an unfavourable setting, the quality of its contraceptive services is poor, maternal mortality is very high, marriage and childbearing occur at very young ages, and HIV/AIDS is on the increase.

In Pakistan, the national report to the ECO (Economic Cooperation Organization)/UNFPA Conference in 1996 revealed that in recognition of the lack of effective impact of population policies stretching back over many five-year plans, a strong population policy had been incorporated in the Eighth Five-year Plan, 1993-1998, aimed at rapid expansion of family planning and primary health services. Targets were presented for the contraceptive prevalence rate and the rate of population growth. Family planning was to be provided in all health outlets, 12,000 village-based family planning workers were being recruited, and 100,000 female health workers were also being recruited to provide primary health care and family planning services.

Indonesia has dropped the former system of targets, and instead the stress has been placed on "demand fulfilment". Deficiencies in quality of care have been investigated, and moves made to increase the reproductive health emphasis of the programme. The Minister of Population advocates positive measures which guide the programme to improvements without unnecessarily condemning the efforts and activities of the past. Well before Cairo, the family planning programme had adopted a family welfare approach, and more recently poverty alleviation emphases have been strengthened as part of this approach.

After the Cairo Conference, the State Family Planning Commission of China held various conferences and seminars over how best to implement the recommendations of the Conference within the prevailing conditions of China. It has announced a gradual change from efforts directed only at family planning to combining family planning with socio-economic development; and a gradual change from the mechanism of social restriction to a service-oriented mechanism based on publicity and education, scientific management and delivery of multiple services coupled with social interaction (Satia, 1997:363). This integrated approach is intended to improve the quality of care and to link family planning services in a broader reproductive health approach. Pilot programmes have been undertaken in a number of counties and provinces to demonstrate how to move towards higher quality of care and assess its impact.

E. Integrating the Bali and Cairo approaches

1. Differences not as great as at first sight

It is easy to stress the "paradigm shift" that took place between the recommendations of the Bali and Cairo conferences, and one would not want to understate the importance of that shift. At the same time, however, a careful examination of the two documents reveals many aspects of continuity as well. One aspect is that both documents explicitly recognize the right of individual countries to autonomy in population policy. As the Bali Declaration expressed it, in the preamble: "Every country ... has the sovereign right to pursue its own population goals, policies and programmes respecting the goal of global sustainable development". Similarly, the Cairo Programme of Action, in the first paragraph of chapter II, "Principles", stated: "The implemen- tation of the recommendations contained in the Programme of Action is the sovereign right of each country, consistent with national laws and development priorities, with full respect for the various religious and ethical values and cultural backgrounds of its people, and in conformity with universally recognized human rights".

Therefore, although moral suasion is exerted on countries by these declarations, there is no mechanism to enforce the implementation of particular aspects of the Programme of Action by countries which, for whatever reason, are reluctant to do so.

As noted earlier, although the Bali Declaration is the one that presents forcefully the need to reduce fertility rates in the interests of social and economic development, the Cairo document also recognizes the benefits to economic and social development resulting from lowering fertility in high-fertility societies. And although the Cairo Programme of Action provides the new paradigm of a population programme focused on reproductive health, the earlier Bali Declaration contains recommendations that are fully compatible with a reproductive health approach. For example, recommendation 19 of the Bali Declaration states 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 and spread of the human immunodeficiency virus and acquired immunodeficiency syndrome.

The recommendations of the Bali Declaration were divided into the following 10 sections:

Population, environment and development
Urbanization, internal and international migration
Family planning and maternal and child health
Population and human resources development
Women and population
Population and poverty alleviation
Mortality and morbidity
Ageing
Population data, research and information dissemination
Resource mobilization

The Cairo Programme of Action is a much more detailed document. Its structure and chapter headings reflect both the shifts of emphasis and the important elements of continuity in the two conferences. Shifts of emphasis are reflected in the highlighting of the chapter "Gender equality, equity and empowerment of women" by placing it near the front of the document, immediately after the chapter on population and development; including a chapter on the family; subsuming family planning in a chapter entitled "Reproductive rights and reproductive health"; including a chapter on education, but not (as in the Bali document) on human resources development or on ageing; and including much more detailed materials about follow-up, divided into four chapters-on national action, international cooperation, partnership with the non-governmental sector, and follow-up to the Conference. Some of these changes are undoubtedly not terribly important, reflecting simply a different organizational approach rather than a symbolically important change. For example, ageing is dealt with in the Cairo document as a subheading rather than a chapter heading; the same is true of poverty alleviation. But the increased emphases on gender, empowerment of women and reproductive health are undoubtedly crucial, and are reflected throughout the content of the document and not only in its basic structure. The absence of a chapter on "human resources development" is probably also important, reflecting disagreement with the "instrumentalist" flavour of much writing on human resources development and agreement with the need for a broader view of "human development" including the concepts of well-being, freedom and empowerment. The increased emphasis on cooperation with NGOs is also new, and reflects the major role played by these organizations in Cairo.

