Family Planning in Asia and the Pacific - International Council on ...

<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong><strong>in</strong> <strong>Asia</strong> & The <strong>Pacific</strong>:Address<strong>in</strong>g The Challenges<strong>International</strong> <strong>Council</strong> onManagement of Population Programmesi

Table ofContentsTitlesForewordPagesv - vi<strong>Asia</strong> <strong>and</strong> <strong>Pacific</strong> Call for <strong>the</strong> Elim<strong>in</strong>ation ofUnmet Need for <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> 1 - 9Report on UNFPA <strong>and</strong> ICOMP Regional Consultation on<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong>: Address<strong>in</strong>g <strong>the</strong> Challenges 11 - 37<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Programmes <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong> <strong>and</strong> Achiev<strong>in</strong>gMillennium Development Goal 5*Amy o. Tsui 39 - 60<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> Isl<strong>and</strong>s: Current Status <strong>and</strong> Prospects forReposition<strong>in</strong>g <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> on <strong>the</strong> Development AgendaGeoffrey Hayes <strong>and</strong> Annette Robertson 61 - 102The Bangladesh <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Programme:Achievements, Gaps <strong>and</strong> <strong>the</strong> Way ForwardBarkat-E-Khuda <strong>and</strong> Samiha Barkat 103 - 125<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> Fertility <strong>in</strong> IndiaAnrudh K. Ja<strong>in</strong> <strong>and</strong> Aparna Ja<strong>in</strong> 127 - 151The Status of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> Reproductive Health <strong>in</strong><strong>the</strong> Republic of MaldivesBhanu Bhakta Niraula 153 - 168The Status of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> Reproductive Health <strong>in</strong> NepalAn<strong>and</strong> Tamang, Gov<strong>in</strong>d Subedi <strong>and</strong> Ca<strong>the</strong>r<strong>in</strong>e Packer 169 - 198Status of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>in</strong> PakistanZeba Sathar <strong>and</strong> Batool Zaidi 199 - 216v

ForewordThe <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong> Regional Office of <strong>the</strong> United Nations Population Fund (UNFPA) <strong>and</strong> <strong>the</strong><strong>International</strong> <strong>Council</strong> on Management of Population Programmes (ICOMP) hold <strong>the</strong> RegionalConsultation on <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong>: Address<strong>in</strong>g <strong>the</strong> Challenges <strong>in</strong> Bangkok from 8to 10 December 2010.The objective of <strong>the</strong> consultation was to ga<strong>in</strong> support from <strong>the</strong> Governments <strong>and</strong> civil societies to prioritize familyplann<strong>in</strong>g programmes <strong>and</strong> <strong>in</strong>crease <strong>in</strong>vestments <strong>in</strong> family plann<strong>in</strong>g <strong>in</strong> order to achieve <strong>the</strong> MDGs, <strong>and</strong> especially,universal access to reproductive health.Although ICPD was emphatic <strong>in</strong> its support to family plann<strong>in</strong>g, many feel that <strong>in</strong> <strong>the</strong> decade that followed,<strong>and</strong> beyond, family plann<strong>in</strong>g has suffered <strong>and</strong> stalled because it did not receive <strong>the</strong> priority that it should havereceived. Political, programmatic <strong>and</strong> f<strong>in</strong>ancial commitments are said to be wan<strong>in</strong>g. These trends have set off analarm bell dur<strong>in</strong>g recent years. This is seen by many as an obstacle to poverty reduction <strong>and</strong> as contribut<strong>in</strong>g to <strong>the</strong>deterioration of <strong>the</strong> environment <strong>and</strong> climate change. Moreover, it is also seen as h<strong>in</strong>der<strong>in</strong>g efforts to achieve o<strong>the</strong>rreproductive health goals, <strong>in</strong>clud<strong>in</strong>g reduction <strong>in</strong> MMR <strong>and</strong> child mortality as well as for stemm<strong>in</strong>g <strong>the</strong> spread ofHIV/AIDS. Therefore, <strong>the</strong>re has been a grow<strong>in</strong>g chorus of calls to reposition <strong>and</strong> revitalize family plann<strong>in</strong>g aspart of <strong>the</strong> development agenda <strong>in</strong> <strong>the</strong> com<strong>in</strong>g years.The Consultation was convened at <strong>the</strong> time when governments <strong>and</strong> donors recognise <strong>the</strong> need for enhanced effortsfor revitaliz<strong>in</strong>g family plann<strong>in</strong>g as part of <strong>the</strong> development agenda <strong>in</strong> <strong>the</strong> com<strong>in</strong>g years. It is evident that improv<strong>in</strong>g<strong>the</strong> access to family plann<strong>in</strong>g is one of <strong>the</strong> most cost-effective ways of reduc<strong>in</strong>g <strong>in</strong>fant <strong>and</strong> maternal mortality.Slower population growth leads to <strong>the</strong> demographic transition, which offers a w<strong>in</strong>dow of demographic dividend<strong>and</strong> also opportunity for <strong>the</strong> countries to make effective <strong>in</strong>vestments <strong>in</strong> health <strong>and</strong> education thus lead<strong>in</strong>g tosusta<strong>in</strong>able socio-economic development.The Consultation reviewed <strong>the</strong> current situation of fertility decl<strong>in</strong>e <strong>and</strong> status of family plann<strong>in</strong>g programmes <strong>in</strong>selected countries <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong>. Specifically <strong>the</strong> Conference focused on <strong>the</strong> successes <strong>and</strong> challenges facedby countries <strong>in</strong> implement<strong>in</strong>g <strong>the</strong>ir family plann<strong>in</strong>g programmes followed by <strong>the</strong>matic sessions on key componentsof a susta<strong>in</strong>able family plann<strong>in</strong>g programmes such as reproductive health commodity security; fund<strong>in</strong>g for familyplann<strong>in</strong>g programmes; <strong>in</strong>equality <strong>in</strong> access; quality of care <strong>and</strong> meet<strong>in</strong>g <strong>the</strong> needs of special groups <strong>in</strong>clud<strong>in</strong>gyoung people.The <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong> Call for <strong>the</strong> Elim<strong>in</strong>ation of Unmet Needs for <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> endorsed at <strong>the</strong> end of<strong>the</strong> Consultation urged <strong>the</strong> governments <strong>and</strong> stakeholders to ensure equitable access to quality family plann<strong>in</strong>g<strong>in</strong>formation <strong>and</strong> services. Ten strategic actions were proposed to <strong>the</strong> governments <strong>and</strong> stakeholders to fur<strong>the</strong>rcommit to universal access to family plann<strong>in</strong>g, especially to address unmet need, with<strong>in</strong> <strong>the</strong> context of sexual <strong>and</strong>reproductive health, with particular focus on <strong>the</strong> underserved.Approximately 160 high-level officials represent<strong>in</strong>g 23 countries <strong>in</strong> <strong>the</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong> region, nongovernmentalorganisations, development partners, <strong>and</strong> United Nations agencies attended <strong>the</strong> Consultation. Wewould like to express our gratitude to <strong>the</strong> <strong>in</strong>puts <strong>and</strong> active participation from <strong>the</strong> participants that contributedto <strong>the</strong> success of <strong>the</strong> Conference.vii

The present publication conta<strong>in</strong>s <strong>the</strong> Call for Elim<strong>in</strong>ation of Unmet Need of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>, report of <strong>the</strong>Regional Consultations <strong>and</strong> background papers, which provide a detailed on <strong>the</strong> status of family plann<strong>in</strong>g <strong>in</strong> <strong>the</strong><strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong>.It is our hope that this publication will serve as a valuable resource for those <strong>in</strong>volved <strong>in</strong> reproductive health <strong>and</strong>family plann<strong>in</strong>g programmes <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong> region.Nobuko HoribeRegional DirectorUNFPAWasim Zaman, PhDExecutive DirectorICOMPviii

Part 1Part 1<strong>Asia</strong> <strong>and</strong> <strong>Pacific</strong> Call for <strong>the</strong> Elim<strong>in</strong>ation ofUnmet Need for <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Report on UNFPA <strong>and</strong>ICOMP Regional Consultation on<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong>:Address<strong>in</strong>g <strong>the</strong> Challenges1

<strong>Asia</strong> <strong>and</strong> <strong>Pacific</strong> Call for<strong>the</strong> Elim<strong>in</strong>ation of Unmet Needfor <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Preamble1. The impact of well-planned family plann<strong>in</strong>g policies<strong>and</strong> programmes <strong>in</strong> <strong>the</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong> regionis evident from <strong>the</strong> significant reductions <strong>in</strong> fertility,<strong>in</strong>creases <strong>in</strong> contraceptive use <strong>and</strong> decreases <strong>in</strong> unmetneed for contraception <strong>in</strong> most countries <strong>in</strong> <strong>the</strong> regionover <strong>the</strong> past 20 years. However, <strong>in</strong> some countries,despite hav<strong>in</strong>g national family plann<strong>in</strong>g programmes,contraceptive prevalence rates have stagnated <strong>and</strong>unmet need for family plann<strong>in</strong>g has <strong>in</strong>creased, due topoor access to services, ongo<strong>in</strong>g conflict, <strong>and</strong> significantreligious <strong>and</strong> socio-cultural <strong>in</strong>fluences. The high levelsof term<strong>in</strong>ation of pregnancies signify a high unmetneed for contraception <strong>and</strong> unsafe abortions lead tomaternal deaths.2. Even <strong>in</strong> countries with lowered fertility rates, variations<strong>in</strong> unmet need for family plann<strong>in</strong>g exists acrosscommunities <strong>and</strong> needs to be addressed. Disparitiesbetween <strong>the</strong> lowest <strong>and</strong> highest economic qu<strong>in</strong>tileswith regard to total fertility, contraceptive use <strong>and</strong>unmet need are significant <strong>in</strong> most countries.3. While many countries, particularly <strong>in</strong> South-east <strong>Asia</strong>,are on track to achieve a majority of <strong>the</strong> MillenniumDevelopment Goal (MDG) targets, a significantnumber are lagg<strong>in</strong>g beh<strong>in</strong>d <strong>in</strong> achiev<strong>in</strong>g health-relatedMDGs. The possibility of achiev<strong>in</strong>g both targets ofMDG 5 (a: reduce maternal mortality <strong>and</strong> b: achieveuniversal access to reproductive health services) <strong>in</strong> somecountries of <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong> is small. Susta<strong>in</strong>ablecross-sectoral family plann<strong>in</strong>g related policies <strong>and</strong>programmes are needed given <strong>the</strong> lack of recognitionof <strong>the</strong> importance of family plann<strong>in</strong>g to economic <strong>and</strong>social development <strong>and</strong> poverty reduction as well as<strong>the</strong> lack of women’s empowerment.4. Recent analysis of countries <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong>offers strong evidence that meet<strong>in</strong>g <strong>the</strong> need for familyplann<strong>in</strong>g can accelerate <strong>the</strong> achievement of <strong>the</strong> MDGs.Invest<strong>in</strong>g <strong>in</strong> family plann<strong>in</strong>g alone can contributeto reduc<strong>in</strong>g <strong>the</strong> costs of achiev<strong>in</strong>g MDG targets foreducation, child mortality, maternal mortality <strong>and</strong>environmental susta<strong>in</strong>ability. In addition, provid<strong>in</strong>gfamily plann<strong>in</strong>g methods for women who are HIVpositive <strong>and</strong> want to use family plann<strong>in</strong>g methods,will reduce costs related to prevent<strong>in</strong>g mo<strong>the</strong>r-to-childtransmission of HIV <strong>and</strong> support of orphans.5. Although family plann<strong>in</strong>g is an <strong>in</strong>tegral part of <strong>the</strong>agenda agreed at <strong>the</strong> 1994 <strong>International</strong> Conferenceon Population <strong>and</strong> Development (ICPD), <strong>in</strong>vestments<strong>in</strong> family plann<strong>in</strong>g by many countries <strong>and</strong> donorshave decl<strong>in</strong>ed drastically, result<strong>in</strong>g <strong>in</strong> stagnation ofprogramme achievements.6. The high proportion of young people enter<strong>in</strong>greproductive age groups, <strong>in</strong> many <strong>Asia</strong> <strong>and</strong> <strong>Pacific</strong>Isl<strong>and</strong> countries has significant implications forappropriate contraceptive service. The <strong>in</strong>creas<strong>in</strong>gproportion of unmarried young people—a populationgroup whose contraceptive needs are not well met <strong>in</strong>many <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> Isl<strong>and</strong> countries, <strong>the</strong> low useof contraceptives among married <strong>and</strong> unmarried <strong>and</strong>disturb<strong>in</strong>g rates of abortions signify <strong>the</strong> need forreorient<strong>in</strong>g contraceptive services to those underservedgroups most <strong>in</strong> need. O<strong>the</strong>r groups <strong>in</strong> need of specialattention <strong>in</strong>clude older women, poor <strong>and</strong> uneducatedwomen, <strong>and</strong> migrants.GoalThe goal of <strong>the</strong> “<strong>Asia</strong> <strong>and</strong> <strong>Pacific</strong> Call for Elim<strong>in</strong>ationof Unmet Need for <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>” is for countries<strong>in</strong> <strong>the</strong> <strong>Asia</strong> <strong>Pacific</strong> Region, particularly governments,parliamentarians, non-governmental organizations, civilsociety groups, private sector <strong>and</strong> development partners,to ensure equitable access to quality family plann<strong>in</strong>g<strong>in</strong>formation <strong>and</strong> services, irrespective of <strong>the</strong>ir age, maritalstatus, residence, ethnicity or religion <strong>and</strong> thus elim<strong>in</strong>ateunmet need for contraception.Guid<strong>in</strong>g Pr<strong>in</strong>ciplesThe participants of <strong>the</strong> ” <strong>Asia</strong> <strong>Pacific</strong> Regional Consultationon Address<strong>in</strong>g <strong>the</strong> Challenges for <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>” were <strong>and</strong>cont<strong>in</strong>ue to be guided by <strong>the</strong> follow<strong>in</strong>g set of pr<strong>in</strong>ciples:Implement<strong>in</strong>g a rights based approach to familyplann<strong>in</strong>g;Address<strong>in</strong>g unmet need for family plann<strong>in</strong>g for allpersons regardless of age, marital status, gender,education, residence, ethnic group, <strong>in</strong>come <strong>and</strong>religion;3

Ensur<strong>in</strong>g that <strong>in</strong> <strong>the</strong> health system family plann<strong>in</strong>g ispromoted as an essential component of sexual <strong>and</strong>reproductive health;Maximis<strong>in</strong>g opportunities for family plann<strong>in</strong>g throughan <strong>in</strong>tegrated approach with<strong>in</strong> <strong>the</strong> health system;Engag<strong>in</strong>g multiple sectors to adopt family plann<strong>in</strong>g as anational development issue;Promot<strong>in</strong>g family plann<strong>in</strong>g <strong>in</strong>formation <strong>in</strong> a culturallyappropriate <strong>and</strong> gender sensitive manner.Proposed strategiesEach participat<strong>in</strong>g <strong>Asia</strong> <strong>and</strong> <strong>Pacific</strong> government <strong>and</strong>partner <strong>the</strong>refore recommends <strong>the</strong> follow<strong>in</strong>g strategiesto fur<strong>the</strong>r commit to universal access to family plann<strong>in</strong>g,especially to address unmet need, with<strong>in</strong> <strong>the</strong> context ofsexual <strong>and</strong> reproductive health, <strong>and</strong> with particular focuson <strong>the</strong> underserved:1. Enhanc<strong>in</strong>g leadership, governance <strong>and</strong> politicalcommitment for reposition<strong>in</strong>g family plann<strong>in</strong>g<strong>in</strong> <strong>the</strong> national development agenda2. Rais<strong>in</strong>g <strong>and</strong> susta<strong>in</strong><strong>in</strong>g adequate f<strong>in</strong>ancialresources for ensur<strong>in</strong>g universal access tofamily plann<strong>in</strong>g <strong>in</strong>formation, services <strong>and</strong>commodities,3. Improv<strong>in</strong>g <strong>the</strong> quality <strong>and</strong> coverage of familyplann<strong>in</strong>g <strong>in</strong>formation <strong>and</strong> service delivery toensure free <strong>and</strong> <strong>in</strong>formed choice through <strong>the</strong>provision of a broader range of methods for all,<strong>in</strong>clud<strong>in</strong>g <strong>the</strong> underserved groups4. Empower<strong>in</strong>g <strong>in</strong>dividuals, especially <strong>the</strong>underserved, <strong>and</strong> communities to exercise<strong>the</strong>ir rights to dem<strong>and</strong> <strong>and</strong> use family plann<strong>in</strong>g<strong>in</strong>formation <strong>and</strong> services5. Recogniz<strong>in</strong>g <strong>and</strong> respond<strong>in</strong>g to <strong>the</strong> uniqueneeds of young people for quality sexual <strong>and</strong>reproductive health <strong>in</strong>formation <strong>and</strong> services6. Ensur<strong>in</strong>g commodity security <strong>in</strong>clud<strong>in</strong>g policy,dem<strong>and</strong> creation <strong>and</strong> logistics management toensure susta<strong>in</strong>able supplies of a broad rangeof contraceptives to all, <strong>in</strong>clud<strong>in</strong>g underservedgroups7. Ensur<strong>in</strong>g an adequate <strong>and</strong> equitably distributedsupply of skilled human resources to providequality family plann<strong>in</strong>g <strong>in</strong>formation <strong>and</strong>services8. Streng<strong>the</strong>n<strong>in</strong>g partnerships <strong>and</strong> collaborationwith stakeholders, <strong>in</strong>clud<strong>in</strong>g religious groups,for mak<strong>in</strong>g family plann<strong>in</strong>g <strong>in</strong>formation <strong>and</strong>services available, accessible, acceptable <strong>and</strong>affordable to all9. Improv<strong>in</strong>g data collection <strong>and</strong> analysis ofdisaggregated data for monitor<strong>in</strong>g <strong>in</strong>equities<strong>and</strong> evaluat<strong>in</strong>g <strong>the</strong> impact of family plann<strong>in</strong>g forall10. Undertak<strong>in</strong>g operations <strong>and</strong> socio culturalresearch to improve knowledge base for policy<strong>and</strong> programm<strong>in</strong>g reformsDetailed strategies1. Enhanc<strong>in</strong>g leadership,governance <strong>and</strong> politicalcommitment for reposition<strong>in</strong>gfamily plann<strong>in</strong>g <strong>in</strong> <strong>the</strong> nationaldevelopment agenda<strong>in</strong>clude family plann<strong>in</strong>g, with<strong>in</strong> <strong>the</strong> context of maternal<strong>and</strong> child health <strong>and</strong> family health, <strong>in</strong> <strong>the</strong> national social<strong>and</strong> economic development agenda on a medium <strong>and</strong>long term perspective.enhance recognition of <strong>the</strong> l<strong>in</strong>ks between familyplann<strong>in</strong>g <strong>and</strong> environmental socio-economic resources<strong>and</strong> development <strong>and</strong> place high priority to relevantpolicies that promote family plann<strong>in</strong>g <strong>in</strong> <strong>the</strong> <strong>Asia</strong><strong>and</strong> <strong>Pacific</strong> region with<strong>in</strong> <strong>the</strong> context of nationaldevelopment progress;prioritize <strong>in</strong>vestment <strong>in</strong> access to family plann<strong>in</strong>g<strong>and</strong> o<strong>the</strong>r sexual <strong>and</strong> reproductive health services,emphasiz<strong>in</strong>g national policies <strong>and</strong> programmes thatwill reduce <strong>in</strong>equities <strong>in</strong> access to services <strong>and</strong> healthoutcomes. Ensure that this priority is protected,especially <strong>in</strong> situations of f<strong>in</strong>ancial <strong>and</strong> economic crisis<strong>and</strong> natural disaster;sensitize parliamentarians to <strong>the</strong> importance of familyplann<strong>in</strong>g <strong>in</strong>clud<strong>in</strong>g reproductive health commoditysecurity, <strong>and</strong> streng<strong>the</strong>n <strong>the</strong>ir leadership role <strong>in</strong>undertak<strong>in</strong>g evidence-based advocacy for <strong>in</strong>clusion offamily plann<strong>in</strong>g <strong>in</strong> <strong>the</strong> political agenda;ensure adequate resources are allocated for familyplann<strong>in</strong>g <strong>and</strong> efficiently used <strong>in</strong> a decentralised sett<strong>in</strong>gwhere decision-mak<strong>in</strong>g <strong>and</strong> resource allocation isdevolved to sub-national authorities;develop or streng<strong>the</strong>n measures to reposition familyplann<strong>in</strong>g, <strong>in</strong> <strong>the</strong> context of a rights-based <strong>and</strong> gendersensitiveapproach, <strong>in</strong> its national development agendathrough assess<strong>in</strong>g <strong>and</strong> identify<strong>in</strong>g:4

<strong>the</strong> extent to which family plann<strong>in</strong>g <strong>and</strong> sexual <strong>and</strong>reproductive health has been prioritised <strong>in</strong> <strong>the</strong> healthsystem, <strong>and</strong> with<strong>in</strong> health system streng<strong>the</strong>n<strong>in</strong>g effortsas well as streng<strong>the</strong>n<strong>in</strong>g of appropriate <strong>in</strong>stitutional<strong>and</strong> coord<strong>in</strong>ation l<strong>in</strong>kages <strong>in</strong> countries where familyplann<strong>in</strong>g <strong>and</strong> sexual <strong>and</strong> reproductive health are notmanaged from a s<strong>in</strong>gle <strong>in</strong>stitution;f<strong>in</strong>ancial, legal, <strong>and</strong> o<strong>the</strong>r barriers to access, especiallyfor disadvantaged, marg<strong>in</strong>alised <strong>and</strong> underservedgroups, such as adolescents;review <strong>and</strong>, where necessary, take steps to augmentpolicies <strong>and</strong> legislation that are appropriate for achiev<strong>in</strong>guniversal access to family plann<strong>in</strong>g <strong>and</strong> address<strong>in</strong>gunmet need for FP, <strong>in</strong> l<strong>in</strong>e with <strong>the</strong> goals of ICPD <strong>and</strong><strong>the</strong> MDGs, <strong>and</strong> ensure <strong>the</strong>ir effective implementation;streng<strong>the</strong>n a multi-sectoral approach to promote familyplann<strong>in</strong>g through engag<strong>in</strong>g wi<strong>the</strong>ducation: for sexuality <strong>and</strong> reproductive heal<strong>the</strong>ducation <strong>in</strong> schools;rural <strong>and</strong> community development: for promot<strong>in</strong>gcommunity-based <strong>in</strong>formation <strong>and</strong> services <strong>and</strong>engag<strong>in</strong>g civil society leaders, organizations <strong>and</strong>stakeholders;health: for family plann<strong>in</strong>g <strong>in</strong>formation, services <strong>and</strong>commodities delivery;women/gender: for promotion of empowermentof women to enhance <strong>in</strong>formed family plann<strong>in</strong>g<strong>and</strong> reproductive health decisions <strong>and</strong> for girl’seducation;f<strong>in</strong>ance <strong>and</strong> plann<strong>in</strong>g: for ensur<strong>in</strong>g family plann<strong>in</strong>g<strong>in</strong>clusion <strong>in</strong> national/sectoral plans <strong>and</strong> budgets;develop a monitor<strong>in</strong>g <strong>and</strong> accountability framework forensur<strong>in</strong>g implementation <strong>in</strong> an assertive <strong>and</strong> transparentenvironment.2. Rais<strong>in</strong>g <strong>and</strong> susta<strong>in</strong><strong>in</strong>gadequate f<strong>in</strong>ancial resourcesfor ensur<strong>in</strong>g universalaccess to family plann<strong>in</strong>g<strong>in</strong>formation, services <strong>and</strong>commoditiesadvocate for cont<strong>in</strong>u<strong>in</strong>g <strong>and</strong> <strong>in</strong>creased nationalgovernment <strong>in</strong>vestments <strong>in</strong> family plann<strong>in</strong>g for reduc<strong>in</strong>gunmet need;advocate for <strong>in</strong>creased resources from donors <strong>and</strong> o<strong>the</strong>rdevelopment partners, <strong>in</strong>clud<strong>in</strong>g <strong>in</strong>ternational f<strong>in</strong>ancial<strong>in</strong>stitutions, to meet unmet needs <strong>in</strong> countries which donot have adequate resources <strong>and</strong> to meet <strong>the</strong> needs of<strong>the</strong> poorest of <strong>the</strong> poor <strong>and</strong> o<strong>the</strong>r vulnerable or excludedpopulation;prepare evidence-based advocacy for mak<strong>in</strong>g <strong>the</strong> casefor <strong>in</strong>creased <strong>in</strong>vestment <strong>in</strong> family plann<strong>in</strong>g as <strong>the</strong>most cost-effective way to meet MDGs <strong>and</strong> stimulateeconomic growth <strong>and</strong> dim<strong>in</strong>ish poverty;provide additional fund<strong>in</strong>g to scale-up provenapproaches to reach<strong>in</strong>g <strong>the</strong> disadvantaged;engage with development partners for cont<strong>in</strong>uedsupport to <strong>the</strong> exist<strong>in</strong>g global f<strong>in</strong>anc<strong>in</strong>g mechanisms,such as <strong>the</strong> RHCS Coalition <strong>and</strong> <strong>the</strong> UNFPA’s GlobalProgramme to enhance reproductive health commoditysecurity;ensure f<strong>in</strong>ancial protection to meet dem<strong>and</strong> <strong>and</strong>services for family plann<strong>in</strong>g, especially for populationswho cannot afford, <strong>and</strong> explore <strong>in</strong>novative payments/<strong>in</strong>centives <strong>and</strong> <strong>in</strong>surance for meet<strong>in</strong>g <strong>the</strong> needs of <strong>the</strong>underserved; e.g., through <strong>in</strong>surance scheme or socialsafety net, conditional cash transfer, private publicpartnerships, <strong>and</strong> community participation;broaden <strong>the</strong> family plann<strong>in</strong>g resource base throughengag<strong>in</strong>g <strong>in</strong> public-private sector partnerships;ensure effective <strong>and</strong> efficient use of exist<strong>in</strong>g resourcesfor family plann<strong>in</strong>g, <strong>in</strong>clud<strong>in</strong>g pooled procurement;assess <strong>and</strong> report regularly on actual resource allocations<strong>and</strong> utilisation for advanc<strong>in</strong>g equitable access to familyplann<strong>in</strong>g <strong>and</strong> sexual <strong>and</strong> reproductive health at national<strong>and</strong> sub-national levels, <strong>in</strong>clud<strong>in</strong>g undertak<strong>in</strong>g cost<strong>in</strong>gstudies to plan sufficient resources for family plann<strong>in</strong>g;identify mechanisms for tagg<strong>in</strong>g resources <strong>in</strong> SWAps<strong>and</strong> pooled fund<strong>in</strong>g mechanisms, so that it is possible toascerta<strong>in</strong> <strong>the</strong> impact of contribution to family plann<strong>in</strong>g<strong>and</strong> its relative impact;ensure <strong>in</strong>clusion of family plann<strong>in</strong>g <strong>in</strong> a basic packageof health services <strong>and</strong> <strong>the</strong> national health <strong>in</strong>surancescheme;promote a closer coord<strong>in</strong>ation between <strong>the</strong> reproductivehealth/family plann<strong>in</strong>g department/agency <strong>and</strong> <strong>the</strong>HIV <strong>and</strong> maternal <strong>and</strong> newborn health departments tobe able to optimally use resources;ensure that national commitment to family plann<strong>in</strong>g/reproductive health is translated effectively <strong>in</strong> policies,programmes <strong>and</strong> budgets.3. Improv<strong>in</strong>g <strong>the</strong> quality <strong>and</strong>coverage of family plann<strong>in</strong>g<strong>in</strong>formation <strong>and</strong> servicedelivery to ensure free <strong>and</strong><strong>in</strong>formed choice, through <strong>the</strong>provision of a broader range5

of methods for all, <strong>in</strong>clud<strong>in</strong>g tounderserved groupsdesign programmes <strong>and</strong> policies to make familyplann<strong>in</strong>g <strong>and</strong> reproductive health services available toall, <strong>and</strong> close to where disadvantaged groups live <strong>and</strong>work through:encourag<strong>in</strong>g <strong>the</strong> culture of “no missed opportunities”by <strong>in</strong>tegrat<strong>in</strong>g family plann<strong>in</strong>g services <strong>in</strong>to healthservices <strong>and</strong> mak<strong>in</strong>g family plann<strong>in</strong>g a cross cutt<strong>in</strong>g<strong>the</strong>me,<strong>in</strong>stitut<strong>in</strong>g delivery systems <strong>and</strong> management supportto underserved areas such as urban slums, rural <strong>and</strong>remote areas, <strong>and</strong> <strong>in</strong>formal settlements throughcommunity based distribution,develop<strong>in</strong>g <strong>the</strong> most appropriate constellation ofpublic <strong>and</strong> private sector quality services to reachdisadvantaged populations <strong>in</strong> a cost effective mannerto reach all, <strong>in</strong>clud<strong>in</strong>g disadvantaged;<strong>in</strong>stitute l<strong>in</strong>kages or <strong>in</strong>tegration with MCH, STI <strong>and</strong>HIV with<strong>in</strong> <strong>the</strong> health system <strong>and</strong> primary health caresett<strong>in</strong>g to <strong>in</strong>crease opportunities for counsell<strong>in</strong>g forFP;ensure l<strong>in</strong>kages between family plann<strong>in</strong>g service <strong>and</strong>counsell<strong>in</strong>g <strong>and</strong> post-partum <strong>and</strong> post abortion care;promote <strong>the</strong> improvement of quality family plann<strong>in</strong>gthrough adopt<strong>in</strong>g evidence-based family plann<strong>in</strong>gguidel<strong>in</strong>es <strong>and</strong> tools for improved quality of care thatalso provide guidance for underserved groups <strong>and</strong><strong>in</strong>clude follow up of clients to ensure cont<strong>in</strong>uity ofcontraception use;ensure wide selection of safe, effective, affordable <strong>and</strong>accessible modern methods for <strong>in</strong>formed choice of allclients at all service delivery po<strong>in</strong>ts, where possible;undertake tra<strong>in</strong><strong>in</strong>g of service providers <strong>in</strong> counsell<strong>in</strong>gfor <strong>in</strong>formed choice of broad method mix, especially <strong>in</strong>communicat<strong>in</strong>g with clients with special communicationchallenges;<strong>in</strong>clude <strong>and</strong> exp<strong>and</strong> premarital counsell<strong>in</strong>g <strong>and</strong> providenewly married couples with family plann<strong>in</strong>g <strong>in</strong> allcommunities;promote programmes aimed at education <strong>and</strong> servicesfor young people focus<strong>in</strong>g ontra<strong>in</strong><strong>in</strong>g <strong>and</strong> supervis<strong>in</strong>g health professionals toprovide youth friendly services,ensur<strong>in</strong>g broad range of quality contraceptive optionsfor all young people, <strong>in</strong>clud<strong>in</strong>g most at risk youngpeople <strong>and</strong> unmarried women, especially options foreffective contraception <strong>and</strong> proper use of emergencyoral contraception,<strong>in</strong>clud<strong>in</strong>g adolescents, parents <strong>and</strong> teachers <strong>in</strong> <strong>the</strong>development <strong>and</strong> implementation of programmes;compulsory <strong>in</strong>clusion of curricula hours for <strong>in</strong>teractiveadolescent sexual <strong>and</strong> reproductive health <strong>in</strong> schoolhealth programmetailor services to people who are multiply disadvantaged(for example, by disability, HIV status, ethnicity,emergency situations) to overcome <strong>the</strong>ir particularconstra<strong>in</strong>ts to access <strong>and</strong> use of family plann<strong>in</strong>g <strong>and</strong>sexual <strong>and</strong> reproductive health services;<strong>in</strong>crease <strong>the</strong> number of community delivery outlets <strong>and</strong>community <strong>in</strong>formation/education to ensure reach<strong>in</strong>gunderserved groups through improv<strong>in</strong>g structures <strong>and</strong>encourag<strong>in</strong>g mechanisms for community based deliverysystems <strong>and</strong> community outreach;undertake quality assurance of services throughappropriate supervision with<strong>in</strong> <strong>the</strong> context ofdecentralized sett<strong>in</strong>gs <strong>and</strong> community based systems;promote family plann<strong>in</strong>g with<strong>in</strong> <strong>the</strong> socio-culturalcontext <strong>in</strong> a community based sett<strong>in</strong>g;identify l<strong>in</strong>kages of family plann<strong>in</strong>g with<strong>in</strong> o<strong>the</strong>rdimensions of sexual <strong>and</strong> reproductive health , such asprevention of sex selective foeticide <strong>and</strong> unsafe abortion,with<strong>in</strong> <strong>the</strong> country specific context.4. Empower<strong>in</strong>g <strong>in</strong>dividuals,especially <strong>the</strong> underserved,<strong>and</strong> communities to exercise<strong>the</strong>ir rights to dem<strong>and</strong> familyplann<strong>in</strong>g <strong>in</strong>formation <strong>and</strong>servicespromote culturally appropriate <strong>and</strong> gender sensitivebehavior change communication strategies to generate<strong>and</strong> susta<strong>in</strong> dem<strong>and</strong> for use of FP;orient providers to respect rights & choices <strong>and</strong> improveaccess to quality counsel<strong>in</strong>g services.<strong>in</strong>form <strong>in</strong>dividuals of <strong>the</strong>ir right to <strong>the</strong> full complement offamily plann<strong>in</strong>g <strong>in</strong>formation, services <strong>and</strong> commodities;<strong>in</strong>form <strong>in</strong>dividuals about <strong>the</strong>ir contraceptive options,<strong>the</strong> advantages <strong>and</strong> disadvantages of various options<strong>and</strong> enable <strong>the</strong>m to make an <strong>in</strong>formed decision aboutwhich method to adoptempower communities to seek accountability from <strong>the</strong>health system with regard to <strong>the</strong> provision of familyplann<strong>in</strong>g <strong>in</strong>formation, services <strong>and</strong> suppliespromote community based promotion <strong>and</strong> distributionof family plann<strong>in</strong>g <strong>in</strong>formation <strong>and</strong> commoditiesengage men <strong>and</strong> boys to take action with<strong>in</strong> <strong>the</strong>ir families6

<strong>and</strong> communities to challenge <strong>the</strong> status quo of gender<strong>and</strong> o<strong>the</strong>r <strong>in</strong>equalities <strong>and</strong> actively model social changeto improve access to family plann<strong>in</strong>g services for all <strong>in</strong>need.encourage greater participation of men <strong>in</strong> contraception,<strong>and</strong> dispel myths about male methods of contraception5. Recogniz<strong>in</strong>g <strong>and</strong> respond<strong>in</strong>gto <strong>the</strong> unique needs of youngpeople for quality sexual<strong>and</strong> reproductive health<strong>in</strong>formation <strong>and</strong> servicesrecognise <strong>the</strong> heterogeneity of youth, <strong>and</strong> <strong>the</strong> diverseneeds of different segments of youth, for example, <strong>the</strong>married <strong>and</strong> <strong>the</strong> unmarried, those <strong>in</strong> rural <strong>and</strong> urbanareas, those <strong>in</strong> <strong>and</strong> out of school etc, <strong>and</strong> promote <strong>in</strong>tersectorall<strong>in</strong>kages to enable effective <strong>and</strong> acceptable reachof services to youth <strong>in</strong> <strong>the</strong>se different circumstances ;promote enabl<strong>in</strong>g policies encompass<strong>in</strong>g <strong>the</strong> married<strong>and</strong> unmarried young people;streng<strong>the</strong>n mean<strong>in</strong>gful <strong>in</strong>volvement of young people,<strong>in</strong>clud<strong>in</strong>g <strong>the</strong> married people <strong>in</strong> policy <strong>and</strong> programmedevelopment;<strong>in</strong>stitute youth friendly service delivery mechanismsthat will facilitate youth access to contraceptive supplies,counsell<strong>in</strong>g <strong>and</strong> treatment <strong>in</strong> a non-threaten<strong>in</strong>g <strong>and</strong> safeenvironment;sensitise providers to shed traditional ambivalence orprejudices about provid<strong>in</strong>g sexual <strong>and</strong> reproductivehealth services to <strong>the</strong> unmarried <strong>and</strong> enhance <strong>the</strong>irskills <strong>in</strong> engag<strong>in</strong>g <strong>the</strong> unmarried.ensure access to comprehensive <strong>and</strong> age-appropriatesexual <strong>and</strong> reproductive health education, beg<strong>in</strong>n<strong>in</strong>g atan early age <strong>and</strong> prior to sexual <strong>in</strong>itiation both for youngpeople out of school, <strong>and</strong> those <strong>in</strong> school, <strong>and</strong> work toexp<strong>and</strong> sexuality education <strong>in</strong> schools <strong>and</strong> universitiesrecognize that <strong>in</strong> sett<strong>in</strong>gs <strong>in</strong> which child marriagepersists, married young women are particularlydisadvantaged <strong>and</strong> unlikely to seek care, <strong>and</strong> services for<strong>the</strong>m must <strong>in</strong>clude outreach <strong>and</strong> sensitive counsell<strong>in</strong>g;implement activities that promote more equitablerelationships <strong>and</strong> more open communication on sexual<strong>and</strong> reproductive health issues between young people<strong>and</strong> adult gate keepers <strong>and</strong> particularly parents;work towards more equitable cultural <strong>and</strong> gendernorms; engage men <strong>and</strong> boys to take action with<strong>in</strong> <strong>the</strong>irfamilies <strong>and</strong> communities to challenge <strong>the</strong> status quo ofgender <strong>and</strong> o<strong>the</strong>r <strong>in</strong>equalities <strong>and</strong> actively model socialchange to improve access to family plann<strong>in</strong>g services forall <strong>in</strong> need.6. Ensur<strong>in</strong>g commodity securitythrough establishment offavourable policy, f<strong>in</strong>anc<strong>in</strong>g<strong>and</strong> effective systems forsupply cha<strong>in</strong> management,to ensure susta<strong>in</strong>ablesupplies of a broad range ofcontraceptives to allundertake/update country situation analysis forimproved reproductive health commodity securityprogramm<strong>in</strong>g by:us<strong>in</strong>g disaggregated data, regional economic <strong>and</strong>education differences <strong>and</strong> disadvantaged groupsto underst<strong>and</strong> fully gaps for reproductive healthcommodity security,analys<strong>in</strong>g policy <strong>and</strong> programm<strong>in</strong>g barriers, e.g.procurement logistics, human resources needs<strong>and</strong> quality, for reproductive health commoditysecurity strategy for advocacy, cost effectiveness <strong>and</strong>predictable <strong>and</strong> susta<strong>in</strong>able fund<strong>in</strong>g <strong>in</strong>clud<strong>in</strong>g forconsideration at <strong>the</strong> sub-national level consider<strong>in</strong>gdevolved, decentralised systems;develop/update national reproductive health commoditysecurity strategies for advocacy; cost-effectiveness <strong>and</strong>predictable <strong>and</strong> susta<strong>in</strong>able fund<strong>in</strong>g, <strong>in</strong>clud<strong>in</strong>g forconsideration at <strong>the</strong> sub-national level <strong>and</strong> consider<strong>in</strong>gdevolved, decentralised systems;support procurement of contraceptives for broadenedmethod mix <strong>in</strong> all service delivery po<strong>in</strong>ts <strong>and</strong> communityoutlets;streng<strong>the</strong>n capacity for forecast<strong>in</strong>g <strong>in</strong>clud<strong>in</strong>g forunmarried people through appropriate capacity build<strong>in</strong>gat all levels of <strong>the</strong> supply cha<strong>in</strong>;facilitate proper management of <strong>in</strong>ventory <strong>and</strong> systemswith consideration to <strong>in</strong>tegration of contraceptivelogistics management <strong>in</strong>to <strong>the</strong> health system supplycha<strong>in</strong> management;undertake capacity build<strong>in</strong>g of commodity managers<strong>and</strong> health care providers manag<strong>in</strong>g commodities <strong>in</strong> <strong>the</strong>primary health care sett<strong>in</strong>g with particular attention onmonitor<strong>in</strong>g <strong>and</strong> evaluation;promote <strong>and</strong> adhere to prequalification mechanisms ofWHO for quality product availability for both public<strong>and</strong> private sector:governments work with manufacturers to ensureadherence to <strong>in</strong>ternational st<strong>and</strong>ards of quality of <strong>the</strong>commoditiescapacity build<strong>in</strong>g for regulatory agencies to monitor7

<strong>and</strong> undertake <strong>in</strong> country quality assurancetechnical exchange <strong>and</strong> support to help local <strong>and</strong>generics manufacturers meet <strong>in</strong>ternational st<strong>and</strong>ardsencourage self reliance <strong>and</strong>, where applicable, encouragelocal production of commodities which meet WHOqualifications;streng<strong>the</strong>n logistics management <strong>in</strong>formation systems<strong>and</strong> develop an <strong>in</strong>formation system <strong>and</strong> strategy tocapture data for contraceptive usage <strong>and</strong> dem<strong>and</strong> for<strong>the</strong> total market.streng<strong>the</strong>n <strong>the</strong> distribution of contraceptives toespecially hard-to-reach areas;7. Ensur<strong>in</strong>g an adequate <strong>and</strong>equitably distributed supplyof skilled human resourcesto provide quality familyplann<strong>in</strong>g <strong>in</strong>formation <strong>and</strong>servicestra<strong>in</strong> health programme managers <strong>and</strong> planners on howto utilize relevant data to <strong>in</strong>form policy <strong>and</strong> practicethat affects disadvantaged;undertake tra<strong>in</strong><strong>in</strong>g of staff to enhance <strong>the</strong>ir managementskills, to improve <strong>the</strong>ir effectiveness <strong>and</strong> also enhancetransparency <strong>and</strong> encourage good governance practices;support capacity development of a critical mass ofsusta<strong>in</strong>able human resources to plan, provide <strong>and</strong>monitor:family plann<strong>in</strong>g services,commodity management;ensure that <strong>the</strong> tra<strong>in</strong><strong>in</strong>g of all medical <strong>and</strong> healthprofessionals <strong>in</strong>cludes sensitization on attitudes <strong>and</strong>behaviour towards all family plann<strong>in</strong>g clients, so thatclients’ rights to confidential, ethical <strong>and</strong> user-friendlyservices are respected;streng<strong>the</strong>n <strong>the</strong> capacity of family plann<strong>in</strong>g motivators<strong>and</strong> educators for reach<strong>in</strong>g underserved groups us<strong>in</strong>g aculturally <strong>and</strong> gender sensitive approach;review <strong>the</strong> curriculum at medical, nurs<strong>in</strong>g <strong>and</strong> midwiferytra<strong>in</strong><strong>in</strong>g <strong>in</strong>stitutions to <strong>in</strong>tegrate family plann<strong>in</strong>g as acompulsory element of <strong>the</strong> curriculum;provide appropriate tra<strong>in</strong><strong>in</strong>g courses, manuals <strong>and</strong>demonstration kits for premarital counsellors.promote task shift<strong>in</strong>g <strong>and</strong> <strong>the</strong> use of tra<strong>in</strong>ed non-medicalpersonnel to provide family plann<strong>in</strong>g services to areaswhere certified medical personnel are not available.,ensure equal distribution of family plann<strong>in</strong>g <strong>and</strong> healthpersonnel to all areas, <strong>in</strong>clud<strong>in</strong>g <strong>the</strong> hard-to-reach areas,<strong>and</strong> provide <strong>in</strong>centives to family plann<strong>in</strong>g <strong>and</strong> healthpersonnel work<strong>in</strong>g <strong>in</strong> hard-to-reach areas.sensitise providers about gender disparities <strong>and</strong> women'srights <strong>in</strong> <strong>the</strong> area of contraception.8. Streng<strong>the</strong>n<strong>in</strong>g partnerships<strong>and</strong> collaboration withstakeholders, <strong>in</strong>clud<strong>in</strong>gwomen’s groups, youthorganization <strong>and</strong> whenappropriate with <strong>in</strong>digenousgroup <strong>and</strong> religious leaders,for mak<strong>in</strong>g family plann<strong>in</strong>g<strong>in</strong>formation <strong>and</strong> servicesavailable, accessible,acceptable <strong>and</strong> affordable toalldevelop/streng<strong>the</strong>n national <strong>and</strong> sub-nationalmechanisms for coord<strong>in</strong>at<strong>in</strong>g organisations work<strong>in</strong>g<strong>in</strong> family plann<strong>in</strong>g <strong>and</strong> reproductive health commoditysecurity;support <strong>the</strong> development <strong>and</strong> implementation ofpolicies <strong>and</strong>/or strategies conducive to private-publicpartnerships that meet <strong>the</strong> needs of disadvantagedgroups, particularly <strong>the</strong> poor <strong>and</strong> <strong>the</strong> young. Theprivate sector participation will be with<strong>in</strong> <strong>the</strong> context ofcorporate social responsibility.encourage non-governmental organisations <strong>and</strong> <strong>the</strong>private sector to participate fully <strong>in</strong> <strong>in</strong>creas<strong>in</strong>g access tofamily plann<strong>in</strong>g <strong>in</strong>formation, services <strong>and</strong> commoditiesby provid<strong>in</strong>g services particularly <strong>in</strong> areas of comparativeadvantage;engage <strong>in</strong> South South Cooperation <strong>and</strong> North SouthCooperation for build<strong>in</strong>g systems <strong>and</strong> capacity <strong>in</strong>family plann<strong>in</strong>g advocacy, with knowledge shar<strong>in</strong>gof lesson learned <strong>and</strong> best practices management <strong>and</strong>service delivery <strong>in</strong> <strong>the</strong> region, particularly for reach<strong>in</strong>gunderserved <strong>and</strong> those with greatest needs;streng<strong>the</strong>n partnerships with organisations for<strong>in</strong>troduc<strong>in</strong>g or fur<strong>the</strong>r streng<strong>the</strong>n<strong>in</strong>g social market<strong>in</strong>gof family plann<strong>in</strong>g methods promotion, especially forunderserved groups;streng<strong>the</strong>n public <strong>and</strong> private sector partnership formonitor<strong>in</strong>g supply cha<strong>in</strong> management <strong>and</strong> usage of allfamily plann<strong>in</strong>g commodities;engage, sensitize, groom <strong>and</strong> develop l<strong>in</strong>kages withmedia as partners;8

engage journalists <strong>and</strong> media outlets to raise awarenessof disparities <strong>in</strong> access to family plann<strong>in</strong>g <strong>in</strong>formation,services <strong>and</strong> commodities, particularly among married<strong>and</strong> unmarried adolescents;create a supportive environment for family plann<strong>in</strong>gthrough public <strong>in</strong>formation <strong>and</strong> communications basedon appropriate language <strong>and</strong> techniques <strong>and</strong> methodssuch as development <strong>the</strong>atre; behaviour changecommunication <strong>and</strong> o<strong>the</strong>r <strong>in</strong>digenous <strong>in</strong>formation,education, communication activities that will targetilliterate <strong>and</strong> disadvantaged groups;mobilize <strong>the</strong> community, especially women, men <strong>and</strong>youth, <strong>and</strong> o<strong>the</strong>r appropriate organizations to supportFP;demystify <strong>the</strong> language used <strong>in</strong> family plann<strong>in</strong>g sothat political leaders, media persons <strong>and</strong> <strong>the</strong> generalpopulation can relate to language;engage <strong>the</strong> active participation of national leaders,parliamentarians, women leaders, youth leaders, religiousleaders, traditional leaders <strong>and</strong> o<strong>the</strong>r community leadersto support family plann<strong>in</strong>g <strong>and</strong> advocat<strong>in</strong>g for improvedaccess to family plann<strong>in</strong>g services <strong>and</strong> commodities.9. Exp<strong>and</strong> <strong>and</strong> improveknowledge based policydialogue for programmemonitor<strong>in</strong>g <strong>and</strong> servicedeliveryimprove & develop health <strong>in</strong>formation systems <strong>and</strong>streng<strong>the</strong>n a consistent st<strong>and</strong>ard <strong>in</strong> <strong>in</strong>formation systems<strong>in</strong> health, sub-nationally <strong>and</strong> <strong>in</strong>tegrate it fully <strong>in</strong>to <strong>the</strong>national monitor<strong>in</strong>g of contraceptive prevalence <strong>and</strong>evaluation of family plann<strong>in</strong>g services;develop, implement <strong>and</strong> improve <strong>the</strong> exist<strong>in</strong>g monitor<strong>in</strong>gsystem to evaluate <strong>the</strong> efficiency <strong>and</strong> effectiveness offamily plann<strong>in</strong>g programmes <strong>and</strong> use <strong>the</strong> results to<strong>in</strong>form improvements <strong>in</strong> policies <strong>and</strong> programmes;facilitate fur<strong>the</strong>r analysis of facilities based householdsurveys, <strong>in</strong>clud<strong>in</strong>g DHS <strong>and</strong> <strong>in</strong> country surveys <strong>and</strong>monitor progress <strong>and</strong> trends <strong>in</strong> <strong>in</strong>equity <strong>in</strong> reduc<strong>in</strong>gunmet need for family plann<strong>in</strong>g;support efforts to ma<strong>in</strong>ta<strong>in</strong> <strong>and</strong> fur<strong>the</strong>r streng<strong>the</strong>n<strong>Asia</strong> <strong>and</strong> <strong>Pacific</strong> regional, sub-regional, national <strong>and</strong>sub-national data collection, analysis <strong>and</strong> report<strong>in</strong>g ofdisaggregated family plann<strong>in</strong>g data <strong>in</strong>clud<strong>in</strong>g MDG5b;build capacity for data collection <strong>and</strong> analysis at national,sub-national <strong>and</strong> local levels for data <strong>in</strong>terpretation <strong>and</strong><strong>in</strong>formation shar<strong>in</strong>g about family plann<strong>in</strong>g dem<strong>and</strong>with<strong>in</strong> m<strong>in</strong>istries <strong>and</strong> also between Governments,NGOs <strong>and</strong> all health professional associations;build capacity at regional level (such as SAARCfor South <strong>Asia</strong>n countries, ASEAN <strong>and</strong> for <strong>Pacific</strong>Isl<strong>and</strong>s) <strong>in</strong>clud<strong>in</strong>g data analysis, software <strong>and</strong> tra<strong>in</strong><strong>in</strong>g<strong>in</strong> <strong>the</strong> areas of service statistics, <strong>in</strong>ventory/logisticsmanagement <strong>and</strong> f<strong>in</strong>ance/accounts,engage relevant stakeholders, <strong>in</strong>clud<strong>in</strong>g civil society,<strong>in</strong> plann<strong>in</strong>g, monitor<strong>in</strong>g <strong>and</strong> evaluation of familyplann<strong>in</strong>g programme, especially those aimed at reach<strong>in</strong>gdisadvantaged groups.10. Undertak<strong>in</strong>g operations <strong>and</strong>socio-cultural research toimprove knowledge basefor policy <strong>and</strong> programm<strong>in</strong>greformssupport research, both technically <strong>and</strong> f<strong>in</strong>ancially,to assess <strong>the</strong> effects of <strong>in</strong>terventions such as healthcommunication, community-based distribution,<strong>in</strong>tegrated/l<strong>in</strong>ked services, on reduc<strong>in</strong>g <strong>in</strong>equities <strong>in</strong>family plann<strong>in</strong>g access <strong>and</strong> use;undertake cross-country comparisons <strong>and</strong> <strong>in</strong>tra-countrystudies to address l<strong>in</strong>ger<strong>in</strong>g barriers;undertake operations research for:access (method availability, affordability, <strong>in</strong>equity,adolescents, males, for-profit sector provision)quality of service provision <strong>and</strong> care (method choice,counsell<strong>in</strong>g, method discont<strong>in</strong>uation <strong>and</strong> failure)cost<strong>in</strong>g <strong>and</strong> cost-effectivenessundertake social research on elim<strong>in</strong>at<strong>in</strong>g unmet need(cultural, economic, behavioural) on:contraception <strong>and</strong> abortion decision <strong>and</strong> choicereligion, culture, authorityadolescent sexual <strong>and</strong> reproductive health<strong>in</strong>stitute regional program for data <strong>in</strong>formation/resources/systems9

Report on <strong>the</strong> RegionalConsultationThe report outl<strong>in</strong>es highlights from each session <strong>in</strong> l<strong>in</strong>ewith <strong>the</strong> agenda <strong>and</strong> presents key issues raised dur<strong>in</strong>gdiscussions. Key po<strong>in</strong>ts from country presentationswere raised, as well as <strong>the</strong> ma<strong>in</strong> po<strong>in</strong>ts from governmentcounterparts when comments were provided.Open<strong>in</strong>g SeasonIntroduction byDr. Wasim Zaman, Executive Director of ICOMPDr. Wasim Zaman, Executive Director of ICOMP,provided an <strong>in</strong>troduction to <strong>the</strong> consultation by outl<strong>in</strong><strong>in</strong>gits focus <strong>and</strong> expected outcome. He highlighted that<strong>the</strong>re rema<strong>in</strong>ed a large, well-documented, unmet need forfamily plann<strong>in</strong>g, overwhelm<strong>in</strong>gly among <strong>the</strong> poor. Therewas diversity of unmet need among nations, but alsowith<strong>in</strong> nations <strong>and</strong> particularly among special groups,such as young people <strong>and</strong> marg<strong>in</strong>alized groups. Twooverarch<strong>in</strong>g regional studies on <strong>the</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong>region, as well as 12 county-level situation analyseshad been prepared as background to <strong>the</strong> consultation.Fur<strong>the</strong>r, <strong>the</strong>matic sessions on key components of asusta<strong>in</strong>able multisectoral family plann<strong>in</strong>g programmewere conducted. Countries <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong>were leaders <strong>in</strong> <strong>the</strong> implementation of family plann<strong>in</strong>gprogrammes; however, <strong>the</strong>re was still a large unmet needfor family plann<strong>in</strong>g, as well as a need for improvement<strong>in</strong> access to services <strong>and</strong> to address marg<strong>in</strong>alizedpopulations <strong>and</strong> groups. The emphasis overall was thatfamily plann<strong>in</strong>g could never be anyth<strong>in</strong>g o<strong>the</strong>r thanvoluntary.The focus of <strong>the</strong> consultation was:To review <strong>the</strong> current situation of fertility decl<strong>in</strong>e<strong>and</strong> status of family plann<strong>in</strong>g <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong>,<strong>in</strong>clud<strong>in</strong>g successes, challenges <strong>and</strong> how chang<strong>in</strong>gneeds were be<strong>in</strong>g dealt with;To review <strong>the</strong> status of reproductive health commoditysecurity, with specific focus on contraceptive needsprojections, availability, logistics for appropriatedistribution <strong>and</strong> fund<strong>in</strong>g;To review <strong>the</strong> challenges of deliver<strong>in</strong>g good-quality<strong>and</strong> equitable services <strong>and</strong> meet<strong>in</strong>g <strong>the</strong> unmet needsof adolescents <strong>and</strong> young people, as well as peoplewho were poor, disadvantaged <strong>and</strong> marg<strong>in</strong>alized;To develop strategies for ensur<strong>in</strong>g a “rights-basedapproach” to family plann<strong>in</strong>g;To review <strong>the</strong> gaps <strong>in</strong> fund<strong>in</strong>g of family plann<strong>in</strong>g<strong>and</strong> <strong>the</strong>ir implications for action for governments ofcountries <strong>in</strong> <strong>the</strong> region <strong>and</strong> donors.The expected outcomes of <strong>the</strong> regional consultation wereensured commitments to allocate resources for familyplann<strong>in</strong>g <strong>and</strong> action plans for policy <strong>and</strong> programmechanges aimed at achiev<strong>in</strong>g universal access to reproductivehealth services, <strong>in</strong>clud<strong>in</strong>g family plann<strong>in</strong>g, keep<strong>in</strong>g <strong>in</strong> m<strong>in</strong>d<strong>the</strong> priority needs of disadvantaged <strong>and</strong> marg<strong>in</strong>al groups.Keynote address byH.E. Mr. Gou Q<strong>in</strong>gm<strong>in</strong>g, Vice-M<strong>in</strong>ister, NationalPopulation <strong>and</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Commission of Ch<strong>in</strong>a(delivered on behalf of <strong>the</strong> Vice-M<strong>in</strong>ister by Mr. HuHongtao, Director General, Department of <strong>International</strong>Cooperation, National Population <strong>and</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Commission of Ch<strong>in</strong>a)The <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> region played a lead<strong>in</strong>g role <strong>in</strong>world population affairs s<strong>in</strong>ce 61 per cent of <strong>the</strong> globalpopulation lived <strong>in</strong> <strong>the</strong> region. The focus on familyplann<strong>in</strong>g reflected a renewed underst<strong>and</strong><strong>in</strong>g of <strong>the</strong><strong>in</strong>ternational community regard<strong>in</strong>g <strong>the</strong> importance offamily plann<strong>in</strong>g <strong>and</strong> <strong>the</strong> resumption of its importantstatus <strong>in</strong> population activities. The close partnershipbetween United Nations agencies <strong>and</strong> <strong>in</strong>ternationalNGOs rema<strong>in</strong>ed important <strong>in</strong> ensur<strong>in</strong>g a renewed focuson family plann<strong>in</strong>g. The fact that <strong>the</strong> consultation wasjo<strong>in</strong>tly hosted by UNFPA <strong>and</strong> ICOMP reflected thatclose partnership.Ch<strong>in</strong>a was a country with <strong>the</strong> largest population <strong>in</strong> <strong>the</strong>world: a total population that had reached 1.33 billionpeople at <strong>the</strong> end of 2009. Ch<strong>in</strong>a had made remarkableprogress <strong>in</strong> <strong>the</strong> areas of population <strong>and</strong> development,characterized by ris<strong>in</strong>g life expectancy <strong>and</strong> decl<strong>in</strong><strong>in</strong>gmaternal mortality <strong>and</strong> total fertility rates. A key po<strong>in</strong>t ofCh<strong>in</strong>a’s experience <strong>in</strong> address<strong>in</strong>g <strong>the</strong> issues of population<strong>and</strong> family plann<strong>in</strong>g <strong>in</strong>cluded uphold<strong>in</strong>g <strong>the</strong> promotionof family plann<strong>in</strong>g as a basic state policy. The country’sfive-year programme for national social <strong>and</strong> economicdevelopment <strong>in</strong>corporated population issues. Also, Ch<strong>in</strong>ahad <strong>in</strong>vested <strong>in</strong> <strong>the</strong> establishment <strong>and</strong> improvement of a11

family plann<strong>in</strong>g <strong>and</strong> reproductive health service networkthat covered both rural <strong>and</strong> urban areas for <strong>the</strong> provisionof st<strong>and</strong>ard, comprehensive <strong>and</strong> quality-of-care services.Comprehensive <strong>and</strong> extended family care-oriented publicservices l<strong>in</strong>ked with consistent <strong>in</strong>formation, education<strong>and</strong> communication (IEC) activities were promotedthroughout <strong>the</strong> country.In addition, Ch<strong>in</strong>a had <strong>in</strong>creased its fiscal <strong>in</strong>vestment<strong>in</strong> population <strong>and</strong> family plann<strong>in</strong>g activities, withaccountability systems <strong>in</strong>corporated <strong>in</strong>to work plans.Also, Ch<strong>in</strong>a encouraged communities to participate <strong>in</strong>family plann<strong>in</strong>g <strong>and</strong> reproductive health by improv<strong>in</strong>ga benefits-oriented policy system. F<strong>in</strong>ally, Ch<strong>in</strong>a hadbeen actively engaged <strong>in</strong> policy dialogue <strong>and</strong> experienceshar<strong>in</strong>g<strong>in</strong> terms of both South-South <strong>and</strong> South-North-South cooperation.Some recommendations based on Ch<strong>in</strong>a’s experience <strong>in</strong>promot<strong>in</strong>g family plann<strong>in</strong>g <strong>in</strong>cluded <strong>the</strong> follow<strong>in</strong>g: Reposition family plann<strong>in</strong>g, <strong>in</strong>ject new vitality <strong>and</strong>budget; Ensure official attention to family plann<strong>in</strong>g <strong>in</strong> nationaldevelopment strategies; Review <strong>and</strong> improve <strong>the</strong> RH service network <strong>and</strong>commodities; Seek <strong>and</strong> promote South-South cooperation <strong>and</strong><strong>the</strong> shar<strong>in</strong>g of experiences <strong>and</strong> partnerships betweencountries.Welcome address byMs. Nobuko Horibe, Director, UNFPA <strong>Asia</strong> <strong>and</strong> <strong>Pacific</strong>Regional Office.Ms. Horibe welcomed all delegates to <strong>the</strong> l<strong>and</strong>markevent, br<strong>in</strong>g<strong>in</strong>g <strong>in</strong> participants from 24 countries toreposition family plann<strong>in</strong>g on national developmentagendas. She stressed that unwanted pregnancy waspreventable <strong>and</strong> avoidable. Under <strong>the</strong> 1994 <strong>International</strong>Conference on Population <strong>and</strong> Development (ICPD),countries committed <strong>the</strong>mselves to “achieve, by 2015,universal access to a full range of safe <strong>and</strong> reliable familyplann<strong>in</strong>g <strong>and</strong> reproductive health services”. However,<strong>the</strong>re currently was less focus on family plann<strong>in</strong>g ow<strong>in</strong>gto a variety of factors, <strong>in</strong>clud<strong>in</strong>g competition for fund<strong>in</strong>gdue to <strong>the</strong> emerg<strong>in</strong>g HIV epidemic <strong>and</strong> less recognitionthat family plann<strong>in</strong>g was l<strong>in</strong>ked to poverty reduction.In 2006, a new target was added to MillenniumDevelopment Goal (MDG) 5, highlight<strong>in</strong>g <strong>the</strong> needto monitor progress towards decreas<strong>in</strong>g unmet needfor family plann<strong>in</strong>g. It had brought back much neededattention to family plann<strong>in</strong>g. <strong>Family</strong> plann<strong>in</strong>g hadproven to be one of <strong>the</strong> most cost-effective <strong>in</strong>vestmentsfor society. Studies showed that each dollar spent onfamily plann<strong>in</strong>g could save governments up to US$31 <strong>in</strong> costs for health care, water, education, hous<strong>in</strong>g,sewers <strong>and</strong> o<strong>the</strong>r waste disposal etc. Furnish<strong>in</strong>g moderncontraceptives to all women who needed such methodsmore than paid for itself, sav<strong>in</strong>g multiple dollars on<strong>the</strong> cost of maternal <strong>and</strong> newborn care for each dollar<strong>in</strong>vested. Despite <strong>the</strong> evidence, <strong>the</strong>re had not been an<strong>in</strong>crease <strong>in</strong> <strong>in</strong>vestments <strong>in</strong> family plann<strong>in</strong>g.The majority of countries <strong>in</strong> South-East <strong>and</strong> East <strong>Asia</strong>had achieved remarkable <strong>in</strong>creases <strong>in</strong> family plann<strong>in</strong>gutilization, yet <strong>the</strong>re was still a need to cont<strong>in</strong>ue<strong>in</strong>vest<strong>in</strong>g <strong>in</strong> family plann<strong>in</strong>g to meet <strong>the</strong> needs of <strong>the</strong> highproportion of young people enter<strong>in</strong>g <strong>the</strong> reproductiveage group. Countries <strong>in</strong> South <strong>Asia</strong>, West <strong>Asia</strong> <strong>and</strong> <strong>the</strong><strong>Pacific</strong> presented a mixed picture. There were countriesthat had reached replacement fertility levels <strong>and</strong> enjoyedhigh levels of utilization of contraceptives; <strong>the</strong>re weresome countries that had stagnat<strong>in</strong>g family plann<strong>in</strong>gservice coverage rates; <strong>and</strong> some o<strong>the</strong>rs that still had lowutilization of family plann<strong>in</strong>g services. Many countriesstill had a high unmet need for family plann<strong>in</strong>g <strong>and</strong><strong>in</strong>creas<strong>in</strong>g abortion rates. The unmet need for familyplann<strong>in</strong>g rema<strong>in</strong>ed disparate among various socioeconomicgroups.<strong>Family</strong> plann<strong>in</strong>g also contributed substantially towomen’s empowerment <strong>and</strong> long-term environmentalsusta<strong>in</strong>ability. It was time to review exist<strong>in</strong>g policies<strong>and</strong> focus on unmet needs, particularly for address<strong>in</strong>g<strong>the</strong> unmet needs of <strong>the</strong> young, unmarried population.There was a need to streng<strong>the</strong>n <strong>the</strong> quality of services,<strong>in</strong>clud<strong>in</strong>g susta<strong>in</strong>ed availability <strong>and</strong> wider choice ofcontraceptives, as well as better coord<strong>in</strong>ation with nongovernmental<strong>and</strong> private sectors, as research showedthat young people did not go to public health centres forfamily plann<strong>in</strong>g.Fur<strong>the</strong>r, a multisectoral approach should be applied toensure that family plann<strong>in</strong>g was considered an essentialnational development strategy for poverty reduction<strong>and</strong> a necessary health strategy aimed at protect<strong>in</strong>g <strong>the</strong>health <strong>and</strong> well-be<strong>in</strong>g of women, families <strong>and</strong> societies.It was hoped that <strong>the</strong> consultation would result <strong>in</strong> aplan of action that was operational <strong>and</strong> was relevantfor all countries <strong>and</strong> that would contribute to ensur<strong>in</strong>gthat every birth was wanted. A plan was needed thatwould eventually lead to sav<strong>in</strong>g <strong>the</strong> lives of manywomen <strong>and</strong> children, facilitate achievement of MDGs<strong>and</strong> contribute to alleviat<strong>in</strong>g poverty <strong>and</strong> hunger for all.Some 200 million women worldwide, especially <strong>in</strong> <strong>the</strong>poorest countries, still had an unmet need for effectivecontraception. The current <strong>in</strong>vestment <strong>in</strong> family plann<strong>in</strong>gneeded to be doubled to meet that unmet need.12

SESSION 1: Chang<strong>in</strong>gContext of <strong>Family</strong><strong>Plann<strong>in</strong>g</strong>Moderator:Dr. Anrudh Ja<strong>in</strong>, Dist<strong>in</strong>guished Scholar, Population<strong>Council</strong>The objective of <strong>the</strong> session was to review <strong>the</strong> currentsituation of fertility decl<strong>in</strong>e <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong> bydiscuss<strong>in</strong>g successes, chang<strong>in</strong>g needs <strong>and</strong> challenges.The session <strong>in</strong>cluded presentations from twooverarch<strong>in</strong>g papers developed as technical resourcesfor <strong>the</strong> consultation, as well as a presentation related toreproductive health commodity security. <strong>Asia</strong> <strong>and</strong> <strong>the</strong><strong>Pacific</strong> was a good place to take stock of <strong>the</strong> situations<strong>in</strong>ce many countries had served as pioneers for familyplann<strong>in</strong>g. The session addressed contraceptive methodswith<strong>in</strong> reproductive health <strong>and</strong> advocacy for women’seducation <strong>and</strong> economic development.<strong>Family</strong> plann<strong>in</strong>g programmes <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong><strong>and</strong> achiev<strong>in</strong>g MDG5b byDr. Amy O. Tsui, Director, The Bill <strong>and</strong> Mel<strong>in</strong>da GatesInstitute of Population <strong>and</strong> Reproductive Health, JohnHopk<strong>in</strong>s UniversityThe presentation focused on a review of trends <strong>in</strong>patterns of government responses to fertility levels<strong>and</strong> contraceptive service provision, as well as a reviewof variations <strong>in</strong> contraceptive practice levels, useeffectiveness <strong>and</strong> equity <strong>in</strong> coverage. The <strong>Asia</strong>n <strong>and</strong><strong>Pacific</strong> region was <strong>the</strong> site of <strong>the</strong> historic beg<strong>in</strong>n<strong>in</strong>gs ofnational family plann<strong>in</strong>g programmes, which predatedpopulation development frameworks. The <strong>in</strong>itial familyplann<strong>in</strong>g programmes were often embedded <strong>in</strong> economicdevelopment plans, stimulated by voluntary <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Associations <strong>and</strong> promotion of family plann<strong>in</strong>gservice delivery. Early family plann<strong>in</strong>g programmes weredata driven from <strong>the</strong> beg<strong>in</strong>n<strong>in</strong>g, based on f<strong>in</strong>d<strong>in</strong>gs fromnational household surveys <strong>and</strong> well-monitored throughvarious <strong>in</strong>formation systems. Also, family plann<strong>in</strong>gwas often positioned with<strong>in</strong> high-level coord<strong>in</strong>at<strong>in</strong>gadm<strong>in</strong>istrative entities, a phenomenon which was notseen <strong>in</strong> o<strong>the</strong>r regions of <strong>the</strong> world.India was <strong>the</strong> first country to adopt family plann<strong>in</strong>g<strong>in</strong> its national economic development plan <strong>in</strong> 1951; itwas followed by Sri Lanka, Bangladesh/Pakistan <strong>and</strong><strong>the</strong> Republic of Korea <strong>in</strong> 1959 to 1961, <strong>and</strong> Malaysia,Indonesia, Philipp<strong>in</strong>es, Thail<strong>and</strong> <strong>and</strong> Nepal between1965 <strong>and</strong> 1975. A grow<strong>in</strong>g percentage of governmentswere provid<strong>in</strong>g direct support for <strong>the</strong> provision ofcontraceptives.The presentation also addressed contraceptive methodmix, use effectiveness <strong>and</strong> coverage <strong>in</strong> <strong>the</strong> region.Contraceptive prevalence levels were high, althoughsignificant variation was apparent. The higher <strong>the</strong>population contraceptive prevalence rate, <strong>the</strong> less likely<strong>the</strong>re would be significant disparity by socio-economicstatus, whe<strong>the</strong>r measured <strong>in</strong> terms of <strong>in</strong>come, assetsor education. The populous countries <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong><strong>Pacific</strong> showed low <strong>in</strong>equity <strong>in</strong> contraceptive use, whichsuggested that government commitment <strong>and</strong> privatesector supply assured a degree of contraceptive accessthat corresponded well to <strong>the</strong> dem<strong>and</strong> for contraceptionamong married couples.The presentation also addressed reproductive healthcommodity security <strong>in</strong> <strong>the</strong> region. Ch<strong>in</strong>a, India <strong>and</strong>Iran were examples of countries that had been largelyself-sufficient <strong>in</strong> <strong>the</strong>ir family plann<strong>in</strong>g programme, withcommercial access to contraceptive commodities hav<strong>in</strong>gbeen made through <strong>the</strong> private sector. Afghanistan,Bangladesh <strong>and</strong> Indonesia were examples of countriesthat had accepted <strong>in</strong>ternational assistance <strong>in</strong> <strong>the</strong> <strong>in</strong>itialstages of <strong>the</strong>ir family plann<strong>in</strong>g programmes. Thematurity of family plann<strong>in</strong>g programmes <strong>in</strong> <strong>the</strong> regionprovided considerable equity <strong>in</strong> coverage for many, butnot all, countries.A review of partial contraceptive security <strong>in</strong>dex scoressuggested uneven security <strong>in</strong> contraceptive procurementability across <strong>the</strong> region. That could hide <strong>the</strong> role of anactive private sector. Decentralization <strong>in</strong> procurementcould pose challenges <strong>and</strong> it could be difficult todeterm<strong>in</strong>e to what extent <strong>the</strong>re were earmarked funds<strong>in</strong> government budgets for contraceptive procurement.Households were a major source of domestic spend<strong>in</strong>gon reproductive health <strong>and</strong> family plann<strong>in</strong>g. A highpercentage of total f<strong>in</strong>anc<strong>in</strong>g that was consumer-basedwas an <strong>in</strong>dication of susta<strong>in</strong>able contraceptive security.The future agenda of family plann<strong>in</strong>g for <strong>the</strong> regionneeded to take <strong>in</strong>to consideration population momentum<strong>and</strong> growth which would put pressure on exist<strong>in</strong>g familyplann<strong>in</strong>g resources; governance <strong>and</strong> policy models forcontraceptive security would vary country to country<strong>and</strong> no one programme model could fit every situation<strong>and</strong> factors <strong>in</strong>fluenc<strong>in</strong>g contraceptive dem<strong>and</strong> would bewide rang<strong>in</strong>g, both across <strong>and</strong> with<strong>in</strong> countries.The presentation closed with some comments on how tofur<strong>the</strong>r <strong>the</strong> agenda for family plann<strong>in</strong>g: One suggestion was <strong>the</strong> development of a regionalplan of action around family plann<strong>in</strong>g. The MaputoPlan of Action for <strong>the</strong> Operationalisation of <strong>the</strong>Cont<strong>in</strong>ental Policy Framework for Sexual <strong>and</strong>Reproductive Health <strong>and</strong> Rights 2007-2010 waspresented as a possible framework; It was suggested that all entry po<strong>in</strong>ts at which family13

plann<strong>in</strong>g <strong>in</strong>formation, counsell<strong>in</strong>g <strong>and</strong> services couldbe <strong>in</strong>troduced along <strong>the</strong> cont<strong>in</strong>uum of sexual health<strong>and</strong> reproductive care should be utilized; Contraceptive security would be achieved whennational <strong>and</strong> subnational budgets <strong>in</strong>cluded earmarksfor essential medic<strong>in</strong>es, <strong>in</strong>clud<strong>in</strong>g contraceptives; Of <strong>the</strong> 47 governments <strong>in</strong> <strong>the</strong> <strong>Asia</strong>n region, 17 of <strong>the</strong>mdid not directly support contraceptive access. Effortsneeded to be made to conv<strong>in</strong>ce those governments of<strong>the</strong> value of mak<strong>in</strong>g such <strong>in</strong>vestments.Fertility <strong>and</strong> family plann<strong>in</strong>g <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> byDr. Geoffrey Hayes, Development Consultant, NewZeal<strong>and</strong>The presentation was based on an analysis of recentlyconducted Demographic <strong>and</strong> Health Surveys (DHS) topresent <strong>the</strong> situation of unmet need for family plann<strong>in</strong>g<strong>in</strong> <strong>the</strong> <strong>Pacific</strong>. The study revealed some commoncharacteristics across <strong>the</strong> <strong>Pacific</strong> region but also greatvariation, which made it difficult to generalize.The comparative study assessed whe<strong>the</strong>r <strong>the</strong> fertilitytransition had stalled <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> isl<strong>and</strong> countries <strong>and</strong>territories <strong>and</strong> if so, what were some of its causes. Theresearch suggested that fertility transition had stalled <strong>in</strong>some countries, but not all. A review of long-term fertilitychange showed a slow fertility decl<strong>in</strong>e. It was noted thatsome countries <strong>in</strong>itially presented rapid fertility decl<strong>in</strong>e;however, that was followed by a layer<strong>in</strong>g off.An analysis of family plann<strong>in</strong>g programmes <strong>in</strong> <strong>the</strong><strong>Pacific</strong> showed a relationship between fertility transition<strong>and</strong> family plann<strong>in</strong>g programmes. Some programmesstalled, reversed or slowed down, <strong>the</strong> effect of whichwas evident <strong>in</strong> fertility <strong>and</strong> contraceptive prevalence ratefigures. Kiribati was highlighted as an example where <strong>the</strong>total fertility rate (TFR) was over 6 children per woman<strong>in</strong> <strong>the</strong> 1960s; <strong>the</strong> country experienced a rapid decl<strong>in</strong>e <strong>in</strong>fertility, which co<strong>in</strong>cided with <strong>the</strong> <strong>in</strong>itiation of <strong>the</strong> familyplann<strong>in</strong>g programme, to a TFR of 4; yet TFR rema<strong>in</strong>edat that level for 20 years.An analysis of contraceptive prevalence rate (CPR)trends <strong>in</strong> <strong>the</strong> region showed a trend upwards <strong>in</strong> <strong>the</strong> caseof Fiji, Papua New Gu<strong>in</strong>ea <strong>and</strong> Solomon Isl<strong>and</strong>s, somego<strong>in</strong>g up <strong>and</strong> <strong>the</strong>n stall<strong>in</strong>g as <strong>in</strong> <strong>the</strong> case <strong>in</strong> Vanuatu, <strong>the</strong>Federated States of Micronesia <strong>and</strong> Kiribati, <strong>and</strong> o<strong>the</strong>rsdecl<strong>in</strong><strong>in</strong>g as <strong>in</strong> <strong>the</strong> case of Cook Isl<strong>and</strong>s, Samoa <strong>and</strong>Tonga. Generally, <strong>in</strong> <strong>the</strong> <strong>Pacific</strong>, CPR did not get muchabove 40 per cent. The presentation addressed some of<strong>the</strong> reasons <strong>and</strong> relationships <strong>in</strong> that situation. Primarily,<strong>the</strong> research revealed a weak relationship between CPR<strong>and</strong> education. Also, <strong>the</strong> CPR <strong>in</strong> <strong>the</strong> region seemed tonot be closely associated with rural <strong>and</strong> urban residence;<strong>in</strong> fact, <strong>the</strong>re were some examples of higher CPRlevels <strong>in</strong> rural areas. The research could not present acorrelation between household wealth <strong>and</strong> CPR levels.However, <strong>the</strong>re were relationships between CPR, age<strong>and</strong> parity, as well as a measure of connection betweenaccess to health centres or hav<strong>in</strong>g been visited by a familyplann<strong>in</strong>g nurse.The presentation discussed <strong>the</strong> relationship between keydevelopment <strong>in</strong>dicators, CPR <strong>and</strong> TFR. The researchrevealed a strong relationship between TFR <strong>and</strong> <strong>the</strong><strong>in</strong>fant mortality rate (IMR). Higher gross domesticproduct did not translate <strong>in</strong>to higher TRF or CPR,which suggested a weak relationship between <strong>the</strong> two.The research revealed a moderately strong relationshipbetween life expectancy <strong>and</strong> TFR. F<strong>in</strong>ally, researchrevealed a weak relationship between TFR <strong>and</strong> poverty.Patterns <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> were not <strong>the</strong> same as <strong>in</strong> o<strong>the</strong>rregions.In terms of unmet need for family plann<strong>in</strong>g, <strong>the</strong> <strong>Pacific</strong>region displayed considerable variation. Samoa presenteda high percentage of unmet need (just over 40%), whileSolomon Isl<strong>and</strong>s presented a low percentage of unmetneed (under 10%). Fur<strong>the</strong>r, contraceptive use variedwidely country by country.The research suggested that <strong>the</strong> <strong>Pacific</strong> isl<strong>and</strong> countriesdid not follow <strong>the</strong> expectation of <strong>the</strong> st<strong>and</strong>arddemographic transition model. Patterns of reportedcontraceptive use <strong>and</strong> unmet need varied so much thatit was necessary to take a country-by-country approach.However, it could be concluded that uneducatedwomen were less likely than <strong>the</strong>ir educated peers touse contraception <strong>and</strong> more likely to have an unmetneed. O<strong>the</strong>r than <strong>in</strong> Papua New Gu<strong>in</strong>ea <strong>and</strong> SolomonIsl<strong>and</strong>s, <strong>the</strong> ma<strong>in</strong> reason for unmet need was not accessbut “unwill<strong>in</strong>gness”, which was aris<strong>in</strong>g from fear of sideeffects, health concerns or some form of socioculturalopposition. Fur<strong>the</strong>r, adolescents faced <strong>the</strong> largestbarriers to <strong>the</strong> use of contraception for socioculturalreasons. In many countries, service providers <strong>in</strong> publichealth facilities were slowly ab<strong>and</strong>on<strong>in</strong>g <strong>the</strong>ir moralisticattitude towards adolescent sexuality. The researchshowed that NGOs did much better <strong>in</strong> address<strong>in</strong>g <strong>the</strong>needs of adolescents.The presentation outl<strong>in</strong>ed a number of measures forgovernments to take <strong>in</strong> order to improve access to<strong>and</strong> use of family plann<strong>in</strong>g services, based on f<strong>in</strong>d<strong>in</strong>gsfrom <strong>the</strong> research. One key recommendation was toimprove <strong>the</strong> quality, scope <strong>and</strong> accessibility of familyplann<strong>in</strong>g programmes through <strong>the</strong> tra<strong>in</strong><strong>in</strong>g of providers<strong>in</strong> counsell<strong>in</strong>g skills; to streng<strong>the</strong>n primary healthcare, especially <strong>in</strong> rural areas, for a widened choice ofcontraceptives; to place more emphasis on communityoutreach; as well as to ensure that family plann<strong>in</strong>gservices rema<strong>in</strong>ed free of cost. Also, <strong>the</strong> research revealed14

that improv<strong>in</strong>g <strong>in</strong>formation <strong>and</strong> knowledge throughresearch would contribute to stronger programmes.Some suggestions to achieve that <strong>in</strong>cluded fur<strong>the</strong>ranalysis of DHS results <strong>and</strong> conduct<strong>in</strong>g country-specificqualitative research to better underst<strong>and</strong> <strong>and</strong> address <strong>the</strong>causes of unmet need <strong>and</strong> <strong>the</strong> sociocultural obstacles toservice provision.It was imperative to address sociocultural barriers <strong>in</strong>order to asses use by: ensur<strong>in</strong>g that reproductive rightswere highlighted <strong>in</strong> policies <strong>and</strong> tra<strong>in</strong><strong>in</strong>g; design<strong>in</strong>gtailored methods of youth-friendly services for youngpeople; <strong>and</strong> work<strong>in</strong>g towards greater outreach <strong>and</strong>sensitization <strong>in</strong> condom programm<strong>in</strong>g. Countries shouldendeavour to streng<strong>the</strong>n <strong>the</strong>ir policies <strong>and</strong> strategies byplac<strong>in</strong>g emphasis on <strong>the</strong> central role of family plann<strong>in</strong>g <strong>in</strong>reproductive health policies <strong>and</strong> strategies <strong>and</strong> clarify<strong>in</strong>g<strong>the</strong> relationship between <strong>the</strong> two. Policies <strong>and</strong> strategiesshould re<strong>in</strong>force <strong>the</strong> concept of reproductive rights for all,<strong>in</strong>clud<strong>in</strong>g adolescents <strong>and</strong> older women, as well as ensurethat disadvantaged groups were highlighted <strong>in</strong> policies<strong>and</strong> strategies. Ano<strong>the</strong>r measure was for countries toimplement reproductive health commodity securityplans, <strong>in</strong>clud<strong>in</strong>g tra<strong>in</strong><strong>in</strong>g <strong>in</strong> logistics, warehous<strong>in</strong>g, supplycha<strong>in</strong> management <strong>and</strong> appo<strong>in</strong>t<strong>in</strong>g <strong>and</strong> tra<strong>in</strong><strong>in</strong>g staff tomanage distribution at <strong>the</strong> subnational level.Address<strong>in</strong>g universal access to family plann<strong>in</strong>gthrough reproductive health commodity security byMr. Jagdish Upadhyay, Chief, Commodity Security Branch,UNFPAThe presentation focused on <strong>the</strong> pivotal role reproductivehealth commodity security played <strong>in</strong> address<strong>in</strong>g universalaccess to family plann<strong>in</strong>g. Most maternal deaths could beprevented by access to contraceptives <strong>in</strong> order to avoidun<strong>in</strong>tended pregnancies, as well as access to skilled careat <strong>the</strong> time of birth <strong>and</strong> timely access to good-qualityemergency obstetric care <strong>in</strong> <strong>the</strong> case of complications.However, those <strong>in</strong>terventions were dependent on asecure, reliable stream of reproductive health supplies ofcontraceptives, medic<strong>in</strong>es <strong>and</strong> o<strong>the</strong>r kits <strong>and</strong> equipment.Reproductive health supplies were crucial componentsof maternal survival.Reproductive health commodities security (RHCS) wasa prerequisite for achiev<strong>in</strong>g MDGs. RHCS was achievedwhen all <strong>in</strong>dividuals could obta<strong>in</strong> <strong>and</strong> use affordable,good-quality reproductive health commodities of <strong>the</strong>irchoice whenever <strong>the</strong>y needed <strong>the</strong>m. It was more than asupply-side issue as it had elements related to quality ofcare, access <strong>and</strong> dem<strong>and</strong>. Also, RHCS <strong>in</strong>volved ensur<strong>in</strong>gthat people, especially women, <strong>the</strong> newborn <strong>and</strong> youngpeople, faced no obstacles <strong>in</strong> access<strong>in</strong>g <strong>and</strong> utiliz<strong>in</strong>g lifesav<strong>in</strong>g<strong>and</strong> health-promot<strong>in</strong>g supplies.RHCS l<strong>in</strong>ked reproductive health <strong>and</strong> HIV preventiontoge<strong>the</strong>r through <strong>the</strong> supply of contraceptives, maternal<strong>and</strong> newborn drugs, STI drugs <strong>and</strong> o<strong>the</strong>r equipment, kits<strong>and</strong> emergency supplies with<strong>in</strong> <strong>the</strong> overall managementof <strong>the</strong> health system. Research showed that about 30 percent of maternal deaths (over 100,000 maternal deaths)<strong>and</strong> nearly 10 per cent of childhood deaths (about 1million) could be reduced through family plann<strong>in</strong>g.Many nations would witness a doubl<strong>in</strong>g or tripl<strong>in</strong>g <strong>in</strong><strong>the</strong> size of <strong>the</strong>ir populations <strong>in</strong> <strong>the</strong> com<strong>in</strong>g decades.In some of those countries, women were more likelyto die of unsafe abortion than most diseases. Donorexpenditures for family plann<strong>in</strong>g had decl<strong>in</strong>ed. In 1997,family plann<strong>in</strong>g had been supported by US$ 653 million<strong>in</strong> donations, which was reduced by over US$ 80 millionto US$ 572 million <strong>in</strong> 2008. By comparison, fund<strong>in</strong>gfor HIV/AIDS activities had <strong>in</strong>creased from US$ 294million <strong>in</strong> 1997 to US$ 7.7 billion <strong>in</strong> 2008.The presentation concluded by highlight<strong>in</strong>g somepriority actions: Support for country-led health plans, supported bypredictable <strong>and</strong> susta<strong>in</strong>able <strong>in</strong>vestments. Integrateddelivery of health services <strong>and</strong> life-sav<strong>in</strong>g <strong>in</strong>terventions– enabl<strong>in</strong>g women <strong>and</strong> <strong>the</strong>ir children to accessprevention, treatment <strong>and</strong> care when <strong>and</strong> where <strong>the</strong>yneeded it; Support to establish stronger health systems, withsufficient skilled health workers at <strong>the</strong>ir core; Use of <strong>in</strong>novative approaches to f<strong>in</strong>anc<strong>in</strong>g, productdevelopment <strong>and</strong> <strong>the</strong> efficient delivery of healthservices; Improved monitor<strong>in</strong>g <strong>and</strong> evaluation to ensure <strong>the</strong>accountability of all actors for results; Review of national policies <strong>and</strong> priorities to ensure afocus on <strong>in</strong>-country <strong>in</strong>equalities; Avoidance of fragmentation <strong>and</strong> decentralization ofprocurement; Enhanced private sector participation; Build<strong>in</strong>g of emergency preparedness; Assur<strong>in</strong>g good-quality production <strong>and</strong> distribution,regulations <strong>and</strong> tariff issues; Build<strong>in</strong>g of South-South collaboration <strong>and</strong> exchanges,which was especially relevant <strong>in</strong> <strong>the</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong>region.Discussion po<strong>in</strong>ts:Question/issue:Global fund<strong>in</strong>g for HIV had <strong>in</strong>creased <strong>in</strong> comparisonto family plann<strong>in</strong>g <strong>and</strong> reproductive health. Would itbe useful to separate family plann<strong>in</strong>g from reproductivehealth <strong>in</strong> order to ensure that family plann<strong>in</strong>g receivedmore attention?15