Other important indications of evolution of thinking between the Bali and Cairo documents are the inclusion in the Cairo Programme of Action of a section on adolescents in the key chapter on reproductive rights and reproductive health, and of a section on HIV/AIDS, which was in fact dealt with in the Bali Declaration, though given less prominence. Issues of adolescent reproductive health, however, were entirely missing from the Bali document. Even at the time, this was a serious omission, and is even more so today, with lengthening periods of sexual maturity before marriage and evidence of increasing levels of premarital sexual activity in many countries of the region. The Cairo emphasis therefore represents a real step forward in bringing the needs of adolescents fully into the spotlight and forcing planners to take a realistic approach to issues of life-and-death importance to many young people.

The elements of continuity between the Bali and Cairo documents should also be noted. These include a primary health-care focus in the discussion of health issues, similar treatment of the issues of migration and urbanization, and calls for the integration of demographic factors in development planning and for a range of research and training to support population policies.

There are many remaining questions in implementing the Cairo approach to population and development. One concerns the broadening and perhaps reduced precision of the mandate of population policy. As many have remarked, this is likely to lead to reduced donor interest. There is a clear need for continued efforts to explain and popularize the reproductive health approach and the emphasis it contains on increased individual freedom and on human development, broadly conceived. Hard-nosed donors concerned about the threat of rapid population growth also need to be convinced of its efficacy in reducing population growth rates. This is a case that can be made, but many feminist proponents of the approach avoid making it because they remain ambivalent about the goal of fertility reduction. Surely the time is ripe for a return to the emphasis on the joint contribution of family planning to women's welfare and to reduced fertility. It is certainly time to stress that a concern for reproductive health can be quite consistent with a simultaneous concern with larger questions of interventions to encourage fertility decline.

2. Clear objectives needed to guide programmes and maintain enthusiasm

As mentioned earlier, in India, efforts to introduce a target-free approach have met with considerable scepticism and confusion on the part of many officials and workers. The same can certainly be said of China and Indonesia. The family planning programmes involved are all very large, with a long-established way of doing things and an esprit de corps based on a belief that what is being done is important for national development and that it has met with a considerable degree of success. Negative reactions underline the need to maintain clear programme objectives and assessment procedures that can monitor worker performance without driving workers to inappropriate approaches. More will be said below on appropriate assessment procedures.

3. Reproductive health emphasis much needed to ensure humanitarian approaches and procedures

The Cairo emphasis on the empowerment of women and on a more humane attitude to women in the implementation of family planning programmes, though not new, was promoted so strongly that it has to be seen as a major contribution of the Cairo Conference. The benefit of such an emphasis in this region cannot be disputed. In societies that are both patriarchal and hierarchical in social structure (and this applies to a greater or lesser extent to most ESCAP members), the dangers of women becoming mere pawns in programmes aimed at fertility reduction are ever-present - despite the strong evidence that access to the knowledge and means to control their fertility brings enormous potential gains in welfare. Change in the attitudes of service providers in such contexts is crucial, to respect the dignity and worth of women and to take their rights seriously. Such attitudes have to be promoted from the top to the bottom of the health and family planning hierarchy. There have been numerous examples of a casual attitude to the rights of women, of the poor, and especially of poor women, leading to inexcusable excesses, oversights and casualness in applying basic principles in the provision of health and family planning services.

4. Urbanization and migration issues

There was not much change in emphasis on these issues between the Bali and Cairo documents. The ESCAP region, though it has reached an urbanization level of only about 37 per cent (or indeed because it has reached only this level), poses enormous planning issues in relation to urban growth. The potential for rural-urban migration remains immense, and the gradual "urbanization" of rural populations, particularly in the shadow area of large cities, provides both challenges and opportunities. The region contains 11 of the world's 20 largest megacities. The planning issues of these megacities constitute a great challenge, and understanding their demographic dynamics, for the megacities as a whole and for their component districts, is necessary for effective planning.

It is important to note new challenges for countries of the ESCAP region related to the transitional state of the economies of Central Asia and of the economic crisis facing East and South-East Asia. The transition has resulted in a substantial movement of ethnic Russians from other countries of the former Soviet Union, resulting in negative rates of population growth in a number of Central Asian republics. The economic crisis has resulted in the announcement by both Malaysia and Thailand of policies to repatriate large numbers of foreign workers-understandable in the light of contracting employment in these countries, but bringing increased problems to neighbouring countries, notably Indonesia and Myanmar, which have come to rely on both the release of pressure on local labour markets and the remittances brought in by migrant workers.