Response:The presentation on reproductive health commoditysecurity <strong>in</strong>cluded a comparison between HIV allocations<strong>and</strong> RH allocation as an illustration of how f<strong>in</strong>anc<strong>in</strong>ghad changed. HIV also needed more fund<strong>in</strong>g. Globalf<strong>in</strong>anc<strong>in</strong>g worked very strangely; family plann<strong>in</strong>g wascurrently gett<strong>in</strong>g less focus, <strong>and</strong> strategies needed tobe implemented <strong>in</strong> order to br<strong>in</strong>g those issues to <strong>the</strong>forefront.Question/issue:Decentralization was good but not for procurement;however, <strong>in</strong> Indonesia decentralization was started<strong>in</strong> 2001. Currently, <strong>the</strong>re were 500 districts witha decentralized system, <strong>the</strong> majority of which hadplaced low priority on <strong>the</strong> family plann<strong>in</strong>g programme<strong>and</strong> put more emphasis on physical procurement.Decentralization was good <strong>in</strong> <strong>the</strong>ory but many countrieswere challenged <strong>in</strong> its operationalization. The issue ofvertical <strong>and</strong> <strong>in</strong>tegrated programmes was discussed.Experiences from Bangladesh, India <strong>and</strong> Pakistanhighlighted some perspectives related to family plann<strong>in</strong>gprogrammes. Bangladesh had attempted to <strong>in</strong>tegrateits programme <strong>in</strong> 1998 <strong>and</strong> 2003. The programmewas revised to start a vertical programme for health<strong>and</strong> family plann<strong>in</strong>g. India had determ<strong>in</strong>ed that familyplann<strong>in</strong>g programmes worked best if <strong>the</strong>y were run as acomponent of mo<strong>the</strong>r <strong>and</strong> child health programmes.Response:There were many perspectives related to vertical versus<strong>in</strong>tegrated programmes. Evidence suggested that familyplann<strong>in</strong>g did benefit from be<strong>in</strong>g part of an overall system.Verticality did not deliver enough.Response:NGOs also played an important <strong>and</strong> active role <strong>in</strong>provid<strong>in</strong>g family plann<strong>in</strong>g services. In <strong>the</strong> <strong>Pacific</strong>, for<strong>in</strong>stance, IPPF affiliates were <strong>in</strong>strumental <strong>in</strong> reach<strong>in</strong>g<strong>and</strong> deliver<strong>in</strong>g services to young people.Question/issue:The presentations revealed that some countries weresubstantially left beh<strong>in</strong>d despite operat<strong>in</strong>g familyplann<strong>in</strong>g programmes. What would be <strong>the</strong> reasons forthat outcome?Response:There were many reasons why countries were leftbeh<strong>in</strong>d. In countries where prevalence was low, such asTimor-Leste, <strong>in</strong>frastructure played a role; gender roleswith high levels of gender <strong>in</strong>equality contributed to <strong>the</strong>situation <strong>in</strong> Afghanistan, while high levels of unmetneed affected Pakistan.Question/issue:The experience of India showed that <strong>in</strong>tegration offamily plann<strong>in</strong>g did not always work. It was suggestedthat <strong>the</strong> programme lost its focus along <strong>the</strong> way. O<strong>the</strong>rf<strong>in</strong>d<strong>in</strong>gs from India related to <strong>the</strong> relationship betweenCPR <strong>and</strong> TFR, use of condoms <strong>and</strong> o<strong>the</strong>r spac<strong>in</strong>gmethods which did not translate <strong>in</strong>to changes <strong>in</strong> TFR.For example, condom use had gone up but that had nottranslated <strong>in</strong>to a lower<strong>in</strong>g of <strong>the</strong> birth rate.Response:Sou<strong>the</strong>rn India had <strong>the</strong> lowest levels of sterilization.There seemed to be <strong>in</strong>terest <strong>in</strong> hav<strong>in</strong>g smaller families.There were also many people that did not <strong>in</strong>tend to useany contraceptive method. Spac<strong>in</strong>g was as important assterilization.Question/issue:Adolescent sexual <strong>and</strong> reproductive health comprisedimportant elements to be considered when assess<strong>in</strong>gfertility behaviour. Evidence showed that age at marriagewas an important factor <strong>in</strong> determ<strong>in</strong><strong>in</strong>g reproductivehealth behaviour. Access of young people to <strong>in</strong>formation<strong>and</strong> services rema<strong>in</strong>ed a central issue.Response:Evidence showed that youth did not usually access publichealth services; <strong>the</strong> challenge was to develop public (oro<strong>the</strong>r) health services to ensure <strong>the</strong>y got <strong>the</strong> services <strong>the</strong>yneeded.SESSION 2: Voices fromcountriesModerator:Mr. Thomas Osias, Executive Director, Commission onPopulation, Philipp<strong>in</strong>esCountry case studies <strong>and</strong> responses <strong>and</strong>/or statementsfrom government counterpartsThe second session <strong>in</strong>cluded presentations from allcountries clustered around similarities <strong>in</strong> <strong>the</strong>ir familyplann<strong>in</strong>g situation or <strong>the</strong> approach of <strong>the</strong>ir programme.The first group <strong>in</strong>cluded Afghanistan, Pakistan, PapuaNew Gu<strong>in</strong>ea <strong>and</strong> Timor-Leste, which representedcountries with high fertility rates. The second group<strong>in</strong>cluded countries that could present success <strong>and</strong> alsostagnation of <strong>the</strong>ir family plann<strong>in</strong>g programme, suchas Bangladesh, India, Indonesia <strong>and</strong> Nepal. The thirdcluster addressed countries that presented challenges<strong>in</strong> susta<strong>in</strong><strong>in</strong>g universal access to family plann<strong>in</strong>g; <strong>the</strong>y<strong>in</strong>cluded Malaysia, Sri Lanka <strong>and</strong> Thail<strong>and</strong>. The f<strong>in</strong>al16

at a hospital would be offered post-partum IUDs upondischarge. Currently, between approximately 12 <strong>and</strong> 15per cent of women deliver<strong>in</strong>g at hospitals were providedwith IUDs.Countries that presented challenges <strong>in</strong> susta<strong>in</strong><strong>in</strong>guniversal access to family plann<strong>in</strong>gSri Lanka byDr. A.T.P.L Abeykoon, Institute for Health PolicySri Lanka had had a long history with regard tomaternal care <strong>and</strong> data collection, with early registrationof births <strong>and</strong> deaths. Evidence suggested that expansionof maternal <strong>and</strong> child health services contributedto lower<strong>in</strong>g of mortality rates. The family plann<strong>in</strong>gprogramme started <strong>in</strong> 1953 through <strong>the</strong> establishmentof <strong>the</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Association, which was providedwith an annual grant. Responsibility for <strong>the</strong> familyplann<strong>in</strong>g programme was repeatedly shifted. Initially,it was under <strong>the</strong> M<strong>in</strong>istry of Health <strong>and</strong> l<strong>in</strong>ked to <strong>the</strong>maternal <strong>and</strong> child health programme, but was movedlater to be coord<strong>in</strong>ated by <strong>the</strong> M<strong>in</strong>istry of Plan <strong>and</strong>Implementation. <strong>Family</strong> plann<strong>in</strong>g was aga<strong>in</strong> moved to beunder <strong>the</strong> overall coord<strong>in</strong>ation of <strong>the</strong> M<strong>in</strong>istry of Health,where it currently rema<strong>in</strong>ed. It was suggested that those<strong>in</strong>stitutional shifts had been completed at <strong>the</strong> right time<strong>and</strong> actually served <strong>the</strong> programme well.Future challenges for Sri Lanka <strong>in</strong>cluded identify<strong>in</strong>gvulnerable groups <strong>in</strong> geographic pockets, prioritiz<strong>in</strong>glogistics management <strong>and</strong> commodity security,develop<strong>in</strong>g age appropriate BCC approaches, promot<strong>in</strong>gequal participation of men <strong>and</strong> women, streng<strong>the</strong>n<strong>in</strong>gadm<strong>in</strong>istration of justice with regard to address<strong>in</strong>ggender-based violence (especially domestic violence),streng<strong>the</strong>n<strong>in</strong>g database use, as well as advocat<strong>in</strong>g for<strong>in</strong>formed choice <strong>in</strong> <strong>the</strong> use of family plann<strong>in</strong>g services.Malaysia byDr. Norliza Ahmad, Director, Human Reproduction,National Population <strong>and</strong> <strong>Family</strong> Development Board,MalaysiaThe national family plann<strong>in</strong>g policy for Malaysia was<strong>in</strong>itiated <strong>in</strong> 1996, coord<strong>in</strong>ated through <strong>the</strong> NationalPopulation <strong>and</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Development Board(NPFDB). <strong>Family</strong> plann<strong>in</strong>g was <strong>in</strong>tegrated <strong>in</strong>to <strong>the</strong>primary health system <strong>and</strong> l<strong>in</strong>ked with reproductivehealth efforts. The population growth rate was reducedfrom 3 to 2 per cent annually.The presentation highlighted socio-economicdifferentials <strong>in</strong> contraceptive use. Urban areas presentedhigher percentages of contraceptive use, at 35.5 per cent,<strong>and</strong> rural, east coast <strong>and</strong> women at 40 years presentedlower figures of contraceptive use: between 26 <strong>and</strong> 31per cent. Unmet need had <strong>in</strong>creased from 25 per cent<strong>in</strong> 1988 to 36 per cent <strong>in</strong> 2004, <strong>and</strong> factors affect<strong>in</strong>gunmet need <strong>in</strong>cluded geographic location, ethnicity,urban/rural residence, level of education <strong>and</strong> older age.The M<strong>in</strong>istry of Health managed cl<strong>in</strong>ics <strong>and</strong> establishedguidel<strong>in</strong>es. It also managed decentralized procurement,dissem<strong>in</strong>ation <strong>and</strong> monitor<strong>in</strong>g. NPFDB managedcl<strong>in</strong>ics, outreach programmes, centralized procurement<strong>and</strong> dissem<strong>in</strong>ation <strong>and</strong> monitor<strong>in</strong>g. The Federation ofReproductive Health Associations <strong>in</strong> Malaysia managedcl<strong>in</strong>ics, based on <strong>in</strong>ternational fund<strong>in</strong>g from donors suchas <strong>the</strong> <strong>International</strong> Planned Parenthood Federation(IPPF). Most procurement was carried out centrally <strong>and</strong><strong>the</strong>re had been no reports of shortages <strong>in</strong> supplies.L<strong>in</strong>kages between family plann<strong>in</strong>g <strong>and</strong> o<strong>the</strong>r services,such as those focused on HIV <strong>and</strong> STIs, were established<strong>in</strong> <strong>the</strong> programme. Specific services were developed thattargeted young people, <strong>in</strong>clud<strong>in</strong>g mak<strong>in</strong>g use of socialmedia. One gap <strong>in</strong>cluded women at <strong>the</strong> end of <strong>the</strong>irreproductive period; <strong>the</strong>re was no special programmetarget<strong>in</strong>g that age group despite <strong>the</strong> high unmet needamong older women.The ma<strong>in</strong> recommendations <strong>in</strong>cluded plac<strong>in</strong>g specialattention on key target groups, <strong>in</strong>clud<strong>in</strong>g those withunmet need; husb<strong>and</strong>s who were apa<strong>the</strong>tic to <strong>the</strong> benefitsof planned parenthood; marg<strong>in</strong>alized groups that mightlack knowledge <strong>and</strong> access; users of traditional methods;<strong>and</strong> those who feared side effects, as well as foreignworkers <strong>and</strong> young people.Thail<strong>and</strong> byDr. Kittipong Saejeng, Director, Bureau of ReproductiveHealth, Department of Health, Thail<strong>and</strong>In 1970, Thail<strong>and</strong> adopted a national population policywhich focused on voluntary family plann<strong>in</strong>g. Theprogramme had recorded many achievements, <strong>in</strong>clud<strong>in</strong>gan <strong>in</strong>crease <strong>in</strong> CPR from 53 per cent 1978 to 80 percent <strong>in</strong> 2009 <strong>and</strong> a decrease <strong>in</strong> TFR from 6 childrenper woman <strong>in</strong> 1965 to 1.5 <strong>in</strong> 2008. Currently, fertility<strong>in</strong> Thail<strong>and</strong> was below <strong>the</strong> replacement level. The ma<strong>in</strong>reasons for those achievements <strong>in</strong>cluded governmentpolicy, an effective organization <strong>and</strong> managementsystem, <strong>and</strong> work<strong>in</strong>g through a national family plann<strong>in</strong>gcommittee.Rapid socio-economic changes <strong>and</strong> RH context resulted<strong>in</strong> low fertility <strong>in</strong> Thail<strong>and</strong>. However, <strong>the</strong> level ofunwanted pregnancy rema<strong>in</strong>ed high <strong>and</strong> <strong>the</strong>re was acont<strong>in</strong>uous need for more youth-friendly <strong>and</strong> gendersensitiveservices. O<strong>the</strong>r concerns <strong>in</strong>cluded a young ageat first sexual <strong>in</strong>tercourse, currently between 15 <strong>and</strong> 16years, <strong>and</strong> low levels of condom use among young people.The young age at first <strong>in</strong>tercourse <strong>and</strong> unprotected sexhad led to an <strong>in</strong>creased trend <strong>in</strong> pregnancies <strong>in</strong> <strong>the</strong> agegroup 15-19 years, <strong>and</strong> an <strong>in</strong>creased trend of STIs <strong>in</strong> <strong>the</strong>age group 15-24 years.21

media to reach target groups; improv<strong>in</strong>g <strong>the</strong> quality ofcare; streng<strong>the</strong>n<strong>in</strong>g supply cha<strong>in</strong>s; tra<strong>in</strong><strong>in</strong>g of humanresources <strong>in</strong> RHCS; advocat<strong>in</strong>g all partners to considerquantity <strong>and</strong> quality for universal access; provid<strong>in</strong>gguidel<strong>in</strong>es for effective utilization of <strong>the</strong> country’s drugrevolv<strong>in</strong>g fund; actively engag<strong>in</strong>g <strong>the</strong> donor community;<strong>and</strong> streng<strong>the</strong>n<strong>in</strong>g <strong>the</strong> health system.Response from government:The national population policy had been drafted <strong>in</strong> 1992;family plann<strong>in</strong>g was highlighted <strong>in</strong> Myanmar based on<strong>the</strong> <strong>in</strong>creas<strong>in</strong>g trend of fertility levels. The ma<strong>in</strong> problem<strong>in</strong>cluded unmet need (17%). The government adopted anRH strategy <strong>and</strong> was <strong>in</strong>terested <strong>in</strong> regional collaborationto share experiences related to implementation of familyplann<strong>in</strong>g programmes.Discussion po<strong>in</strong>tsQuestion/issue:The Philipp<strong>in</strong>es was asked why it was challenged <strong>in</strong>implement<strong>in</strong>g broader development issues beyondpolitical tenure when many o<strong>the</strong>r countries could achievechanges <strong>in</strong> development <strong>and</strong> <strong>the</strong> macro environment.Response:In <strong>the</strong> Philipp<strong>in</strong>es, political tenure was important: <strong>the</strong>country depended on work with<strong>in</strong> sympa<strong>the</strong>tic prov<strong>in</strong>ces.However, <strong>the</strong>re was not enough support (political orphysical) to respond to <strong>the</strong> actual need. Pass<strong>in</strong>g lawsto <strong>in</strong>stitutionalize family plann<strong>in</strong>g programmes wasone political measure that could be taken to developprogrammes beyond political tenure. There wereattempts to <strong>in</strong>stitutionalize law while ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g ahealthy dialogue with <strong>the</strong> Church. The Philipp<strong>in</strong>eswas challenged by <strong>the</strong> f<strong>in</strong>e l<strong>in</strong>e between Church <strong>and</strong>State. It was a sectarian State <strong>and</strong> a Catholic country.The high levels of unmet need did push women to haveunsafe abortions. <strong>Family</strong> plann<strong>in</strong>g <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es hadbecome a by-word. The current adm<strong>in</strong>istration wouldplay a role <strong>and</strong> efforts were be<strong>in</strong>g made to work towardsresponsible parenthood.Comments were made related to risk mitigation, as wellas <strong>the</strong> importance of analys<strong>in</strong>g actual spend<strong>in</strong>g versusbudgets. There were issues related to <strong>the</strong> cost of policy.If decentralization did not work, countries should movetowards centralization. Systems needed to be flexible toadapt to specific needs.Bhutan byDr. Sunun Gatsu, M<strong>in</strong>istry of HealthIn Bhutan, family plann<strong>in</strong>g was <strong>in</strong>tegrated <strong>in</strong>to <strong>the</strong>general health-care system <strong>in</strong> 1974 <strong>and</strong> featured <strong>the</strong><strong>in</strong>troduction of various methods (low-dose pills,<strong>in</strong>jectables <strong>and</strong> IUDs). Also, a nationwide campaign ofpopulation plann<strong>in</strong>g had been <strong>in</strong>itiated. The nationalpolicy on family plann<strong>in</strong>g focused on <strong>the</strong> voluntary basisof <strong>the</strong> programme; access to <strong>in</strong>formation <strong>and</strong> educationregard<strong>in</strong>g pregnancy; counsell<strong>in</strong>g on FP methods;surgical contraceptives as well as support to <strong>in</strong>fertilecouples were offered.TFR was 3 children per woman <strong>and</strong> <strong>the</strong> CPR trend was35 per cent. Teenage pregnancy was twice as common <strong>in</strong>rural areas compared with urban areas. Key issues fac<strong>in</strong>g<strong>the</strong> programme <strong>in</strong>cluded teenage pregnancies; unsafeabortion; limited access to services due to <strong>the</strong> shortageof tra<strong>in</strong>ed staff <strong>and</strong> <strong>the</strong> great distance to health centres.Currently, contraceptive commodities were be<strong>in</strong>gprovided by UNFPA.Nepal byMr. Naresh Pratap K.C., Director, <strong>Family</strong> Health Division,Department of Health ServicesNepal was currently draft<strong>in</strong>g a new constitution aftera decade-long armed conflict. The prelim<strong>in</strong>ary draftdid make reference to <strong>the</strong> right to equality, <strong>the</strong> rightto propriety <strong>and</strong> <strong>in</strong>heritance (which would have animpact on <strong>the</strong> role of women <strong>and</strong> could make womenmore <strong>in</strong>dependent), as well as women’s right to RH,free medical care <strong>and</strong> essential care services. Address<strong>in</strong>ggender-based violence was a priority for Nepal; <strong>the</strong>government had formed a special committee on <strong>the</strong> issue<strong>and</strong> declared 2010 “a year free of gender-based violence”.There was a commitment to address<strong>in</strong>g FP effectively. Theexpectation was that <strong>the</strong> new constitution would help <strong>in</strong><strong>the</strong> implementation of family plann<strong>in</strong>g <strong>in</strong>terventions.Cambodia byH.E. Ms. Lork Kheng, Member, National AssemblyCommissionHealth promotion for <strong>the</strong> people was one of <strong>the</strong> toppriorities of <strong>the</strong> government; it <strong>in</strong>volved address<strong>in</strong>greproductive health concerns, maternal mortality, HIV/AIDS <strong>and</strong> communicable diseases. A national strategyhad been adopted with a focus on family plann<strong>in</strong>g, birthspac<strong>in</strong>g, safe abortion, nutrition <strong>and</strong> maternal care.However, Cambodia still faced slow progress <strong>in</strong> <strong>the</strong> useof modern contraceptives (an <strong>in</strong>crease of only 1.5%) <strong>and</strong>CPR was 28 per cent. Evidence showed that campaignsdid not reach youth <strong>and</strong> rural areas.The annual budget allocated to <strong>the</strong> M<strong>in</strong>istry of Healthfor health promotion had been <strong>in</strong>creased by 19 percent, which reflected <strong>the</strong> government’s commitmentto achiev<strong>in</strong>g MDGs. Focus would be placed onreach<strong>in</strong>g young people through mass media techniques,establish<strong>in</strong>g private partnerships <strong>and</strong> adoption of fiveyearnational action plans.Lao People’s Democratic Republic by H.E. Dr.24

Bounkoung Phichit, Deputy M<strong>in</strong>ister of HealthThe government recognized <strong>the</strong> importance ofstreng<strong>the</strong>n<strong>in</strong>g <strong>the</strong> health sector as a part of its povertyalleviation efforts. The country had taken significantsteps to create sexual <strong>and</strong> reproductive health policy,with an emphasis on reduc<strong>in</strong>g maternal mortalityrates. The M<strong>in</strong>istry of Health established strategiesfocused on family plann<strong>in</strong>g, <strong>and</strong> maternal <strong>and</strong> neonatalhealth. Currently, <strong>the</strong> total unmet need was 27 per cent.Community-based programmes were effective tools for<strong>in</strong>creas<strong>in</strong>g knowledge <strong>and</strong> dem<strong>and</strong>. The governmenthad agreed to exp<strong>and</strong> <strong>the</strong> scope of <strong>the</strong> community-basedprogramme, <strong>and</strong> was committed to work with o<strong>the</strong>rcountries <strong>in</strong> <strong>the</strong> <strong>Asia</strong>-<strong>Pacific</strong> region.Viet Nam byH.E Dr. Nguyen Ba Thuy, Vice-M<strong>in</strong>ister of HealthThe Government of Viet Nam had made a strongcommitment to family plann<strong>in</strong>g through polices <strong>and</strong>legal guidel<strong>in</strong>es. TFR had decl<strong>in</strong>ed rapidly, reach<strong>in</strong>g <strong>the</strong>replacement level. CPR was 79 per cent <strong>in</strong> 2009 <strong>and</strong>CPR for modern methods had <strong>in</strong>creased. Also, <strong>the</strong>rewas a steady <strong>in</strong>crease <strong>in</strong> CPR among married couples.Among <strong>the</strong> issues challeng<strong>in</strong>g Viet Nam were a possible<strong>in</strong>crease <strong>in</strong> <strong>the</strong> fertility rate; a high imbalance <strong>in</strong> <strong>the</strong> sexratio at birth; <strong>the</strong> needs of <strong>the</strong> ag<strong>in</strong>g population; poorstatus of health <strong>and</strong> well-be<strong>in</strong>g of <strong>the</strong> population; deliveryof family plann<strong>in</strong>g commodities <strong>and</strong> services; <strong>in</strong>creas<strong>in</strong>glevels of migration; <strong>and</strong> ris<strong>in</strong>g levels of abortion amongadolescents.Kiribati byH.E. Dr. Kautu Tenaua, M<strong>in</strong>ister of HealthImplementation of <strong>the</strong> family plann<strong>in</strong>g programme <strong>in</strong>Kiribati was challenged by limited contraceptive choice<strong>and</strong> service delivery, as well as strong cultural <strong>and</strong> religiousbarriers to contraceptive use. The government wasexplor<strong>in</strong>g whe<strong>the</strong>r market<strong>in</strong>g could be used differently.The population density was 127 persons per sq kmoverall, yet density varied widely from isl<strong>and</strong> to isl<strong>and</strong>.CPR was 22 per cent; pills <strong>and</strong> implants were <strong>the</strong> ma<strong>in</strong>contraceptive choices. <strong>Family</strong> plann<strong>in</strong>g was promotedamong mo<strong>the</strong>rs dur<strong>in</strong>g <strong>the</strong> delivery of antenatal <strong>and</strong>post-natal care; nurses were also encouraged to promotefamily plann<strong>in</strong>g. The average household size was 5.6persons <strong>in</strong> rural areas <strong>and</strong> 7.5 <strong>in</strong> urban areas. The averagepopulation growth rate was 1.8 per cent annually. Thetotal population was 92,533 <strong>in</strong> 2005.Solomon Isl<strong>and</strong>s byDr. August<strong>in</strong>e Gasivaka Melly, Medical Officer (MasterTra<strong>in</strong>er <strong>in</strong> <strong>the</strong> National Non-Scalpel VasectomyProgramme), M<strong>in</strong>istry of Health <strong>and</strong> Medical ServicesThe government had addressed family plann<strong>in</strong>g s<strong>in</strong>ce<strong>the</strong> early 1970s through <strong>the</strong> National PopulationPolicy <strong>and</strong> <strong>the</strong> National Population <strong>Council</strong>. Technicaladvisory committees <strong>and</strong> RHCS committees providedadvice on family plann<strong>in</strong>g. <strong>Family</strong> plann<strong>in</strong>g services <strong>and</strong>products were available from all government healthcentres. Fur<strong>the</strong>r, many services were provided by <strong>the</strong><strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Association, Save <strong>the</strong> Children <strong>and</strong>faith-based organizations. CPR had risen from 11 to 27per cent. Current issues fac<strong>in</strong>g Solomon Isl<strong>and</strong>s <strong>in</strong>cludedsociocultural <strong>and</strong> socio-economic barriers, as well asgender <strong>in</strong>equality. Also, <strong>the</strong>re were unmet needs acrossall age groups <strong>and</strong> ethnic groups. Strategies <strong>in</strong>cludedupdat<strong>in</strong>g of <strong>the</strong> family plann<strong>in</strong>g manual based on WHOmedical eligibility criteria <strong>and</strong> conduct<strong>in</strong>g outreachwith<strong>in</strong> family health-care strategies. The governmentwas currently draft<strong>in</strong>g <strong>the</strong> country’s first reproductivehealth policy, which could play a role <strong>in</strong> revitaliz<strong>in</strong>g <strong>the</strong>family plann<strong>in</strong>g programme.Vanuatu byMs. Apisai Tokon, National Reproductive Health/FPCoord<strong>in</strong>ator, M<strong>in</strong>istry of Health ServicesVanuatu had revised its reproductive health policy<strong>and</strong> strategy that called for l<strong>in</strong>ks with <strong>the</strong> educationsector, as well as improved service delivery. A st<strong>and</strong><strong>in</strong>gparliamentary committee had recently been establishedthat would address <strong>the</strong> previously fragmented approachto family plann<strong>in</strong>g.By <strong>the</strong> mid-2000s, CPR had <strong>in</strong>creased gradually to 28per cent. Key challenges <strong>in</strong>cluded user acceptance due to<strong>the</strong> society be<strong>in</strong>g a male-dom<strong>in</strong>ant one; human resourcesnumbers <strong>and</strong> capacity; <strong>and</strong> government fund<strong>in</strong>g. Keyrecommendations <strong>in</strong>cluded add<strong>in</strong>g a budget l<strong>in</strong>e forRHCS; sensitiz<strong>in</strong>g planners <strong>and</strong> f<strong>in</strong>ancers on population<strong>and</strong> development; <strong>and</strong> streng<strong>the</strong>n<strong>in</strong>g male-<strong>in</strong>volvement<strong>in</strong>terventions.SESSION 3: ReproductiveHealth CommoditySecurityModerator:Mr. Jagdish Upadhyay, Chief, Commodity Security Branch,UNFPAThe third session focused on identify<strong>in</strong>g ways to improvereproductive health commodity security. It <strong>in</strong>cluded apresentation on <strong>the</strong> global reproductive health commoditysecurity movement through <strong>the</strong> Reproductive HealthSupplies Coalition, a presentation on experiences from<strong>the</strong> local production of contraceptives <strong>and</strong> reproductive25

<strong>and</strong> advocacy for long-term methods.Recommendations <strong>in</strong>cluded establish<strong>in</strong>g <strong>and</strong> recogniz<strong>in</strong>g<strong>the</strong> well-function<strong>in</strong>g task force, <strong>and</strong> conduct<strong>in</strong>g a<strong>the</strong>matic review. In addition, it was recommended thata national strategy on RHC be formulated which wouldaddress <strong>the</strong> skewed method mix <strong>and</strong> adapt <strong>the</strong> currentprocurement process for a new sector programme.Integration of maternal, neonatal <strong>and</strong> child health;tuberculosis; malaria; <strong>and</strong> HIV commodity supplysystems <strong>in</strong> <strong>the</strong> Lao People’s Democratic Republic by Dr.Kaisone Chounramany, Director, MCH, M<strong>in</strong>istry ofHealthThe presentation focused on ways to streng<strong>the</strong>n MNCH<strong>and</strong> o<strong>the</strong>r health commodity logistics management <strong>and</strong><strong>in</strong>formation systems to ensure <strong>in</strong>creased efficiency.In 2009, <strong>the</strong> M<strong>in</strong>istry of Health had succeeded <strong>in</strong>transferr<strong>in</strong>g different logistics systems <strong>in</strong>to one.Previously, two vertical systems were operat<strong>in</strong>g fordifferent forms of health commodities. In order tostreaml<strong>in</strong>e <strong>and</strong> l<strong>in</strong>k <strong>the</strong> different systems, efforts weremade for <strong>in</strong>tegration of <strong>the</strong> supply cha<strong>in</strong>. MPSC alsomonitored stock levels, provided tra<strong>in</strong><strong>in</strong>g <strong>in</strong> commodity<strong>and</strong> <strong>in</strong>formation management. The government alsoreceived support from development partners.Ways forward <strong>in</strong>cluded build<strong>in</strong>g capacity of MPSCto serve as a sector-wide logistics operator; creat<strong>in</strong>gmanageable <strong>and</strong> cost-effective solutions to transport<strong>in</strong>gpublic health commodities to districts <strong>and</strong> develop<strong>in</strong>g<strong>the</strong> capacity to monitor stocks of essential medic<strong>in</strong>es <strong>and</strong>contraceptives at <strong>the</strong> lowest level of <strong>the</strong> supply cha<strong>in</strong>.Discussion po<strong>in</strong>tsQuestion/issue:Afghanistan had to look at <strong>in</strong>creas<strong>in</strong>g dem<strong>and</strong> <strong>and</strong>was required to <strong>in</strong>crease access to commodity security.However, attempts to <strong>in</strong>crease dem<strong>and</strong> through <strong>the</strong>provision of free contraceptives still had not resulted <strong>in</strong>a change <strong>in</strong> CPR. How much should be allocated for<strong>in</strong>creas<strong>in</strong>g dem<strong>and</strong> through IEC <strong>and</strong> BCC?Response:Experiences from <strong>the</strong> Reproductive Health SuppliesCoalition suggested that mak<strong>in</strong>g supplies availablewould not create dem<strong>and</strong>. There were always issuesrelated to dem<strong>and</strong> versus supplies. There were a numberof factors that came <strong>in</strong>to play, <strong>in</strong>clud<strong>in</strong>g <strong>the</strong> role of <strong>the</strong>private sector versus public sector, <strong>and</strong> <strong>the</strong> compositionof <strong>the</strong> method mix. The budget levels depended on <strong>the</strong>level of CPR, but more resources should be allocatedfor dem<strong>and</strong> creation. A thorough situation analysisshould reveal how much should be allocated for dem<strong>and</strong>creation.Question/issue:The Reproductive Health Supplies Coalition was askedto clarify its network<strong>in</strong>g role between governments <strong>and</strong>manufacturers. There was a concern that go<strong>in</strong>g through<strong>the</strong> Coalition could entail higher costs.Response:The pharmaceutical sector did play a part; however, ithad no <strong>in</strong>herent role <strong>in</strong> <strong>the</strong> work of <strong>the</strong> Coalition. TheCoalition worked to streng<strong>the</strong>n generic manufacturers.Question/issue:The Reproductive Health Supplies Coalition was askedhow <strong>the</strong> coalition identified which countries neededsupport.Response:In <strong>the</strong> Coalition’s list of countries, 14 were classified asfocus countries where work had been completed <strong>in</strong> closecollaboration with members of relevant work<strong>in</strong>g groups.A strategic plan was used as a case control to measureimpact. The work of <strong>the</strong> Coalition related to globaltrends <strong>and</strong> was based on track<strong>in</strong>g certa<strong>in</strong> <strong>in</strong>dicators.Question/issue:Lao People’s Democratic Republic was asked about <strong>the</strong>process for procur<strong>in</strong>g contraceptives <strong>and</strong> whe<strong>the</strong>r <strong>the</strong>rewas a national procurement process or if each prov<strong>in</strong>cecarried out its own procurement.Response:UNFPA procured contraceptives for <strong>the</strong> country. When<strong>the</strong> family plann<strong>in</strong>g programme had been started <strong>in</strong>1994, a different report<strong>in</strong>g process was used. There wasnow a unified system under a centre for medical supplieswhich was responsible for distribution of supplies to<strong>the</strong> country. Currently, efforts were be<strong>in</strong>g made to lookat <strong>the</strong> national immunization programmes <strong>in</strong> order todeterm<strong>in</strong>e how to relate those to family plann<strong>in</strong>g.Question/issue:It was noted that Ch<strong>in</strong>a had ma<strong>in</strong>ta<strong>in</strong>ed stable levels ofcontraceptive procurement but that <strong>the</strong>re was a sharp<strong>in</strong>crease s<strong>in</strong>ce 2007. What was <strong>the</strong> reason for that?Response:Ch<strong>in</strong>a had <strong>in</strong> recent years <strong>in</strong>creased its <strong>in</strong>vestment <strong>in</strong>public health, both at <strong>the</strong> national <strong>and</strong> prov<strong>in</strong>cial levels,which had <strong>in</strong>creased procurement. Also, <strong>the</strong>re had beenpublic sector <strong>in</strong>vestment <strong>in</strong> research <strong>and</strong> development.Question/issue:It was also noted that Ch<strong>in</strong>a’s production of essential27

medic<strong>in</strong>es <strong>and</strong> essential generic drugs positioned itwell for South-South cooperation. Some questionswere related to that issue, especially if o<strong>the</strong>rs couldpromote low-cost production, how could <strong>the</strong> qualityof <strong>the</strong> products be safeguarded <strong>and</strong> how could <strong>the</strong>re beassurance that <strong>the</strong> products were made <strong>in</strong> accordancewith st<strong>and</strong>ards. UNFPA had always stressed <strong>the</strong>importance of <strong>the</strong> prequalification process.FUNDING FORSUSTAINABILITY:Dialogue withdonors on policies<strong>and</strong> correspond<strong>in</strong>g<strong>in</strong>vestments <strong>in</strong> family<strong>Plann<strong>in</strong>g</strong>Moderator:Ms. Nobuko Horibe, Regional Director, UNFPA APROThe session addressed fund<strong>in</strong>g for susta<strong>in</strong>ability<strong>and</strong> <strong>in</strong>cluded a dialogue with donors on policies <strong>and</strong>correspond<strong>in</strong>g <strong>in</strong>vestments <strong>in</strong> family plann<strong>in</strong>g, withpresentations by representatives of <strong>the</strong> World Bank,USAID, AusAID, NZAID <strong>and</strong> UNFPA.The World Bank: policies <strong>and</strong> <strong>in</strong>vestments forreproductive health byDr. Sadia Chowdhury, Coord<strong>in</strong>ator, Reproductive <strong>and</strong>Child Health Programme, World BankThe presentation focused on <strong>the</strong> World Bank’s approachtowards family plann<strong>in</strong>g <strong>and</strong> its approach to MDGs 4, 5<strong>and</strong> 6. The presentation also addressed <strong>the</strong> commitmentof <strong>the</strong> World Bank to RH <strong>and</strong> its aims <strong>in</strong> support of RH<strong>in</strong>terventions. In 2010, <strong>the</strong> Bank adopted <strong>the</strong> RH ActionPlan which focused on support<strong>in</strong>g <strong>the</strong> developmentof more effective national health systems, support<strong>in</strong>g<strong>in</strong>creased use of RH services <strong>and</strong> especially work<strong>in</strong>gwith <strong>the</strong> poor <strong>and</strong> youth. The World Bank <strong>in</strong>vestedma<strong>in</strong>ly <strong>in</strong> South <strong>Asia</strong>, Africa, East <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong>.Focus countries <strong>in</strong> East <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong> <strong>in</strong>cludedCambodia, Indonesia, <strong>the</strong> Lao People’s DemocraticRepublic, Papua New Gu<strong>in</strong>ea, Timor-Leste <strong>and</strong> various<strong>Pacific</strong> isl<strong>and</strong> countries or territories. Focus countries<strong>in</strong> South <strong>Asia</strong> were Afghanistan, Bangladesh, India,Pakistan <strong>and</strong> Sri Lanka. The World Bank was a memberof H4+ (compris<strong>in</strong>g Jo<strong>in</strong>t United Nations Programmeon HIV/AIDS (UNAIDS), United Nations Children’sFund, UNFPA, WHO <strong>and</strong> World Bank), with jo<strong>in</strong>taction plans <strong>in</strong> Afghanistan, Bangladesh, Bhutan, Nepal<strong>and</strong> Papua New Gu<strong>in</strong>ea.In terms of mov<strong>in</strong>g forward, <strong>the</strong> Bank recognized <strong>the</strong>urgent need to scale up efforts to improve reproductivehealth outcomes, not only by add<strong>in</strong>g more money butalso by do<strong>in</strong>g better with <strong>the</strong> resources available, wi<strong>the</strong>mphasis on improv<strong>in</strong>g exist<strong>in</strong>g health systems.USAID byDr. Aye Aye Thw<strong>in</strong>, Director, Office of Public Health,USAIDThe presentation focused on key components ofUSAID’s work related to reproductive health, whichwas positioned to improve <strong>the</strong> health situation ofwomen <strong>and</strong> girls. The core pr<strong>in</strong>ciples of USAID’s workwere based on a women <strong>and</strong> girl-centred approach,which was operated through exist<strong>in</strong>g platforms. Thelong-term benefits of that approach <strong>in</strong>cluded <strong>in</strong>creasedchild survival, country ownership <strong>and</strong> <strong>the</strong> streng<strong>the</strong>n<strong>in</strong>gof health systems. The Reproductive Mo<strong>the</strong>r <strong>and</strong> ChildAlliance, a public <strong>and</strong> private global alliance, was viewedas a strategic entry po<strong>in</strong>t.AusAID byMs. Michelle Sullivan, First Secretary, Regional Programme,AusAIDThe presentation outl<strong>in</strong>ed AusAID’s commitment tofamily plann<strong>in</strong>g <strong>and</strong> reproductive health. AusAID’sfund<strong>in</strong>g for family plann<strong>in</strong>g was <strong>in</strong>tegrated with<strong>in</strong><strong>the</strong> AusAID focus on maternal <strong>and</strong> child health. Thegovernment had <strong>in</strong>creased fund<strong>in</strong>g for reproductivehealth <strong>and</strong> family plann<strong>in</strong>g through support<strong>in</strong>g IPPF<strong>and</strong> UNPFA, as well as specific country programmes.The focus was on streng<strong>the</strong>n<strong>in</strong>g health systems throughimplementation of strong, robust national plans. Inorder to ensure susta<strong>in</strong>ability, AusAID stressed <strong>the</strong> needto work through partnerships.NZAID byMs. Salli Davidson, Senior Health Advisor, NZAIDThe presentation focused on NZAID’s support forfamily plann<strong>in</strong>g <strong>and</strong> reproductive health. The workwas focused on sector-wide support through corecontributions to various agencies. The health sectorprogramme was conducted <strong>in</strong> collaboration with o<strong>the</strong>rdonors <strong>in</strong> <strong>the</strong> region. NZAID stressed <strong>the</strong> cont<strong>in</strong>uousdialogue with countries related to SRH, MDG 5 <strong>and</strong>family plann<strong>in</strong>g as a component of those areas.UNFPA byMr. Jagdish Upadhyay, Chief of Commodity SecurityBranch, UNFPAThe presentation focused on ways that countriesshould work on fundrais<strong>in</strong>g for susta<strong>in</strong>ed contraceptivecommodity security. The ma<strong>in</strong> recommendation was28

that countries needed to develop strong situationanalysis skills not only to determ<strong>in</strong>e <strong>the</strong> “what” but also<strong>the</strong> “why”. Fur<strong>the</strong>r, present<strong>in</strong>g a strong strategy for SRH<strong>and</strong> RH commodities that <strong>in</strong>cluded costed packages of<strong>in</strong>tervention would play an important role <strong>in</strong> secur<strong>in</strong>gfund<strong>in</strong>g.Discussion po<strong>in</strong>tsQuestions/issues:Questions were raised on what percentage of fund<strong>in</strong>gfor national programmes was com<strong>in</strong>g from donors? Itseemed as if dependence on donors was chang<strong>in</strong>g <strong>and</strong>per capita expenditure on health was com<strong>in</strong>g more fromnational budgets than had previously been <strong>the</strong> case.Response:The session focused on donors as one part of <strong>the</strong>fund<strong>in</strong>g spectrum. It was true that governments weretak<strong>in</strong>g a larger role <strong>in</strong> fund<strong>in</strong>g national family plann<strong>in</strong>gprogrammes, which was good for susta<strong>in</strong>ability.Questions/issues:The Philipp<strong>in</strong>es used scorecards for accountabilitypurposes: all stakeholders <strong>in</strong> <strong>the</strong> process used a donorscorecard to measure how well <strong>the</strong>y were abid<strong>in</strong>g by <strong>the</strong>Paris declaration <strong>and</strong> how donors provided assistance.Response:The World Bank positioned its work with <strong>the</strong> Secretary-General of <strong>the</strong> United Nations Global Strategy forWomen’s <strong>and</strong> Children’s Health, which <strong>in</strong>cluded 49countries, 25 of which had already made commitments.The strategy could be viewed as a global accountabilitymechanism. The World Bank worked to ma<strong>in</strong>ta<strong>in</strong> itself asaccountable on country <strong>and</strong> global levels. Accountabilityrema<strong>in</strong>ed a challenge. Many were good at announc<strong>in</strong>gfund<strong>in</strong>g but not always so good <strong>in</strong> follow<strong>in</strong>g up on <strong>the</strong>delivery of funds.Response:USAID also supported <strong>the</strong> development of strategies<strong>and</strong> was look<strong>in</strong>g at ways to improve capacity. Therewere challenges to be<strong>in</strong>g able to regulate <strong>and</strong> direct <strong>the</strong>public sector. The use of a score card was an <strong>in</strong>terest<strong>in</strong>gsystem.Papua New Gu<strong>in</strong>ea currently had one of <strong>the</strong> worstMMR trends <strong>in</strong> <strong>the</strong> world. How could <strong>the</strong> country dealwith that strategically?Response:AusAID supported countries <strong>in</strong> strategically address<strong>in</strong>g<strong>the</strong>ir challenges. Examples of such assistance <strong>in</strong>cluded<strong>the</strong> support allocated for draft<strong>in</strong>g national strategies<strong>and</strong> work<strong>in</strong>g with<strong>in</strong> <strong>the</strong> area of strategic plann<strong>in</strong>g. TheGovernment of Australia was committed to support<strong>in</strong>gPapua New Gu<strong>in</strong>ea to keep its commitments. Therewere also funds for UNFPA to convene a parliamentaryhear<strong>in</strong>g on family plann<strong>in</strong>g <strong>in</strong> that country.Response:NZAID recognized that Papua New Gu<strong>in</strong>ea hadadopted good policies <strong>and</strong> had <strong>the</strong> needed data to<strong>in</strong>itiate a programme. It was important to enter <strong>in</strong>topolicy dialogue on a central level.Response:Countries were encouraged to take ownership, workwith different sectors <strong>and</strong> m<strong>in</strong>istries; for <strong>in</strong>stance,ensur<strong>in</strong>g that <strong>the</strong> M<strong>in</strong>istry of F<strong>in</strong>ance was <strong>in</strong>volved <strong>in</strong>public health plann<strong>in</strong>g processes.SESSION 4: Address<strong>in</strong>g<strong>the</strong> chalengges to qualityof care <strong>in</strong> family plann<strong>in</strong>g<strong>and</strong> focus<strong>in</strong>g on <strong>the</strong>needs of special groupsInequities <strong>in</strong> access<strong>in</strong>g family plann<strong>in</strong>g services <strong>in</strong><strong>the</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> region by Ms. Sujatha Ram,Monitor<strong>in</strong>g <strong>and</strong> Evaluation Resident Advisor, MeasureEvaluation, ICF Macro)The presentation focused on f<strong>in</strong>d<strong>in</strong>gs <strong>and</strong> analysis fromDemographic <strong>and</strong> Health Surveys (DHS) that hadbeen conducted <strong>in</strong> <strong>the</strong> region. DHS was a nationallyrepresentative household survey that provided dataon population, health <strong>and</strong> nutrition. It used st<strong>and</strong>ardsurvey protocol, <strong>in</strong>clud<strong>in</strong>g questionnaires <strong>and</strong> sampl<strong>in</strong>gmethods, as well as extra modules on specific topics.DHS was cross-sectional <strong>and</strong> took snapshots of <strong>the</strong>situation. Local statistical agencies carried out DHS.Key similarities across <strong>the</strong> region <strong>in</strong>cluded significantlevels of unmet need, <strong>in</strong>clud<strong>in</strong>g a large percentage ofunmet need among youth. Also, knowledge of at least onemethod was high. The majority of married women usedmodern methods compared with traditional methods(<strong>the</strong> adolescent group used <strong>the</strong> lowest percentage ofmodern methods). The method mix varied by country<strong>and</strong> depended on access to services. Also, while <strong>the</strong> levelsof unmet need varied by country, generally rural areashad more unmet need than urban areas. The lowestwealth qu<strong>in</strong>tiles had higher unmet need compared with<strong>the</strong> highest wealth qu<strong>in</strong>tiles. The youngest marriedwomen had <strong>the</strong> highest unmet need.29

Thus, while knowledge of modern methods was highacross <strong>the</strong> region, contraceptive use varied. The use oftraditional methods existed regardless of age or wealthqu<strong>in</strong>tile. Reasons for not us<strong>in</strong>g modern methods po<strong>in</strong>tedto programme areas that needed quality improvement.The analysis of DHS data revealed that adolescentsneeded specific attention as well as access to familyplann<strong>in</strong>g services, which was an issue <strong>in</strong> rural areasacross <strong>the</strong> region.Role of counsell<strong>in</strong>g <strong>in</strong> family plann<strong>in</strong>g services byMs. N<strong>in</strong>uk Widyantoro, Chair, Women’s HealthFoundationThe presentation focused on <strong>the</strong> role of counsell<strong>in</strong>g as acrucial, yet often overlooked, component <strong>in</strong> <strong>the</strong> deliveryof good-quality care. A focus on counsell<strong>in</strong>g gave backwomen <strong>the</strong>ir rights.Counsell<strong>in</strong>g was a process that <strong>in</strong>volved empower<strong>in</strong>g aclient <strong>in</strong> mak<strong>in</strong>g his or her own decision. The criteriafor be<strong>in</strong>g an effective counsellor were that he or sheneeded to believe that each client had <strong>the</strong> right to decide;counsellors needed to have a warm, friendly <strong>and</strong> nonjudgmentalpersonality, as well as personal motivationto help o<strong>the</strong>rs. The effective counsellor needed to beskilful <strong>in</strong> <strong>in</strong>terpersonal communication. Two-waycommunication, us<strong>in</strong>g both verbal <strong>and</strong> non-verbal cues,was a crucial component of effective <strong>and</strong> good-qualitycounsell<strong>in</strong>g.Entry po<strong>in</strong>ts to good counsell<strong>in</strong>g <strong>in</strong>cluded supportfor peer education. Tra<strong>in</strong><strong>in</strong>g programmes that weredeveloped for peer education could be adapted tocounsell<strong>in</strong>g. Counsell<strong>in</strong>g would serve <strong>the</strong> communitywith <strong>in</strong>formation <strong>and</strong> knowledge regard<strong>in</strong>g SRHR <strong>and</strong>could play a role <strong>in</strong> community empowerment.Inequity <strong>in</strong> family plann<strong>in</strong>g <strong>and</strong> reproductive healthservices <strong>in</strong> Indonesia byMr. Kartono Muhammed, Women’s Health Foundation,IndonesiaThe presentation focused on some of <strong>the</strong> causes of<strong>in</strong>equity <strong>and</strong> low achievement <strong>in</strong> family plann<strong>in</strong>g <strong>and</strong>reproductive health services <strong>in</strong> Indonesia. Contribut<strong>in</strong>gfactors <strong>in</strong>cluded a lack of underst<strong>and</strong><strong>in</strong>g among decisionmakersat <strong>the</strong> central <strong>and</strong> local levels <strong>and</strong> <strong>in</strong> politicalparties; ambiguity of laws; lack of strong commitmentfrom <strong>the</strong> central government, as well as lack of clearobjectives for FP programmes.Indonesia was divided <strong>in</strong>to 33 prov<strong>in</strong>ces with a totalof 370 districts. Based on a decentralization process,<strong>the</strong> responsibility for family plann<strong>in</strong>g <strong>and</strong> reproductivehealth was at <strong>the</strong> district/municipal levels. Health <strong>and</strong>family plann<strong>in</strong>g policy was formulated <strong>and</strong> carried outat <strong>the</strong> local level. The sudden decentralization thatIndonesia had experienced was not positive as mostdistrict heads <strong>and</strong> mayors were not prepared to take overrelated responsibilities. Population <strong>and</strong> family plann<strong>in</strong>gwere not on <strong>the</strong>ir list of priorities, which resulted <strong>in</strong>those issues be<strong>in</strong>g neglected.There were also some social <strong>and</strong> environmental factors,<strong>in</strong>clud<strong>in</strong>g <strong>the</strong> health-care system still be<strong>in</strong>g based ona fee-for-service system paid out of pocket; <strong>the</strong> rise ofreligious fundamentalism had put political pressureon <strong>the</strong> government. There was also a decl<strong>in</strong>e <strong>in</strong> FPcampaigns <strong>and</strong> services, as well as <strong>the</strong> disb<strong>and</strong><strong>in</strong>g of fieldworkers.It was expected that Indonesia could achieve MDG5 onlyby 2025, unless strong efforts were <strong>in</strong>itiated. Indonesiapresented a paradox <strong>in</strong> terms of maternal mortality ratio<strong>and</strong> CPR, both of which were high. Those phenomenasuggested that someth<strong>in</strong>g was miss<strong>in</strong>g <strong>in</strong> <strong>the</strong> analysis,potentially l<strong>in</strong>ked to unsafe abortion practices.Discussion po<strong>in</strong>tsQuestion/issue:DHS had been conducted <strong>in</strong> Pakistan s<strong>in</strong>ce 1984 (or for26 years). F<strong>in</strong>d<strong>in</strong>gs showed that <strong>the</strong>re were <strong>in</strong>equalities<strong>in</strong> <strong>the</strong> programme. It was suggested that DHS be movedto a second-generation survey that would exam<strong>in</strong>e suchmatters as distance to facilities, causes <strong>and</strong> transportcosts, <strong>and</strong> that costs be broken down better.Response:It was encourag<strong>in</strong>g to conduct fur<strong>the</strong>r studies that lookedmore closely at <strong>in</strong>equalities <strong>and</strong> looked beh<strong>in</strong>d <strong>in</strong>itialfigures. The development of some supplementary surveysunder DHS had been embarked upon. Informationrelated to that development was available on <strong>the</strong> DHSwebsite. Research could be conducted that would becomplementary to <strong>the</strong> DHS surveys. Also, flexibilityexisted <strong>in</strong> terms of add<strong>in</strong>g to <strong>the</strong> DHS questionnaire.The survey had evolved to a po<strong>in</strong>t where it already<strong>in</strong>cluded more <strong>in</strong>formation on cost<strong>in</strong>g, for example.Question/issue:Although DHS <strong>in</strong>cluded contraceptive knowledge,that could depend on how <strong>the</strong> surveys were <strong>in</strong>formed.Almost all persons surveyed (99%) had knowledge ofcontraceptive methods, but might not be sure how touse a certa<strong>in</strong> contraceptive. It was not clear if <strong>the</strong> surveysreally presented what were real needs.Response:The call for additional <strong>in</strong>formation was useful; perhapsit could be satisfied through <strong>the</strong> provision of qualitativedata.30

Question/issue:DHS was time-consum<strong>in</strong>g <strong>and</strong> expensive. One concernwas that <strong>the</strong>re were no mechanisms <strong>in</strong> place to supportcountries <strong>in</strong> <strong>the</strong> development of <strong>the</strong>ir own methods totrack CPR. The <strong>in</strong>formation was delayed. It was alsosuggested that DHS cut <strong>the</strong> number of questions <strong>in</strong> <strong>the</strong>questionnaire.• Comments were raised related to efforts to reduce <strong>the</strong>costs of DHS.• It was reiterated that counsell<strong>in</strong>g played a veryimportant role <strong>in</strong> service delivery. Many women started<strong>and</strong> <strong>the</strong>n stopped us<strong>in</strong>g contraceptives. Evidence wasneeded to show <strong>the</strong> important role of quality of care,<strong>in</strong>clud<strong>in</strong>g conv<strong>in</strong>c<strong>in</strong>g data for shar<strong>in</strong>g with o<strong>the</strong>rs.• WHO had conducted a study on client-providerrelationships, which provided evidence on counsell<strong>in</strong>gneeds.Question/issue:Indonesia <strong>and</strong> Iran (through its university-basedprogramme) were examples of countries that <strong>in</strong>cludedcounsell<strong>in</strong>g as a component <strong>in</strong> <strong>the</strong>ir family plann<strong>in</strong>gprogrammes. Indonesia had high levels of CPR. Whatemphasis was placed on emergency obstetric care <strong>and</strong>skilled birth attendants?Response:One negative factor fac<strong>in</strong>g Indonesia was <strong>the</strong> highmobility of doctors.• Experience had shown that, <strong>in</strong> order to providegood <strong>in</strong>formation, it was important to empower <strong>the</strong>providers, who were usually <strong>the</strong> lowest paid employees<strong>in</strong> <strong>the</strong> family plann<strong>in</strong>g programme even though <strong>the</strong>ywere <strong>the</strong> ones <strong>in</strong> contact with <strong>the</strong> clients. Cont<strong>in</strong>uedevaluations were needed to assess counsell<strong>in</strong>g skills,which should be a component of family plann<strong>in</strong>gprogrammes.• Client satisfaction as an assessment po<strong>in</strong>t was notvery useful <strong>in</strong> determ<strong>in</strong><strong>in</strong>g what were <strong>the</strong> reproductive<strong>in</strong>tentions of people.SESSION 5: Advocacy<strong>and</strong> Actions for Tak<strong>in</strong>gForward Commitmentsto Invest<strong>in</strong>g <strong>in</strong> <strong>Family</strong><strong>Plann<strong>in</strong>g</strong>Moderator:Mr. Najib M. Assifi, Deputy Director, UNFPA APROThe purpose of <strong>the</strong> session was to explore opportunitiesfor advocacy through parliamentarians. There weremany success stories of parliamentarians who stood up,advocated <strong>and</strong> took action for reproductive health. Also,<strong>the</strong>re were examples of not fully us<strong>in</strong>g <strong>the</strong> potential ofparliamentarians. The session was developed as a roundtable with media-led questions to parliamentarians. Thesession also <strong>in</strong>cluded presentations related to youngpeople’s access to contraceptive services, with <strong>in</strong>sightsfrom UNFPA <strong>and</strong> Pathf<strong>in</strong>der <strong>International</strong>, as wellas experiences from India. The session ended with apanel discussion featur<strong>in</strong>g young people from selectedcountries.Round-table discussion with parliamentarians <strong>and</strong>media experts.The follow<strong>in</strong>g section outl<strong>in</strong>ed key po<strong>in</strong>ts raised dur<strong>in</strong>g<strong>the</strong> round-table discussion with parliamentarians fromIndonesia, Papua New Gu<strong>in</strong>ea <strong>and</strong> <strong>the</strong> Philipp<strong>in</strong>es, ledby journalists from Indonesia <strong>and</strong> Pakistan.Hon. Dr. Sumaryati Arjoso, Member of Parliament,Indonesia.Hon. Dr. Sumaryati addressed <strong>the</strong> context ofdecentralization <strong>in</strong> Indonesia <strong>and</strong> <strong>the</strong> importance ofstreng<strong>the</strong>n<strong>in</strong>g networks on all levels. He also raised issuesrelated to adolescent sexual <strong>and</strong> reproductive health <strong>and</strong>highlighted <strong>the</strong> need for work<strong>in</strong>g with <strong>and</strong> advocat<strong>in</strong>gtoge<strong>the</strong>r with community leaders. He voiced concernthat family plann<strong>in</strong>g had lost its momentum once <strong>the</strong>country reached replacement-level fertility.Hon. Congressman Mr. Rodolfo Biazon, Member ofParliament, Philipp<strong>in</strong>es.Hon. Congressman Mr. Rodolfo Biazon suggestedthat population growth <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es was putt<strong>in</strong>gpressure on <strong>the</strong> country’s natural resources. Heemphasized <strong>the</strong> need to get <strong>the</strong> message of populationplann<strong>in</strong>g to <strong>the</strong> people <strong>and</strong> forg<strong>in</strong>g a partnership betweenmedia <strong>and</strong> politicians to do so. He acknowledged thatmany campaigners were still at <strong>the</strong> advocacy stage.He suggested that population growth could act as anobstacle to economic development.31

Hon. Mr. Malakai Tabar, Chairman, ParliamentarianGroup on Population, Development <strong>and</strong> <strong>the</strong>Millennium Development Goals, Papua New Gu<strong>in</strong>eaHon. Mr. Malakai Tabar emphasized <strong>the</strong> need forencourag<strong>in</strong>g responsible government officials to takeaction, supported by evidence <strong>and</strong> data. The newlyestablished Committee on Population, Development<strong>and</strong> <strong>the</strong> MDGs was highlighted as one way throughwhich <strong>the</strong> country could move forward. He reiterated<strong>the</strong> need for committee members to make effective useof <strong>in</strong>formation <strong>and</strong> surveys. The need to advocate onall levels of government, <strong>in</strong>clud<strong>in</strong>g prov<strong>in</strong>ces <strong>and</strong> ruralareas, was also addressed.Hon. Mr. Raymond Palat<strong>in</strong>o, Congressman,Philipp<strong>in</strong>e Congress.Hon. Mr. Paymond Palat<strong>in</strong>o presented experiences froma recent meet<strong>in</strong>g of young parliamentarians to advocatefor RH <strong>and</strong> family plann<strong>in</strong>g for youth. It was evidentthat youth did know about RH <strong>and</strong> FP so effortsfrom <strong>the</strong> past had been not wasted. He stressed <strong>the</strong>importance of mak<strong>in</strong>g commitments to mobilize o<strong>the</strong>rparliamentarians <strong>and</strong> <strong>the</strong> need to reach <strong>the</strong> public. Hemade a call for <strong>the</strong> use of new social media for generat<strong>in</strong>gdebate, dialogue <strong>and</strong> focus on family plann<strong>in</strong>g.Question-<strong>and</strong>-Answer SessionMs. Huma Khawar, Journalist, PakistanMs. Khawar stated that <strong>the</strong> consultation was an exampleof a meet<strong>in</strong>g where media were treated as partners. Sheraised a question related to parliamentarians be<strong>in</strong>gaccessible to <strong>the</strong> media. Media often experienceddifficulties <strong>in</strong> access<strong>in</strong>g parliamentarians.Response (Hon. Mr. Rodolfo Biazon, <strong>the</strong> Philipp<strong>in</strong>es):Politicians sought <strong>the</strong> attention of media, as <strong>the</strong>y needed<strong>the</strong> media for exposure. However, public exposureneeded to be susta<strong>in</strong>ed, which meant establish<strong>in</strong>g closerelationships with <strong>the</strong> media. A politician could notgenerate public support without advocacy <strong>and</strong> that wasnot possible without media.Response (Hon. Dr. Sumaryati Arjoso, Indonesia):Media played a role <strong>in</strong> ensur<strong>in</strong>g good governance;parliamentarians had to have good access to media.Response (Hon. Mr. Malakai Tabar, Papua NewGu<strong>in</strong>ea):Media played a strong role <strong>in</strong> governance <strong>and</strong> <strong>in</strong>address<strong>in</strong>g issues such as corruption; however, <strong>the</strong>rewere also differences between media <strong>and</strong> government.The media needed to follow up on key issues.Ms. Maria Hart<strong>in</strong>gsih, Journalist, IndonesiaMs. Hart<strong>in</strong>gsih addressed <strong>the</strong> issue of religiousconservatism. It was evident that <strong>the</strong> political <strong>in</strong>fluenceof religious leaders had become stronger <strong>in</strong> manycountries. The examples from Iran were very encourag<strong>in</strong>g.However, <strong>the</strong> region also faced <strong>the</strong> opposite situation,with religious leaders <strong>in</strong> Indonesia hav<strong>in</strong>g issued a fatwaforbidd<strong>in</strong>g free distribution of condoms.Response (Hon. Dr. Sumaryati Arjoso, Indonesia):In Indonesia, it was very sensitive to talk aboutcondoms <strong>and</strong> safe abortion. Many believed thatpromot<strong>in</strong>g condoms meant promot<strong>in</strong>g extramarital sex.Parliamentarians <strong>and</strong> o<strong>the</strong>rs should cont<strong>in</strong>ue to conductadvocacy, <strong>and</strong> <strong>the</strong> media could play an important role <strong>in</strong>that process.Response:(Hon. Mr. Rodolfo Biazon, <strong>the</strong> Philipp<strong>in</strong>es): Religion<strong>and</strong> culture were factors that needed to be addressed.One way to do so could be through consultation with<strong>in</strong>terfaith groups (ma<strong>in</strong>ly Christian but also Muslim).There were examples of fatwas that had been issued <strong>in</strong>support of family plann<strong>in</strong>g, expressed <strong>in</strong> terms of birthspac<strong>in</strong>g.Discussion po<strong>in</strong>tsQuestion/issue:The parliamentarian from Timor-Leste, who was on <strong>the</strong>Committee on Reproductive Health <strong>and</strong> Education,noted some of <strong>the</strong> similarities between Timor-Leste <strong>and</strong><strong>the</strong> Philipp<strong>in</strong>es <strong>and</strong> raised questions related to <strong>the</strong> ma<strong>in</strong>factors of <strong>in</strong>creas<strong>in</strong>g population size <strong>in</strong> <strong>the</strong> countriesrepresented on <strong>the</strong> panel. The role of <strong>the</strong> Church as afactor was also raised. F<strong>in</strong>ally, experiences related topromot<strong>in</strong>g <strong>the</strong> use of condoms as a contraceptive methodwere questioned.Response (Hon. Mr. Rodolfo Biazon, <strong>the</strong> Philipp<strong>in</strong>es):Some <strong>in</strong>sight <strong>in</strong>to <strong>the</strong> population <strong>in</strong>crease <strong>in</strong> <strong>the</strong>Philipp<strong>in</strong>es was provided. In three generations, <strong>the</strong>population had <strong>in</strong>creased six-fold. The reasons for that<strong>in</strong>crease were rooted <strong>in</strong> <strong>the</strong> culture <strong>in</strong> rural Philipp<strong>in</strong>es.Rural Philipp<strong>in</strong>es once constituted of 80 per cent of<strong>the</strong> country’s population: farmers or those who workedon farms needed to produce many children to share<strong>the</strong> work. However, <strong>the</strong> proportion of rural versusurban populations had subsequently reversed, withonly 40 per cent currently be<strong>in</strong>g rural <strong>and</strong> 60 per centurban. Throughout that transition, <strong>the</strong> Church hadbeen promot<strong>in</strong>g large family size. In 1972, a policy offree distribution of contraceptives was an attempt toaddress population growth; it had been <strong>in</strong>itiated aspart of martial law. Dur<strong>in</strong>g 14 years of martial law <strong>the</strong>population growth rate dropped to 2 per cent annually.32

Response (Hon. Dr. Sumaryati Arjoso, Indonesia):Legislation was be<strong>in</strong>g drafted to streng<strong>the</strong>n governmentcommitment to education <strong>and</strong> family plann<strong>in</strong>g. Theexpectation was that family plann<strong>in</strong>g supplies could bem<strong>and</strong>ated only by law; policymakers who had previouslybeen reluctant were revers<strong>in</strong>g <strong>the</strong>ir op<strong>in</strong>ions <strong>and</strong>support<strong>in</strong>g <strong>the</strong> family plann<strong>in</strong>g programme.Question/issue:In Indonesia, it seemed as if health <strong>and</strong> gender issuesdid not ga<strong>in</strong> media attention. The focus of <strong>the</strong> mediawas on politics <strong>and</strong> economics. Were <strong>the</strong>re some tipsfrom <strong>the</strong> media on how to attract attention to sensitiveissues, such as reproductive health, family plann<strong>in</strong>g <strong>and</strong>gender?Response:(Ms. Maria Hart<strong>in</strong>gsih, Journalist, Indonesia):“Bad news is good news” described <strong>the</strong> nature of <strong>the</strong>media. Editorial meet<strong>in</strong>gs were basically a debate <strong>and</strong>competitive <strong>in</strong> decid<strong>in</strong>g on what a newspaper wanted tohighlight <strong>in</strong> terms of angle <strong>and</strong> ideology. One suggestedstrategy to relay <strong>the</strong> issue of family plann<strong>in</strong>g through<strong>the</strong> media was to relate it to human security. Populationgrowth was a non-traditional human security threat.O<strong>the</strong>r suggestions <strong>in</strong>cluded organiz<strong>in</strong>g special events foryouth or specific marg<strong>in</strong>alized groups so that <strong>the</strong> mediacould report on <strong>the</strong> event <strong>and</strong> use it as an entry po<strong>in</strong>t tofur<strong>the</strong>r develop stories.Response:(Ms. Huma Khawar, Journalist, Pakistan): Healthservice promoters usually did not have a strategy <strong>and</strong>were not able to position a story <strong>in</strong> an effective way.Very often stories were lost <strong>in</strong> difficult abbreviations/acronyms with too much medical jargon. A story neededto be compell<strong>in</strong>g <strong>and</strong> <strong>in</strong>terest<strong>in</strong>g.Question/issue:The parliamentarian from Viet Nam stated thatparliament had made a strong commitment to<strong>in</strong>vestments <strong>and</strong> achieved much progress yet still facedmany challenges. What were <strong>the</strong> challenges <strong>in</strong> advocacy<strong>and</strong> implementation <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es? What were <strong>the</strong>challenges <strong>in</strong> <strong>in</strong>vest<strong>in</strong>g <strong>in</strong> policy <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es?Response (Hon. Mr. Rodolfo Biazon, <strong>the</strong> Philipp<strong>in</strong>es):One of <strong>the</strong> key challenges fac<strong>in</strong>g <strong>the</strong> Philipp<strong>in</strong>es wasdeal<strong>in</strong>g with Church opposition. The Church challengedhow government resources were <strong>in</strong>vested. A law neededto be <strong>in</strong> place to m<strong>and</strong>ate government <strong>in</strong>vestment <strong>in</strong>health <strong>and</strong> family plann<strong>in</strong>g.Question/issue:It was recognized that parliaments played an importantrole <strong>in</strong> fur<strong>the</strong>r<strong>in</strong>g family plann<strong>in</strong>g <strong>and</strong> <strong>the</strong> idea was raisedto establish a caucus group of parliaments to network <strong>in</strong>all countries, work<strong>in</strong>g towards achiev<strong>in</strong>g MDGs.Response:Many networks <strong>and</strong> forums were currently operat<strong>in</strong>g,<strong>in</strong>clud<strong>in</strong>g <strong>the</strong> <strong>Asia</strong>n Forum of Parliamentarianson Population <strong>and</strong> Development (AFPPD), <strong>and</strong><strong>Pacific</strong> Parliamentary Assembly on Population <strong>and</strong>Development (PPAPD).Question/issue:In Nepal, <strong>the</strong> sale of condoms had stalled. Questionswere raised related to stories emerg<strong>in</strong>g that <strong>the</strong> mayor ofManila had banned over-<strong>the</strong>-counter sale of condoms.What were <strong>the</strong> media <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es do<strong>in</strong>g toconv<strong>in</strong>ce <strong>the</strong> Church or o<strong>the</strong>r religious groups to notsupport such action?Response (Ms. Maria Hart<strong>in</strong>gsih, Journalist,Indonesia):<strong>Family</strong> plann<strong>in</strong>g was a very sensitive issue <strong>in</strong> manycountries. The media had to be careful <strong>in</strong> how to raiseissues as <strong>the</strong>y could be misunderstood by leaders. Whenmedia released a story on implementation of Sharia law<strong>in</strong> local areas <strong>in</strong> Indonesia, <strong>the</strong>y were accused of be<strong>in</strong>gantagonistic to Islam. One must be careful when choos<strong>in</strong>gan angle; one way could be to look at reproductive health<strong>in</strong> <strong>the</strong> context of human rights.Response (Ms. Huma Khawar, Journalist, Pakistan):Writ<strong>in</strong>g for <strong>the</strong> English-language press meant lesspressure than writ<strong>in</strong>g <strong>in</strong> <strong>the</strong> vernacular. In Pakistan,<strong>the</strong> Urdu press faced major problems. Also, <strong>the</strong>re wereno regional vernacular terms, which made it difficultto translate concepts <strong>and</strong> terms for <strong>the</strong> benefit of <strong>the</strong>regional press.Question/issue:Some questions were raised for <strong>the</strong> youth attend<strong>in</strong>g <strong>the</strong>consultation: <strong>in</strong> walk<strong>in</strong>g through shopp<strong>in</strong>g malls <strong>in</strong> <strong>Asia</strong><strong>and</strong> <strong>the</strong> <strong>Pacific</strong>, it was strik<strong>in</strong>g how <strong>the</strong> youth culturewas similar <strong>in</strong> dress, talk <strong>and</strong> body language across <strong>the</strong>region. In most countries, youth constituted at least 25per cent of <strong>the</strong> population. Because of <strong>the</strong>ir similarities,<strong>the</strong>re were opportunities <strong>and</strong> challenges to reach thatgroup. The parliamentarians on <strong>the</strong> panel were askedhow <strong>the</strong>y reached youth.Response:A study of youth cultures <strong>in</strong> many countries concludedthat <strong>the</strong> best service was to provide comprehensive,<strong>in</strong>tegrated reproductive health <strong>in</strong>formation <strong>in</strong> school33

curricula. If <strong>the</strong> state was unwill<strong>in</strong>g to provide sucha service, l<strong>in</strong>ks should be forged with <strong>the</strong> NGOcommunity.Question/issue:Hon. Mr. Raymond Palat<strong>in</strong>o, Congressman for <strong>the</strong>Philipp<strong>in</strong>e Congress, was asked to comment on how totackle a grow<strong>in</strong>g number of young fundamentalists, asituation also faced by Indonesia. Had <strong>the</strong> Philipp<strong>in</strong>esfaced any challenges <strong>in</strong> deal<strong>in</strong>g with religion? What wereways to advocate issues among young people who mightnot have had a good underst<strong>and</strong><strong>in</strong>g of <strong>the</strong> issues.Response (Hon. Mr. Raymond Palat<strong>in</strong>o, <strong>the</strong>Philipp<strong>in</strong>es):There was no major problem <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es. Therewas a separatist movement, but it had not translated <strong>in</strong>todifficulties <strong>in</strong> <strong>the</strong> provision of services. Experiences from<strong>the</strong> Philipp<strong>in</strong>es suggested that it was best to providepolitical <strong>and</strong> economic reforms <strong>in</strong> those areas.Response (Hon. Dr. Sumaryati Arjoso, Indonesia):Condom promotion for HIV prevention <strong>in</strong> Indonesiawas complicated as it was often viewed as promot<strong>in</strong>gextramarital sex. One entry po<strong>in</strong>t was to use children’srights.Access of Young Peopleto Contraceptive ServicesModerator:H.E. Dr. Nadera Hayat Burhani, Deputy M<strong>in</strong>ister ofHealth, AfghanistanThe session <strong>in</strong>cluded presentations on unmet needfor contraception among adolescents from a globalperspective, programme experiences from India <strong>and</strong> VietNam on youth-friendly services <strong>and</strong> behavioural changecommunication, as well as <strong>the</strong> lack of access of youngpeople to services <strong>in</strong> India. The session closed with a paneldiscussion featur<strong>in</strong>g young people from Bangladesh,India, <strong>the</strong> Marshall Isl<strong>and</strong>s <strong>and</strong> <strong>the</strong> Philipp<strong>in</strong>es.Unmet need for contraception among adolescents by Dr.Nuriye Ortayli, <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Advisor, UNFPAThe presentation focused on address<strong>in</strong>g unmet need forcontraception among adolescents. Youth were <strong>the</strong> mostunderserved group <strong>and</strong> were disadvantaged <strong>in</strong> terms ofrealiz<strong>in</strong>g <strong>the</strong>ir wishes to avoid pregnancy. Young peoplewere be<strong>in</strong>g left beh<strong>in</strong>d. The largest cohort of adolescents,<strong>in</strong>dividuals between 10 <strong>and</strong> 19 years old, were <strong>in</strong> aperiod of transition from childhood to adulthood, <strong>and</strong><strong>the</strong> current group represented <strong>the</strong> largest cohort ofadolescents that <strong>the</strong> world had ever seen.Evidence showed that adolescents were sexually active.More than three quarters were sexually active by age 20.The assumption had been that sex started with marriage<strong>and</strong> many surveys covered unmarried youth; however,evidence showed that adolescents did engage <strong>in</strong> sexbefore marriage. The age at first marriage, based on DHSfigures, varied across <strong>the</strong> region; however, a substantialnumber of young people got married before <strong>the</strong> age of15. Among that group, <strong>the</strong> use of contraception was lowfor a variety of reasons: some wanted to get pregnant,while o<strong>the</strong>rs wanted to avoid pregnancy but did not have<strong>the</strong> means to do so.Across <strong>the</strong> region, <strong>the</strong> youngest age group wasdisadvantaged <strong>in</strong> terms of realiz<strong>in</strong>g <strong>the</strong>ir wishes to avoidpregnancy. Analysis of total dem<strong>and</strong> <strong>and</strong> total dem<strong>and</strong>satisfied among age groups showed that young peoplehad been left beh<strong>in</strong>d. Those patterns were evident <strong>in</strong>Cambodia, India, Nepal <strong>and</strong> Pakistan. In many sett<strong>in</strong>gsdem<strong>and</strong> was low, but total dem<strong>and</strong> satisfied was evenlower.Access of young people to reproductive health services,<strong>in</strong>clud<strong>in</strong>g contraceptive services – experience from <strong>the</strong>region by Ms. Sono Aibe – Senior Advisor for StrategicInitiatives, Pathf<strong>in</strong>der <strong>International</strong>The presentation focused on experiences <strong>and</strong>conclusions from <strong>in</strong>terventions implemented byPathf<strong>in</strong>der <strong>International</strong> on public sector youth <strong>in</strong> anSRH programme <strong>in</strong> Viet Nam <strong>and</strong> <strong>the</strong> PRACHAR(Promot<strong>in</strong>g Change <strong>in</strong> Reproductive Behaviour <strong>in</strong>Bihar) programme <strong>in</strong> rural parts of India’s Bihar state.Experiences related to youth-friendly services <strong>in</strong> VietNam showed that public sector facilities were <strong>the</strong> mostsusta<strong>in</strong>able <strong>and</strong> cost-effect <strong>in</strong>terventions. However, ifboys <strong>and</strong> high-risk groups did not want to visit publichealth centres, mobile services could reach large numbersof youth that might not seek services <strong>in</strong> o<strong>the</strong>r locations.Multi-purpose centres had proven to be quite costly <strong>and</strong>did not reach many with RH services, especially if thosecentres were built as st<strong>and</strong>-alone structures. They weretoo costly unless located <strong>in</strong> urban areas.Experiences related to behavioural change communication<strong>in</strong> Bihar <strong>in</strong>cluded <strong>in</strong>creased dem<strong>and</strong> for contraceptives.Audience segmentation <strong>and</strong> message tailor<strong>in</strong>g weregood methods to address that approach. Efforts werebe<strong>in</strong>g made to target unmarried boys <strong>and</strong> girls, as wellas newlywed youth. The <strong>in</strong>itiative had <strong>in</strong>spired <strong>the</strong> activeengagement of gatekeepers, work<strong>in</strong>g through communitychange agents that went from door to door <strong>and</strong> worked34

with local <strong>the</strong>atre groups. The results <strong>in</strong>cluded <strong>in</strong>creasedcontraceptive use.The presentation suggested <strong>the</strong> need for better datawith<strong>in</strong> government health systems; go<strong>in</strong>g beyond <strong>the</strong>traditional def<strong>in</strong>ition of education <strong>and</strong> <strong>in</strong>stead look<strong>in</strong>gat life skills. Also, work<strong>in</strong>g towards delay<strong>in</strong>g <strong>the</strong> age atmarriage <strong>and</strong> first birth <strong>and</strong> ensur<strong>in</strong>g access to affordablecontraceptives for all youth were o<strong>the</strong>r importantmeasures to take.The presentation concluded with suggest<strong>in</strong>g that, s<strong>in</strong>ce<strong>the</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> region had been a leader <strong>in</strong> familyplann<strong>in</strong>g, it was now time to become a leader aga<strong>in</strong> <strong>in</strong>adolescent family plann<strong>in</strong>g <strong>and</strong> reproductive health.Meet<strong>in</strong>g <strong>the</strong> sexual <strong>and</strong> reproductive health of youth:<strong>in</strong>sights from India by Dr. Shireen Jejeeboy, SeniorAssociate, Population <strong>Council</strong>, IndiaThe presentation focused on <strong>the</strong> sexual <strong>and</strong> reproductivehealth of youth based on programme experiences <strong>in</strong>India. There was evidently a dem<strong>and</strong> for sexual <strong>and</strong>reproductive health services among youth, but it was notbe<strong>in</strong>g met. Key obstacles that youth faced <strong>in</strong> meet<strong>in</strong>g<strong>the</strong>ir SRH needs <strong>in</strong>cluded lack of access to, <strong>and</strong> lack ofcapacity of, relevant services. There was a lack of goodqualitycare. Youth lacked <strong>in</strong>formation <strong>and</strong> negotiationskills. Evidence showed that tak<strong>in</strong>g a multisectoralapproach to <strong>the</strong> issue was crucial.The presentation <strong>in</strong>cluded an analysis of DHS data onmarried <strong>and</strong> non-married youth. The data revealed thatpremarital sex was happen<strong>in</strong>g, primarily <strong>in</strong> rural areas<strong>and</strong> across all states. Early marriage was persist<strong>in</strong>g, ashalf of youth were married before 18. Most of thoseyouth wanted just two children.Evidence showed that unmarried youth wished to avoidpregnancy, yet few had practised contraception. Among<strong>the</strong> married group, very few delayed <strong>the</strong> first birth, oftenbecause of sociocultural factors. Unmet need amongyouth was twice that of older populations. Abortion wasmost common among youth <strong>and</strong> was conducted <strong>in</strong> <strong>the</strong>second trimester.Programmatic implications <strong>in</strong>cluded tak<strong>in</strong>gmultisectoral action with a focus on collaboration withall relevant partners <strong>in</strong>clud<strong>in</strong>g government <strong>and</strong> NGOs.Fur<strong>the</strong>r, it was imperative to realize <strong>and</strong> take actionon <strong>the</strong> commitments conta<strong>in</strong>ed <strong>in</strong> policy documents.Health-care providers needed to be oriented towardsovercom<strong>in</strong>g <strong>the</strong>ir own bias. Efforts should be placed on<strong>in</strong>itiat<strong>in</strong>g sexuality education. Also, advocacy should betargeted towards <strong>in</strong>creas<strong>in</strong>g <strong>the</strong> age at marriage, as wellas <strong>in</strong>creas<strong>in</strong>g <strong>in</strong>vestment <strong>in</strong> youth.PANEL DISCUSSION WITHYOUNG PEOPLE FROMSELECTED COUNTRIES:Bangladesh, India, TheMarshall Isl<strong>and</strong>s <strong>and</strong> ThePhilipp<strong>in</strong>esYoung people <strong>in</strong>volved <strong>in</strong> advocat<strong>in</strong>g for sexual <strong>and</strong>reproductive health <strong>and</strong> rights for youth <strong>in</strong> <strong>the</strong>ir countriesconducted a panel discussion which <strong>in</strong>cluded briefstatements, discussions <strong>and</strong> a question-<strong>and</strong>-answersession.Bangladesh:Ms. Syefa Ahmed stated that one third of <strong>the</strong> population<strong>in</strong> Bangladesh comprised youths. Generally, parentsrarely talked about sexuality <strong>and</strong> youth did not haveanywhere to go for <strong>in</strong>formation <strong>and</strong> services. Youthissues should be facilitated <strong>and</strong> addressed <strong>in</strong> differentsectors, with emphasis on youth-friendl<strong>in</strong>ess.Philipp<strong>in</strong>es:Ms. Lady Lisondra suggested that <strong>the</strong> largest culturalbarrier <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es was underst<strong>and</strong><strong>in</strong>g <strong>the</strong> sexualrights of young people. Her ma<strong>in</strong> recommendationwas for <strong>the</strong> Philipp<strong>in</strong>es to pass <strong>the</strong> RH bill <strong>and</strong> ensurethat sexuality education was <strong>in</strong>corporated <strong>in</strong>to schoolcurricula.Marshall Isl<strong>and</strong>s:Ms. Tata Kalles stated that 80 per cent of young people<strong>in</strong> <strong>the</strong> Marshall Isl<strong>and</strong>s knew about condoms but only5 per cent used <strong>the</strong>m. Key cultural barriers militat<strong>in</strong>gaga<strong>in</strong>st <strong>the</strong>ir use were that sex was not allowed, yet peoplestill became sexually active. Radio <strong>and</strong> television could<strong>in</strong>form but youth could not access <strong>the</strong> commodities <strong>the</strong>yneeded.India:Ms. Suchitra Rath <strong>in</strong>dicated that experiences fromOrissa state showed that community health workersshould have <strong>the</strong> capacity to provide counsell<strong>in</strong>g <strong>and</strong>create dem<strong>and</strong>.Discussion po<strong>in</strong>tsQuestion/issue:What should be done with out-of-school youth, a veryvulnerable group? As <strong>the</strong> curriculum on adolescent sexual<strong>and</strong> reproductive health rema<strong>in</strong>ed deficient <strong>and</strong> teacherswere shy <strong>in</strong> teach<strong>in</strong>g courses on adolescent reproductivehealth, what could be done to address that problem?35

dialogue as well as regional <strong>in</strong>itiatives <strong>and</strong> events. <strong>Family</strong>plann<strong>in</strong>g would be highlighted <strong>in</strong> <strong>the</strong> next State of <strong>the</strong>World Population report, <strong>and</strong> would be brought forwarddur<strong>in</strong>g <strong>the</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> population meet<strong>in</strong>g to be held<strong>in</strong> 2012.Dr. Wasim Zamam, ICOMP, concluded <strong>the</strong> consultationby reiterat<strong>in</strong>g <strong>the</strong> crucial role that effective managementof programmes played <strong>in</strong> address<strong>in</strong>g family plann<strong>in</strong>g <strong>and</strong>unmet needs <strong>in</strong> <strong>the</strong> achievement of MDG 5. The ambitionof <strong>the</strong> consultation was to br<strong>in</strong>g <strong>in</strong> <strong>the</strong> best possible currentknowledge, wisdom <strong>and</strong> data to show <strong>the</strong> gaps <strong>in</strong> access,dem<strong>and</strong> <strong>and</strong> need for family plann<strong>in</strong>g. It was obvious thatample evidence existed of <strong>the</strong> situation, but <strong>the</strong> use of suchevidence was seriously lack<strong>in</strong>g. The consultation was closedwith a call for collective action on all levels.CONCLUSIONThe consultation provided an opportunity for a broadspectrum of politicians, programme adm<strong>in</strong>istrators,donors, media <strong>and</strong> NGO representatives, as well asyouth to discuss <strong>the</strong> multifaceted levels of ensur<strong>in</strong>g <strong>the</strong>availability of family plann<strong>in</strong>g for a population. The crucialrole of political commitment was highlighted, as well as <strong>the</strong>courage of those who needed to navigate through a hostilepolitical <strong>and</strong> social climate to provide <strong>the</strong> needed services<strong>and</strong> support for families.<strong>Family</strong> plann<strong>in</strong>g was an important component for achiev<strong>in</strong>gsocial <strong>and</strong> economic development <strong>in</strong> a country, yet it wasoften overlooked. The emphasis was to position familyplann<strong>in</strong>g as a choice. There was a need to empower parents,poor marg<strong>in</strong>alized groups, populations <strong>in</strong> conflict or liv<strong>in</strong>g<strong>in</strong> isolated <strong>and</strong> rural areas to make <strong>in</strong>formed choices on <strong>the</strong>number of children <strong>the</strong>y wanted <strong>and</strong> when <strong>the</strong>y wantedto have <strong>the</strong>m. The region was fac<strong>in</strong>g a cont<strong>in</strong>u<strong>in</strong>g problemof early marriage, which significantly affected maternalmortality figures as a girl under 16 was five times morelikely to die <strong>in</strong> childbirth than a woman <strong>in</strong> her twenties.Country experiences from <strong>the</strong> region suggested thattak<strong>in</strong>g a multisectoral approach, focused on collaboration<strong>and</strong> l<strong>in</strong>kages between policy commitments <strong>and</strong> <strong>the</strong>irimplementation <strong>and</strong> susta<strong>in</strong>ed fund<strong>in</strong>g would be mosteffective <strong>in</strong> <strong>the</strong> delivery of family plann<strong>in</strong>g services to apopulation. The crucial role of health service providers<strong>and</strong> community-based health workers was highlightedthroughout <strong>the</strong> consultation, with a call to ensure thatprogrammes oriented health-care providers towardsovercom<strong>in</strong>g <strong>the</strong>ir own biases. Fur<strong>the</strong>r, ensur<strong>in</strong>g susta<strong>in</strong>ed<strong>in</strong>vestment <strong>in</strong> youth, <strong>in</strong>clud<strong>in</strong>g sexuality education <strong>and</strong>counsell<strong>in</strong>g, constituted o<strong>the</strong>r key components that werehighlighted. There was a need for advocat<strong>in</strong>g <strong>and</strong> work<strong>in</strong>gwith community leaders to reduce maternal mortality, <strong>and</strong>for streng<strong>the</strong>n<strong>in</strong>g networks of decision-makers at all levels.The role of <strong>the</strong> media also needed to be taken <strong>in</strong>to account<strong>in</strong> <strong>the</strong> design <strong>and</strong> delivery of family plann<strong>in</strong>g programmes.Overall, <strong>the</strong> region was experienc<strong>in</strong>g ris<strong>in</strong>g levels of unmetneed, especially fac<strong>in</strong>g specific <strong>and</strong>, <strong>in</strong> some cases, new,groups such as migrants <strong>and</strong> ethnic m<strong>in</strong>orities, a situationwhich highlighted equity issues with<strong>in</strong> countries.The Plan of Action agreed at <strong>the</strong> close of <strong>the</strong> three-dayconsultation was an important step <strong>in</strong> reposition<strong>in</strong>g familyplann<strong>in</strong>g on global <strong>and</strong> national development agendas.There was a now a need for country-specific action plans tomeet <strong>the</strong> diversified unmet needs <strong>in</strong> countries of <strong>the</strong> <strong>Asia</strong>n<strong>and</strong> <strong>Pacific</strong> region.37

<strong>Asia</strong><strong>Asia</strong><strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Programmes <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong><strong>Pacific</strong> <strong>and</strong> Achiev<strong>in</strong>g Millennium DevelopmentGoal 5*Amy O. Tsui,Johns Hopk<strong>in</strong>s Bloomberg School of Public Health39

BackgroundGlobal development efforts today are framed largely by<strong>the</strong> Millennium Development Goals (MDGs). Of thoseeight Goals, <strong>the</strong> one most widely acknowledged to beoff-track is No. 5, “Improv<strong>in</strong>g maternal health”. Target 5bof that Goal, “Universal access to reproductive health”, isexperienc<strong>in</strong>g <strong>the</strong> same lack of progress <strong>in</strong> low-resourcesett<strong>in</strong>gs. Achiev<strong>in</strong>g MDG 5 <strong>and</strong> Target 5b is seen to bekey to <strong>the</strong> achievement of all <strong>the</strong> MDGs (Cates et al.,2010). <strong>Family</strong> plann<strong>in</strong>g, <strong>in</strong>clud<strong>in</strong>g specifically <strong>the</strong> practiceof contraception, is a social <strong>and</strong> health <strong>in</strong>tervention thatdirectly addresses all objectives under that Target, whe<strong>the</strong>rby avert<strong>in</strong>g births that carry high mortality risk for <strong>the</strong>mo<strong>the</strong>r <strong>and</strong> newborn, prevent<strong>in</strong>g un<strong>in</strong>tended pregnancies,reduc<strong>in</strong>g STI/HIV transmission through consistentcondom use, enabl<strong>in</strong>g women <strong>and</strong> girls to decide when <strong>and</strong>how many children to bear, or by alter<strong>in</strong>g <strong>the</strong> dynamics ofpopulation change to facilitate susta<strong>in</strong>able development.As def<strong>in</strong>ed by <strong>the</strong> 1987 report 1 of <strong>the</strong> Brundtl<strong>and</strong>Commission, “Susta<strong>in</strong>able development is developmentthat meets <strong>the</strong> needs of <strong>the</strong> present without compromis<strong>in</strong>g<strong>the</strong> ability of future generations to meet <strong>the</strong>ir own needs”.Contraceptive practice has been <strong>the</strong> primary proximatedeterm<strong>in</strong>ant beh<strong>in</strong>d fertility transitions <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong><strong>Pacific</strong> <strong>and</strong> o<strong>the</strong>r develop<strong>in</strong>g regions, <strong>and</strong> a behavioural<strong>in</strong>novation embraced by governments <strong>in</strong> <strong>the</strong> region tosecure susta<strong>in</strong>able development. Susta<strong>in</strong>able developmentrema<strong>in</strong>s <strong>the</strong> collective aim of all eight MDGs.The develop<strong>in</strong>g world has a long history of family plann<strong>in</strong>gefforts embedded <strong>in</strong> population development policies,with <strong>the</strong> strongest record be<strong>in</strong>g <strong>in</strong> <strong>Asia</strong> <strong>and</strong> Lat<strong>in</strong> America.These efforts materialized between <strong>the</strong> mid-1960s <strong>and</strong>late 1980s, all predat<strong>in</strong>g <strong>the</strong> formation of <strong>the</strong> MDGframework. Rob<strong>in</strong>son <strong>and</strong> Ross (2007) <strong>in</strong> The Global<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Revolution: Three Decades of PopulationPolicies <strong>and</strong> Programs wrote <strong>the</strong> follow<strong>in</strong>g:The years just after 1960 saw<strong>the</strong> appearance of a new fertilitydeterm<strong>in</strong>ant—organized actions bywhole societies to br<strong>in</strong>g birth rates downto match fall<strong>in</strong>g death rates, <strong>and</strong> to ease<strong>the</strong> accompany<strong>in</strong>g dislocations faced byeducational, medical, economic, hous<strong>in</strong>g<strong>and</strong> family system <strong>in</strong>stitutions <strong>and</strong> o<strong>the</strong>rs.Those actions were also meant to givewomen greater control over <strong>the</strong>ir ownchildbear<strong>in</strong>g <strong>and</strong> to relieve families from<strong>the</strong> unexpected burdens of rais<strong>in</strong>g moresurviv<strong>in</strong>g children than <strong>in</strong> <strong>the</strong> past. Thetwo results toge<strong>the</strong>r, societal benefits <strong>and</strong>personal benefits, flowed from programsbased on new contraceptive technologiesthat could be deployed to wholepopulations. (Preface)Indeed, long before modern contraceptive technologiesas we know <strong>the</strong>m today became widely available, India<strong>in</strong> 1951 was <strong>the</strong> first country to adopt family plann<strong>in</strong>gas part of its economic development plan. O<strong>the</strong>r <strong>Asia</strong>ncountries followed suit shortly <strong>the</strong>reafter: Pakistan(1960), <strong>the</strong> Republic of Korea (1961), Ch<strong>in</strong>a <strong>and</strong> Fiji(1962), S<strong>in</strong>gapore <strong>and</strong> Sri Lanka (1965), with non-<strong>Asia</strong>n countries, such as Egypt <strong>and</strong> Turkey, committ<strong>in</strong>g<strong>the</strong>mselves <strong>in</strong> 1965 to <strong>the</strong> support of family plann<strong>in</strong>g.This show of national commitment occurred one decadebefore develop<strong>in</strong>g countries’ contrast<strong>in</strong>g views on familyplann<strong>in</strong>g’s role <strong>in</strong> economic development would lead <strong>the</strong>mto align <strong>the</strong>mselves <strong>in</strong> political blocs at <strong>the</strong> 1974 WorldPopulation Conference <strong>in</strong> Bucharest. It was not until 20years later that <strong>the</strong> reproductive health/reproductive rightsframework emerged at <strong>the</strong> 1994 <strong>International</strong> Conferenceon Population <strong>and</strong> Development. In 1976 nearly half of <strong>the</strong>37 governments <strong>in</strong> <strong>the</strong> <strong>Asia</strong>n region at that time reportedto <strong>the</strong> United Nations that <strong>the</strong>ir fertility levels were toohigh (United Nations, 2009a). The demographic <strong>in</strong>tentof manag<strong>in</strong>g national fertility levels – because populationgrowth rates were too high – was voiced by nearly twofifths of governments <strong>in</strong> <strong>the</strong> region. Two thirds of <strong>the</strong>m (25governments) were also directly support<strong>in</strong>g contraceptiveaccess, <strong>and</strong> by 2009, four fifths (39 governments or 83%of <strong>the</strong> total 47 governments <strong>in</strong> <strong>the</strong> <strong>Asia</strong>n region) weresupport<strong>in</strong>g such access.<strong>Asia</strong> had a population of 1,886 million persons <strong>in</strong> 1965,<strong>and</strong> countries where governments had declared for familyplann<strong>in</strong>g had annual population growth rates that rangedfrom 2.07 per cent (India) to 3.27 per cent (Fiji). Theserates are higher than those found among most countries<strong>in</strong> sub-Saharan Africa today, <strong>the</strong> world’s fast<strong>in</strong>g grow<strong>in</strong>gregion <strong>in</strong> demographic terms. With a population of4,167 million persons currently, <strong>Asia</strong>’s estimated annualpopulation growth rate is 1.05 per cent (United Nations,2009b). Total fertility rates (TFRs) range from below<strong>the</strong> replacement level <strong>in</strong> nearly all countries <strong>in</strong> East <strong>Asia</strong>to below 2.5 births per woman <strong>in</strong> 11 Sou<strong>the</strong>ast <strong>Asia</strong>ncountries, but above 3.0 <strong>in</strong> countries such as Afghanistan(5.7), Bhutan (3.1), Cambodia (3.3), <strong>the</strong> Lao People’sDemocratic Republic (3.5), Pakistan (4.0), <strong>the</strong> Philipp<strong>in</strong>es(3.2), Tajikistan (3.4) <strong>and</strong> Timor-Leste (5.7). With thisrange, not surpris<strong>in</strong>gly, 28 per cent of <strong>the</strong> 47 governments<strong>in</strong> <strong>the</strong> region view <strong>the</strong>ir current fertility levels as be<strong>in</strong>g too41