5. Integrating population into development planning

The need to understand the interrelationship between demographic and other elements of development has long been recognized in the ESCAP region, and many countries have a long history of work in this area. Others, however, have not. The Cairo approach implies some modifications to traditional ways of viewing this interrelationship, with emphasis on a holistic approach stressing poverty alleviation and sustainable development. It remains very important, however, to conduct the demographic analyses and population projections that can provide the basis for country-specific population and development status reports, and to analyse the developmental implications of sharp changes in growth rates and shares of different age groups in the population that are taking place in the region (Higgins and Williamson, 1997; Jones, 1997; Hugo, 1996).

F. Funding problems

A major problem facing the population community since Cairo has been a major shortfall in funds from donor agencies, both multilateral and bilateral, and the difficulty of generating sufficient domestic funds to enable the full Programme of Action to be carried out. The Programme estimated that on a global scale, $17 billion would be needed in 2000, of which $10.2 billion would be needed for family planning, $5.0 billion for the additional reproductive health component, a further $1.3 billion for STDs/HIV/AIDS programmes and $500 million for research, data, and policy analysis. It was estimated that overall, about one third of these costs would need to be covered from external sources - about $5.7 billion in 2000. These funds have not been forthcoming, for a variety of reasons. "Aid fatigue" appears to be widespread in Western countries. Whether, in addition, donors have been less interested in contributing to the Cairo programme of Action because of a perceived downplaying of the urgency of fertility reduction (e.g. Caldwell, 1996) is hard to assess.

What is clear is that countries of the ESCAP region are being forced to rely more on domestic sources than the Cairo document envisaged. The impact of the funding shortfall will unfortunately be most severe in high-fertility countries, which also tend to be the poorer countries of the region. It will also pose grave difficulties for a number of East and South-East Asian countries in the current climate of financial crisis and recession. Another unfortunate result will be to pose barriers to the further development of South-South approaches.

In this context, the need for effective utilization of all available financial resources is clearly crucial. providing high-quality reproductive health services is expensive, and many of the shortcomings currently observed result from infrastructure deficiencies. Financial shortfalls will therefore militate against the achievement of goals. To sound an optimistic note, however, it is also clear that in reorienting health and family planning services to a reproductive health approach, much can be done without any additional expenditure of funds, because what is crucial is often reorganization of services and reorientation of attitudes on the part of service providers. Faundes (1996) argues, based on Latin American experience, that there are good prospects for primary health-care budgets to be increased, and for women's reproductive health to gain a greater share of these budgets; that underutilization of facilities and improper use of human resources could be redressed by improvements in management, logistics and supervision; that the extra workload required by longer time spent with clients initially will reduce subsequent workloads because of better understanding and less need for follow-up care; and that adding family planning services to primary health-care centres could quickly increase access to family planning services. Most of these arguments probably hold true in many countries of the ESCAP region as well.

A final point to make here is that many of the policies stressed in the Programme of Action are policies which are likely to be followed quite apart from their effect on population and women's empowerment: for example, education, poverty alleviation, the environment and labour market policies. The additional spin-offs of their support in the Cairo agenda provide an additional reason for funding these policies and may lead to a stronger level of support than would otherwise have been forthcoming. Although such additional support is not included as part of the population funding package required, it may have important demographic consequences.

G. Some key issues in implementation

1. Will a well-implemented reproductive health programme lower fertility?

One argument made by many critics of the Cairo agenda is that the reproductive health approach will dilute family planning efforts and lead to a diminished impact on fertility. This has a plausible ring to it, as reproductive health approaches require more investment in health services not directly related to family planning. On the other hand, the conclusion is contested by others, on the grounds that the uptake of family planning would be higher if services were planned with community involvement, and oriented towards client needs, offering them real choices and paying more attention to them as individuals and to their total circumstances. A paper by Sinding, Ross and Rosenfield (1994) argued that if women could have only the number of children they desired, the effect on total fertility rates would more than exceed the governments' targets for fertility reduction in 13 out of 17 countries whose governments had quantitative targets to reduce fertility. On a world scale, depending on whether a more conservative or liberal definition of unmet need was used, meeting this unmet need would bring developing country fertility below that of the United Nations medium projection or even approach the low projection.