AimsThe aims of <strong>the</strong> present paper <strong>in</strong> address<strong>in</strong>g family plann<strong>in</strong>gprogrammes <strong>in</strong> <strong>the</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> region are:To review trends <strong>in</strong> patterns of government response tofertility levels <strong>and</strong> contraceptive service provisionTo review national variations <strong>in</strong> contraceptive practicelevels <strong>and</strong> changes <strong>the</strong>re<strong>in</strong>, <strong>the</strong> use-effectiveness of<strong>the</strong> composition of <strong>the</strong> methods used <strong>and</strong> equity <strong>in</strong>coverageTo assess contraceptive commodity security, <strong>in</strong>ternalf<strong>in</strong>anc<strong>in</strong>g <strong>and</strong> <strong>in</strong>ternational assistance for familyplann<strong>in</strong>g <strong>and</strong> o<strong>the</strong>r population activitiesTo derive lessons from <strong>the</strong> long history of familyplann<strong>in</strong>g <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong> for policy directions,programme models <strong>and</strong> f<strong>in</strong>anc<strong>in</strong>g needs <strong>in</strong> order toachieve MDG 5b by 2015National response <strong>in</strong> <strong>the</strong> early yearsto <strong>the</strong> provision of fertility <strong>and</strong>contraceptive servicesThe early development <strong>and</strong> maturation of 12 nationalexperiences with family plann<strong>in</strong>g programmes <strong>in</strong> <strong>Asia</strong> arecaptured <strong>in</strong> Rob<strong>in</strong>son <strong>and</strong> Ross (2007) for Bangladesh,Hong Kong SAR, India, Indonesia, Malaysia, Nepal,Pakistan, <strong>the</strong> Philipp<strong>in</strong>es, <strong>the</strong> Republic of Korea, S<strong>in</strong>gapore,Sri Lanka <strong>and</strong> Thail<strong>and</strong>. Each country case study covers<strong>the</strong> <strong>in</strong>ception of conjo<strong>in</strong>t <strong>in</strong>terests <strong>in</strong> population policy<strong>and</strong> family plann<strong>in</strong>g programmes as subsequently playedout over three decades; <strong>the</strong>y were prepared by experts with<strong>the</strong> knowledge of <strong>in</strong>siders on <strong>the</strong> ground. Each chapterprovides a chronology of l<strong>and</strong>mark events that <strong>the</strong> authorsperceived to be relevant to <strong>the</strong> evolution of family plann<strong>in</strong>g<strong>in</strong> <strong>the</strong> country concerned. In a meta-analytic manner, <strong>the</strong>seevents are collectively detailed <strong>in</strong> Table 1. The reportedevents appear to cluster around several doma<strong>in</strong>s of activity:(a) policy formulation <strong>and</strong> oversight; (b) programmedesign <strong>and</strong> outreach; (c) contraceptive service delivery; (d)contraceptive methods; <strong>and</strong> (e) research <strong>and</strong> evaluation.For example, India was reported as hav<strong>in</strong>g launched itsnational family plann<strong>in</strong>g programme <strong>in</strong> 1947 <strong>and</strong> alsohav<strong>in</strong>g <strong>in</strong>cluded recognition of <strong>and</strong> support for servicesas part of five economic development plans (1956, 1956,1961, 1976 <strong>and</strong> 1977). The service delivery design offamily plann<strong>in</strong>g programmes <strong>in</strong> Malaysia <strong>and</strong> <strong>the</strong> Republicof Korea was characterized by <strong>in</strong>itiatives <strong>in</strong> rural outreach,deployment of a vertical family plann<strong>in</strong>g workforce,expansion of service outlets <strong>and</strong> <strong>in</strong>tegration with maternal<strong>and</strong> child health (MCH) services, all <strong>in</strong> <strong>the</strong> early 1960s tomid-1970s.We can observe several patterns of programme developmentreported across <strong>the</strong>se 12 national case studies concentratedbetween <strong>the</strong> early 1960s <strong>and</strong> mid-1980s. First, familyplann<strong>in</strong>g was frequently <strong>in</strong>corporated <strong>in</strong>to economicplans as a means by which population growth could bemanaged <strong>in</strong> order to improve prospects for development(e.g., India, Malaysia, Nepal, Pakistan/Bangladesh, <strong>the</strong>Philipp<strong>in</strong>es, <strong>the</strong> Republic of Korea <strong>and</strong> Sri Lanka). Targets<strong>and</strong> <strong>in</strong>centives were not frequently cited as key events,except <strong>in</strong> India, <strong>the</strong> Republic of Korea <strong>and</strong> Sri Lanka.F<strong>in</strong>ancial <strong>in</strong>centives were added to enhance programmeperformance <strong>in</strong> Nepal, <strong>the</strong> Republic of Korea, S<strong>in</strong>gapore<strong>and</strong> Sri Lanka, all <strong>in</strong> <strong>the</strong> late 1960s to mid-1970s. <strong>Family</strong>plann<strong>in</strong>g slogans were cited as key means for alter<strong>in</strong>g socialideation about family formation <strong>and</strong> family size norms <strong>in</strong>Hong Kong SAR, <strong>the</strong> Republic of Korea <strong>and</strong> S<strong>in</strong>gapore,while address<strong>in</strong>g religious opposition was noted forIndonesia, <strong>the</strong> Philipp<strong>in</strong>es <strong>and</strong> Sri Lanka.Second, <strong>the</strong> establishment of voluntary family plann<strong>in</strong>gassociations (FPAs) – today <strong>the</strong> affiliates of <strong>the</strong><strong>International</strong> Planned Parenthood Federation (IPPF)– is perceived to be significant <strong>in</strong> 8 of <strong>the</strong> 12 countries.Voluntary FPAs have often served <strong>the</strong> function of pilot<strong>in</strong>gservice <strong>in</strong>terventions <strong>and</strong> <strong>in</strong>troduc<strong>in</strong>g new contraceptivemethods. The IPPF affiliates’ programmes <strong>and</strong> operationshave matured over time <strong>and</strong> currently focus on advanc<strong>in</strong>gsexual <strong>and</strong> reproductive health <strong>and</strong> rights. The affiliatesfocus strategically on <strong>the</strong> “Five As”: adolescents, advocacy,AIDS, abortion <strong>and</strong> access. However, <strong>the</strong>ir potential <strong>in</strong> <strong>the</strong><strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> region warrants fur<strong>the</strong>r consideration fortest<strong>in</strong>g programme <strong>in</strong>novations or complement<strong>in</strong>g publicmodels of service delivery. In addition o<strong>the</strong>r franchises,such Marie Stopes <strong>International</strong> <strong>and</strong> Sun Cl<strong>in</strong>ic networksorganized through Population Services <strong>International</strong> orDKT <strong>International</strong>, have also considerably exp<strong>and</strong>ed <strong>the</strong>realm of contraceptive <strong>and</strong> pregnancy term<strong>in</strong>ation serviceaccess.Among <strong>the</strong> o<strong>the</strong>r notable service <strong>in</strong>novations <strong>in</strong> <strong>the</strong> early1970s was <strong>the</strong> demedicalization of contraceptive servicedelivery to authorize lower-tier health workers, especially<strong>in</strong> rural areas, to provide cl<strong>in</strong>ical methods, such as IUDs<strong>and</strong> <strong>in</strong>jectables. Today, under <strong>the</strong> rubric of “task-shift<strong>in</strong>g”,<strong>the</strong> delivery of <strong>in</strong>jectables is permitted for communitybasedhealth providers. In <strong>the</strong> history of family plann<strong>in</strong>g <strong>in</strong><strong>Asia</strong>, desensitization <strong>and</strong> demedicalization of contraceptivedelivery were made most famous <strong>in</strong> Thail<strong>and</strong>, through <strong>the</strong>work of <strong>the</strong> Population <strong>and</strong> Community DevelopmentAssociation <strong>and</strong> <strong>the</strong> national family plann<strong>in</strong>g programme.However, <strong>in</strong>novations to exp<strong>and</strong> delivery were tested <strong>in</strong>programmes <strong>in</strong> India, Indonesia, Malaysia, Pakistan <strong>and</strong><strong>the</strong> Republic of Korea as well. In fact, a quiet revolution<strong>in</strong> contraceptive provision has taken place <strong>in</strong> Indonesia,with <strong>in</strong>jectables represent<strong>in</strong>g half of all contraceptive use(31.8% of 61.4% overall prevalence) <strong>and</strong> private midwivesnow supply<strong>in</strong>g 40 per cent of this method on a fee basis(Statistics Indonesia <strong>and</strong> Macro <strong>International</strong>, 2008).43

TableTable1EventNational policyYears Reported as Key Events <strong>in</strong> Timel<strong>in</strong>e of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Efforts <strong>in</strong> Selected <strong>Asia</strong>n CountriesIncluded with economic developmentplanRepublicof KoreaHongKongCountryS<strong>in</strong>gapore Thail<strong>and</strong> Indonesia Malaysia Philipp<strong>in</strong>es India1961, 1963 1970 19641969, 1961,1976Bangladesh/PakistanSriLankaNepal1952, 1977 1960 1959, 1975,1980National FP program launched 1966 1972 1967 1947** 1968<strong>Family</strong> size sloganeer<strong>in</strong>g 1961, 1971 1975 1987Mo<strong>the</strong>rs clubs/community mobilizationbegun1968Targets adopted 19641955, 1978,19981962, 1966,1975- 19771968-1972F<strong>in</strong>ancial <strong>in</strong>centives added 1974 1969, 1984 1977 1968-1969Religious opposition/political supportshiftEarly1980s1969 1970Service deliveryFP voluntary association established 1961 1950-1955* 1949 1957 1958 1965, 1969 1949 1959FP workers engaged/deployed 1962 - 1964 1972 1963Urban based centers/ hospitals engaged 1974 1966 1976 1975Rural expansion/ CBD launched 1974 Early 1970s 1970 1962 1973Service centers exp<strong>and</strong>ed 1962 1974 1979 1961 1969-1973Service <strong>in</strong>tegration with MCH 1971 1970,1993Private sector engagement 1986 (PK) 1978Outreach Adolescent outreach/School-based sexuality education begunPremarital counsel<strong>in</strong>g/cl<strong>in</strong>ic(also to immigrants)1967, 1996 19721979, 2002MenPromotion 1986, 2001Men's cl<strong>in</strong>ic 200144

Women's healthCampaign 1992Older women 1999Cervical cancer services/ Pap smears 2003 1974Contraceptve method mixVasectomy 1962 1970-1977IUD 1964 1965Pill 1968 1970Injectable 1977Abortion legalized/term<strong>in</strong>ation services 1973 1979 1970 1971offeredFemale sterilization tra<strong>in</strong><strong>in</strong>g begun 1975 1976 1970 1972 1975 mid-1970sSubfertility/Infertility 1956, 1981Government implementation at high levelMOH/social sector equivalent 1962, 1973 1966 1967 2001 1973 (BG)National board/commission 19661970,1999- 20011989, 1996 1968 1950 1965Prime m<strong>in</strong>ister/ equivalent directive 1963 1983 1966 1967, 1970 1975 1949, 1972 1968Population m<strong>in</strong>isterial status Late 1960s 1990 (PK)Research <strong>and</strong> evaluationSurvey/evaluation/MIS efforts beg<strong>in</strong> 1965 1967, 1991 19661968-1969,1975 (PK)Specialist research center established 1971 1978 1964, 1969 1972, 1977Low/lower fertility recognized 1977 Early 1980s 1975 (BG) 20001987 1976Source: Box 11.1, 12.1, to 21.1 <strong>in</strong> Rob<strong>in</strong>son <strong>and</strong> Ross (eds.), The Global <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Revolution.*Eugenics League reorganized/renamed as FP Assoc of HK**Considerable number of earlier discrete, local activitiesRole of pilot projects (Thail<strong>and</strong>, Indonesia, Ceylon/Sri Lanka), tim<strong>in</strong>g of <strong>in</strong>dependence (India, Pakistan/Bangladesh, Malaysia, Indonesia), tim<strong>in</strong>g of civil strife (Pakistan/Bangladesh), donortechnical assistance (SIDA, USAID, Population <strong>Council</strong>)45

A third observation is that reported outreach to specialpopulations, such as adolescents, men <strong>and</strong> older women,began much later – after <strong>the</strong> 1980s, for <strong>the</strong> most part.Address<strong>in</strong>g client populations outside <strong>the</strong> ma<strong>in</strong>stream ofmarried couples with wives of childbear<strong>in</strong>g age requiredresources that were often not available until contraceptiveprevalence reached robust enough levels where privatizedservices could contribute. Adolescents represent a hugelyimportant segment of <strong>the</strong> population <strong>in</strong> <strong>the</strong> <strong>Asia</strong>n <strong>and</strong><strong>Pacific</strong> region; however, social norms regard<strong>in</strong>g premaritalsex tend to work aga<strong>in</strong>st actively promot<strong>in</strong>g family plann<strong>in</strong>gservices among this group.A fourth observation from Table 1 is that family plann<strong>in</strong>gprogrammes <strong>in</strong> <strong>the</strong> twenty-first century enjoy a profoundlydifferent mix of available contraceptive methods thanprogrammes did <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong> <strong>in</strong> <strong>the</strong> latter halfof <strong>the</strong> twentieth century. Initially only oral contraceptives<strong>and</strong> condoms were available, followed by IUDs, with<strong>the</strong>ir hormonal comb<strong>in</strong>ations <strong>and</strong> <strong>in</strong>trauter<strong>in</strong>e designs<strong>in</strong>troduc<strong>in</strong>g many undesirable side effects, such asbreakthrough bleed<strong>in</strong>g, nausea <strong>and</strong> weight ga<strong>in</strong>. Currentcontraceptive technologies m<strong>in</strong>imize side effects muchmore effectively <strong>and</strong> offer a range of options that can meet<strong>the</strong> needs of any <strong>in</strong>terested female or male user. In <strong>the</strong>cluster of reported key events around contraceptives, <strong>the</strong>sequential <strong>in</strong>troduction of new <strong>and</strong> ref<strong>in</strong>ed methods hasoffered additional options to new segments of potentialusers, <strong>the</strong>reby rais<strong>in</strong>g overall use. Liberalized access topregnancy term<strong>in</strong>ation services is reported for HongKong SAR, India, <strong>the</strong> Republic of Korea <strong>and</strong> S<strong>in</strong>gapore.However, reports of <strong>the</strong> sponsored provision of <strong>in</strong>fertilityor sub-fertility services are notably <strong>in</strong>frequent.Fifth, <strong>the</strong> importance of build<strong>in</strong>g a data-driven base ofevidence on <strong>the</strong> progress of contraceptive adoption<strong>and</strong> <strong>the</strong> fertility transition, <strong>in</strong> <strong>the</strong> context of chang<strong>in</strong>g<strong>in</strong>fant <strong>and</strong> child mortality levels <strong>and</strong> social <strong>and</strong> economicdevelopment, was cited for nearly every one of <strong>the</strong> 12country case studies. Dissem<strong>in</strong>ation of f<strong>in</strong>d<strong>in</strong>gs fromnational surveys, <strong>in</strong> particular <strong>the</strong> early knowledgeattitude-practice(KAP) surveys, followed by <strong>the</strong> WorldFertility <strong>and</strong> Demographic <strong>and</strong> Health Survey (DHS)programmes, gave credence to <strong>the</strong> measured dem<strong>and</strong>for family plann<strong>in</strong>g <strong>and</strong> <strong>the</strong> systemic ability of both <strong>the</strong>public <strong>and</strong> private health sectors to respond with services.The serial availability of such national-level results <strong>in</strong>Bangladesh, Indonesia, Nepal <strong>and</strong> <strong>the</strong> Philipp<strong>in</strong>es, <strong>and</strong>more recently India, cannot be underestimated for <strong>the</strong>irability to <strong>in</strong>form <strong>and</strong> shape family plann<strong>in</strong>g, reproductive,child <strong>and</strong> sexual health policies <strong>and</strong> programmes regionally.Authors of <strong>the</strong> case studies also cited <strong>the</strong> establishment ofspecialist research centres devoted to family plann<strong>in</strong>g <strong>and</strong>family welfare, <strong>in</strong>clud<strong>in</strong>g <strong>the</strong> Korean Institute for <strong>Family</strong><strong>Plann<strong>in</strong>g</strong>, <strong>the</strong> National Institute of Health <strong>and</strong> <strong>Family</strong>Welfare of India, <strong>and</strong> <strong>the</strong> University of <strong>the</strong> Philipp<strong>in</strong>es’Population Institute.F<strong>in</strong>ally, a sixth lesson to be lifted from <strong>the</strong>se country casestudies is <strong>the</strong> <strong>in</strong>itial adm<strong>in</strong>istrative locus of nationalfamily plann<strong>in</strong>g efforts, whe<strong>the</strong>r under <strong>the</strong> highestpolitical authority, such as a president or prime m<strong>in</strong>ister, or<strong>in</strong>stitutionalized <strong>in</strong> a national commission, <strong>in</strong>ter-m<strong>in</strong>isterialbody with a policy or service implementation m<strong>and</strong>ate, or<strong>in</strong>tegrated <strong>in</strong>to <strong>the</strong> m<strong>in</strong>istry of health. These corporateentities <strong>in</strong>itially enjoyed senior-level membership <strong>and</strong>direct access to <strong>the</strong> decision-mak<strong>in</strong>g authority of a primem<strong>in</strong>ister or m<strong>in</strong>ister of f<strong>in</strong>ance or plann<strong>in</strong>g. Often <strong>the</strong>se werenational population commissions which <strong>in</strong>cluded oversightover <strong>the</strong> deployment of a family plann<strong>in</strong>g workforce <strong>and</strong>services, <strong>and</strong> disbursement of centrally budgeted resources.The Indonesian National Population <strong>and</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Board <strong>and</strong> similar committees <strong>in</strong> Malaysia, S<strong>in</strong>gapore <strong>and</strong>Viet Nam, as well as <strong>the</strong> Commission on Population <strong>in</strong><strong>the</strong> Philipp<strong>in</strong>es, are well-known examples. Over time, <strong>the</strong>maturation of <strong>the</strong> family plann<strong>in</strong>g programmes saw manyof <strong>the</strong>ir functions absorbed <strong>in</strong>to m<strong>in</strong>istries of health <strong>and</strong>social affairs. Follow<strong>in</strong>g a board or commission model didnot guarantee a successful national programme however,<strong>and</strong> nei<strong>the</strong>r was one absolutely necessary, as <strong>in</strong> <strong>the</strong> case of<strong>the</strong> national revitalization of family plann<strong>in</strong>g <strong>in</strong> <strong>the</strong> IslamicRepublic of Iran (Roudi-Fahimi, 2002). A national-levelentity, however, afforded significant public visibility <strong>and</strong>credence of <strong>the</strong> importance of family plann<strong>in</strong>g <strong>in</strong> <strong>the</strong>framework of population <strong>and</strong> development efforts.One can visually appreciate trends <strong>in</strong> government supportfor contraceptive method access <strong>in</strong> Figure 1 (dashed redl<strong>in</strong>e) aga<strong>in</strong>st <strong>the</strong> backdrop of government views on <strong>the</strong> levelof fertility beg<strong>in</strong>n<strong>in</strong>g <strong>in</strong> 1976 through to 2009. In 1976,46 per cent (17 governments) of <strong>the</strong> 37 <strong>the</strong>n <strong>in</strong> <strong>the</strong> <strong>Asia</strong>nregion viewed <strong>the</strong>ir fertility as be<strong>in</strong>g too high (diagonallyhatched area), with 49 per cent consider<strong>in</strong>g it satisfactory(solid area). Over time, <strong>the</strong> number of governments grewto 47, with those hold<strong>in</strong>g <strong>the</strong> view of high fertility decl<strong>in</strong><strong>in</strong>gto 32 per cent <strong>in</strong> 2009. At <strong>the</strong> same time, direct supportfor contraceptive access among <strong>the</strong> same governments heldsteady at about 68-71 per cent from 1976 to 1996 <strong>and</strong><strong>the</strong>n <strong>in</strong>creased to 83 per cent <strong>in</strong> 2009 (United Nations,2009a). While expressed commitment to contraceptiveaccess rema<strong>in</strong>s strong nationally, actual levels of use at <strong>the</strong>population level reveal a different picture of utilization.Contraceptive prevalence levels <strong>and</strong>method compositionTable 2, based on <strong>the</strong> United Nations World ContraceptiveUse 2009 wallchart, provides a snapshot of contraceptiveprevalence rates (CPRs) among women of reproductiveage <strong>in</strong> union <strong>in</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> countries, both <strong>in</strong> termsof overall use, use of modern or traditional methods <strong>and</strong>specific methods used. Annual change <strong>in</strong> use levels over46

FigureFigure1<strong>Asia</strong> region government views on <strong>the</strong> level of fertility:1976, 1986, 1996 <strong>and</strong> 2009<strong>and</strong> percent of government provid<strong>in</strong>g direct support to contraceptive accessSource: United Nations, World Population Policies 2009<strong>the</strong> 10-year period from 1997 to 2007 is also given, as is<strong>the</strong> value of <strong>the</strong> Bongaarts <strong>in</strong>dex of contraception (Cc),which is driven by <strong>the</strong> use-effectiveness levels of <strong>the</strong>contraceptives <strong>in</strong> use.In comparison with contraceptive prevalence <strong>in</strong> o<strong>the</strong>rdevelop<strong>in</strong>g regions of <strong>the</strong> world, especially sub-SaharanAfrica, levels are high <strong>in</strong> <strong>the</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> region,although significant variation is apparent. Moreover, <strong>the</strong>size of <strong>the</strong> eligible population of married females 15 to 49years of age underscores a uniquely volum<strong>in</strong>ous scale ofprotection to be provided through organized services. Thisranges from 258.5 million <strong>in</strong> Ch<strong>in</strong>a <strong>and</strong> 220 million <strong>in</strong> India,to 45.4 million <strong>in</strong> Indonesia down to several thous<strong>and</strong>s <strong>in</strong>countries <strong>and</strong> territories <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> region.Based on data for <strong>the</strong> years from 1994 to 2007,contraceptive methods <strong>in</strong> use are predom<strong>in</strong>antly modernacross countries <strong>in</strong> <strong>the</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> region, although<strong>the</strong> practice of natural (traditional) methods of familyplann<strong>in</strong>g is high <strong>in</strong> Japan, which relies significantly oncondoms (40.7%) <strong>and</strong> withdrawal (11.8%). The use ofwithdrawal is also high <strong>in</strong> Iran (11.4%), Cambodia (8.3%)<strong>and</strong> <strong>the</strong> Philipp<strong>in</strong>es (7.3%). The use of <strong>the</strong> rhythm method(periodic abst<strong>in</strong>ence) does not exceed 10 per cent <strong>in</strong> anycountry, but overall traditional method use is 10 per centor higher <strong>in</strong> Malaysia (24.6%), Turkmenistan (16.6%),Sri Lanka (15.3%), Nauru (12.6%), Viet Nam (10.8%),<strong>the</strong> Democratic People’s Republic of Korea (10.4%) <strong>and</strong><strong>the</strong> Republic of Korea (10%), <strong>in</strong> addition to <strong>the</strong> fouraforementioned countries.Male sterilization use exceeds 10 per cent <strong>in</strong> <strong>the</strong> Republicof Korea (15.7%) <strong>and</strong> Bhutan (13.6%) only, <strong>and</strong> is 6.9per cent <strong>in</strong> Ch<strong>in</strong>a <strong>and</strong> 6.3 per cent <strong>in</strong> Nepal. Femalesterilization, on <strong>the</strong> o<strong>the</strong>r h<strong>and</strong>, is a frequently adoptedmethod <strong>in</strong> India (37.3%), Ch<strong>in</strong>a (33.1%) <strong>and</strong> Thail<strong>and</strong>(26.6%). Similarly IUDs are heavily used <strong>in</strong> Uzbekistan(49.7%), Viet Nam (43.7%), <strong>the</strong> Democratic People’sRepublic of Korea (42.8%), Ch<strong>in</strong>a (39.6%), Turkmenistan(39%), Kazakhstan (36.2%), Kyrgyzstan (32%), Mongolia(28.9%) <strong>and</strong> Tajikistan (26.3%). Injectables predom<strong>in</strong>ate<strong>in</strong> Indonesia (34.6%), Cook Isl<strong>and</strong>s (20.8%), Kiribati(20.7%), Sri Lanka (15.3%), Myanmar (14.8%), Thail<strong>and</strong>(13.2%), Mongolia (11.9%) <strong>and</strong> Nepal (10.9%). The pillcaptures users <strong>in</strong> Thail<strong>and</strong> (36.7%), Bangladesh (28.5%)<strong>and</strong> Iran (25.1%), as well as <strong>in</strong> Cook Isl<strong>and</strong>s (24%) <strong>and</strong>Guam (22.6%), while also be<strong>in</strong>g a key contraceptivemethod (over 10%) for users <strong>in</strong> Cambodia, Indonesia,Laos, Malaysia, Maldives, Mongolia, Palau, <strong>the</strong> Philipp<strong>in</strong>es,S<strong>in</strong>gapore, Vanuatu <strong>and</strong> Viet Nam. In addition to Japan,condoms are a significant method of choice <strong>in</strong> Hong KongSAR (45.6%) <strong>and</strong> S<strong>in</strong>gapore (22%).It is important to evaluate <strong>the</strong> annual percentage po<strong>in</strong>tchange <strong>in</strong> CPRs between 1997 <strong>and</strong> 2007, s<strong>in</strong>ce <strong>the</strong> trendl<strong>in</strong>e between national-level TFRs <strong>and</strong> CPRs suggests that,for every 1.5 percentage po<strong>in</strong>t <strong>in</strong>crease <strong>in</strong> <strong>the</strong> latter, TFRwill decl<strong>in</strong>e by 0.1 child, or that a rise of 15 percentagepo<strong>in</strong>ts will be associated with a 1.0 child decl<strong>in</strong>e <strong>in</strong> TFR(Ross et al., 1993). Several countries approach or exceedthis figure, e.g., India (1.1), Afghanistan (1.4), Nepal (2.2)<strong>and</strong> Cambodia (2.3), while some show regression <strong>in</strong> CPRswith negative values, e.g., Kazakhstan <strong>and</strong> Kyrgyzstan47

TableTable2Current Contraceptive Prevalence among Childbear<strong>in</strong>g-Aged Women Married or <strong>in</strong> Union:Latest Year Available for Selected <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> CountriesCountry or areaContraceptive prevalence bWomen aged 15-49, marriedor <strong>in</strong>union aAnySterilizationmodern Anymethod modernYear(s) (thous<strong>and</strong>s) method Female MalePrevalence of modern methods PrevPillInjectableorimplantCh<strong>in</strong>a 2001 258475 86.9 86.2 33.1 6.9 0.0 0.3Hong Kong SAR 2002 1054 84.0 79.8 14.1 0.0 7.9 0.0Democratic People's Republic of 2002 3275 68.6 58.2 4.4 0.8 3.7 0.0Japan 2005 14500 54.3 44.4 1.5 0.4 1.0 0.0Mongolia 2005 465 66.0 60.6 2.4 0.1 11.5 11.9Republic of Korea 2003 7682 84.5 74.5 15.6 15.7 2.0 0Afghanistan 2006 4522 18.6 15.5 0.7 0.0 8.1 5.4Bangladesh 2007 34086 55.8 47.5 5.0 0.7 28.5 7.7Bhutan 2000 82 30.7 30.7 3.1 13.6 3.4 5.9India 2005/06 219989 56.3 48.5 37.3 1.0 3.1 0.1Iran (Islamic Republic of ) 2002 12016 73.3 58.9 15.2 2.3 25.1 2.7Kazakhstan 2006 2876 50.7 48.7 0.5 0.0 6.7 0.3Kyrgyzstan 2005/06 892 47.8 45.5 0.9 0.0 5.1 1.2Maldives 2004 47 39.0 34.0k 7.0 1.0 13.0 3.0Nepal 2006 5457 48.0 44.2 18.0 6.3 3.5 10.9Pakistan 2006/07 26639 29.6 21.7 8.2 0.1 2.1 2.4Sri Lanka 2006/07 3447 68.0 52.7 16.9 0.7 7.9 15.3Tajikistan 2005 1091 37.9 33.1 0.4 0.4 2.1 2.4Turkmenistan 2000 748 61.8 45.2 1.8 0.0 1.2 1.0Uzbekistan 2006 5275 64.9 59.3 2.1 0.1 2.3 2.8Cambodia 2005 2126 40.0 27.1 1.7 0.1 12.6 8.1Indonesia 2007 45382 61.4 57.4 3.0 0.2 13.2 34.6Lao People's Dem Republic 2000 822 32.2 28.9 4.7 0.0 12.9 7.7Malaysia 1994 3021 54.5 29.8 0.0 0.0 13.4 0.0Myanmar 2001 7481 37.0 32.8 4.6 1.5 9.8 14.8Philipp<strong>in</strong>es 2005/06 13922 50.6 35.6 10.4 0.1 16.6 2.8S<strong>in</strong>gapore 1997 644 62.0 53.0 0.0 0.0 10.0 0.0Thail<strong>and</strong> 2006 12104 81.1 79.8 26.6 0.9 36.7 13.2Timor-Leste 2003 110 10.0 7.0 0.6 0.0 0.8 5.6Viet Nam 2007 15494 79.0 68.2 4.4 0.3 10.4 1.0Cook Isl<strong>and</strong>s 1996 2 63.2 60.4 11.3 0.0 22.6 20.8Guam 2002 24 66.6 58.3 18.2 3.9 24.0 4.6Kiribati 2000 10 36.1 31.1 1.4 1.0 6.5 20.7Nauru 2007 1 35.6 23.0 13.3 0.2 0.6 2.3Palau 2003 3 32.8 29.7 1.2 0.0 16.9 10.0Papua New Gu<strong>in</strong>ea 1996 849 25.9 19.6 7.6 0.2 4.4 6.8Samoa 1998 23 24.5 23.2 2.1 0.1 6.4 12.4Vanuatu 1995 26 39.0 32.1 10.3 0.0 13.8 0.1Source: United Nations, 2009 World Contraceptive Use Chart Note: Contraceptive Index based on Bongaarts 1982;def<strong>in</strong>ed as Cc = 1.08*u*e, where u*e is method mix weighted by use-effectiveness values (e); see <strong>in</strong>dicates highly effective impact.48

alence of modern methodsIUDVag<strong>in</strong>albarriermethod c(percentage us<strong>in</strong>g contraception among women who are married or <strong>in</strong> union a )O<strong>the</strong>rmodernmethods dPrevalence of traditional methodsAnytraditionalmethodRhythmCondomWithdrawalO<strong>the</strong>rTraditionalMethodsAnnual change, 1997to 2007 (percentagepo<strong>in</strong>ts)AnyMethodAnyModernMethod39.6 4.4 1.8 0.7 0.0 0.0 0.0 0.3 0.3 0.0988.7 45.6 3.4 4.3t 2.9 0.0 1.4 -0.2 -0.4 0.19942.8 5.8 0.7 10.4p 0.0 0.0 0.0 0.1 0.2 0.4020.9 40.7 0.0 16.8 3.4 11.8 1.6 -0.6 -0.6 0.44928.9 5.3 0.2 0.3 5.4 4.7 0.1 0.7 0.7 1.6 0.34316.1 8.5 16.6 10.0p 0.0 0.0 0.0 0.0 0.5 0.2511.0 2.2 0.0 0.0 4.3 0.5 0.6 3.2 1.4 1.2 0.8040.9 4.5 0.0 8.3 4.9 2.9 0.6 0.7 0.6 0.4623.4 1.2 0.0 0.0 0.0 0.0 0.0 0.6 0.6 0.6801.7 5.2 0.0 0.0 7.8 4.9 2.5 0.3 1.1 0.8 0.4297.6 6.0 0.0 14.3 1.7 11.4 1.2 0.1 0.3 0.28736.2 4.8 0.1 0.1 2.0 0.5 0.4 1.1 -1.2 -0.1 0.49132.0 5.8 0.3 0.1 2.3 0.7 0.5 1.1 -1.2 -0.3 0.5242.0 9.0 0.0 0.0 5.0p 0.0 0.0 0.0 0.2 0.5 0.6510.7 4.8 0.0 0.0 3.7 1.2 2.6 0.0 2.2 1.5 0.5102.3 6.8 0.0 7.9 3.6 4.1 0.2 0.6 0.5 0.7146.3 5.5 0.0 0.0 15.3 9.6 5.5 0.2 0.0 0.6 0.33626.3 1.4 0.0 0.0 4.9 0.3 1.4 3.2 0.4 0.6 0.63139.0 2.0 0.0 0.2 16.6 2.1 5.3 9.2 .. .. 0.4319.7 2.1 0.1 0.1 5.6 1.7 1.1 2.8 0.6 0.5 0.3521.8 2.9 0.0 0.0 12.9 4.5 8.3 0.2 2.3 1.6 0.6214.9 1.3 0.0 0.0 4.0 1.5 2.1 0.4 0.4 0.3 0.3893.0 0.5 0.0 0.0 3.2 2.2 0.7 0.3 0.6 0.6 0.6833.9 5.3 0.0 7.2 2 4.6 8.8 6.9 8.9 .. .. 0.6101.8 0.3 0.0 4.1 1.8 1.0 1.3 0.4 0.4 0.6374.1 1.6 0.0 0.0 15.1 7.0 7.3 0.8 0.4 0.5 0.5165.0 22.0 16.0 9.0p 0.0 0.0 2.0 .. .. 0.4961.2 1.2 0.0 0.0 1.3 0.9 0.0 0.4 -0.1 0.0 0.1760.0 0.0 0.0 0.0 2.9 1.1 0.0 1.8 -1.7 -1.8 0.91243.7 8.3 0.0 0.0 10.8 7.2 3.3 0.3 0.4 1.2 0.2183.3 2.4 0.0 0.0 2.8 0.0 0.0 0.0 -1.3 -1.5 0.3880.7 6.9 0.0 0.0 8.3 2.5 2.1 3.7 .. .. 0.3540.9 0.4 0.1 0.0 5.0 2.9 1.0 1.1 .. .. 0.6493.8 2.8 0.0 12.6 4.7 4.5 3.3 .. .. 0.6700.9 0.6 0.0 0.0 3.1 0.6 0.0 2.5 .. .. 0.6880.1 0.5 0.0 0.0 6.3 2.9 0.6 2.8 .. .. 0.7571.3 0.9 0.0 0.0 1.3 0.6 0.4 0.3 .. .. 0.7564.1 0.0 3.8 6.9 4.2 0.0 2.7 .. .. 0.630ContraceptiveIndex49

Figure(-1.2), Cook Isl<strong>and</strong>s (-1.3) <strong>and</strong> Timor-Leste (-1.7). Theconsistency of ga<strong>in</strong>s or losses <strong>in</strong> CPRs can be evaluatedaga<strong>in</strong>st <strong>the</strong> Cc values <strong>in</strong> <strong>the</strong> last column. A Cc valuethat is close to 0 implies a strong suppressive effect fromcontraceptive use on fertility, while one that approaches 1signifies little impact. Ch<strong>in</strong>a, with a CPR of 86.2 per centthat is heavily concentrated <strong>in</strong> female sterilization <strong>and</strong> IUDuse, has a Cc value of 0.098, reflect<strong>in</strong>g impressively highcontraceptive use-effectiveness. By comparison, althoughAfghanistan’s CPR is ris<strong>in</strong>g, <strong>the</strong> method mix <strong>in</strong>volves lessreliable methods (pill, condom <strong>and</strong> traditional methods)for a Cc value of 0.804, whereas Nepal has a Cc value of0.510, reflected <strong>in</strong> a modern method mix with significantfemale sterilization <strong>and</strong> <strong>in</strong>jectable use.The l<strong>in</strong>k between contraceptive use effectiveness (Cc) <strong>and</strong><strong>the</strong> CPR is visible <strong>in</strong> Figure 2, based on <strong>the</strong> countries <strong>in</strong>Table 2. The nearly perfect l<strong>in</strong>ear relationship between Cc<strong>and</strong> CPR is attributable not only to <strong>the</strong> method-specificuse-effectiveness levels but also to <strong>the</strong> notable practiceof long-term methods <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong>. 2 Countryvalues that fall above <strong>the</strong> l<strong>in</strong>e (e.g., <strong>the</strong> Democratic People’sRepublic of Korea, Malaysia, <strong>the</strong> Republic of Korea <strong>and</strong>S<strong>in</strong>gapore) have a method mix that <strong>in</strong>cludes significant useof traditional methods, with lower use-effectiveness <strong>and</strong>less fertility-suppressive impact.Table 2 <strong>and</strong> Figure 2 convey two important messages forcontraceptive protection to avert unplanned pregnancies<strong>and</strong> <strong>the</strong> derivation of o<strong>the</strong>r health benefits. First, <strong>the</strong> range ofavailable methods enables people practis<strong>in</strong>g contraceptionto manage <strong>the</strong>ir pregnancy risk at vary<strong>in</strong>g stages of exposuredur<strong>in</strong>g <strong>the</strong>ir reproductive lifespan. This suggests that <strong>the</strong>more method options that are made available, <strong>the</strong> morechoice <strong>the</strong>re would be <strong>and</strong> <strong>the</strong> more effective contraceptivepractice could be. Second, <strong>the</strong> concentration of use <strong>in</strong> <strong>the</strong>long-term methods <strong>in</strong> <strong>Asia</strong>, particularly East <strong>and</strong> South<strong>Asia</strong>n countries, is unduplicated <strong>in</strong> o<strong>the</strong>r develop<strong>in</strong>gregions, such as <strong>the</strong> Middle East <strong>and</strong> sub-Saharan Africa.This concentration imbues contraceptive users <strong>in</strong> <strong>the</strong><strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> region with significant use-effectiveness.Long-term methods require a greater extent of cl<strong>in</strong>icaltra<strong>in</strong><strong>in</strong>g <strong>and</strong> appropriate service environments (hygienicconditions, occasionally female providers, <strong>and</strong> follow-upprotocols), which add to overall programme requirements.Undoubtedly, <strong>the</strong> substantial use-effectiveness ofcontraceptive practice <strong>in</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> countries hasfacilitated <strong>the</strong> avoidance of unwanted births. Liu et al.(2008) estimated that <strong>the</strong> practice of contraception circa1999 <strong>in</strong> <strong>the</strong> <strong>Asia</strong>n region was responsible for avert<strong>in</strong>g 133.2million to 174.2 million births annually. This implies <strong>the</strong>prevention of a large number of pregnancy term<strong>in</strong>ationsunder unsafe conditions, as well as maternal <strong>and</strong> newborndeaths, depend<strong>in</strong>g on <strong>the</strong> risk profile of <strong>the</strong> womenpractis<strong>in</strong>g contraception. Compounded over multiple yearsof use, contraceptive protection prolonged by <strong>the</strong> use oflong-term methods also will prevent maternal depletion,lead<strong>in</strong>g to healthier mo<strong>the</strong>rs able to withst<strong>and</strong> <strong>the</strong> energy<strong>and</strong> nutritional dem<strong>and</strong>s posed by subsequent pregnancies<strong>and</strong> deliveries.Contraceptive prevalence <strong>and</strong>economic equityCont<strong>in</strong>uously assess<strong>in</strong>g <strong>the</strong> disparities <strong>in</strong> access to familyplann<strong>in</strong>g services <strong>in</strong> <strong>the</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> region is a meansFigure2Scatterplot <strong>and</strong> Trendl<strong>in</strong>e of Bongaarts Contraceptive Index (Cc) with Contraceptive Prevalence Ratefor East, South-Central, South Eastern <strong>and</strong> Melanesia/Micronesia/Polynesian Countries <strong>and</strong> percentof government provid<strong>in</strong>g direct support to contraceptive accessSource: United Nations, World Population Policies 200950

for monitor<strong>in</strong>g progress towards achiev<strong>in</strong>g MDG 5b.A major UNFPA review (Ortayli <strong>and</strong> Malarcher, 2010)found that <strong>the</strong> percentage of dem<strong>and</strong> for contraceptionthat was satisfied among <strong>in</strong>dividuals of different economicstatus showed <strong>the</strong> smallest gap <strong>in</strong> Central <strong>Asia</strong> <strong>and</strong> <strong>the</strong>widest <strong>in</strong> sub-Saharan Africa. Gillespie et al. (2007)observed that higher fertility <strong>and</strong> lower contraceptive useare found among poorer relative to wealthier populations<strong>in</strong> many countries <strong>and</strong> <strong>the</strong> disparities should be consideredan <strong>in</strong>equity. Townsend (2010) suggested <strong>in</strong>equities <strong>in</strong>programme operations could be reduced <strong>in</strong> three ways:through better underst<strong>and</strong><strong>in</strong>g at <strong>the</strong> development stageof <strong>in</strong>terventions, through better programme design <strong>and</strong>through post-programme evaluation of <strong>the</strong> distribution ofbenefits.A broader review of socio-economic differences <strong>in</strong> health,nutrition <strong>and</strong> population <strong>in</strong>dicators for develop<strong>in</strong>gcountries was conducted by Gwatk<strong>in</strong> et al. (2007) <strong>and</strong><strong>in</strong>cluded measures of both contraceptive prevalence <strong>and</strong><strong>the</strong> extent to which persons practis<strong>in</strong>g contraceptionreported <strong>the</strong> source of <strong>the</strong>ir contraceptive method as <strong>the</strong>public sector. This assessment exam<strong>in</strong>ed health conditionsamong wealth qu<strong>in</strong>tile subgroups us<strong>in</strong>g largely DHS data.It also calculated <strong>the</strong> concentration <strong>in</strong>dex (CI), which isa helpful summary measure of <strong>in</strong>equity, by exam<strong>in</strong><strong>in</strong>g<strong>the</strong> degree to which <strong>the</strong> distribution of a health benefit isequally enjoyed or not by <strong>in</strong>dividuals <strong>in</strong> all economic classes.If contraceptive prevalence, as an <strong>in</strong>dicator of coverage, islowest among those <strong>in</strong> <strong>the</strong> poorest wealth qu<strong>in</strong>tile <strong>and</strong>highest among persons from <strong>the</strong> wealthiest qu<strong>in</strong>tile, <strong>the</strong>CI value will be large <strong>and</strong> positive. The closer CI is to avalue of zero, <strong>the</strong> less <strong>in</strong>come-related <strong>in</strong>equality exists <strong>in</strong><strong>the</strong> <strong>in</strong>dicator’s distribution.Table 3 shows trends <strong>in</strong> CPR by wealth qu<strong>in</strong>tile forseven <strong>Asia</strong>n countries where two or more DH Surveyswere conducted between 1992 <strong>and</strong> 2008 (Bangladesh,Cambodia, India, Indonesia, Nepal, <strong>the</strong> Philipp<strong>in</strong>es <strong>and</strong>Viet Nam). Unlike <strong>in</strong> o<strong>the</strong>r regions, such as sub-SaharanAfrica, <strong>the</strong> <strong>in</strong>equity <strong>in</strong> CPR by wealth qu<strong>in</strong>tile is relativelylow <strong>in</strong> <strong>the</strong>se <strong>Asia</strong>n countries <strong>and</strong> o<strong>the</strong>rs where CPR is high(<strong>in</strong> excess of 70%). Figure 3 illustrates <strong>the</strong> equity patternfor Indonesia between 1997 <strong>and</strong> 2007, where those <strong>in</strong><strong>the</strong> four highest qu<strong>in</strong>tiles experienced relatively similarcoverage of contraception. The largest disparity is for those<strong>in</strong> <strong>the</strong> poorest qu<strong>in</strong>tile, with CPRs about 10 percentagepo<strong>in</strong>ts beh<strong>in</strong>d those <strong>in</strong> <strong>the</strong> o<strong>the</strong>r wealth subgroups. Theconcentration <strong>in</strong>dex values are relatively low, reach<strong>in</strong>g closeto zero <strong>in</strong> <strong>the</strong> most recent survey year for Bangladesh,Cambodia, India, Indonesia, <strong>the</strong> Philipp<strong>in</strong>es <strong>and</strong> VietNam. It is 0.10 or greater only <strong>in</strong> Nepal. This value isfar smaller than those found <strong>in</strong> Guatemala <strong>in</strong> 1998/99(0.357), Pakistan <strong>in</strong> 1990/91 (0.512), or Ethiopia <strong>in</strong> 2000(0.786), for example (Gwatk<strong>in</strong> et al., 2007:135).While <strong>in</strong>come-related rates of contraceptive use are notavailable for many o<strong>the</strong>r <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> countries,<strong>the</strong> level of <strong>in</strong>equity will be related to <strong>the</strong> overall levelof use: <strong>the</strong> higher is <strong>the</strong> population CPR, <strong>the</strong> less likelywould significant disparity by socio-economic status befound, whe<strong>the</strong>r measured <strong>in</strong> terms of <strong>in</strong>come, assets, oreducation. The fact that <strong>the</strong>se populous countries showlow <strong>in</strong>equity <strong>in</strong> contraceptive use suggests that governmentcommitment <strong>and</strong> private sector supply assure a degree ofcontraceptive access that corresponds well to <strong>the</strong> dem<strong>and</strong>for contraception among married couples. Such a degreeof equity <strong>in</strong> contraceptive coverage is a goal which low<strong>in</strong>comecountries <strong>in</strong> o<strong>the</strong>r regions are striv<strong>in</strong>g to atta<strong>in</strong>.Contraceptive commodity security<strong>and</strong> programme f<strong>in</strong>anc<strong>in</strong>gThe history of f<strong>in</strong>anc<strong>in</strong>g family plann<strong>in</strong>g programmes <strong>in</strong> <strong>the</strong>develop<strong>in</strong>g world is one that has relied as much on <strong>in</strong>ternalresources as on <strong>the</strong> contributions of donor agencies <strong>in</strong> <strong>the</strong>form of f<strong>in</strong>ancial, technical or material assistance. Ch<strong>in</strong>a,India <strong>and</strong> Iran are examples of countries that have beenlargely self-sufficient <strong>in</strong> <strong>the</strong> f<strong>in</strong>anc<strong>in</strong>g <strong>and</strong> programm<strong>in</strong>gof <strong>the</strong>ir national family plann<strong>in</strong>g efforts, with commercialaccess to contraceptive commodities available through<strong>the</strong> private sector. In o<strong>the</strong>r countries, such as Bangladesh,Indonesia <strong>and</strong> more recently Afghanistan, <strong>in</strong>ternationalassistance has been more actively furnished <strong>in</strong> <strong>the</strong> <strong>in</strong>itialstages of <strong>the</strong> national programme, although comparativelyspeak<strong>in</strong>g, <strong>in</strong>ternal assistance levels dwarf external levelswhen <strong>in</strong>-k<strong>in</strong>d resources of human <strong>and</strong> physical capital(tra<strong>in</strong>ed providers, health cl<strong>in</strong>ic build<strong>in</strong>gs <strong>and</strong> equipment)are <strong>in</strong>cluded <strong>in</strong> total costs.Assistance for contraceptive commodities <strong>and</strong> medicalsupplies has been provided largely by UNFPA, GTZ(German Agency for <strong>International</strong> Cooperation) <strong>and</strong> <strong>the</strong>United States Agency for <strong>International</strong> Development(USAID). While <strong>the</strong>se <strong>and</strong> o<strong>the</strong>r donor agencies havebeen steady sources of commodity assistance, chang<strong>in</strong>gpolitical situations <strong>in</strong> <strong>the</strong> home countries of governmentsprovid<strong>in</strong>g such support make <strong>the</strong>ir contributionsvulnerable year after year. Threats to fund<strong>in</strong>g can disrupt<strong>the</strong> timely supply <strong>and</strong> delivery of contraceptive methods torecipient countries <strong>and</strong> compromise <strong>the</strong>ir cont<strong>in</strong>uous useby clients, especially those <strong>in</strong> <strong>the</strong> poorest segments of <strong>the</strong>population. Ris<strong>in</strong>g contraceptive dem<strong>and</strong>, made <strong>in</strong>evitableby <strong>the</strong> demographics of grow<strong>in</strong>g populations, can jo<strong>in</strong>tlylead to “stock-outs” (<strong>in</strong>adequate <strong>in</strong>ventory levels to meetcurrent dem<strong>and</strong>) at various po<strong>in</strong>ts of delivery, frustrat<strong>in</strong>gusers’ habituated preferences for specific types of familyplann<strong>in</strong>g methods.UNFPA, USAID <strong>and</strong> its implement<strong>in</strong>g projects, along witho<strong>the</strong>r partners, such as <strong>the</strong> Reproductive Health Supplies51