How realistic is it, though, to argue that the reproductive health approach could lead to a complete meeting of unmet need? Sinding and others recognize that this cannot be achieved quickly. Even to meet the conservative estimate of 17 per cent of unmet need in the developing world, excluding China, would mean raising the contraceptive prevalence from about 42 to 59 per cent. To achieve such an increase within seven years would be impossible, if historic experience is any guide, because of the limited human and material infrastructure for reproductive health programmes in many countries. But the increase could almost be achieved in 10 years. A focus on unmet need, they argue, cannot guarantee either the early satisfaction of all need or a rapid reduction in fertility. But the same can be said of demographic targets. Both approaches require a continued expansion of service outreach towards the underserved and continued efforts to improve contraceptive technology and raise programmatic standards. The difference in the two approaches is in their assumptions and in their approaches to the public.

2. New assessment procedures

Effective performance monitoring and evaluation are needed to ensure that the design and implementation of essential packages of reproductive health services are giving value for money. Selection of appropriate indicators, the levels of the system to apply them and the frequency of measurement are essential parts of the design of a strategy. A reproductive health approach requires new assessment procedures, stressing different factors from those traditionally used to measure the productivity of family planning programmes and of individual workers. Accountability measures are needed of how well client needs are met, including client satisfaction and unmet need. The need for such new assessment procedures is pressing, particularly in programmes where rigid criteria have been used in the past and where, without them, managers fear that workers will slacken their efforts. Some work has been done along these lines, including Jain's HARI index (Helping Individuals Achieve their Reproductive Intentions), the COPE model of the Association for Voluntary Contraception, with more of a management emphasis, and indicators developed by WHO (Mancey-Jones and Graham, 1997). UNFPA (1997) has recently developed a set of indicators which covers not only reproductive health but also the other main foci of UNFPA in the post-Cairo period: population and development strategies and advocacy/IEC.

3. Issues of integration of family planning with health and other social policies

Reproductive health is often understood as adding service components to existing programmes. But it actually requires institutional structures that promote a holistic perspective and a weaving together of services through gender-sensitive quality care (Satia, 1997: 357-358). Caldwell (1996: 71-72) has raised some crucial issues on the integration of family planning into reproductive health programmes, based on the conditions prevailing in many developing countries. He stresses the need to focus on "the extent to which the identification of reproductive ill-health is possible in remote rural areas and urban slums of very poor countries; the possibility of effective treatment; whether the costs would cripple or limit family planning programmes; and whether family planning programmes should proceed in areas where full reproductive health cannot be guaranteed". A wide range of practical issues must be faced in moving ahead with a reproductive health approach in countries whose health services are severely lacking in facilities and personnel. To give just one example, countries must decide whether paramedical staff can prescribe antibiotics to treat some reproductive tract infections and STDs. "Some NGOs and government programmes have demonstrated that it is possible to deliver a wide range of reproductive health services utilizing paramedical staff. Beyond creating commitment and an enabling environment, two aspects will need attention: innovative and appropriate IEC and counselling, and a referral network. How effectively the government can provide them on a large scale remains an open issue" (Satia, 1997:358).

As Tom Merrick has noted, the design of a cost-effective reproductive health programme requires a participatory process involving all major stakeholders, including technical experts as well as potential consumers of services, the community, front-line providers in both public and private sectors, programme managers, health advocates and donors. While the content of a basic package of reproductive health services, including prevention of unwanted pregnancy, safe pregnancy and delivery, prevention and management of reproductive tract infections and STDs, as well as interventions to prevent harmful practices and promote positive ones, has been identified, the key issue is how to deliver such a package in specific country settings (WHO, 1997; Tsui and others, 1997). The capacity of facilities at various levels to deliver the package needs to be assessed, as well as the skills of providers, the adequacy of support, procurement and logistics systems, and management capacity.

The Cairo Conference saw fierce debate about the role of abortion and whether it should ever be seen as an acceptable method of birth control. Abortion is illegal in many countries of the ESCAP region, although this does not prevent it from happening, often under unsafe and unhygienic conditions. The Programme of Action deals with the problem of unsafe abortion, which has to be seen as a serious issue for a reproductive health programme. Many abortions result from the sexual activity of unmarried youth, and this also represents a key challenge to reproductive health programmes. As a highly sensitive issue, there is a tendency to ignore it or take unrealistic approaches to dealing with it that may satisfy conservative elements in the older generation but fail to come to grips with the real issues. In the light of the growing danger of HIV/AIDS, there is no room for prudery or unrealistic attitudes that place the welfare and indeed the lives of the young at risk.