FigureTableTable3Trends <strong>in</strong> contraceptive prevalence among childbear<strong>in</strong>g aged women <strong>in</strong> union by wealth qu<strong>in</strong>tile<strong>and</strong> concentration <strong>in</strong>dices: <strong>Asia</strong>n Demographic <strong>and</strong> Health Surveys 1992-2008Country <strong>and</strong> YearQu<strong>in</strong>tilesPopulationLow 2nd 3rd 4th High AverageCIBangladesh 1996/1997 38.8 40.8 43.7 38.8 48.5 42.1 0.044Bangladesh 1999/2000 37.4 43.7 44.8 43.5 50.2 44.0 0.057Bangladesh 2004 44.7 47.7 46.6 47.4 50.0 47.3 0.025Bangladesh 2007 54.8 54.7 54.1 55.2 59.9 55.8 0.021Cambodia 2000 12.5 15.4 20.1 19.9 25.4 18.8 0.162Cambodia 2005 30.7 34.3 38.7 41.3 54.0 40.0 0.007India 1992/1993 24.9 27.5 36.1 42.0 50.6 56.5 0.145India 1998/1999 29.3 34.9 44.9 49.7 54.6 42.6 0.129India 2005/2006 42.2 51.1 46.8 62.5 67.5 64.0 0.060Indonesia 1997 46.2 55.6 56.9 58.0 56.9 54.7 0.060Indonesia 2002/2003 48.6 57.9 60.0 59.3 58.1 56.7 0.032Indonesia 2007 53.0 63.3 62.4 63.8 63.5 61.4 0.028Nepal 1992/1993 15.7 21.2 23.2 26.6 44.9 26.0 0.209Nepal 2001 23.8 28.7 31.7 38.9 55.2 35.4 0.180Nepal 2006 32.9 42.6 49.2 52.8 60.9 48.0 0.109Philipp<strong>in</strong>es 1998 19.6 26.2 33.0 33.0 29.4 28.2 0.115Philipp<strong>in</strong>es 2003 23.8 33.8 35.7 37.9 35.2 33.4 0.072Philipp<strong>in</strong>es 2008 40.8 52.7 54.0 55.8 50.0 50.7 0.052Vietnam 1997 47.0 57.3 59.3 59.4 55.5 55.8 0.014Vietnam 2002 57.9 57.9 58.1 58.0 51.6 56.7 -0.025Note: A concentration <strong>in</strong>dex value of zero (0) <strong>in</strong>dicates no <strong>in</strong>come-related <strong>in</strong>equality.Figure3 Contraceptive prevalence by wealth qu<strong>in</strong>tile: Indonesia 1997, 2002, 2007Source: United Nations, World Population Policies 200952

Coalition, seek to ensure that contraceptive security isenjoyed by every person, <strong>in</strong> that s/he is able to choose,obta<strong>in</strong> <strong>and</strong> use high-quality, affordable contraceptives“whenever s/he needs <strong>the</strong>m”. The contraceptive security<strong>in</strong>dex (CSI) was constructed at <strong>the</strong> country level to raiseawareness, advocate, prioritize <strong>and</strong> monitor progress. CSIhas been used <strong>in</strong> 2003, 2006 <strong>and</strong> 2009 for more than60 develop<strong>in</strong>g countries (Aronovich et al., 2010), which<strong>in</strong>cluded a few <strong>Asia</strong>n countries but no <strong>Pacific</strong> ones.The <strong>in</strong>dex has five components: supply cha<strong>in</strong> (logistics),f<strong>in</strong>ance, health <strong>and</strong> social environment, access, <strong>and</strong>utilization; for <strong>the</strong>se <strong>the</strong>re are 17 <strong>in</strong>dicators. Table 4presents 6 of <strong>the</strong> 17 <strong>in</strong>dicators which were selected to show<strong>the</strong> strength of <strong>the</strong> logistics, forecast<strong>in</strong>g <strong>and</strong> procurementsystems, public sector target<strong>in</strong>g <strong>and</strong> contraceptive policy.The total score of <strong>the</strong>se 6 <strong>in</strong>dicators is 72 po<strong>in</strong>ts <strong>and</strong> <strong>the</strong>percentage of maximum is shown for <strong>the</strong> 7 <strong>Asia</strong>n countriesfor which CSI data were available over <strong>the</strong> 3 roundsconducted between 2003 <strong>and</strong> 2009. Figure 4 graphs<strong>the</strong> 2009 partial CSI scores for five of <strong>the</strong>se countries.Bangladesh <strong>and</strong> Indonesia show <strong>the</strong> highest partial CSIscores (75.7% <strong>and</strong> 68.1% respectively), followed by <strong>the</strong>Philipp<strong>in</strong>es (42.5%) <strong>and</strong> India (41.3%), while Pakistanranks last (12.2%). The partial scores do not exhibit al<strong>in</strong>ear trend over <strong>the</strong> years: Bangladesh <strong>and</strong> <strong>the</strong> Philipp<strong>in</strong>eshad a higher score (87.2% <strong>and</strong> 62.8% respectively) <strong>in</strong> 2006than <strong>in</strong> 2009.Although <strong>the</strong> CSI scores have <strong>the</strong>ir imperfections, <strong>the</strong>yprovide a quantitative sense of how well contraceptivecommodity security may be served by exist<strong>in</strong>g logisticsprocurementsystems <strong>and</strong> national commitment <strong>in</strong> <strong>the</strong>form of earmarked budgetary resources for commoditypurchases. The ability to measure <strong>and</strong> assess progress ona regular basis is a critical activity <strong>and</strong> evaluation protocolof family plann<strong>in</strong>g programmes. A data system, such asCSI, available for all <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> countries wouldsignificantly advance contraceptive security for <strong>the</strong> region.Households are a major source of domestic spend<strong>in</strong>g onreproductive health <strong>and</strong> family plann<strong>in</strong>g <strong>and</strong> should not beneglected when assess<strong>in</strong>g <strong>the</strong> national profile of f<strong>in</strong>anc<strong>in</strong>g.Figure 5 displays <strong>the</strong> distribution of estimated domesticexpenditures on population by source of funds <strong>in</strong> 2008.Compiled for <strong>the</strong> UNFPA F<strong>in</strong>ancial Resource Flowsfor Population Activities project, <strong>the</strong> latest such reportof which (UNFPA <strong>and</strong> NIDI, 2010) shows that $15.8billion (current United States dollars) was spent <strong>in</strong> <strong>the</strong><strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> region, as compared with $3.01 billion<strong>in</strong> sub-Saharan Africa, $2.55 billion <strong>in</strong> Lat<strong>in</strong> America<strong>and</strong> <strong>the</strong> Caribbean, $1.01 billion <strong>in</strong> West <strong>Asia</strong> <strong>and</strong> NorthAfrica <strong>and</strong> $0.83 billion <strong>in</strong> Eastern <strong>and</strong> Sou<strong>the</strong>rn Europe.The lead<strong>in</strong>g <strong>Asia</strong>n figure is a function of <strong>the</strong> region’spopulation size, but more importantly, <strong>in</strong> this figure, 71per cent of <strong>the</strong> spend<strong>in</strong>g was by consumers, i.e., out-ofpocketexpenditures on health care, <strong>and</strong> 28 per cent wasby governments. NGO spend<strong>in</strong>g accounted for a negligibleamount. Government spend<strong>in</strong>g as a fraction of <strong>the</strong> totalwas nearly half or greater <strong>in</strong> <strong>the</strong> o<strong>the</strong>r develop<strong>in</strong>g regions.The high percentage of total f<strong>in</strong>anc<strong>in</strong>g that was consumerbasedis an <strong>in</strong>dication of susta<strong>in</strong>able contraceptive security,although national spend<strong>in</strong>g will always be a requisite for<strong>in</strong>troduc<strong>in</strong>g advances <strong>in</strong> contraceptive technologies, ref<strong>in</strong><strong>in</strong>gpolicy <strong>and</strong> service protocols, tra<strong>in</strong><strong>in</strong>g <strong>and</strong> supervis<strong>in</strong>ghealth providers’ st<strong>and</strong>ards of care, conduct<strong>in</strong>g monitor<strong>in</strong>g<strong>and</strong> evaluation, <strong>and</strong> subsidiz<strong>in</strong>g <strong>the</strong> services for <strong>the</strong> poorestsegment of persons practis<strong>in</strong>g contraception.The maturation <strong>and</strong> <strong>in</strong>stitutionalization of national familyplann<strong>in</strong>g programmes with<strong>in</strong> <strong>the</strong> health sector mostfrequently has required less <strong>and</strong> less external assistanceover time. In addition, global resources for familyplann<strong>in</strong>g/reproductive health have been decl<strong>in</strong><strong>in</strong>g, from43 per cent ($722.8 million) of <strong>the</strong> total <strong>in</strong> 1998 to 6 percent ($572.4 million) <strong>in</strong> 2008. Resources for HIV/AIDSprevention <strong>and</strong> treatment have been grow<strong>in</strong>g from $336.2million to over $7.7 billion over <strong>the</strong> same period. Thishas shifted <strong>the</strong> geographic dest<strong>in</strong>ation of <strong>in</strong>ternationalfund<strong>in</strong>g for population assistance, as tracked through <strong>the</strong>UNFPA F<strong>in</strong>ancial Resource Flows project, which obta<strong>in</strong>sdata from donor agencies, governments <strong>and</strong> o<strong>the</strong>r sources.Population assistance fund<strong>in</strong>g <strong>in</strong>cludes family plann<strong>in</strong>g<strong>and</strong> reproductive health services, STI/HIV preventionprogrammes, <strong>and</strong> basic research, data <strong>and</strong> population <strong>and</strong>development policy analysis. In 2008, two thirds of <strong>the</strong>total $10.4 billion <strong>in</strong> estimated fund<strong>in</strong>g ($6,983 million<strong>in</strong> 1993 United States dollars) was directed towards sub-Saharan Africa, while 18 per cent ($1,873 million) wasdirected towards <strong>the</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> region.Although donor support for population activities <strong>in</strong> <strong>the</strong><strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> region is a small fraction of <strong>the</strong> totalexpenditures, it would none<strong>the</strong>less be helpful to exam<strong>in</strong>e<strong>the</strong>ir estimated levels <strong>and</strong> channels of distribution. Table 5is drawn from <strong>the</strong> UNFPA report on F<strong>in</strong>ancial ResourceFlows <strong>and</strong> shows, <strong>in</strong> current United States dollars, <strong>the</strong>change <strong>in</strong> donor expenditures over <strong>the</strong> 10-year periodbetween 1998 <strong>and</strong> 2008. Because <strong>the</strong>se expenditure data<strong>in</strong>clude fund<strong>in</strong>g for STI/HIV programmes, sizeable<strong>in</strong>creases are noted <strong>in</strong> some countries where diseasetransmission risk is judged to be significant or where geopoliticalconsiderations have raised <strong>the</strong> status of <strong>the</strong>secountries as deserv<strong>in</strong>g recipients. For <strong>the</strong> populations of<strong>in</strong>terest shown <strong>in</strong> <strong>the</strong> table, <strong>the</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> regionreceived $1,132 million <strong>in</strong> 2008, $1,050 million <strong>in</strong> <strong>Asia</strong><strong>and</strong> <strong>the</strong> rema<strong>in</strong>der <strong>in</strong> <strong>the</strong> <strong>Pacific</strong>. The overall level of donorexpenditure <strong>in</strong> 2008 was 2.79 times that of <strong>the</strong> 1998 level(<strong>in</strong> current United States dollars). Significant rises <strong>in</strong>donor expenditures are seen for Afghanistan, Kazakhstan,Kyrgyzstan, <strong>the</strong> Democratic People’s Republic of Korea,<strong>the</strong> Philipp<strong>in</strong>es, Tajikistan, Thail<strong>and</strong>, Uzbekistan <strong>and</strong> Viet54

Nam. Nearly all economies <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> region reflectmajor <strong>in</strong>creases <strong>in</strong> donor expenditures on population,except for Fiji, Kiribati <strong>and</strong> Tuvalu.Assum<strong>in</strong>g a relatively constant level of fund<strong>in</strong>g <strong>in</strong>to 2009,<strong>the</strong> per capita expenditure by donors (for women ofchildbear<strong>in</strong>g age <strong>in</strong> union) is $1.49. It varies by subregion,from $0.31 <strong>in</strong> East <strong>Asia</strong> to $4.36 <strong>in</strong> Sou<strong>the</strong>astern <strong>Asia</strong>,to $45.34 <strong>in</strong> <strong>the</strong> <strong>Pacific</strong>, where economies of scale are lessimmediate <strong>and</strong> HIV fund<strong>in</strong>g may be a major contributor.Aga<strong>in</strong>, countries of strategic global <strong>in</strong>terest <strong>and</strong> withspecial sexual <strong>and</strong> reproductive health needs, such asAfghanistan or those <strong>in</strong> Central <strong>Asia</strong>, show higher percapita <strong>in</strong>vestments by donors than o<strong>the</strong>r countries.Although much of <strong>the</strong> fund<strong>in</strong>g data may be driven byrises <strong>in</strong> STI/HIV programme support, <strong>the</strong> latter presentopportunities for family plann<strong>in</strong>g services to be l<strong>in</strong>ked toor <strong>in</strong>tegrated with sexual health <strong>and</strong> exp<strong>and</strong> <strong>the</strong> realmof efforts for prevent<strong>in</strong>g both unplanned pregnancy <strong>and</strong>sexually transmitted <strong>in</strong>fection.The unf<strong>in</strong>ished agenda <strong>and</strong> go<strong>in</strong>gforwardWhile family plann<strong>in</strong>g has been hailed as one of <strong>the</strong> 10greatest public health achievements of <strong>the</strong> twentiethcentury (CDC, 1999), as is <strong>the</strong> case with o<strong>the</strong>r successfulpublic health <strong>in</strong>itiatives, one cannot simply declare victory<strong>and</strong> shift attention <strong>and</strong> resources to ano<strong>the</strong>r health priority.Assur<strong>in</strong>g contraceptive security <strong>in</strong>formation <strong>and</strong> carenecessitates cont<strong>in</strong>ually align<strong>in</strong>g both supply <strong>and</strong> dem<strong>and</strong>factors, us<strong>in</strong>g available public <strong>and</strong> private resources tomeet <strong>the</strong> needs of <strong>the</strong> economically disadvantaged usersforemost, <strong>and</strong> to obta<strong>in</strong> maximum equity <strong>in</strong> care. Nationalconditions for supply <strong>and</strong> dem<strong>and</strong> factors vary considerablyacross <strong>the</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> region, from highly organizedsystems of service delivery <strong>in</strong> Ch<strong>in</strong>a <strong>and</strong> India, wherenormative dem<strong>and</strong> has <strong>in</strong>creas<strong>in</strong>gly conformed to whatearlier generations of childbear<strong>in</strong>g women have beenprovided, to nascent or underperform<strong>in</strong>g systems, suchas <strong>in</strong> Timor-Leste, Laos or Pakistan, where unsatisfieddem<strong>and</strong> is often high.There are several “certa<strong>in</strong>ties” that will frame <strong>the</strong> futureagenda of family plann<strong>in</strong>g for <strong>the</strong> region: (a) populationmomentum <strong>and</strong> growth <strong>in</strong> <strong>the</strong> population of sexuallyactive <strong>in</strong>dividuals <strong>and</strong> those of childbear<strong>in</strong>g age will placepressure on exist<strong>in</strong>g family plann<strong>in</strong>g resources <strong>in</strong>dependentof o<strong>the</strong>r changes <strong>in</strong> contraceptive supply <strong>and</strong> dem<strong>and</strong>; (b)governance <strong>and</strong> policy models for contraceptive securitywill vary country to country where no one programmemodel will fit every situation; <strong>and</strong> (c) factors <strong>in</strong>fluenc<strong>in</strong>g<strong>in</strong>dividual contraceptive dem<strong>and</strong> will be wide rang<strong>in</strong>g,not just across but also with<strong>in</strong> countries. Social normswill play a role <strong>in</strong> ideational change around sexual activity,gender responsibility for <strong>and</strong> roles <strong>in</strong> plann<strong>in</strong>g pregnancy<strong>and</strong> <strong>the</strong> preference for contraceptive method. Trends <strong>in</strong>gender equity <strong>in</strong> access to educational, employment <strong>and</strong>economic opportunities will raise contraceptive dem<strong>and</strong><strong>and</strong> <strong>in</strong>teract with social environmental changes <strong>and</strong> stageof <strong>the</strong> reproductive lifespan. For example, a rise <strong>in</strong> condomuse among urban couples <strong>in</strong> nor<strong>the</strong>rn India has beenobserved, although at <strong>the</strong> completion of childbear<strong>in</strong>g <strong>the</strong>ireventual method of choice may be female sterilization, anevent that is occurr<strong>in</strong>g at <strong>in</strong>creas<strong>in</strong>gly younger ages ( Ja<strong>in</strong>et al., 2010). Social market<strong>in</strong>g of <strong>and</strong> improved access tocondoms <strong>in</strong> urban areas may be enabl<strong>in</strong>g couples to practisebirth spac<strong>in</strong>g, as well as satisfy <strong>the</strong>ir preferences for thismethod. Condom use is much higher <strong>in</strong> urban than ruralareas of India, <strong>and</strong> <strong>in</strong> <strong>the</strong> nor<strong>the</strong>rn than sou<strong>the</strong>rn statesof that country. Such <strong>in</strong>ternal variation at early stages offamily formation is likely to be replicated <strong>in</strong> o<strong>the</strong>r sett<strong>in</strong>gsas sophistication with <strong>the</strong> practice of fertility-regulat<strong>in</strong>gmethods exp<strong>and</strong>s.Unsatisfied contraceptive dem<strong>and</strong>, i.e., unmet need, varieswidely as well, as <strong>in</strong>dicated <strong>in</strong> countries where data areavailable. Laos, Maldives <strong>and</strong> Pakistan register some of<strong>the</strong> highest levels of unmet need (40%, 37% <strong>and</strong> 33%respectively) <strong>in</strong> <strong>the</strong> region. Unmet need is substantial forCambodia (25%), Nepal (24%), Myanmar (20%), <strong>the</strong>Philipp<strong>in</strong>es (17%), <strong>the</strong> Democratic People’s Republic ofKorea (16%) <strong>and</strong> Mongolia (14%). These levels occuramong married couples where <strong>the</strong> wife is not practis<strong>in</strong>gcontraception but desires to space or limit future births;<strong>the</strong>se levels imply cont<strong>in</strong>ued vulnerability to <strong>the</strong> risk ofan unplanned pregnancy until <strong>the</strong> need is met. Globallythis figure is estimated to be 215 million women, with apredom<strong>in</strong>ant share be<strong>in</strong>g <strong>in</strong> <strong>the</strong> <strong>Asia</strong>n region, <strong>and</strong> <strong>the</strong><strong>in</strong>cidence of un<strong>in</strong>tended pregnancies is estimated at 75million annually (S<strong>in</strong>gh et al., 2009).At <strong>the</strong> same time, it is evident that reduc<strong>in</strong>g unmet needto zero or negligible levels is possible <strong>and</strong> nearly assuredwhere contraceptive prevalence is high, e.g., <strong>in</strong> Viet Namwith 5 per cent unmet need <strong>and</strong> Indonesia with 9 per cent.This <strong>in</strong>dicator is one through which progress towardsachiev<strong>in</strong>g MDG 5b is be<strong>in</strong>g monitored, <strong>and</strong> zero tolerancefor unmet contraceptive need merits consideration foradoption by all countries fully committed to improv<strong>in</strong>g <strong>the</strong>human condition. The cost-effectiveness of contraceptionre<strong>in</strong>forces <strong>the</strong> social <strong>and</strong> health value of its universal access.In terms of cost per disability-adjusted life year (DALY),modern contraceptive methods cost $62 (<strong>in</strong> 2008 UnitedStates dollars), compared with <strong>the</strong> cost for anti-retroviral<strong>the</strong>rapy ($150 <strong>in</strong> India or $252-$547 <strong>in</strong> sub-SaharanAfrica) or <strong>the</strong> cost for oral rehydration <strong>the</strong>rapy ($1,268)(S<strong>in</strong>gh et al., 2009).Recent calculations from <strong>the</strong> Health Policy Initiativeproject of <strong>the</strong> Futures Group show that contributionsfrom meet<strong>in</strong>g unmet need for family plann<strong>in</strong>g can reduce55

TableTable5Donor expenditures for population assistance <strong>in</strong> countries <strong>and</strong> territorires of<strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong>, by channel of distribution: 1998 <strong>and</strong> 2008 (Current US $ 000s)2009 Women aged1998Country or area15-49, married or <strong>in</strong> Current% Multilateralunion a (thous<strong>and</strong>s)% BilateralUSD $% NGOASIA AND THE PACIFIC 758007 405,287 29 28 43ASIA 756677 383,547Eastern <strong>Asia</strong> 293722 10,801Ch<strong>in</strong>a (<strong>in</strong>cl Hong Kong SAR) 259529 6,693 17 7 77Democratic People's Republic of Korea 3275 676 0 92 8Mongolia 465 3,229 10 76 14Republic of Korea 7682 203 28 72 0South-Central <strong>Asia</strong> 324000 212,138Afghanistan 4522 813 0 42 58Bangladesh 34086 87,699 16 36 48Bhutan 82 924 0 100 0India 219989 58,134 33 15 52Iran (Islamic Republic of ) 12016 2,127 0 95 5Kazakhstan 2876 2,418 10 53 37Kyrgyzstan 892 1,324 0 56 44Maldives 47 497 0 98 2Nepal 5457 22,051 22 34 45Pakistan 26639 28,561 52 27 21Sri Lanka 3447 3,942 16 63 16Tajikistan 1091 568 0 69 31Turkmenistan 748 730 0 94 6Uzbekistan 5275 2,350 23 62 15South-Eastern <strong>Asia</strong> 103734 152,647Cambodia 2126 21,806 30 37 32Indonesia 45382 53,134 33 15 52Lao People's Democratic Republic 822 3,542 67 32 2Malaysia 3021 251 2 57 41Myanmar 7481 2,424 20 41 39Philipp<strong>in</strong>es 13922 46,625 35 12 53Thail<strong>and</strong> 12104 4,249 31 5 64Timor-Leste 110 na na na naViet Nam 15494 20,616 49 37 14PACIFICMelanesia/Micronesia/Polynesia 1330 7,961Solomon Isl<strong>and</strong>s 132 365 0 18 82Cook Isl<strong>and</strong>s 2 81 0 100 0Fiji 216 810 0 100 0Kiribati 10 62 0 100 0Marshall Isl<strong>and</strong>s 15 60 0 100 0Micronesia Federated States 27 103 0 100 0Palau 3 8 0 100 0Papua New Gu<strong>in</strong>ea 849 6,312 88 11 1Samoa 23 56 0 77 23Tonga 24 45 0 91 9Tuvalu 3 27 0 100 0Vanuatu 26 32 0 88 12Melanesia/Micronesia/Polynesia totals exclude Nauru, Guam, Tokelau, Trust Territory of <strong>Pacific</strong> Isl<strong>and</strong>s, Niue56

2008 2009% Bilateral % Multilateral % NGOexpenditureper woman $1998-2008 %change <strong>in</strong>expenditureCurrentUSD $1,132,628 18 38 44 1.49 179.51,050,434 1.39 173.990,249 0.31 735.684,084 17 67 17 0.32 1156.3310 11 0 89 0.09 -54.15,855 30 55 15 12.59 81.3- 0 0 0 na447,603 1.38 111.072,438 19 52 29 16.02 8810.093,415 19 48 34 2.74 6.52,099 66 30 4 25.60 127.2168,655 13 48 39 0.77 190.14.727 4 96 0 0.39 122.213,674 1 83 16 4.75 465.514,710 9 71 20 16.49 1011.0488 91 0 9 10.38 -1.831,059 21 22 57 5.69 40.927,963 27 42 31 1.05 -2.14,178 36 1 62 1.21 6.07,739 16 45 40 7.09 1262.5821 2 0 98 1.10 12.55,637 12 51 38 1.07 139.9452,275 4.36 196.365,877 20 43 37 30.99 202.1168,655 13 48 39 3.72 217.48,404 44 35 20 10.22 137.3152 66 0 34 0.05 -39.417,910 25 46 29 2.39 638.949,566 12 24 64 3.56 6.345,979 20 68 11 3.80 982.17,731 14 49 37 70.28 na88,001 38 15 47 5.68 326.960,307 45.34 657.51,723 75 0 25 13.05 372.197 100 0 0 48.50 19.81,002 59 0 41 4.64 23.7918 100 0 0 91.80 1380.6948 98 0 2 63.20 1480.01851 100 0 0 68.56 1697.1227 100 0 0 75.67 2737.551,237 20 7 73 60.35 711.7493 83 0 17 21.43 780.4383 97 0 3 15.96 751.13 98 2 0 1.00 -88.91,425 70 0 30 54.81 4353.157

<strong>the</strong> Heads of State of 53 member countries of <strong>the</strong> AfricanUnion are provided with annual updates. There are recent<strong>in</strong>dications that <strong>the</strong> policy climate is shift<strong>in</strong>g <strong>in</strong> favour offamily plann<strong>in</strong>g support <strong>in</strong> that region.2. Can <strong>the</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> regionelim<strong>in</strong>ate unmet contraceptiveneed <strong>and</strong> what does it needto know about barriers tocontraceptive practice <strong>in</strong> order todo so?Quite evidently zero unmet need or universal access tocontraception is possible. However barriers persist <strong>and</strong><strong>in</strong>clude <strong>in</strong>adequate education <strong>and</strong> counsell<strong>in</strong>g aboutcontraceptive methods <strong>and</strong> restricted choice of methods.Misplaced fear of side effects <strong>and</strong> <strong>in</strong>fertility fromcontraceptive use among consumers requires improvedtra<strong>in</strong><strong>in</strong>g of community <strong>and</strong> cl<strong>in</strong>ical health providers sothat <strong>the</strong>y will be able to provide high-quality counsell<strong>in</strong>g<strong>and</strong> services. A particular paradox is <strong>the</strong> reliance on <strong>the</strong>term<strong>in</strong>ation of un<strong>in</strong>tended pregnancies borne out of nonuseof contraceptives for fear of lifetime <strong>in</strong>fertility. Often<strong>the</strong>se pregnancy term<strong>in</strong>ations take place under unsafeconditions which <strong>the</strong>n lead to sepsis <strong>and</strong> subsequentlyto <strong>in</strong>fertility. In addition all entry po<strong>in</strong>ts at which familyplann<strong>in</strong>g <strong>in</strong>formation, counsell<strong>in</strong>g <strong>and</strong> services can be<strong>in</strong>troduced along <strong>the</strong> cont<strong>in</strong>uum of sexual health <strong>and</strong>reproductive care should be utilized. Pre-conception,pre-nuptial, prenatal, postpartum, post-abortion, STI<strong>and</strong> well-baby care visits offer opportunities for familyplann<strong>in</strong>g <strong>in</strong>tegration <strong>and</strong> l<strong>in</strong>kage. Moreover, <strong>in</strong>fertilityservices should not be ignored as a deserv<strong>in</strong>g componentof family plann<strong>in</strong>g care.3. What are <strong>the</strong> prospects forpermanent appropriations forcontraceptive commodities <strong>in</strong>national <strong>and</strong> subnational budgetsor contraceptive service coverageby national health <strong>in</strong>surance plans?Contraceptive security will be achieved when national<strong>and</strong> subnational budgets <strong>in</strong>clude earmarks for essentialmedic<strong>in</strong>es, <strong>in</strong>clud<strong>in</strong>g contraceptives. This capability willalso require technical capacity <strong>in</strong> forecast<strong>in</strong>g, logisticsmanagement <strong>and</strong> procurement, as well as <strong>in</strong> address<strong>in</strong>gcontraceptive import regulations. It will require <strong>the</strong> abilityto track national health accounts <strong>and</strong> subaccounts forfamily plann<strong>in</strong>g <strong>and</strong> reproductive health. Assurance ofcontraceptive supply through <strong>the</strong>se means addresses <strong>the</strong>needs primarily of those served through public sectorfacilities <strong>and</strong> would need to be augmented by coverageof private service consumption through national health<strong>in</strong>surance plans. Donor organizations that substantiallysubsidize contraceptive delivery, <strong>in</strong> countries such asEthiopia, Ghana, Kenya, Nigeria, Rw<strong>and</strong>a <strong>and</strong> Tanzania <strong>in</strong>sub-Saharan Africa, are <strong>in</strong>creas<strong>in</strong>gly focused on target<strong>in</strong>gpermanent budgetary resources. In an effort to eventually“graduate” recipient countries from family plann<strong>in</strong>gassistance, donor agencies, such as USAID, are <strong>in</strong>still<strong>in</strong>g<strong>and</strong> promot<strong>in</strong>g measures for self-sufficiency <strong>in</strong> f<strong>in</strong>anc<strong>in</strong>gcontraceptives earlier than <strong>the</strong>y did <strong>in</strong> <strong>the</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong>region <strong>in</strong> <strong>the</strong> 1970s <strong>and</strong> 1980s.4. What additional compell<strong>in</strong>gevidence is needed to fosteruniversal <strong>and</strong> permanent policysupport for direct access tocontraception?Although 83 per cent of <strong>the</strong> 47 governments <strong>in</strong> <strong>the</strong><strong>Asia</strong>n region directly support contraceptive access, 17per cent do not. Universal access to contraception impliesconv<strong>in</strong>c<strong>in</strong>g <strong>the</strong> rema<strong>in</strong><strong>in</strong>g eight governments of <strong>the</strong> valueof <strong>in</strong>vest<strong>in</strong>g <strong>in</strong> this health <strong>and</strong> development <strong>in</strong>tervention.The national return on prevent<strong>in</strong>g un<strong>in</strong>tended pregnanciesis often difficult to document s<strong>in</strong>ce averted births are notvisible, immediately measurable or tangible as would be areduction <strong>in</strong> <strong>the</strong> <strong>in</strong>cidence of new cases of a disease dur<strong>in</strong>gan epidemic, for example. Pregnancies that do occur areusually judged to be desired <strong>and</strong> healthy. Three compell<strong>in</strong>garguments have emerged with grow<strong>in</strong>g evidence of <strong>the</strong>irmerits. First, at <strong>the</strong> population level, chang<strong>in</strong>g populationage structures, with fewer youthful dependents, cancontribute to <strong>the</strong> economic benefits known as <strong>the</strong>“demographic bonus” or “demographic dividend”. Second,family plann<strong>in</strong>g confers health benefits on mo<strong>the</strong>rs, children<strong>and</strong> families by reduc<strong>in</strong>g adverse pregnancy outcomes,<strong>and</strong> well-spaced births (<strong>and</strong> well-nourished children) areassociated with stronger cognitive performance <strong>in</strong> school.Third, <strong>the</strong> grow<strong>in</strong>g consensus around <strong>the</strong> foetal orig<strong>in</strong>s ofchronic disease <strong>in</strong> adulthood suggests that contraceptivepractice can improve birth outcomes by prolong<strong>in</strong>g <strong>the</strong><strong>in</strong>terval between pregnancies, which <strong>in</strong> turn leads to betterfoetal growth <strong>and</strong> development, per<strong>in</strong>atal outcomes <strong>and</strong>normal birth-weight <strong>in</strong>fants, with reduced risk of diabetes,hypertension <strong>and</strong> cardiovascular disease later <strong>in</strong> life.Marshall<strong>in</strong>g <strong>the</strong> local scientific evidence for <strong>the</strong>se expectedbenefits is a policy research enterprise that can havesignificant pay-offs not only for MDG 5b but all eightMDGs. The record of family plann<strong>in</strong>g <strong>in</strong> <strong>the</strong> <strong>Asia</strong>n <strong>and</strong><strong>Pacific</strong> region is a long, active <strong>and</strong> historic one, withmany lessons to be shared with o<strong>the</strong>r develop<strong>in</strong>g regions,particularly <strong>in</strong> terms of national commitment <strong>in</strong> <strong>the</strong> contextof economic development plann<strong>in</strong>g; <strong>in</strong>ter-m<strong>in</strong>isterialcoord<strong>in</strong>at<strong>in</strong>g entities; demedicalized services; <strong>and</strong> equitableservice coverage. Revitaliz<strong>in</strong>g <strong>and</strong> rais<strong>in</strong>g <strong>the</strong> visibility of59

family plann<strong>in</strong>g will be critical <strong>in</strong> order to meet <strong>the</strong> healthychildbear<strong>in</strong>g needs of ris<strong>in</strong>g cohorts of young adults <strong>and</strong>rega<strong>in</strong> <strong>the</strong> momentum of past achievements by ensur<strong>in</strong>gequitable <strong>and</strong> universal coverage across all countries <strong>in</strong><strong>the</strong> region. In this manner <strong>the</strong> susta<strong>in</strong>able developmentof future generations will not be compromised if <strong>the</strong>contraceptive needs of today’s generations can be fulfilled.End Note1Gro Harlem Brundtl<strong>and</strong>, Our Common Future:Report of <strong>the</strong> World Commission on Environment <strong>and</strong>Development. Published as an annex to United NationsGeneral Assembly document A/42/427, Development<strong>and</strong> <strong>International</strong> Co-operation: Environment, 2 August1987.2The follow<strong>in</strong>g use-effectiveness values from Liu et al.(2008) were used: female sterilization, 0.994; malesterilization, 0.998; pill, 0.912; <strong>in</strong>jectable, 0.942; IUD,0.964; condom, 0.857; vag<strong>in</strong>al barrier, 0.736; o<strong>the</strong>r modernmethod, 0.818; rhythm, 0.745; withdrawal, 0.784; <strong>and</strong>o<strong>the</strong>r traditional method, 0.412.REFERENCESAronovich, Dana, Marie Tien, <strong>and</strong> Nadia Olson.Contraceptive Security Index 2003-2009. Presentationat <strong>the</strong> Annual Meet<strong>in</strong>g of <strong>the</strong> Global Health <strong>Council</strong>,June 15, 2010. John Snow, Inc. DELIVER Project,Wash<strong>in</strong>gton, DC.Cates. Willard Jr., Quarraisha Abdool Karim, WafaaEl-Sadr, Debra W. Haffner, Gladys Kalema-Zikusoka, Khama Rogo, Tricia Petruney, <strong>and</strong> E.Megan Advidson Averil. <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> <strong>the</strong>Millennium Development Goals. 2010. Science329(24): 1603.Centers for Disease Control <strong>and</strong> Prevention (CDC).Achievements <strong>in</strong> Public Health, 1900-1999: <strong>Family</strong><strong>Plann<strong>in</strong>g</strong>. MMWR. Morbidity <strong>and</strong> Mortality WeeklyReport, 1999; 48(47),1073-1080.Gillespie, Duff, Saifudd<strong>in</strong> Ahmed, Amy Tsui <strong>and</strong> ScottRadloff. 2007. Unwanted Fertility among <strong>the</strong>Poor: An Inequity? Bullet<strong>in</strong> of <strong>the</strong> World HealthOrganization 85(2): 100-107.Gwatk<strong>in</strong>, David, Shea Rutste<strong>in</strong>, Kiersten Johnson,Eldaw Suliman, Adam Wagstaff <strong>and</strong> AgbessiAmouzou. 2007. Socio-Economic Differences <strong>in</strong>Health, Nutrition <strong>and</strong> Population with<strong>in</strong> Develop<strong>in</strong>gCountries. Wash<strong>in</strong>gton DC: The World Bank,Human Development Network, Health, Nutrition<strong>and</strong> Population.Health Policy Initiative. 2009. <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong><strong>the</strong> MDGs: Sav<strong>in</strong>g Lives, Sav<strong>in</strong>g Resources. FuturesGroup <strong>International</strong>. Wash<strong>in</strong>gton, DC. http://www.healthpolicy<strong>in</strong>itiative.com/Publications/Documents/788_1_<strong>Family</strong>_<strong>Plann<strong>in</strong>g</strong>_<strong>and</strong>_<strong>the</strong>_MDGs_FINAL_June_09_acc.pdfJa<strong>in</strong>, Aparna, Anrudh Ja<strong>in</strong>, <strong>and</strong> Amy Tsui. 2010. AQuiet Revolution <strong>in</strong> Condom Use <strong>in</strong> Urban India.Paper presented at <strong>the</strong> 2011 Annual Meet<strong>in</strong>g of <strong>the</strong>Population Association of America. March 31-April2, 2011, Wash<strong>in</strong>gton, DC.Liu, Li, Stan Becker, Amy Tsui, Saifudd<strong>in</strong> Ahmed.2008. Three Methods of Estimat<strong>in</strong>g Births AvertedNationally by Contraception. Population Studies62(2): 191-210.Population Reference Bureau. 2010. Onl<strong>in</strong>e DataF<strong>in</strong>der.http://www.prb.org/DataF<strong>in</strong>der/Topic/Rank<strong>in</strong>gs.aspx?<strong>in</strong>d=35Population Reference Bureau. <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Worldwide: 2008 Data Sheet. Wash<strong>in</strong>gton, DC:Population Reference Bureau. http://www.prb.org/pdf08/fpds08.pdfRob<strong>in</strong>son, Warren <strong>and</strong> John Ross (Eds.) 2007. TheGlobal <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Revolution: Three Decades ofPopulation Policies <strong>and</strong> Programs. Wash<strong>in</strong>gton, DC:The World Bank.Roudi-Fahimi, Farzaneh. 2002. Iran’s <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Program: Respond<strong>in</strong>g to a Nation’s Needs. Wash<strong>in</strong>gtonDC: Population Reference Bureau. http://www.prb.org/pdf/IransFamPlanProg_Eng.pdfS<strong>in</strong>gh, Susheela, Jacquel<strong>in</strong>e Darroch, Lori S. Ashford,<strong>and</strong> Michael Vlassoff. Add<strong>in</strong>g It Up: The Costs <strong>and</strong>Benefits of Invest<strong>in</strong>g <strong>in</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> Maternal<strong>and</strong> Newborn Health. New York: GuttmacherInstitute, 2009.Statistics Indonesia (Badan Pusat Statistik-BPS) <strong>and</strong>Macro <strong>International</strong>. 2008. Indonesia Demographic<strong>and</strong> Health Survey 2007. Calverton, Maryl<strong>and</strong>, USA:BPS <strong>and</strong> Macro <strong>International</strong>United Nations. 2009a. World Population Policies2009. ST/ESA/SER.A/293. New York: UnitedNations, Department of Economic <strong>and</strong> Social Affairs,Population Division. http://www.un.org/esa/population/publications/wpp2009/wpp2009.htmUnited Nations. 2009b. World Population Prospects: The2008 Revision. ST/ESA/SER.A/287. New York:United Nations, Department of Economic <strong>and</strong> SocialAffairs, Population Division.United Nations, 2009c. World Contraceptive UseWallchart 2009. 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<strong>Pacific</strong><strong>Pacific</strong><strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> Isl<strong>and</strong>s:Current Status <strong>and</strong> Prospects for Reposition<strong>in</strong>g <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> on <strong>the</strong> Development AgendaGeoffrey Hayes * <strong>and</strong> Annette Robertson #* Consultant Demographer, New Zeal<strong>and</strong>;# Deputy Director of <strong>the</strong> UNFPA <strong>Pacific</strong> Subregional Office, Suva, Fiji.61

Introduction<strong>Family</strong> plann<strong>in</strong>g <strong>and</strong> fertility decl<strong>in</strong>e:research questions<strong>Family</strong> plann<strong>in</strong>g <strong>and</strong> contraceptionThe <strong>International</strong> Planned Parenthood Federation (IPPF)def<strong>in</strong>es family plann<strong>in</strong>g as:"The conscious effort of couples <strong>and</strong><strong>in</strong>dividuals to plan for <strong>and</strong> atta<strong>in</strong> <strong>the</strong>irdesired number of children <strong>and</strong> to regulate<strong>the</strong> spac<strong>in</strong>g <strong>and</strong> tim<strong>in</strong>g of <strong>the</strong>ir births.<strong>Family</strong> plann<strong>in</strong>g is achieved throughcontraception <strong>and</strong> through <strong>the</strong> treatmentof <strong>in</strong>voluntary <strong>in</strong>fertility 1 . "This simple <strong>and</strong> clear def<strong>in</strong>ition belies <strong>the</strong> long <strong>and</strong> torturedhistory through which family plann<strong>in</strong>g has become acceptedas normal behaviour across a wide spectrum of countries,both developed <strong>and</strong> develop<strong>in</strong>g, among all social classes <strong>and</strong>ethnic groups, <strong>and</strong> among members of all major religions.As of 2008, 63 per cent of married women <strong>in</strong> <strong>the</strong> worldwere us<strong>in</strong>g family plann<strong>in</strong>g <strong>and</strong> 90 per cent of <strong>the</strong>se wereus<strong>in</strong>g a modern method (Population Reference Bureau,2008). The worldwide use of contraception has doubledbetween 1980 <strong>and</strong> 2008 <strong>and</strong> is currently <strong>in</strong>creas<strong>in</strong>g atabout 1 per cent per year. To <strong>the</strong> pioneers who commenced<strong>the</strong> family plann<strong>in</strong>g movement <strong>in</strong> <strong>the</strong> late n<strong>in</strong>eteenth <strong>and</strong>early twentieth centuries <strong>the</strong>se numbers <strong>and</strong> trends wouldbe little short of amaz<strong>in</strong>g.However, <strong>the</strong> undoubted success of <strong>the</strong> family plann<strong>in</strong>gmovement must be qualified. The use of contraceptionvaries widely at <strong>the</strong> country level – from 86 per cent ofmarried women <strong>in</strong> Ch<strong>in</strong>a to under 2 per cent <strong>in</strong> Chad.In West Africa as a whole, only 9 per cent of women usea modern method of family plann<strong>in</strong>g; <strong>in</strong> Middle Africa,only 7 per cent. Outside Africa, low contraceptive use canbe found <strong>in</strong> Afghanistan (8.5%), East Timor (8.6%) <strong>and</strong>Azerbaijan (11.9%)(Population Reference Bureau, 2008).It is apparent that <strong>the</strong> global average contraceptive use rateis <strong>in</strong>flated by very high contraceptive prevalence <strong>in</strong> Ch<strong>in</strong>a.Among <strong>the</strong> less developed countries, contraceptive usedrops from 56 per cent of married women to 45 per centwhen Ch<strong>in</strong>a is excluded. Thus, less than half of all marriedwomen <strong>in</strong> less developed countries o<strong>the</strong>r than Ch<strong>in</strong>a areus<strong>in</strong>g contraception. Fur<strong>the</strong>rmore, of <strong>the</strong> 210 millionpregnancies that occur annually worldwide, only 47 per centresult <strong>in</strong> a planned birth; 22 per cent of pregnancies end <strong>in</strong>an <strong>in</strong>duced abortion <strong>and</strong> 17 per cent are ei<strong>the</strong>r unwantedor mistimed (Shah, 2002). In less developed countries, 100million married women would prefer to avoid a pregnancybut are not us<strong>in</strong>g any form of contraception to achievethat end (Ashford, 2003). Such women are said to have an“unmet need” for family plann<strong>in</strong>g.An unmet need for family plann<strong>in</strong>g not only places womenat risk of hav<strong>in</strong>g an unwanted birth, but also <strong>in</strong>creases <strong>the</strong>risk of maternal death or morbidity. Recourse to an illegalabortion <strong>in</strong>creases <strong>the</strong> risk of maternal death. Unwantedbirths pose risks for children’s health <strong>and</strong> well-be<strong>in</strong>g,<strong>in</strong>clud<strong>in</strong>g <strong>the</strong> possibility of neglect <strong>and</strong> <strong>in</strong>fant death.Stalled fertility transitionsIt has also become evident that many develop<strong>in</strong>g countries<strong>in</strong> various regions <strong>and</strong> subregions of <strong>the</strong> world haveexperienced “stalled” fertility transitions (Bongaarts, 2008).This phenomenon is also evident <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> region. Thereis a subgroup of <strong>Pacific</strong> isl<strong>and</strong> countries <strong>in</strong> which TFRshave rema<strong>in</strong>ed between 3.5 <strong>and</strong> 4.0 for more than a decadeafter <strong>in</strong>itially fall<strong>in</strong>g rapidly from about 7 or 8 <strong>in</strong> <strong>the</strong> 1960s<strong>and</strong> 1970s. A plausible explanation for this is that familyplann<strong>in</strong>g programmes were much stronger <strong>in</strong> <strong>the</strong> past than<strong>the</strong>y are today. It is a short step from that propositionto <strong>the</strong> view that, if family plann<strong>in</strong>g programmes were“streng<strong>the</strong>ned”, <strong>the</strong> fertility transition might be <strong>in</strong>ducedto cont<strong>in</strong>ue until replacement-level fertility was reached.Such arguments need to be treated with caution. First, tounderst<strong>and</strong> fertility levels <strong>and</strong> trends it is essential to take<strong>in</strong>to account all <strong>the</strong> factors that could contribute to fertilitychange (or its absence) <strong>in</strong> a specific country or group ofcountries, not only family plann<strong>in</strong>g programmes. Thereis a large literature that discusses <strong>the</strong> relative importance,for example, of socio-economic factors <strong>and</strong> mortalitydecl<strong>in</strong>e, as well as changes <strong>in</strong> norms <strong>and</strong> values <strong>and</strong> o<strong>the</strong>r“ideational” determ<strong>in</strong>ants of fertility. While <strong>the</strong> extent ofcontraception is obviously a key proximate determ<strong>in</strong>ant offertility levels, <strong>the</strong> socio-economic conditions that lead tocontraceptive use or non-use need to be considered <strong>in</strong> anycomplete explanation.The central facilitat<strong>in</strong>g role that family plann<strong>in</strong>gprogrammes play <strong>in</strong> contribut<strong>in</strong>g to fertility decl<strong>in</strong>e issupported by <strong>the</strong> generally close association betweencontraceptive prevalence rates <strong>and</strong> total fertility rates.In some countries it appears that <strong>the</strong> stalled fertilitytransition is related to a slow <strong>in</strong>crease, or even decl<strong>in</strong>e, <strong>in</strong>contraceptive prevalence. These circumstances have led tovarious efforts to “reposition” family plann<strong>in</strong>g on nationaldevelopment agendas. This implies that family plann<strong>in</strong>gshould be given higher priority with<strong>in</strong> reproductive healthprogrammes, <strong>in</strong>clud<strong>in</strong>g more fund<strong>in</strong>g.Many of <strong>the</strong>se concerns are applicable to <strong>the</strong> regionencompass<strong>in</strong>g <strong>the</strong> <strong>Pacific</strong> isl<strong>and</strong>s. As already noted, <strong>in</strong>63

several countries, <strong>the</strong> fertility transition has slowed or“stalled”. In some cases <strong>the</strong>re has been no change <strong>in</strong> <strong>the</strong>level of fertility <strong>in</strong> two decades. Similarly, contraceptiveuse has rema<strong>in</strong>ed well below <strong>the</strong> average for less developedcountries, even 50 years after family plann<strong>in</strong>g programmeswere first <strong>in</strong>troduced, <strong>and</strong> <strong>in</strong> several countries contraceptiveuse appears to be decl<strong>in</strong><strong>in</strong>g. Thus, it is plausible that a“reposition<strong>in</strong>g” of family plann<strong>in</strong>g <strong>in</strong> <strong>the</strong> region would havea positive effect <strong>in</strong> reduc<strong>in</strong>g <strong>the</strong> level of unmet need <strong>and</strong>facilitat<strong>in</strong>g fur<strong>the</strong>r decl<strong>in</strong>e <strong>in</strong> fertility levels (Robertson,2009).<strong>Family</strong> plann<strong>in</strong>g <strong>and</strong> <strong>the</strong> ICPDProgramme of ActionTo reposition family plann<strong>in</strong>g on <strong>the</strong> development agendaof <strong>Pacific</strong> isl<strong>and</strong> countries, as <strong>in</strong> o<strong>the</strong>r regions of <strong>the</strong> world,it is first necessary to underst<strong>and</strong> <strong>the</strong> current status offamily plann<strong>in</strong>g programmes <strong>and</strong> to identify <strong>the</strong> factorsthat have contributed to this status. This is more complexthan it first appears. Prior to <strong>the</strong> 1994 ICPD Programmeof Action, <strong>the</strong> pr<strong>in</strong>ciple measure of success of a familyplann<strong>in</strong>g programme was <strong>the</strong> contraceptive prevalence rate(CPR) or <strong>the</strong> “acceptor” rate. In most countries it couldbe assumed that <strong>the</strong>re was a reasonably close relationshipbetween CPR <strong>and</strong> fertility levels (as measured by TFR). IfCPR was ris<strong>in</strong>g as a result of family plann<strong>in</strong>g programmes,<strong>the</strong>n reduced fertility could be expected. Thus, familyplann<strong>in</strong>g reduced fertility <strong>and</strong> <strong>the</strong> reduction of fertilitycontributed to reduced population growth <strong>and</strong> more rapideconomic growth. After ICPD, both CPR <strong>and</strong> TFR lostfavour as policy targets because <strong>the</strong> use of such statisticalmeasures appeared to violate <strong>the</strong> pr<strong>in</strong>ciple of voluntarism<strong>and</strong> <strong>the</strong> aim of meet<strong>in</strong>g <strong>in</strong>dividual needs. The ICPDProgramme of Action encouraged countries to move awayfrom a macrolevel focus on statistical <strong>in</strong>dicators <strong>and</strong> <strong>the</strong>use of <strong>in</strong>centives <strong>and</strong> dis<strong>in</strong>centives by family plann<strong>in</strong>gprogrammes towards a microlevel approach focused on<strong>the</strong> freely chosen reproductive goals of <strong>in</strong>dividuals <strong>and</strong>couples. This was <strong>in</strong>terpreted by many to mean thatnational population policies should not employ fertility orgrowth targets at all. A more extreme position was thatpopulation policies were no longer necessary <strong>and</strong> countriesshould be discouraged from formulat<strong>in</strong>g <strong>the</strong>m.The ICPD Programme of Action, <strong>in</strong> fact, attempted toma<strong>in</strong>ta<strong>in</strong> a f<strong>in</strong>e balance between population goals at <strong>the</strong>societal level <strong>and</strong> <strong>the</strong> reproductive rights of <strong>in</strong>dividuals <strong>and</strong>couples. The reduction of population growth was treatedas a “legitimate <strong>in</strong>terest” of governments, particularly <strong>in</strong> <strong>the</strong>context of environmental susta<strong>in</strong>ability <strong>and</strong> reduction ofpoverty, but <strong>the</strong> legitimacy of this <strong>in</strong>terest was conditionalon <strong>the</strong> extent to which demographic rates <strong>and</strong> social,economic <strong>and</strong> environmental goals were imbalanced.Thus, “stabilization” of population growth ra<strong>the</strong>r than itsrapid reduction was <strong>the</strong> key policy objective. While familyplann<strong>in</strong>g is mentioned <strong>in</strong> various contexts, <strong>and</strong> familyplann<strong>in</strong>g makes up a significant section <strong>in</strong> <strong>the</strong> chapter onreproductive rights <strong>and</strong> reproductive health, <strong>the</strong> ICPDProgramme of Action goes to some length to <strong>in</strong>sulatefamily plann<strong>in</strong>g from macroeconomic concerns <strong>and</strong> toplace it firmly with<strong>in</strong> <strong>the</strong> context of reproductive health<strong>and</strong> rights. The pr<strong>in</strong>ciple of “<strong>in</strong>formed free choice”, it wasargued, should govern family plann<strong>in</strong>g programmes. Ifeducation <strong>and</strong> services are provided, <strong>in</strong>dividuals can beexpected to “act responsibly <strong>in</strong> <strong>the</strong> light of <strong>the</strong>ir own needs<strong>and</strong> those of <strong>the</strong>ir families <strong>and</strong> communities” (UnitedNations, 1995, para. 7.12). The implication was thatgovernments do not need to set <strong>the</strong> reproductive goals of<strong>in</strong>dividuals <strong>and</strong> families, <strong>and</strong> should not do so.Importantly, this argument was supported by a comparisonof <strong>the</strong> fertility <strong>and</strong> contraceptive use targets conta<strong>in</strong>ed<strong>in</strong> <strong>the</strong> development plans of 12 develop<strong>in</strong>g countries<strong>and</strong> <strong>the</strong> level of fertility that would be achieved only if<strong>the</strong> expressed fertility desires of <strong>in</strong>dividual women wereachieved. Analysis by S<strong>in</strong>d<strong>in</strong>g, et al. (1994) showed that,by reduc<strong>in</strong>g <strong>the</strong> unmet need for family plann<strong>in</strong>g, fertilitylevels would be <strong>the</strong> same, or lower, than <strong>the</strong> demographictargets specified <strong>in</strong> government development plans. Theyconcluded:<strong>Family</strong> plann<strong>in</strong>g still needs quantitative objectives by whichto assess <strong>the</strong>ir performance. But <strong>the</strong>se objectives can <strong>and</strong>should be addressed <strong>in</strong> terms of satisfy<strong>in</strong>g people’s statedneeds ra<strong>the</strong>r than planners’ notions of what a society’sbirthrate should be.This pr<strong>in</strong>ciple was accepted <strong>in</strong> <strong>the</strong> formulation of <strong>the</strong>ICPD Programme of Action <strong>and</strong> has been <strong>the</strong> underly<strong>in</strong>gphilosophy of family plann<strong>in</strong>g programmes s<strong>in</strong>ce <strong>the</strong>n.Address<strong>in</strong>g unmet need ra<strong>the</strong>r than demographic targetshas been <strong>the</strong> cornerstone of reproductive health <strong>and</strong> familyplann<strong>in</strong>g programmes s<strong>in</strong>ce <strong>the</strong> 1994 ICPD.In harmony with this voluntaristic formulation, governmentswere expected to assess <strong>the</strong> extent of <strong>the</strong> “unmet need” forfamily plann<strong>in</strong>g <strong>and</strong> to meet those needs by, among o<strong>the</strong>rmeasures, remov<strong>in</strong>g “all <strong>the</strong> major rema<strong>in</strong><strong>in</strong>g barriers to <strong>the</strong>utilization of family-plann<strong>in</strong>g services” (United Nations,1995, para. 7.19). The Programme of Action fur<strong>the</strong>rstates that “governmental goals for family plann<strong>in</strong>g shouldbe def<strong>in</strong>ed <strong>in</strong> terms of unmet needs for <strong>in</strong>formation <strong>and</strong>services” (United Nations, 1995, para. 7.12). The ICPD +5review of <strong>the</strong> Programme of Action was more explicit <strong>and</strong>proposed that “Where <strong>the</strong>re is a gap between contraceptiveuse <strong>and</strong> <strong>the</strong> proportion of <strong>in</strong>dividuals express<strong>in</strong>g a desireto space or limit <strong>the</strong>ir families, countries should attemptto close this gap by at least 50 per cent by 2005, 75 percent by 2010 <strong>and</strong> 100 per cent by 2015” (United Nations,1999, para. 58).64

The advent of <strong>the</strong> Millennium Development Goals(MDGs) saw <strong>the</strong> reditto<strong>in</strong>troduction of CPR <strong>in</strong>to<strong>in</strong>ternational development frameworks, <strong>in</strong>itially <strong>in</strong> <strong>the</strong>context of reduc<strong>in</strong>g exposure to HIV <strong>and</strong> AIDS <strong>and</strong>ultimately as an <strong>in</strong>dicator of <strong>the</strong> target of ensur<strong>in</strong>g“universal access to reproductive health”, along with <strong>the</strong>extent of “unmet need” for family plann<strong>in</strong>g. It is importantto note that, <strong>in</strong> <strong>the</strong> MDG framework, CPR is not itself atarget but is an <strong>in</strong>dicator used to monitor progress towardsachiev<strong>in</strong>g universal access to reproductive health. On <strong>the</strong>o<strong>the</strong>r h<strong>and</strong>, ICPD+5 proposed specific numerical targetsfor <strong>the</strong> reduction of unmet need, which, it stated, shouldbe elim<strong>in</strong>ated entirely by 2050.Explanatory frameworksAs already noted, any explanation of a slowdown <strong>in</strong><strong>the</strong> fertility transition must go beyond family plann<strong>in</strong>gprogrammes as such, but <strong>the</strong> issue of family plann<strong>in</strong>g <strong>and</strong>unmet need for it is an important po<strong>in</strong>t of departure. In<strong>the</strong> <strong>Pacific</strong>, however, <strong>the</strong> measurement of unmet need hasreceived very little attention until recently. Only one country,Papua New Gu<strong>in</strong>ea, has a measure for two po<strong>in</strong>ts <strong>in</strong> time.Seven <strong>Pacific</strong> isl<strong>and</strong> countries have conducted DHS <strong>in</strong> <strong>the</strong>past four years that provide data on unmet need, but <strong>the</strong>analysis of <strong>the</strong>se data has so far been quite limited. It isalso important to acknowledge that <strong>the</strong> concept of unmetneed is far from simple (Bhushan, 1997). The same level ofunmet need can have different mean<strong>in</strong>gs, depend<strong>in</strong>g on <strong>the</strong>demographic <strong>and</strong> social context. Analysis of unmet needfor programm<strong>in</strong>g purposes needs to be complementedwith measures of fertility preferences <strong>and</strong> <strong>the</strong> dem<strong>and</strong> forcontraception. Fur<strong>the</strong>rmore, a purely descriptive analysisis <strong>in</strong>sufficient. It is essential to underst<strong>and</strong> <strong>the</strong> causes ofunmet need <strong>and</strong> how <strong>the</strong>se vary among different groups<strong>and</strong> <strong>in</strong> different circumstances (Bhushan, 1997).To facilitate such underst<strong>and</strong><strong>in</strong>g it is essential to have anexplanatory framework, or “<strong>the</strong>oretical model” to guideanalysis. In particular, it is necessary to have a model thatis not constra<strong>in</strong>ed by a specific discipl<strong>in</strong>ary approach, suchas economics, sociology or communication studies 2 .A relatively simple, microlevel model of <strong>the</strong> factorsconducive to <strong>the</strong> use of contraception to limit fertility was<strong>in</strong> fact elaborated by Ansley Coale nearly four decades ago(Coale, 1973). Coale specified three “prerequisites” thathad to be met before <strong>in</strong>dividuals would take up familyplann<strong>in</strong>g, lead<strong>in</strong>g to a major decl<strong>in</strong>e <strong>in</strong> fertility:(a) Fertility had to be “with<strong>in</strong> <strong>the</strong> calculus of consciouschoice”. In o<strong>the</strong>r words, parents had to believe that itwas an acceptable mode of behaviour to weigh <strong>the</strong>advantages or disadvantages of hav<strong>in</strong>g ano<strong>the</strong>r child.(b) Reduced fertility had to be perceived as economicallyor socially advantageous to <strong>in</strong>dividual couples.(c) Effective techniques of fertility reduction must beavailable. Practices that would <strong>in</strong> fact prevent births haveto be known <strong>and</strong> <strong>the</strong>re must be sufficient communicationbetween spouses <strong>and</strong> sufficient susta<strong>in</strong>ed will <strong>in</strong> both toemploy <strong>the</strong>m successfully.As noted by Lesthaeghe <strong>and</strong> V<strong>and</strong>erhoeft (2001), Coale’sconceptualization of <strong>the</strong> preconditions for susta<strong>in</strong>edfertility decl<strong>in</strong>e received no fur<strong>the</strong>r attention <strong>in</strong> <strong>the</strong>decades s<strong>in</strong>ce it was <strong>in</strong>troduced; yet it provides a usefulmeans of <strong>in</strong>tegrat<strong>in</strong>g <strong>the</strong> approaches of various discipl<strong>in</strong>es,particularly those of economics, sociology, anthropology<strong>and</strong> communication studies. Lesthaeghe <strong>and</strong> V<strong>and</strong>erhoeftproceeded to reconceptualize Coale’s model <strong>in</strong> terms ofthree dimensions relat<strong>in</strong>g to “read<strong>in</strong>ess” (Coale’s prerequisite2), “will<strong>in</strong>gness” (prerequisite 1) <strong>and</strong> “ability” (prerequisite3). In short, <strong>the</strong> adoption of family plann<strong>in</strong>g to control <strong>the</strong>number or tim<strong>in</strong>g of births that a couple will have requiresthat <strong>the</strong>y be “’ready, will<strong>in</strong>g <strong>and</strong> able’ (R,W,A for short)”. Afur<strong>the</strong>r elaboration of <strong>the</strong>se categories may be useful.Read<strong>in</strong>ess. This precondition reflects <strong>the</strong> approach of<strong>the</strong> economics school, which treats childbear<strong>in</strong>g as autilitarian choice <strong>in</strong>volv<strong>in</strong>g <strong>the</strong> weigh<strong>in</strong>g of advantages<strong>and</strong> disadvantages (or costs <strong>and</strong> benefits), usually for <strong>the</strong>parents <strong>the</strong>mselves. The cost-benefit framework can also<strong>in</strong>corporate situations <strong>in</strong> which <strong>the</strong> balance of advantages<strong>and</strong> disadvantages can be assessed from <strong>the</strong> perspectiveof <strong>the</strong> children. From a “supply-dem<strong>and</strong>” viewpo<strong>in</strong>t,read<strong>in</strong>ess can also be stimulated <strong>in</strong> circumstances <strong>in</strong> which<strong>the</strong> “supply” of children is <strong>in</strong>creas<strong>in</strong>g due to <strong>the</strong> <strong>in</strong>creas<strong>in</strong>gsurvivorship of children.Will<strong>in</strong>gness. An <strong>in</strong>dividual or couple may be ready tolimit childbear<strong>in</strong>g <strong>and</strong> adopt family plann<strong>in</strong>g if <strong>the</strong>yhave decided that <strong>the</strong> advantages of do<strong>in</strong>g so outweigh<strong>the</strong> disadvantages, but <strong>the</strong>y may not be will<strong>in</strong>g to do soif such behaviour is contrary to <strong>the</strong> norms <strong>and</strong> values of<strong>the</strong> community or extended family <strong>in</strong> which <strong>the</strong>y live. Thisprecondition concerns cultural precepts <strong>and</strong> attitudesthat determ<strong>in</strong>e whe<strong>the</strong>r or not <strong>in</strong>terference with “nature”is considered to be legitimate behaviour. These preceptsmay derive from religion or from broader concepts, such as“tradition” or “custom”, <strong>and</strong> be accompanied by sanctions fornon-compliance. At <strong>the</strong> <strong>in</strong>dividual level, <strong>the</strong> will<strong>in</strong>gness togo aga<strong>in</strong>st community norms will depend on psychologicaldispositions. Concerns relat<strong>in</strong>g to risks to health may alsobe <strong>in</strong>cluded <strong>in</strong> this category. A perceived risk to health or <strong>the</strong>possibility of uncomfortable “side effects” may contributeto an <strong>in</strong>dividual’s unwill<strong>in</strong>gness to use contraception, evenif it would be advantageous to do so.Ability. An <strong>in</strong>dividual or couple may be ready (R) <strong>and</strong>will<strong>in</strong>g (W) but not able (A) to practise family plann<strong>in</strong>g65

ecause of a lack of knowledge of contraceptive methods or<strong>the</strong> <strong>in</strong>ability to obta<strong>in</strong> <strong>the</strong> necessary supplies <strong>and</strong> services.Ability is a multidimensional concept that <strong>in</strong>cludes notonly <strong>the</strong> knowledge of a contraceptive method but also <strong>the</strong>means of obta<strong>in</strong><strong>in</strong>g <strong>the</strong> method, such as <strong>the</strong> availability oftransport to a service facility or <strong>the</strong> money to pay for <strong>the</strong>method. <strong>Family</strong> plann<strong>in</strong>g programmes generally focus onability or access, somewhat less on will<strong>in</strong>gness <strong>and</strong> muchless on read<strong>in</strong>ess – which may be considered outside <strong>the</strong>doma<strong>in</strong> of family plann<strong>in</strong>g as normally understood.One advantage of <strong>the</strong> R-W-A conceptualization is that datacollected <strong>in</strong> DHS can be used to measure <strong>the</strong> impact of eachof <strong>the</strong> prerequisites. Fur<strong>the</strong>rmore, <strong>in</strong>dividual respondentscan be classified accord<strong>in</strong>g to which of <strong>the</strong> three groups<strong>the</strong>y comprise, <strong>and</strong> <strong>the</strong> results can be aggregated at <strong>the</strong>national or subnational level.Purpose of this paperIn <strong>the</strong> present paper an attempt is made to place recentDHS results <strong>in</strong>to <strong>the</strong> framework proposed by Lesthaeghe<strong>and</strong> V<strong>and</strong>erhoeft (2001) <strong>in</strong> order to contribute to a betterunderst<strong>and</strong><strong>in</strong>g of low contraceptive use, unmet need <strong>and</strong> <strong>the</strong>stalled fertility transition <strong>in</strong> some <strong>Pacific</strong> isl<strong>and</strong> countries<strong>and</strong> territories. At <strong>the</strong> same time, <strong>the</strong> paper explores someof <strong>the</strong> socio-economic factors that have been measured <strong>in</strong>recent DHS that may account for variations <strong>in</strong> contraceptiveuse <strong>and</strong> unmet need among different groups. F<strong>in</strong>ally, <strong>the</strong>paper considers some of <strong>the</strong> “macrolevel” factors that mightaccount for variations <strong>in</strong> <strong>the</strong> level <strong>and</strong> trends <strong>in</strong> fertilityamong <strong>Pacific</strong> isl<strong>and</strong> countries <strong>and</strong> territories. The overallpurpose is to contribute to <strong>the</strong> development of strategiesto reduce unmet need for contraception <strong>in</strong> accordance with<strong>the</strong> pr<strong>in</strong>ciples laid out <strong>in</strong> <strong>the</strong> ICPD Programme of Action.By analys<strong>in</strong>g <strong>the</strong> socio-economic factors at <strong>the</strong> micro- <strong>and</strong>macrolevels, it is possible that <strong>the</strong> specific role of familyplann<strong>in</strong>g programmes can be more precisely stated.The geographical <strong>and</strong>demographic contextThe isl<strong>and</strong> countries <strong>and</strong> territories of <strong>the</strong> <strong>Pacific</strong> are shown<strong>in</strong> Figure 1. The <strong>Pacific</strong> isl<strong>and</strong>s, toge<strong>the</strong>r with Australia <strong>and</strong>New Zeal<strong>and</strong>, make up <strong>the</strong> region conventionally knownas “Oceania”. The <strong>Pacific</strong> isl<strong>and</strong>s are also conventionallydivided <strong>in</strong>to three subregions: Melanesia, Micronesia <strong>and</strong>Polynesia. These divisions reflect both ethno-culturalvariations <strong>and</strong> geographical characteristics. Melanesianpeople are descendants of <strong>the</strong> very first settlement of <strong>the</strong><strong>Pacific</strong>, which commenced approximately 40,000 yearsago <strong>in</strong> New Gu<strong>in</strong>ea. Melanesians, along with more recentmigrants, occupy <strong>the</strong> largest isl<strong>and</strong> countries <strong>and</strong> territoriesof Fiji, New Caledonia, Papua New Gu<strong>in</strong>ea, SolomonIsl<strong>and</strong>s <strong>and</strong> Vanuatu. Micronesians are descendants of amuch more recent settlement pattern from South-East<strong>Asia</strong> (primarily <strong>the</strong> Philipp<strong>in</strong>es <strong>and</strong> Taiwan) <strong>and</strong> occupy<strong>the</strong> isl<strong>and</strong>s north of <strong>the</strong> equator <strong>and</strong> spread across <strong>the</strong><strong>Pacific</strong> on an east-west axis. Most of <strong>the</strong> isl<strong>and</strong>s occupiedby Micronesians are small <strong>and</strong> of atoll formation, althoughsome are of volcanic orig<strong>in</strong>. Polynesians are descendantsof people who entered <strong>the</strong> <strong>Pacific</strong> from South-East <strong>Asia</strong>5,000 years ago <strong>and</strong> occupied <strong>the</strong> isl<strong>and</strong>s located from <strong>the</strong>central <strong>Pacific</strong> east of Fiji to Pitcairn Isl<strong>and</strong> <strong>in</strong> <strong>the</strong> easternextremity of <strong>the</strong> region 3 .Although orig<strong>in</strong>ally formulated by n<strong>in</strong>eteenth centuryethnographers <strong>and</strong> explorers, <strong>the</strong> dist<strong>in</strong>ction between <strong>the</strong>subregions of <strong>the</strong> <strong>Pacific</strong> rema<strong>in</strong> important today due tovariations <strong>in</strong> social organization, culture <strong>and</strong> geography.Most importantly for population issues, <strong>the</strong> Melanesiansubgroup makes up <strong>the</strong> largest proportion of <strong>the</strong> l<strong>and</strong> areaof <strong>the</strong> overall <strong>Pacific</strong> isl<strong>and</strong>s region. In general, Melanesiais a resource-rich area, Polynesia less so <strong>and</strong> Micronesiamuch less so. The different resource endowments of <strong>the</strong>subregions have played a significant role <strong>in</strong> <strong>the</strong> way <strong>in</strong> whichpopulation issues, <strong>in</strong>clud<strong>in</strong>g fertility, have been addressed– both <strong>in</strong> traditional times <strong>and</strong> <strong>in</strong> <strong>the</strong> modern era.The total population of <strong>the</strong> 22 countries <strong>and</strong> territories of<strong>the</strong> <strong>Pacific</strong> isl<strong>and</strong>s <strong>in</strong> Oceania is currently 9.85 million <strong>and</strong>is grow<strong>in</strong>g at approximately 1.9 per cent per year (Table1). At this growth rate, <strong>the</strong> population will reach 10.0million by <strong>the</strong> end of 2011. Current projections suggestthat <strong>the</strong> population of <strong>the</strong> region could <strong>in</strong>crease by ano<strong>the</strong>r6.5 million by 2050 before stabiliz<strong>in</strong>g (Secretariat of <strong>the</strong><strong>Pacific</strong> Community, 2010).Population growth rates vary widely between countries<strong>and</strong> subregions. At <strong>the</strong> country level, <strong>the</strong> highest growthrates are occurr<strong>in</strong>g <strong>in</strong> <strong>the</strong> Melanesian countries of PapuaNew Gu<strong>in</strong>ea (2.2%) Solomon Isl<strong>and</strong>s (2.7%) <strong>and</strong> Vanuatu(2.5%). These three countries currently account for 89per cent of <strong>the</strong> population growth of <strong>the</strong> larger region. At<strong>the</strong> o<strong>the</strong>r end of <strong>the</strong> scale are <strong>the</strong> Polynesian countries of<strong>the</strong> Cook Isl<strong>and</strong>s, Samoa, Tonga <strong>and</strong> Tuvalu, with annualgrowth rates of less than 0.5 per cent. Some Micronesiancountries, such as <strong>the</strong> Federated States of Micronesia,Marshall Isl<strong>and</strong>s <strong>and</strong> Palau also have low growth rates.At <strong>the</strong> subregional level it is clear that Melanesia accountsfor most population growth <strong>in</strong> <strong>the</strong> larger region (92.5%),<strong>and</strong> Melanesian growth is dom<strong>in</strong>ated by <strong>the</strong> largest country<strong>in</strong> <strong>the</strong> <strong>Pacific</strong>: Papua New Gu<strong>in</strong>ea. Future populationgrowth <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> will be concentrated <strong>in</strong> <strong>the</strong> Melanesiansubregion. Population growth <strong>in</strong> <strong>the</strong> Micronesian <strong>and</strong>Polynesian subregions is currently concentrated <strong>in</strong> <strong>the</strong>territories of Guam <strong>and</strong> French Polynesia, respectively. Theo<strong>the</strong>r countries <strong>in</strong> <strong>the</strong>se subregions have low populationgrowth, with <strong>the</strong> exception of Kiribati <strong>and</strong> Nauru.66

FigureFigure1Oceania <strong>and</strong> <strong>the</strong> <strong>Pacific</strong> isl<strong>and</strong>sA dist<strong>in</strong>ctive feature of <strong>the</strong> demography of Micronesia<strong>and</strong> Polynesia, which is relevant to <strong>the</strong> subject of thispaper, is <strong>the</strong> relationship between natural <strong>in</strong>crease <strong>and</strong>population growth. With some exceptions, most of <strong>the</strong>countries that have low population growth are subject tosignificant external migration, which offsets a considerableproportion of <strong>the</strong> natural <strong>in</strong>crease. In <strong>the</strong> Federated Statesof Micronesia, Samoa <strong>and</strong> Tonga, for example, externalmigration offsets about 80 per cent of natural <strong>in</strong>crease; <strong>in</strong>Marshall Isl<strong>and</strong>s, 90 per cent of current natural <strong>in</strong>crease isoffset by external migration. The rate of natural <strong>in</strong>crease<strong>in</strong> <strong>the</strong>se countries rema<strong>in</strong>s about 2 per cent per year. In<strong>the</strong> absence of external migration flows <strong>the</strong>se countries<strong>and</strong> territories would be subject to significant population<strong>in</strong>crease <strong>in</strong> <strong>the</strong> com<strong>in</strong>g years.The extent of urbanization <strong>in</strong> <strong>the</strong> region encompass<strong>in</strong>g <strong>the</strong><strong>Pacific</strong> isl<strong>and</strong>s varies widely. Some countries <strong>and</strong> territories(Guam, Nauru <strong>and</strong> <strong>the</strong> Nor<strong>the</strong>rn Mariana Isl<strong>and</strong>s) areclassified as 90-100 per cent urban. In <strong>the</strong> larger Melanesiancountries of Papua New Gu<strong>in</strong>ea <strong>and</strong> Solomon Isl<strong>and</strong>s <strong>the</strong>level of urbanization is low, with more than 80 per centof <strong>the</strong> population liv<strong>in</strong>g <strong>in</strong> rural areas, mostly <strong>in</strong> villagesalong traditional l<strong>in</strong>es. Samoa <strong>and</strong> Tonga, <strong>in</strong> Polynesia,also have a low level of urbanization, with 79 <strong>and</strong> 77per cent, respectively, of <strong>the</strong> population be<strong>in</strong>g classifiedas rural. Ano<strong>the</strong>r situation is represented by <strong>the</strong> CookIsl<strong>and</strong>s, Kiribati, Marshall Isl<strong>and</strong>s <strong>and</strong> Tuvalu, <strong>in</strong> whichbetween 44 <strong>and</strong> 65 per cent of <strong>the</strong> population is liv<strong>in</strong>gon one relatively urbanized isl<strong>and</strong> (usually <strong>the</strong> centre ofgovernment), with <strong>the</strong> balance distributed across a numberof widely scattered isl<strong>and</strong>s.With <strong>the</strong> exception of <strong>the</strong> larger Melanesian countries,<strong>Pacific</strong> isl<strong>and</strong> countries have high social <strong>in</strong>dicators relativeto <strong>the</strong> level of per capita <strong>in</strong>come (Table 2). Several countrieshave life expectancy above 70 years <strong>and</strong> high literacy. The<strong>in</strong>cidence of absolute poverty is low <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> but“basic-needs” poverty ranges from 13 per cent <strong>in</strong> Niue to50 per cent <strong>in</strong> Kiribati. Access to improved water sources<strong>and</strong> sanitation is good <strong>in</strong> most countries but more thanhalf <strong>the</strong> population of <strong>the</strong> Federated States of Micronesia,Kiribati, Papua New Gu<strong>in</strong>ea <strong>and</strong> Solomon Isl<strong>and</strong>s lackadequate sanitation.67

TableTable1Basic demographic <strong>in</strong>dicators for <strong>Pacific</strong> isl<strong>and</strong> countries <strong>and</strong> territoriesSubregion/ countryTotalpopulation2010Projectedpopulation2020Currentpopulationgrowth rate(%)Rate ofnatural<strong>in</strong>crease(%)Netmigrationrate (%)Annual<strong>in</strong>crement(number)Percentof annual<strong>in</strong>crement<strong>Pacific</strong> isl<strong>and</strong>s 9,853,023 11,801,200 1.9 2.0 -0.1 183,688 100.0 23Melanesia 8,641,883 10,465,00 2.0 2.1 -0.1 170,169 92.5 19Fiji 847,793 890,400 0.5 1.3 -0.8 4,219 2.3 51New Caledonia 254,525 291,200 1.6 1.1 0.5 4,046 2.2 63Papua New Gu<strong>in</strong>ea 6,744,955 8,267,400 2.2 2.2 0.0 142,876 77.8 13Solomon Isl<strong>and</strong>s 549,574 703,500 2.7 2.7 0.0 14,587 7.9 16Vanuatu 245,036 312,500 2.5 2.5 0.0 6,071 3.3 21Micronesia 547,345 624,200 1.4 1.7 -0.3 7,585 4.1 66Micronesia (Fed Sts ) 111,364 116,500 0.4 1.9 -1.5 455 0.2 22Guam 187,140 224,200 2.7 1.4 1.3 4,984 2.7 93Kiribati 100,835 119,900 1.8 1.9 -0.1 1,805 1.0 44Marshall Isl<strong>and</strong>s 54,439 59,500 0.3 2.6 -2.3 176 0.1 65Nauru 9.976 12,000 2.1 2.1 0.0 203 0.1 100Nor<strong>the</strong>rn Mariana Is. 63,072 70,300 0.0 1.6 -1.6 -18 0.0 90Palau 20,516 21,800 0.6 0.6 0.0 119 0.1 77Polynesia 663,795 712,000 0.8 1.6 -0.8 5,086 2.8 37American Samoa 65,906 74,600 1.2 1.9 -0.7 781 0.4 50Cook Isl<strong>and</strong>s 15,529 16,400 0.5 1.2 -0.7 72 0.0 72French Polynesia 268,767 297,600 1.2 1.2 0.0 3,176 1.7 51Niue 1,479 1,200 -2.3 0.6 -2.9 -36 0.0 36Samoa 183,123 188,400 0.3 2.0 -1.7 615 0.3 21Tonga 103,365 106,500 0.4 2.1 -1.7 372 0.2 23Tuvalu 11,149 11,800 0.5 1.4 -0.9 58 0.0 47Wallis <strong>and</strong> Futuna 13,256 14,300 -0.3 1.1 --0.8 -43 0.0 0Source: Secretariat of <strong>the</strong> <strong>Pacific</strong> Community, 2009; 2010), <strong>and</strong> authors’ estimates.Note: Pitcairn Isl<strong>and</strong>s (population: 66) <strong>and</strong> Tokelau Isl<strong>and</strong>s (population: 1,151) are excluded from <strong>the</strong> table.PercenturbanMost of <strong>the</strong> <strong>in</strong>dependent countries of <strong>the</strong> <strong>Pacific</strong> would beclassified as lower-middle <strong>in</strong>come, but Kiribati, Papua NewGu<strong>in</strong>ea, Solomon Isl<strong>and</strong>s <strong>and</strong> Vanuatu are low-<strong>in</strong>comecountries. While some countries have experienced realeconomic growth, <strong>in</strong> most of <strong>the</strong>m <strong>the</strong> pace of economicgrowth over <strong>the</strong> past two decades has been slow.Fertility levels <strong>and</strong> trendsFertility trendsHas fertility decl<strong>in</strong>e “stalled” <strong>in</strong> <strong>the</strong><strong>Pacific</strong>?Fertility levels <strong>in</strong> most <strong>Pacific</strong> isl<strong>and</strong> countries did notreach <strong>the</strong>ir peak until <strong>the</strong> 1960s or 1970s. In general,fertility peaked at a considerably higher level <strong>in</strong> <strong>the</strong> <strong>Pacific</strong>than <strong>in</strong> o<strong>the</strong>r develop<strong>in</strong>g regions. In Kiribati, Samoa <strong>and</strong>Tonga, for example, TFR reached well above 7 before itstarted to fall. In <strong>the</strong> Cook Isl<strong>and</strong>s TFR peaked at 7.9 at<strong>the</strong> national level <strong>and</strong> at 9.2 <strong>in</strong> some outer isl<strong>and</strong> groups(ESCAP, 1982). This compares with a TFR of 5.9 for <strong>the</strong>less developed countries as a group around <strong>the</strong> same time.Thus, fertility <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> had much fur<strong>the</strong>r to fall than<strong>in</strong> o<strong>the</strong>r less developed regions of <strong>the</strong> world. Moreover <strong>in</strong>many countries it did fall rapidly from peak levels.An extreme example of <strong>the</strong> speed with which fertility fellafter it peaked <strong>in</strong> <strong>the</strong> 1960s can be seen <strong>in</strong> <strong>the</strong> case of <strong>the</strong>Micronesian country of Kiribati. As illustrated <strong>in</strong> Figure 2,<strong>in</strong> <strong>the</strong> 1960s, TFR fluctuated between 6.5 <strong>and</strong> 7.5. Between<strong>the</strong> late 1960s <strong>and</strong> mid-1970s, however, it dropped byalmost 3 births to 4.5, an extremely rapid decl<strong>in</strong>e. For <strong>the</strong>68

next 25 years, however, TFR fluctuated between 4 <strong>and</strong> 5,<strong>and</strong> dropped below 4 only <strong>in</strong> 2000.While Kiribati is an extreme case, Figure 3 showsthat several of <strong>the</strong> larger <strong>Pacific</strong> countries (>100,000population), <strong>in</strong>clud<strong>in</strong>g <strong>the</strong> Federated States of Micronesia,Samoa, Solomon Isl<strong>and</strong>s <strong>and</strong> Tonga, have had similartrends. After peak<strong>in</strong>g between 1960 <strong>and</strong> 1975, TFRdropped steadily (<strong>in</strong> some cases rapidly) <strong>in</strong> <strong>the</strong>se countriesbefore levell<strong>in</strong>g off between 4 <strong>and</strong> 5 <strong>in</strong> <strong>the</strong> 1990s. Although<strong>the</strong>re is no technical def<strong>in</strong>ition of what constitutes a “stalled”fertility transition, <strong>the</strong>re is certa<strong>in</strong>ly a strong impression<strong>in</strong> <strong>the</strong>se countries that <strong>the</strong> pace of fertility decl<strong>in</strong>e slowedsignificantly after reach<strong>in</strong>g a TFR of 5 4 .The periods <strong>in</strong> which fertility decl<strong>in</strong>e has stalled vary fromcountry to country: <strong>in</strong> Tonga fertility decl<strong>in</strong>e stalled for10 years between <strong>the</strong> periods 1970-1975 <strong>and</strong> 1980-1985when TFR stood at about 5.5. Similarly, fertility decl<strong>in</strong>e<strong>in</strong> Papua New Gu<strong>in</strong>ea stalled between <strong>the</strong> periods 1975-1980 <strong>and</strong> 1980-1985 at a similar level. In Samoa, TFRstalled at just under 5 between <strong>the</strong> periods 1975-1980<strong>and</strong> 1995-2000. In Tonga <strong>the</strong> decl<strong>in</strong>e <strong>in</strong> TFR stalled aga<strong>in</strong>at about 4.2 <strong>in</strong> <strong>the</strong> 1995-2000 period <strong>and</strong> has rema<strong>in</strong>edat that level s<strong>in</strong>ce. Although a slowdown <strong>in</strong> <strong>the</strong> pace offertility decl<strong>in</strong>e can be expected towards <strong>the</strong> latter stages of<strong>the</strong> fertility transition, <strong>the</strong> reduced pace of fertility decl<strong>in</strong>e<strong>in</strong> <strong>the</strong>se countries has occurred less than halfway through<strong>the</strong> transition.TableTable2Social <strong>and</strong> economic <strong>in</strong>dicators for <strong>Pacific</strong> isl<strong>and</strong> countries <strong>and</strong> territoriesSubregion/countryExpectation of life atbirth(both sexes)GDP percapita($US) PPP(2007)GNI percapita ($US)Atlas method(2007)Percentage of populationbelow basic-needs povertyl<strong>in</strong>eProportion of populationus<strong>in</strong>g improvedwater source <strong>and</strong>sanitation (%)E0 Ref. year GDP GNI Percentage Ref. year Water SanitationMelanesiaFiji 67.5 2007 4,072 3,750 34.3 2003 92.7 98.8New Caledonia 75.9 2007 -- -- -- -- -- --Papua New54.3 2000 2,111 850 39.6 2002 40.0 45.0Gu<strong>in</strong>eaSolomon Isl<strong>and</strong>s 61.1 1999 1,848 750 22.7 2006 29.8 22.4Vanuatu 67.3 1999 4,052 1,840 15.9 2006 75.3 95.2MicronesiaMicronesia (Federated67.7 2000 2,879 2,280 29.9 2005 94.0 44.0States of )Guam 73.6 2000 -- -- -- -- --Kiribati 61.0 2003 2,255 1,120 50.0 1996 53.1 36.5Marshall Isl<strong>and</strong>s 65.6 1999 +2,500 3,240 20.0 1999 98.4 70.7Nauru 56.2 2006 -- 2,314 -- -- 81.7 96.9Nor<strong>the</strong>rn Mariana 75.3 1999-01 -- -- -- -- -- --Isl<strong>and</strong>sPalau 69.2 2005 -- 8,270 24.9 2006 100.0 100.0PolynesiaAmerican Samoa 72.6 2000 x8,000 -- -- -- -- --Cook Isl<strong>and</strong>s 71.2 1996-02 &9,100 9,986 28.4 2006 95.1 99.3French Polynesia 74.1 2005-07 -- -- -- -- -- --Niue 71.5 2001-06 -- -- 13.0 2004 99.0 100.0Samoa 72.9 2006 4,670 2,700 20.3 2002 97.3 100.0Tonga 70.2 2004-5 3,782 2,480 22.3 2002 98.0 99.0Tuvalu 63.3 1997-02 -- 2,718 21.2 2006 92.5 86.5Wallis <strong>and</strong> Futuna 74.9 1996-03 -- -- -- -- -- --Source: Database of <strong>the</strong> UNFPA <strong>Pacific</strong> Sub-regional Office. Secretariat of <strong>the</strong> <strong>Pacific</strong> Community, 2009 Population Data Sheet.Noumea. AusAID (2009). UNFPA (2008). ADB (2009)Notes: -- not available. + 2008, x 2005, & 200469

TableTable3Reproductive health <strong>and</strong> vital <strong>in</strong>dicators for <strong>Pacific</strong> isl<strong>and</strong> countries <strong>and</strong> territoriesSubregion/countryTotal <strong>Pacific</strong>Total fertilityrate (TFR)TeenagefertilityrateReferenceyear for TFR<strong>and</strong> teenfertilityInfant mortalityrate (IMR)Reference yearfor IMRContraceptiveprevalence rate(CPR)MelanesiaFiji 2.6 37 2003 17.1 2006-08 43 (2007)New Caledonia 2.2 20 2007 6.1 2007 naPapua New Gu<strong>in</strong>ea 4.4 65 2001-06 56.7 2001-06 24 (2006)Solomon Isl<strong>and</strong>s 4.6 67 2004-07 24.3 2002-07 27 (2007)Vanuatu 4.0 64 2009 25.0 2001 38 (2008)MicronesiaMicronesia (Fed. Sts. of ) 4.0 48 2000 37.5 2000 26 (2007)Guam 2.7 57 2002-04 11.7 2005-07 naKiribati 3.5 39 2004-05 52.0 2003 18 (2009)Marshall Isl<strong>and</strong>s 4.4 127 2002-07 21.0 2003-07 42 (2007)Nauru 3.3 78 2006-07 45.8 2006-07 25 (2007)Nor<strong>the</strong>rn Mariana Isl<strong>and</strong>s 1.6 69 1999-01 4.9 2006-08 naPalau 2.0 29 2003 20.1 2004-06 17 (2002)PolynesiaAmerican Samoa 4.0 54 2000 11.3 2006-08 naCook Isl<strong>and</strong>s 2.5 62 2005-06 11.6 2005-09 46 (2005)French Polynesia 2.2 51 2005-07 5.8 2007-08 naNiue 2.6 28 2001-06 7.8 2001-06 21 (2007)Samoa 4.2 38 2006 20.4 2006 27 (2009)Tokelau 4.5 42 1997-01 31.3 2000-03 naTonga 4.2 24 2005 19.0 2004-05 28 (2007)Tuvalu 3.7 44 2002-07 17.3 2006-08 22 (2007)Wallis <strong>and</strong> Futuna 2.0 9 2008 5.2 2005-08 naSources: Secretariat of <strong>the</strong> <strong>Pacific</strong> Community (2010); Rallu <strong>and</strong> Robertson (2009): Demographic <strong>and</strong> Health Survey Reports:Tonga (2009), Samoa (2006), Solomon Isl<strong>and</strong>s (2007), Marshall Isl<strong>and</strong>s (2007), Tuvalu (2007), Nauru (2007).Note: na = not available.It is also apparent from Figure 3 that <strong>the</strong>re is ano<strong>the</strong>rgroup of countries <strong>and</strong> territories (compris<strong>in</strong>g Fiji, FrenchPolynesia, Guam <strong>and</strong> New Caledonia), <strong>in</strong> which TFRdid not become stalled but cont<strong>in</strong>ued to decl<strong>in</strong>e beyond<strong>the</strong> 4-5 plateau before slow<strong>in</strong>g to between 2 <strong>and</strong> 3. It isnoteworthy that three of <strong>the</strong>se economies are dependentterritories of France or <strong>the</strong> United States, Fiji be<strong>in</strong>g <strong>the</strong>only <strong>in</strong>dependent country <strong>in</strong> this group. In <strong>the</strong>se territoriesTFR has followed a pattern of decl<strong>in</strong>e which is very similarto that observed <strong>in</strong> <strong>the</strong> less developed countries (LDCs) asa group (Figure 3).Figure 4 shows that, among <strong>the</strong> politically <strong>in</strong>dependentcountries with populations of 100,000 or more, it is only<strong>in</strong> Fiji that TFR followed a similar course to LDCs asa whole. In fact, <strong>the</strong> rate of decl<strong>in</strong>e <strong>in</strong> Fiji exceeded thatof LDCs for <strong>the</strong> period 1960-1990. Fiji’s rapid fertilitydecl<strong>in</strong>e can be expla<strong>in</strong>ed <strong>in</strong> part by <strong>the</strong> fact that <strong>the</strong> Indo-Fijian population (which has made up 40-50% of Fiji’spopulation over this period) experienced an extremelyrapid decl<strong>in</strong>e <strong>in</strong> fertility from <strong>the</strong> 1970s, <strong>and</strong> TFR for thisgroup has now dropped to below replacement level. Thereis little doubt that Indo-Fijians were quick to take upfamily plann<strong>in</strong>g when government programmes were first<strong>in</strong>troduced. This can <strong>in</strong> turn be attributed to <strong>the</strong> economic<strong>and</strong> political situation of <strong>the</strong> ethnic Indian population ofFiji, which was weaken<strong>in</strong>g after <strong>the</strong> first military coup took70