4. Other specific issues in implementing a reproductive health approach

Enhancing reproductive health involves both turning needs into demands, particularly the need for treatment of conditions that are chronic or asymptomatic in women, and ensuring a supply of good-quality services to meet that demand. To create the demand before there is a supply could result in frustration. The reproductive health approach is consistent with - and perhaps requires - the greater involvement of the community in the programme. But community participation is frequently observed more in rhetoric than in reality, and top-down government programmes normally have great difficulty in opening themselves to effective community participation (Askew and Khan, 1990). The focus of reproductive health programmes on meeting a broader range of needs through providing services with immediate and tangible benefits should make community participation more feasible. However, it would still require the sensitization of community leadership to the importance of reproductive health programmes.

The role of civil society in reproductive health programmes needs to be actively promoted. In particular, NGOs played a major role in establishing the reproductive health focus in Cairo. They also have much to offer in implementation of the approach, and this potential needs to be fully utilized, particularly in view of funding shortfalls which will limit the reach of government programmes.

Finally, cost considerations are crucial. Estimates of the cost of reproductive tract infection case management under various assumptions of infection loads and utilization scenarios in India are formidable (Rama Rao and others, 1996). Ways must be found to reduce costs without sacrificing the quality of care.

5. Training and research

The reproductive health approach implies massive retraining needs. This is because upgrading of skills and reorientation of attitudes of workers at all levels of health and family planning programmes are required towards the new approaches and the wider responsibilities given to them. Physicians, midwives and laboratory and medical technicians will need their clinical, technical and interpersonal skills upgraded. Training needs in other areas promoted by the Cairo Programme of Action should also not be ignored. Monitoring and explanation of demographic trends, policy analysis and the range of social science-based research needs noted below will be impossible to meet in many countries without giving attention to the training of demographers and particularly of those able to link demography with economic, sociological, anthropological and other approaches to understanding human behaviour.

The research needs of the Programme of Action are sufficiently wide and complex to far exceed the likely availability of funds. This will require careful prioritizing of research needs. Clearly, demographic surveys of the traditional kind do not go far towards answering many of the questions demanding answers if reproductive health programmes are to be soundly knowledge- based. For example, traditional demographic surveys do not survey the young and unmarried, nor do they investigate abortion. They do not analyse effectively the social context of decision-making, whether in the family, the community or within government agencies. They do not investigate sexuality, the power relationships between men and women or between children and their parents, or the negotiation of fertility decisions. A range of research methods will be required if such research issues are to be addressed effectively.

A great deal of applied demographic research will be needed in order to guide the effective development of reproductive health programmes. The costs and benefits of alternative modes of service delivery need to be assessed based on a broader understanding of desired outcomes. Operations research, assessment of content and delivery of IEC messages, and programme evaluation techniques will all need to be pressed into service.

Beyond this, the vexed issues of the interrelationship between demographic and socio-economic development require further assessment in individual country contexts. Population-development status reports are needed for each country, stressing interrelationships between demographic structure and dynamics, the poverty situation, and human development, including gender equity and the reproductive health situation.

H. Conclusions

The Cairo agenda has taken population policy into new paths that require action on a wide front. A narrow perspective on the agenda leads to worries that it will serve to restrict family planning efforts. A broader perspective is that it promotes a range of policies to generate conditions conducive to smaller family size. The earlier approach highlighting family planning gave a spurious impression of the power of family planning programmes to reduce fertility - or failed to identify the downside of coercive programmes that did have a forceful impact on fertility - and downplayed other forces. Concern over dilution of the scarce resources available for family planning can be allayed by stronger government commitment, including the commitment of resources, to broader reproductive health goals. Health spending has arguably long been skimped in the budgets of most countries, and a more comprehensive understanding of the benefits of improved health should result in greater budgetary commitment. Much of the social investment advocated by the Cairo Programme of Action requires a reassessment of development budgets. What is required is a rethinking of human development strategies rather than the investment required for family planning.

The implementation of the Cairo consensus is a task that still provides major challenges. But it needs more than just implementation: it needs careful reassessment to prevent it from falling prey to the dogmatism that some of its strongest supporters have accused the traditional population movement of sinking into, "even if this time it is dogmatism with a human face" (Basu, 1997: 11). Both individual country governments and the multilateral and bilateral agencies assisting them in implementing the Cairo Programme of Action must be willing to recognize faults and shortcomings in the Programme as well as unanticipated difficulties that arise in attempts to implement it. Flexibility and imagination in adapting programmes to overcome these difficulties will enable its ideals to be better realized.

End Notes

* Head, Division of Demography and Sociology, The Australian National University, Canberra.

1 Pravin Visaria, "Population and development policies and strategies in the context of the rapidly changing macroeconomic environment", paper No. III in the present publication.

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