FigureFigureFigure2Total fertility rate trends <strong>in</strong> Kiribati from 1950s to 2005 based on census estimates7.57.06.56.05.5TFR5.04.54.03.53.02.51950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 20051968 census1973 census1978 census1985 census1990 census1995 census2000 census2005 censusSources: Secretariat of <strong>the</strong> <strong>Pacific</strong> Community, Statistics <strong>and</strong> Demography Programme.Note: na = not available.Figure3Trends <strong>in</strong> total fertility rate <strong>in</strong> 10 <strong>Pacific</strong> isl<strong>and</strong> countries/territories: 1960-201087FijiNew Cal.Total Fertility Rate65432PNGSolomon IsVanuatuFSMGuamFr PolynesiaSamoaTonga11960-651965-701970-751975-801980-851985-901990-951995-001995-051995-10Source: United Nations Department of Economic Year <strong>and</strong> Social Affairs (2008).LDCsplace <strong>in</strong> 1987. Indo-Fijians followed a multiple strategyof reduc<strong>in</strong>g fertility, <strong>in</strong>vest<strong>in</strong>g <strong>in</strong> <strong>the</strong> education of fewerchildren <strong>and</strong> seek<strong>in</strong>g opportunities to emigrate abroadwhere employment was available.There is also little doubt that socio-economic factorshave also contributed to <strong>the</strong> steady decl<strong>in</strong>e <strong>in</strong> fertility <strong>in</strong><strong>the</strong> French territories <strong>and</strong> Guam. These territories areheavily subsidized by <strong>the</strong>ir metropolitan centres (directlyor <strong>in</strong>directly) <strong>and</strong> have high per capita <strong>in</strong>comes. Similarly,both public <strong>and</strong> private medical systems are well developed71

FigureFigureTFR4Long-term fertility trends <strong>in</strong> <strong>the</strong> <strong>Pacific</strong>, <strong>in</strong>dependent countries only*8.0FijiPNG7.0Solomon IsVanuatu6.0FSMSamoa5.0TongaLDCs4.03.02.01960-651965-701970-751975-801980-851985-901990-951995-001995-051995-10YearSource: United Nations Department of Social <strong>and</strong> Economic Affairs (2008)*Data are not available for countries under 100,000 population from this source.<strong>and</strong> health <strong>in</strong>surance arrangements are comparable withthose <strong>in</strong> developed countries. Such conditions are not easilyreplicable <strong>in</strong> <strong>the</strong> larger <strong>in</strong>dependent countries of westernMelanesia where fertility levels rema<strong>in</strong> higher, average<strong>in</strong>comes are much lower <strong>and</strong> <strong>the</strong> delivery of primary healthservices is much more difficult. The Polynesian countriesof Samoa, Tonga, <strong>and</strong> Tuvalu are already l<strong>in</strong>ked to moredeveloped countries, such as Australia, New Zeal<strong>and</strong><strong>and</strong> <strong>the</strong> United States, through migration, <strong>and</strong> <strong>the</strong>reforebenefit from <strong>the</strong> flow of expertise, development aid <strong>and</strong><strong>in</strong>trafamily transfers. However, <strong>the</strong>se countries are notlikely to become fur<strong>the</strong>r <strong>in</strong>corporated <strong>in</strong>to metropolitancentres or to receive large-scale subsidies from <strong>the</strong>m o<strong>the</strong>rthan <strong>in</strong> <strong>the</strong> form of private remittances <strong>and</strong> official aid 5 .Why has fertility decl<strong>in</strong>e stalled <strong>in</strong>some <strong>Pacific</strong> countries <strong>and</strong> territories?Several arguments have been proposed to expla<strong>in</strong> whyfertility transitions have “stalled” <strong>in</strong> some <strong>in</strong>dependent<strong>Pacific</strong> countries <strong>and</strong> territories while proceed<strong>in</strong>g quiterapidly <strong>in</strong> o<strong>the</strong>rs. It has been suggested that <strong>the</strong> stalledfertility decl<strong>in</strong>es <strong>in</strong> some <strong>Pacific</strong> isl<strong>and</strong> economies <strong>and</strong><strong>the</strong> relatively slow decl<strong>in</strong>es <strong>in</strong> o<strong>the</strong>rs can be attributedto weaknesses <strong>in</strong> family plann<strong>in</strong>g programmes, whe<strong>the</strong>roperated by governments or NGOs. Some have attributedthis weakness to <strong>the</strong> diversion of family plann<strong>in</strong>g fund<strong>in</strong>g<strong>in</strong> particular, <strong>and</strong> reproductive health fund<strong>in</strong>g <strong>in</strong> general,to deal with <strong>the</strong> HIV epidemic. While this may be true<strong>in</strong> some contexts, it is not a sufficient explanation <strong>in</strong>o<strong>the</strong>rs. O<strong>the</strong>r explanations put forward <strong>in</strong>clude <strong>the</strong> riseof religious fundamentalism <strong>and</strong> <strong>the</strong> preference for largefamilies aris<strong>in</strong>g from traditional cultural norms <strong>and</strong> values.Weak or wan<strong>in</strong>g political commitment has also been cited.Ano<strong>the</strong>r explanation that has been proposed <strong>in</strong>cludes <strong>the</strong>assertion that high rates of emigration remove <strong>the</strong> need forfertility reduction, as “surplus” children are eventually ableto emigrate <strong>and</strong> f<strong>in</strong>d work overseas, while support<strong>in</strong>g <strong>the</strong>irfamily at home. While this relationship appears logical, itis difficult to support with empirical evidence <strong>and</strong> somehigh-emigration countries <strong>and</strong> territories, such as <strong>the</strong>Cook Isl<strong>and</strong>s, Palau <strong>and</strong>, more recently Fiji, have achievedlow fertility 6 .Conventional demographic transition <strong>the</strong>ory po<strong>in</strong>ts toano<strong>the</strong>r range of macro variables, <strong>in</strong>clud<strong>in</strong>g mortalitydecl<strong>in</strong>e, education, urbanization <strong>and</strong> <strong>in</strong>dustrialization.Before review<strong>in</strong>g how some of <strong>the</strong> factors relate to fertilitychange <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> it may be useful to provide a briefreview of family plann<strong>in</strong>g.<strong>Family</strong> plann<strong>in</strong>g <strong>and</strong> populationcontrol <strong>in</strong> historical perspectiveAdvocates of family plann<strong>in</strong>g programmes <strong>in</strong> <strong>the</strong> <strong>Pacific</strong>have frequently supported <strong>the</strong>ir arguments by referr<strong>in</strong>gto <strong>the</strong> widespread use of various forms of birth control <strong>in</strong>traditional <strong>Pacific</strong> societies. Such arguments are <strong>in</strong>tendedto demonstrate that <strong>the</strong> idea of deliberate birth controlis not alien to <strong>Pacific</strong> cultures <strong>and</strong> <strong>the</strong>refore should notbe seen as a foreign imposition. This was an importantconsideration <strong>in</strong> <strong>the</strong> 1970s <strong>and</strong> 1980s when <strong>in</strong>ternational72

family plann<strong>in</strong>g programmes were controversial.The ethnographic evidence provides little doubt that birthcontrol was widely practised across <strong>the</strong> <strong>Pacific</strong> prior tosusta<strong>in</strong>ed contact with external societies (Tesfaghiorghis,1995; Lucas <strong>and</strong> Ware, 1981; Connell, 1977; Borrie etal., 1957; McDowell, 1988; Bulmer, 1971). Methods of<strong>in</strong>duc<strong>in</strong>g abortion were well known <strong>and</strong> applied acrossall subregions, <strong>in</strong>clud<strong>in</strong>g <strong>the</strong> <strong>in</strong>gestion of herbal potions<strong>and</strong> massage. Various concoctions made from herbs or <strong>the</strong>bark of particular species of trees were used as a meansof prevent<strong>in</strong>g conception, although some of <strong>the</strong>se methodsmay have resulted <strong>in</strong> sterility (Bulmer, 1971). Whenadditional births were considered a threat to family <strong>and</strong>community survival, <strong>in</strong>fanticide was practised. This alsooccurred when tw<strong>in</strong>s were born because breastfeed<strong>in</strong>g twochildren placed particular stra<strong>in</strong> on <strong>the</strong> mo<strong>the</strong>r <strong>and</strong> placedboth children at risk (Connell, 1977). The survival of onechild required <strong>the</strong> sacrifice of <strong>the</strong> o<strong>the</strong>r.The widest range of practices probably occurred <strong>in</strong> <strong>the</strong>small, resource-poor atolls or isl<strong>and</strong>s. For example, <strong>in</strong> <strong>the</strong>t<strong>in</strong>y Polynesian atoll of Tikopia, studied by <strong>the</strong> em<strong>in</strong>entanthropologist Sir Raymond Firth, community leadersproclaimed that “<strong>the</strong> heads must be measured aga<strong>in</strong>st <strong>the</strong>food” (Firth, 1936). Methods to achieve this <strong>in</strong>cludedprevent<strong>in</strong>g some young men from marry<strong>in</strong>g <strong>and</strong> <strong>the</strong>expulsion of o<strong>the</strong>rs from <strong>the</strong> isl<strong>and</strong> to seek new l<strong>and</strong>. Thesetypes of practices are a form of population control underconditions of extreme resource scarcity.A number of o<strong>the</strong>r social practices had <strong>the</strong> effect of keep<strong>in</strong>gfertility rates significantly lower than <strong>the</strong>y would o<strong>the</strong>rwisehave been, regardless of whe<strong>the</strong>r this was a conscious<strong>in</strong>tention. Extremely long periods of breastfeed<strong>in</strong>g (up tofive years) were common <strong>in</strong> pre-contact <strong>Pacific</strong> culturesow<strong>in</strong>g to <strong>the</strong> absence of suitable wean<strong>in</strong>g foods. Thisresulted <strong>in</strong> long periods of lactational amenorrhea <strong>and</strong>subfecundity. There was also a widespread belief thatsexual <strong>in</strong>tercourse should be avoided while breastfeed<strong>in</strong>gbecause of potential contam<strong>in</strong>ation of breast milk bysemen, result<strong>in</strong>g <strong>in</strong> <strong>the</strong> child becom<strong>in</strong>g sick. The length ofpost-partum abst<strong>in</strong>ence could extend up to five years <strong>in</strong>some Melanesian societies (Heider, 1976), probably <strong>the</strong>longest to be observed <strong>in</strong> any pre-contact culture area.Post-partum abst<strong>in</strong>ence was facilitated <strong>in</strong> part by residentialpatterns. In most parts of western Melanesia, men did notlive with <strong>the</strong>ir wives <strong>and</strong> children but lived separately <strong>in</strong>men’s houses (sometimes called “long houses”) along witholder sons. Similar residence patterns are recorded <strong>in</strong>Polynesian atolls (Carroll, 1975). Women lived separatelywith <strong>the</strong>ir daughters <strong>and</strong> younger children. Women werealso isolated from o<strong>the</strong>rs dur<strong>in</strong>g menstruation <strong>and</strong> lived <strong>in</strong>special houses dur<strong>in</strong>g this time. Male homosexuality hasbeen reported <strong>in</strong> some areas as provid<strong>in</strong>g a separate sexualoutlet. Richer <strong>and</strong> higher-status men who had multiplewives had access to o<strong>the</strong>r sexual partners when one wifewas pregnant or breastfeed<strong>in</strong>g. In some areas of Melanesia,long post-partum abst<strong>in</strong>ence was not associated withhomosexuality, adultery or polygyny (Heider, 1976), butpolygyny is generally associated with long post-partumabst<strong>in</strong>ence <strong>and</strong> lower fertility (Hern, 1992).Ano<strong>the</strong>r practice that limited fertility was late marriage.Marriage <strong>in</strong> many parts of <strong>the</strong> <strong>Pacific</strong> required, <strong>and</strong> <strong>in</strong>some areas still does, <strong>the</strong> payment of “bride price”. Bridewealthis normally paid <strong>in</strong> <strong>the</strong> form of pigs, but for a manto accumulate <strong>the</strong> necessary number of pigs (typically five)would require several years, thus delay<strong>in</strong>g his marriage.O<strong>the</strong>r ceremonial gifts may also be required <strong>and</strong> <strong>the</strong>sewould take time to accumulate. In some parts of Melanesia,<strong>the</strong> birth of a child would also require a payment to <strong>the</strong>mo<strong>the</strong>r’s family. Should <strong>the</strong> fa<strong>the</strong>r be unable to make <strong>the</strong>payment he would rema<strong>in</strong> <strong>in</strong>debted to his wife’s family <strong>and</strong>would lose social status. Such conditions would tend tolimit <strong>and</strong> space births by whatever means were available.The cont<strong>in</strong>uation of many traditional social practices thatlimited fertility <strong>in</strong>to <strong>the</strong> modern era is most evident <strong>in</strong> <strong>the</strong>highl<strong>and</strong>s of Papua New Gu<strong>in</strong>ea, <strong>the</strong> last culture area of<strong>the</strong> <strong>Pacific</strong> to experience contact with <strong>the</strong> outside world 7 .An important feature of <strong>the</strong>se practices was an underly<strong>in</strong>gbelief <strong>in</strong> <strong>the</strong> capacity of women to “pollute” men, <strong>and</strong> anassociated belief that male warrior spirit could be dangerousto children. These beliefs, which cont<strong>in</strong>ue to some extent,had <strong>the</strong> effect of keep<strong>in</strong>g <strong>the</strong> sexes separate <strong>and</strong> antagonisticto each o<strong>the</strong>r. Some anthropologists have l<strong>in</strong>ked male fearof female pollution with resource scarcity, suggest<strong>in</strong>g that“fear of pollution is a form of ideological birth control”(L<strong>in</strong>denbaum cited <strong>in</strong> Faithorn, 1975) 8 . In any case, <strong>the</strong>ritual avoidance of sexual <strong>in</strong>tercourse dur<strong>in</strong>g a wide rangeof occasions (before go<strong>in</strong>g fish<strong>in</strong>g, while conduct<strong>in</strong>g war,or dur<strong>in</strong>g plant<strong>in</strong>g or harvest<strong>in</strong>g, for example) would havelimited fertility but only to <strong>the</strong> extent that coital frequencyis l<strong>in</strong>ked to <strong>the</strong> probability of conception.In some Polynesian societies a high value was placed onpremarital virg<strong>in</strong>ity, particularly among women of highstatus. This practice probably reached an extreme <strong>in</strong> Samoa,where <strong>the</strong> ceremonial virg<strong>in</strong> (taupou) was honoured (Pirie,2000). Elsewhere, <strong>the</strong> age at which women commencedsexual relations was largely determ<strong>in</strong>ed by age at menarche.In Melanesia, <strong>the</strong> age of menarche was much older <strong>in</strong>traditional times than it is today due to <strong>the</strong> limited amountof prote<strong>in</strong> <strong>in</strong> a diet dom<strong>in</strong>ated by root crops. As prote<strong>in</strong><strong>in</strong>take <strong>in</strong>creased with higher consumption of meat <strong>and</strong>more equal access to prote<strong>in</strong> between men <strong>and</strong> women 9 ,<strong>the</strong> age at menarche steadily decl<strong>in</strong>ed.As a consequence of <strong>the</strong> wide range of social practicesacross <strong>the</strong> <strong>Pacific</strong> that were ei<strong>the</strong>r consciously <strong>in</strong>tended73

to limit fertility, or had that effect, it is highly probablethat traditional fertility levels were not particularlyhigh (Carroll, 1975). There is also evidence that, dur<strong>in</strong>gtraditional times <strong>and</strong> well <strong>in</strong>to <strong>the</strong> modern period, women<strong>in</strong> <strong>the</strong> <strong>Pacific</strong> were not particularly enthusiastic abouthav<strong>in</strong>g many children (Connell, 1977; Carroll, 1975). InKiribati, historical data suggests that fertility was relativelylow, probably about four children per woman, prior to <strong>the</strong>1920s (Tesfaghiorghis, 1995). It is <strong>the</strong>refore unlikely thathigh fertility was necessary to compensate for high <strong>in</strong>fantmortality, as presupposed by some versions of demographictransition <strong>the</strong>ory. Pirie (1995; 2000) has argued that<strong>in</strong> Polynesia general mortality due to disease was notparticularly high <strong>in</strong> traditional times (given <strong>the</strong> absence of<strong>the</strong> diseases found <strong>in</strong> <strong>Asia</strong> or Europe) so periods of highfertility would have resulted <strong>in</strong> resource pressures, <strong>and</strong>countermeasures, such as <strong>in</strong>fanticide <strong>and</strong> abortion, wouldhave been employed.As demonstrated by Harris <strong>and</strong> Ross (1987) all pre<strong>in</strong>dustrialsocieties have a particular “mode of reproduction”that is associated <strong>in</strong> broad general terms with its mode ofproduction. Hunter-ga<strong>the</strong>rer societies, for example, tendto limit fertility through abortion or <strong>in</strong>fanticide because<strong>the</strong> ability of women to move with <strong>the</strong> group would beconstra<strong>in</strong>ed by hav<strong>in</strong>g too many young children, giventhat long periods of breastfeed<strong>in</strong>g were essential to childsurvival. At higher levels of economic development thatpermits a more sedentary way of life, higher fertility can betolerated, because <strong>the</strong>re is less conflict between childcare<strong>and</strong> women’s work. As <strong>in</strong>dustrialization develops, <strong>the</strong>conflict between women’s work <strong>and</strong> childbear<strong>in</strong>g <strong>in</strong>creasesaga<strong>in</strong>, <strong>and</strong> <strong>the</strong> tendency to apply fertility control <strong>in</strong>creases.While remnants of traditional practices <strong>and</strong> ideologiesassociated with fertility limitation still exist <strong>in</strong> some <strong>Pacific</strong>countries (Pulea, 1986), reference to traditional “modes ofreproduction” as a way of encourag<strong>in</strong>g <strong>Pacific</strong> isl<strong>and</strong> peopleto adopt family plann<strong>in</strong>g has not proven to be an effectivestrategy. The reasons for this are many <strong>and</strong> complex. First,<strong>in</strong>itial contact with European visitors resulted <strong>in</strong> <strong>the</strong>importation of diseases that previously did not exist <strong>and</strong>to which <strong>Pacific</strong> peoples had no immunity. The epidemicsthat followed <strong>in</strong>creased <strong>the</strong> death rate well above <strong>the</strong> birthrate, result<strong>in</strong>g <strong>in</strong> low or negative population growth <strong>and</strong>fears of “depopulation”. Missionary <strong>and</strong> later colonialauthorities adopted pronatalist policies <strong>and</strong> suppressedmemory of earlier fertility <strong>and</strong> mortality control practicesthat <strong>in</strong> any case were considered immoral. The suppressionof collective memory took place over several generationsto <strong>the</strong> po<strong>in</strong>t where most <strong>Pacific</strong> isl<strong>and</strong>ers today woulddeny that any such practices ever occurred <strong>in</strong> traditionaltimes. Colonial authorities with <strong>the</strong> support of churchesensured that abortion <strong>and</strong> <strong>in</strong>fanticide were crim<strong>in</strong>alized.Formal laws regard<strong>in</strong>g marriage, births <strong>and</strong> deaths werefor <strong>the</strong> most part derived from church law. The decl<strong>in</strong>e<strong>in</strong> traditional population control methods such as postpartumabst<strong>in</strong>ence <strong>and</strong> abst<strong>in</strong>ence from sexual activitydur<strong>in</strong>g ceremonial events resulted <strong>in</strong> an <strong>in</strong>creas<strong>in</strong>g “supply”of children, encouraged by <strong>the</strong> belief <strong>in</strong>stilled by <strong>the</strong> churchthat children are a “gift from God”.It took several decades for mortality levels to decl<strong>in</strong>e <strong>and</strong>fertility to rise to <strong>the</strong> po<strong>in</strong>t where natural <strong>in</strong>crease becamepositive. In some <strong>Pacific</strong> groups this did not occur until<strong>the</strong> 1940s (Bayliss-Smith, 1975). By <strong>the</strong> 1950s, many<strong>Pacific</strong> countries were approach<strong>in</strong>g <strong>the</strong> “natural” fertilitylevels presupposed by demographic transition <strong>the</strong>ory tocharacterize all pre-<strong>in</strong>dustrial societies. By <strong>the</strong> 1950s <strong>in</strong>some areas <strong>and</strong> <strong>the</strong> 1960s <strong>in</strong> o<strong>the</strong>rs, fertility had reachedhigh levels, with TFRs of 7-8 quite common at <strong>the</strong>national level <strong>and</strong> even higher <strong>in</strong> some subregions. At <strong>the</strong>same time, while overall mortality had decl<strong>in</strong>ed relative to<strong>the</strong> period follow<strong>in</strong>g <strong>the</strong> missionary work, <strong>in</strong>fant mortalityrates rema<strong>in</strong>ed quite high. Thus, <strong>the</strong> demographic regimeoperat<strong>in</strong>g <strong>in</strong> most <strong>Pacific</strong> societies began to approximate<strong>the</strong> pretransition situation of “high mortality, high fertility”envisioned by demographic transition <strong>the</strong>ory 10 . Whenfamily plann<strong>in</strong>g programmes were first <strong>in</strong>troduced bycolonial adm<strong>in</strong>istrations, <strong>the</strong> demographic circumstanceswere quite different from those that prevailed <strong>in</strong> traditionaltimesModern family plann<strong>in</strong>g programmes<strong>Family</strong> plann<strong>in</strong>g programmes <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> were<strong>in</strong>itiated <strong>in</strong> <strong>the</strong> late 1950s <strong>and</strong> early 1960s to enhancesocio-economic development through reduction of <strong>the</strong>population growth rate, as well as to improve women’s <strong>and</strong>children’s health (House, 1999a). The earliest programmeswere established <strong>in</strong> Fiji <strong>and</strong> Tonga <strong>in</strong> <strong>the</strong> late 1950s withan official government policy <strong>in</strong> place by 1962 (Pirie,1995; Ivarature, 2000). In Fiji <strong>the</strong> Medical Departmenttook on <strong>the</strong> responsibility of family plann<strong>in</strong>g but <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Associations (affiliated with IPPF) also becameactive. IPPF surveys that revealed high fertility <strong>and</strong> ris<strong>in</strong>gpopulation growth rates provided <strong>the</strong> <strong>in</strong>itial impetus for<strong>the</strong>se family plann<strong>in</strong>g programmes. The Fiji programmewas considered a success as fertility rates among Indo-Fijian women immediately decl<strong>in</strong>ed while <strong>the</strong> fertility ofethnic Fijians began to decl<strong>in</strong>e a decade later <strong>and</strong> at a ra<strong>the</strong>rslower pace (Lev<strong>in</strong> <strong>and</strong> Re<strong>the</strong>rford, 1986). Differentialrates of fertility <strong>and</strong> contraceptive use between <strong>the</strong> twomajor ethnic groups <strong>in</strong> Fiji have persisted until today, withTFR for Indo-Fijians now below replacement level.In Tonga, <strong>the</strong> family plann<strong>in</strong>g programme was supportedby <strong>the</strong> K<strong>in</strong>g, who expressed concern about <strong>the</strong> <strong>in</strong>creas<strong>in</strong>gpopulation, <strong>the</strong> ris<strong>in</strong>g population density of <strong>the</strong> Tongatapuurban area <strong>and</strong> <strong>the</strong> difficulty of provid<strong>in</strong>g traditional l<strong>and</strong>allotments to all eligible males. The programme was<strong>in</strong>stitutionalized when a Tongan medical officer became74

esponsible for <strong>the</strong> family plann<strong>in</strong>g programme, a familyplann<strong>in</strong>g cl<strong>in</strong>ic was opened <strong>and</strong> <strong>the</strong> number of familyplann<strong>in</strong>g acceptors <strong>in</strong>creased over time (Ivarature, 2000).The <strong>in</strong>tegration of family plann<strong>in</strong>g programmes withmaternal <strong>and</strong> child health programmes occurred around1968 <strong>and</strong> contributed to high levels of acceptors be<strong>in</strong>greported. The formation of <strong>the</strong> Tonga <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Association <strong>in</strong> 1969 fur<strong>the</strong>r streng<strong>the</strong>ned advocacy forfamily plann<strong>in</strong>g. In <strong>the</strong> 1970s <strong>and</strong> 1980s, <strong>the</strong> <strong>in</strong>clusion offamily plann<strong>in</strong>g <strong>in</strong> national development plans heightened<strong>the</strong> commitment to family plann<strong>in</strong>g. In 1976, a surveyreported that 45.7 per cent of all women of reproductiveage were us<strong>in</strong>g contraception, with <strong>the</strong> highest level of 63.3per cent be<strong>in</strong>g recorded <strong>in</strong> Kolonga, Tongatapu. The surveyrevealed that acceptors were young, were us<strong>in</strong>g highlyeffective contraceptive methods <strong>and</strong> had fewer childrenonce <strong>the</strong>y adopted family plann<strong>in</strong>g (Ivarature, 2000)(ref ).In Kiribati, family plann<strong>in</strong>g was <strong>in</strong>itiated <strong>in</strong> <strong>the</strong> 1960s <strong>and</strong><strong>the</strong> family plann<strong>in</strong>g campaign was officially launched <strong>in</strong>1968 (Tesfaghiorghis, 1995). While fertility decl<strong>in</strong>ed <strong>in</strong>all age groups between <strong>the</strong> 1960s <strong>and</strong> 1990s, <strong>the</strong> pace ofdecl<strong>in</strong>e was much slower after 1973, concomitant with <strong>the</strong>wan<strong>in</strong>g of <strong>the</strong> family plann<strong>in</strong>g programme (Booth, 1994).In 1972, <strong>the</strong> percentage of family plann<strong>in</strong>g users amongwomen of reproductive age was 40.1 per cent. However,<strong>the</strong>re was significant opposition to <strong>the</strong> family plann<strong>in</strong>gprogramme, particularly from <strong>the</strong> Catholic Church <strong>and</strong>traditional leaders. The family plann<strong>in</strong>g programmestalled <strong>in</strong> <strong>the</strong> 1970s <strong>and</strong> <strong>the</strong> percentage of users droppedto 15.8 per cent. By 1990, CPR was approximately 27 percent, a level which fell short of <strong>the</strong> national target of 35 percent. The relatively high percentage of users on <strong>in</strong>jectables(60%) was noted <strong>in</strong> <strong>the</strong> 1980s but with time, <strong>the</strong> ovulationmethod became <strong>the</strong> more frequently used method <strong>and</strong> <strong>the</strong>use of <strong>in</strong>jectables decl<strong>in</strong>ed to 39 per cent. Fertility studieshave found significant religious <strong>and</strong> geographic variationswith higher fertility rates <strong>in</strong> outer isl<strong>and</strong>s <strong>and</strong> amongCatholics. The geographic differences <strong>in</strong> fertility reflectedmostly <strong>the</strong> religious composition of <strong>the</strong> isl<strong>and</strong>s. Higherfertility rates were also noted among women with lowereducation.O<strong>the</strong>r countries <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> also <strong>in</strong>itiated familyplann<strong>in</strong>g programmes with modest success (Kenyon<strong>and</strong> Power, 2003). The Federated States of Micronesia,Marshall Isl<strong>and</strong>s, Papua New Gu<strong>in</strong>ea, Solomon Isl<strong>and</strong>s<strong>and</strong> Vanuatu – all considered as hav<strong>in</strong>g high fertility <strong>and</strong>some of <strong>the</strong> atolls as hav<strong>in</strong>g high population densities–showed some decl<strong>in</strong>e <strong>in</strong> fertility (Pirie, 1994). Negativereactions, however, <strong>in</strong> part fuelled by fear of side effects,were often reported by women. Papua New Gu<strong>in</strong>ea <strong>and</strong>Solomon Isl<strong>and</strong>s adopted population policies aimed atfertility reduction <strong>in</strong> <strong>the</strong> early 1990s, but data on patternsof contraceptive use over time rema<strong>in</strong> limited <strong>in</strong> <strong>the</strong>secountries <strong>and</strong> <strong>the</strong>ir success is unclear.Follow<strong>in</strong>g <strong>the</strong> 1994 ICPD, st<strong>and</strong>-alone family plann<strong>in</strong>gprogrammes were given lower priority worldwide whilecountries established more <strong>in</strong>tegrated <strong>and</strong> comprehensiveapproaches to reproductive health. This occurred <strong>in</strong><strong>the</strong> <strong>Pacific</strong> as well. The effort to construct an <strong>in</strong>tegratedreproductive health strategy that <strong>in</strong>cluded young, unmarriedpeople <strong>and</strong> moved away from an MCH approach absorbedenergy <strong>and</strong> resources <strong>and</strong> <strong>in</strong> <strong>the</strong> process weakened familyplann<strong>in</strong>g. Globally, <strong>and</strong> <strong>in</strong> some <strong>Pacific</strong> isl<strong>and</strong> countries,funds <strong>and</strong> human resources were diverted to fight <strong>the</strong> HIV<strong>and</strong> AIDS epidemic 11 . However, family plann<strong>in</strong>g had alsoreceived setbacks <strong>in</strong> <strong>the</strong> 1970s <strong>and</strong> 1980s when <strong>the</strong> abusesassociated with forced sterilization, defective IUDs <strong>and</strong>long-act<strong>in</strong>g hormonal contraceptives became well known.The rise of religious <strong>and</strong> political conservatism <strong>and</strong> <strong>the</strong>unwill<strong>in</strong>gness to acknowledge <strong>the</strong> role that universal accessto voluntary family plann<strong>in</strong>g could play <strong>in</strong> reduc<strong>in</strong>g poverty<strong>and</strong> <strong>in</strong>equality were also contribut<strong>in</strong>g factors.While <strong>the</strong> impact of family plann<strong>in</strong>g programmes onfertility rates has been highly significant <strong>in</strong> many <strong>Asia</strong>ncountries, possibly exceed<strong>in</strong>g <strong>the</strong> impact of such socioeconomicfactors as ris<strong>in</strong>g <strong>in</strong>come (Bloom et al., 2002),<strong>the</strong> situation <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> is more complex. Despite <strong>the</strong>existence of virtually free, government-run, voluntary familyplann<strong>in</strong>g programmes, <strong>the</strong> utilization of safe <strong>and</strong> effectivevoluntary contraceptive services based on <strong>in</strong>formed choice<strong>and</strong> a wide range of options, rema<strong>in</strong>s well below potential(Robertson, 2007) 12 .Before review<strong>in</strong>g <strong>the</strong> socio-economic determ<strong>in</strong>ants offertility change at <strong>the</strong> macrolevel that may have contributedto <strong>the</strong> slow or stalled fertility transition <strong>in</strong> some <strong>Pacific</strong>isl<strong>and</strong> countries, it may be <strong>in</strong>structive to look at patternsof contraceptive use <strong>and</strong> <strong>the</strong>ir determ<strong>in</strong>ants as evident <strong>in</strong>recent DHS.Current patterns of contraceptiveuse <strong>and</strong> unmet needCurrent use of contraception <strong>and</strong>trends at <strong>the</strong> national levelContraceptive prevalenceWith 7 of <strong>the</strong> 15 <strong>Pacific</strong> isl<strong>and</strong> countries <strong>and</strong> territorieswith United Nations programmes hav<strong>in</strong>g had a DHSwith<strong>in</strong> <strong>the</strong> past 5 years, it is now possible to comparecontraceptive prevalence rates across those economieswithout recourse to <strong>in</strong>complete service statistics <strong>and</strong> us<strong>in</strong>gcomparable methodology. The figures <strong>in</strong> Table 4 show thatCPR for currently married women <strong>in</strong> <strong>the</strong> period 2005-2009 ranges from a low of 17 per cent <strong>in</strong> Palau to a highof 46 per cent <strong>in</strong> <strong>the</strong> Cook Isl<strong>and</strong>s. The territories at each75

TableTable4Contraceptive prevalence rates (%) <strong>and</strong> trends <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> isl<strong>and</strong>s: 1990, 2000 <strong>and</strong> latest available(currently married women, modern methods)*Country/territory <strong>and</strong> subregionMelanesia1990s 2000s 2005-09Fiji 31 (1991) 44 (2002) 43 (2007)Papua New Gu<strong>in</strong>ea 20 (1996) na 24 (2006)Solomon Isl<strong>and</strong>s 11 (1997) 7 (2001) 27 (2007)Vanuatu 28 (1999) na 38 (2008)MicronesiaMicronesia (Federated States of ) 40 (1990) 49 (2000) 26 (2007)Kiribati 17 (1999) na 18 (2009)Nauru na na 25 (2007)Palau na 17 (2000) 17 (2002)Marshall Isl<strong>and</strong>s 31 (1995) 34 (2001) 42 (2007)PolynesiaCook Isl<strong>and</strong>s 46 (1991) 44 (2000) 46 (2005)Niue 36 (1991) na 21 (2007)Samoa 43 (1996) na 27 (2009)Tonga 33 (1999) 22 (2003) 28 (2007)Tuvalu 39 (1990) 32 (2002) 22 (2007)Sources: 1990 <strong>and</strong> 2000 data from UNFPA (2008); 2006-2009 figures are from DHS reports: Nauru (2007), Marshall Isl<strong>and</strong>s(2007), Samoa (2009), Solomon Isl<strong>and</strong>s (2007), Tuvalu (2000)Vanuatu, 2003-2008 from Z<strong>in</strong>ck (2008). Federated States ofMicronesia from Naduva (2008). Tonga from Wagatakirewa (2008). Cook Isl<strong>and</strong>s from Nawadra-Taylor (2008). Fiji fromUNFPA (2008).* Figures are rounded to <strong>the</strong> nearest percent.end of <strong>the</strong> range are not, however, among those which havehad a recent DHS, so <strong>the</strong> method of measurement is notnecessarily comparable <strong>and</strong> <strong>the</strong> accuracy of <strong>the</strong> figures isquestionable. Given that Palau has one of <strong>the</strong> lowest TFRs<strong>in</strong> <strong>the</strong> <strong>Pacific</strong> (2.0), <strong>the</strong> reported CPR of 17 per cent isquite likely to be an underestimate.It is also likely that Fiji’s reported CPR of 43 per cent isunderestimated given that contraceptives are <strong>in</strong>creas<strong>in</strong>glyavailable from private practitioners <strong>and</strong> pharmacies <strong>and</strong>are not captured <strong>in</strong> health <strong>in</strong>formation system data. It islikely that urban CPRs have been particularly understated<strong>in</strong> Fiji’s service statistics given that CPR <strong>in</strong> rural areaspopulated largely by poor tenant farmers, such as <strong>in</strong> <strong>the</strong>Nor<strong>the</strong>rn Division, has occasionally exceeded that of <strong>the</strong>most urbanized Central Division where a much higherproportion of <strong>the</strong> labour force is <strong>in</strong> white collar <strong>and</strong>professional occupations 13 . In rural areas, governmen<strong>the</strong>alth facilities are <strong>the</strong> ma<strong>in</strong> sources of contraceptives,whereas <strong>in</strong> urban areas o<strong>the</strong>r sources are available – butnot necessarily captured <strong>in</strong> health <strong>in</strong>formation systems.When only CPRs estimated from DHS are considered,however, a similar range of variation is evident. At <strong>the</strong> highend of <strong>the</strong> range is <strong>the</strong> Marshall Isl<strong>and</strong>s with a CPR of 42per cent; at <strong>the</strong> low end of <strong>the</strong> range is <strong>the</strong> neighbour<strong>in</strong>gcountry of Kiribati with a CPR of only 18 per cent. The(unweighted) average CPR for <strong>the</strong> seven countries <strong>and</strong>territories that have had a DHS is about 30 per cent.Clearly, by <strong>the</strong> st<strong>and</strong>ards of <strong>the</strong> less developed countries asa group (with a CPR of 45 per cent if Ch<strong>in</strong>a is excludedor 56 per cent if Ch<strong>in</strong>a is <strong>in</strong>cluded), current contraceptiveprevalence <strong>in</strong> this subset of <strong>Pacific</strong> countries <strong>and</strong> territoriesis surpris<strong>in</strong>gly low, given <strong>the</strong> long history of family plann<strong>in</strong>gprogrammes <strong>in</strong> <strong>the</strong> region.Trends <strong>in</strong> contraceptive use 1990-2010An assessment of contraceptive trends <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> iscomplicated by variations <strong>in</strong> methodology <strong>and</strong> <strong>the</strong> potentialfor error or <strong>in</strong>completeness <strong>in</strong> earlier figures. It is oftenunclear whe<strong>the</strong>r published CPRs <strong>in</strong>clude women us<strong>in</strong>g socalled“traditional” methods or whe<strong>the</strong>r only those us<strong>in</strong>gmodern methods are considered as us<strong>in</strong>g contraception.Also, it is not always clear if <strong>the</strong> denom<strong>in</strong>ator employed is allwomen of reproductive age or only married women. Given76

that estimates of CPR for earlier periods generally derivefrom service statistics based ultimately upon attendanceat family plann<strong>in</strong>g cl<strong>in</strong>ics or rural health centres, couplesus<strong>in</strong>g “withdrawal” or “rhythm” may not be <strong>in</strong>cluded as noattendance at cl<strong>in</strong>ics is required to practise <strong>the</strong>se methods.On <strong>the</strong> o<strong>the</strong>r h<strong>and</strong>, some health departments <strong>in</strong> <strong>the</strong> <strong>Pacific</strong>do give advice on <strong>the</strong> use of “natural” family plann<strong>in</strong>g, <strong>in</strong>which case users of <strong>the</strong>se methods would be recorded <strong>and</strong><strong>in</strong>cluded <strong>in</strong> <strong>the</strong> CPR estimates.Tak<strong>in</strong>g a cautionary approach to <strong>the</strong> figures presented <strong>in</strong>Table 4, it would appear that most countries <strong>and</strong> territories<strong>in</strong> <strong>the</strong> Polynesia subregion have experienced decl<strong>in</strong><strong>in</strong>g orbarely chang<strong>in</strong>g CPRs over <strong>the</strong> past 15 years. In Micronesiaonly Marshall Isl<strong>and</strong>s shows evidence of an <strong>in</strong>creas<strong>in</strong>gCPR while <strong>in</strong> o<strong>the</strong>r countries <strong>the</strong> estimates are fluctuat<strong>in</strong>g(Federated States of Micronesia) or show little change(Kiribati). In Melanesia, however, three countries (PapuaNew Gu<strong>in</strong>ea, Solomon Isl<strong>and</strong>s <strong>and</strong> Vanuatu) show a ris<strong>in</strong>gtrend. Although <strong>the</strong>re are doubts about <strong>the</strong> accuracy of itsearlier estimates, Solomon Isl<strong>and</strong>s has had <strong>the</strong> fastest rateof <strong>in</strong>crease <strong>in</strong> its CPR s<strong>in</strong>ce <strong>the</strong> 1990s, whereas PapuaNew Gu<strong>in</strong>ea’s CPR has risen quite slowly (2.4% <strong>in</strong>creaseper year) <strong>in</strong> <strong>the</strong> decade 1996-2006.That some of <strong>the</strong> poorest countries <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> haveexperienced <strong>in</strong>creas<strong>in</strong>g CPRs <strong>in</strong> <strong>the</strong> past decade <strong>and</strong> ahalf, whereas some relatively better off countries have haddecl<strong>in</strong><strong>in</strong>g or at least static CPRs, suggests that <strong>the</strong> rateof contraceptive uptake at an early stage of <strong>the</strong> fertilitytransition is likely to be higher than at later stages. Thisphenomenon can possibly be expla<strong>in</strong>ed by a fairly generalpattern whereby family plann<strong>in</strong>g programmes achieveearly success followed by a plateau <strong>and</strong> stagnation. As Back(1989) has observed:The work on enhanced <strong>in</strong>ternational distribution ofcontraceptives shows a pattern of <strong>in</strong>itial success thatat first looks encourag<strong>in</strong>g but often reaches a plateau.In <strong>the</strong> <strong>in</strong>troduction of new contraceptive methods to acommunity, <strong>the</strong> tapped are those who are highly motivatedto prevent future pregnancies <strong>and</strong> with <strong>the</strong>se recruits <strong>the</strong>enterprise succeeds. In order to reach beyond <strong>the</strong>se <strong>in</strong>itialrecruits, however, to <strong>the</strong> less motivated <strong>the</strong> availability ofeasy contraceptive methods is not enough <strong>and</strong> <strong>the</strong> cl<strong>in</strong>icprogramme frequently stagnates.This description would appear to describe <strong>the</strong> situation<strong>in</strong> many <strong>Pacific</strong> isl<strong>and</strong> countries <strong>in</strong> <strong>the</strong> 1990s. Womenwho might o<strong>the</strong>rwise have given birth to six or sevenchildren, a situation that prevailed when family plann<strong>in</strong>gprogrammes were <strong>in</strong>stituted <strong>in</strong> <strong>the</strong> 1960s <strong>and</strong> 1970s, werevery motivated to adopt family plann<strong>in</strong>g. Once averagecompleted fertility had dropped to between three <strong>and</strong> fourchildren, <strong>the</strong> motivation to reduce it fur<strong>the</strong>r to betweentwo <strong>and</strong> three children became significantly weaker. Thisproposition would appear to describe <strong>the</strong> recent situationof several countries, <strong>in</strong>clud<strong>in</strong>g Samoa, Tonga, Tuvalu, <strong>and</strong>among <strong>the</strong> Melanesian population of Fiji.Socio-economic determ<strong>in</strong>ants ofcurrent contraception use at <strong>the</strong>microlevelAn alternative, or possibly complementary, explanationis that <strong>the</strong> stagnation or very slow <strong>in</strong>crease <strong>in</strong> <strong>the</strong> useof contraception, <strong>and</strong> <strong>the</strong>refore fertility, is l<strong>in</strong>ked to anoverall stagnation <strong>in</strong> <strong>the</strong> pace of economic growth <strong>and</strong>development. This is <strong>the</strong> reason that was tentativelyoffered by Bongaarts <strong>in</strong> expla<strong>in</strong><strong>in</strong>g <strong>the</strong> slowdown <strong>in</strong> <strong>the</strong>pace of fertility decl<strong>in</strong>e <strong>in</strong> sub-Saharan Africa <strong>in</strong> <strong>the</strong> 1990s,although he also acknowledged that <strong>the</strong> decreas<strong>in</strong>g prioritygiven to family plann<strong>in</strong>g programmes over that period mayalso have contributed to <strong>the</strong> slowdown (Bongaarts, 2008).A slow pace of economic growth <strong>and</strong> development wouldpresumably be reflected <strong>in</strong> a more or less static labour forcestructure. In <strong>the</strong> absence of economic growth fewer peoplewould be mov<strong>in</strong>g up <strong>the</strong> occupational hierarchy to moreskilled <strong>and</strong> higher pay<strong>in</strong>g occupations. If contraceptive useis higher among <strong>the</strong> more educated <strong>and</strong> skilled technical<strong>and</strong> professional workers, overall contraceptive use wouldtend to stagnate if <strong>the</strong>se occupational groups were not<strong>in</strong>creas<strong>in</strong>g <strong>in</strong> proportion to o<strong>the</strong>r groups.In <strong>the</strong> <strong>Pacific</strong>, however, <strong>the</strong> association betweencontraceptive use <strong>and</strong> socio-economic status at <strong>the</strong>microlevel appears to be weak. In three out of <strong>the</strong> sevencountries that have had a DHS (Table 5) contraceptive useis higher among less educated women than among moreeducated women. In Solomon Isl<strong>and</strong>s <strong>the</strong> difference <strong>in</strong>contraceptive use between women with no education <strong>and</strong>those with more than secondary education is very small<strong>and</strong> probably not statistically significant. In Kiribati CPRappears to go down <strong>in</strong> l<strong>in</strong>e with <strong>the</strong> more education thata woman has. The lack of a close association betweeneducational achievement <strong>and</strong> contraceptive use was noted<strong>in</strong> one of <strong>the</strong> earliest “KAP” studies <strong>in</strong> Vanuatu (House,1999a).Also contrary to expectations is that, <strong>in</strong> three countries(Kiribati, Marshall Isl<strong>and</strong>s <strong>and</strong> Solomon Isl<strong>and</strong>s), CPR ishigher <strong>in</strong> rural areas than urban ones, whereas it wouldbe expected that this relationship would be <strong>the</strong> reverse,given that “rural” <strong>in</strong> this context refers to remote isl<strong>and</strong>swith poor transport, communications, access to healthservices, <strong>and</strong> a high proportion of <strong>the</strong> labour force work<strong>in</strong>g<strong>in</strong> subsistence production.In Marshall Isl<strong>and</strong>s, <strong>the</strong> higher CPR <strong>in</strong> rural than urban77

TableTable5Contraceptive use (modern methods) <strong>in</strong> selected <strong>Pacific</strong> isl<strong>and</strong> countries, by socio-economiccharacteristics (currently married women)*Tuvalu2007Nauru2007Marshall Isl<strong>and</strong>s2007Solomon Isl<strong>and</strong>s2007Samoa2009Kiribati2009Papua NewGu<strong>in</strong>ea2006Age-group (years)15-19 -- -- 23.7 12.8 8.1 0.0 12.120-24 10.2 12.7 24.9 18.2 20.8 14.8 18.525-29 20.0 22.2 38.9 18.6 22.3 19.6 22.030-34 19.4 27.0 45.0 29.5 32.5 21.5 26.035-39 31.2 30.1 57.1 35.1 33.2 23.6 30.240-44 30.2 36.8 54.4 32.4 28.9 19.8 30.445-49 22.7 -- 51.1 44.0 23.4 10.1 24.2Total 15-49 22.4 25.1 42.4 27.3 26.7 17.9 24.4Total traditional 8.1 10.5 2.2 5.7 2.0 4.5 8.1Total all methods 30.6. 35.6 44.6 33.0 28.7 22.4 32.4Residence**Urban 23.5 -- 41.2 23.2 26.8 15.9 36.7Rural 21.4 -- 44.7 28.0 26.7 19.7 22.3EducationNo education -- -- -- 28.2 -- 16.7 14.5Primary or less -- -- 47.2 28.7 20.5 20.6 22.2Secondary 18.9 26.1 41.6 21.7 26.4 16.4 29.0Secondary+ 22.2 18.4 36.1 29.5 27.5 13.8 naWealthQu<strong>in</strong>tile 1 (highest) 23.7 36.7 41.6 25.4 32.0 16.7 naQu<strong>in</strong>tile 2 18.4 39.4 45.9 30.0 21.6 14.8 naQu<strong>in</strong>tile 3 22.4 30.8 42.0 31.7 26.7 14.7 naQu<strong>in</strong>tile 4 27.7 39.2 41.7 25.5 25.9 17.9 naQu<strong>in</strong>tile 5 (lowest) 19.7 30.8 37.9 23.8 27.9 26.0 naParity0 0.0 6.0 6.6 3.4 1.7 0.4 3.81 or 2 16.2 13.0 29.8 19.4 18.2 16.0 20.33 or 4 30.5 34.1 53.1 32.4 33.8 27.7 25.15 <strong>and</strong> over 42.6 46.3 60.3 37.5 34.6 23.0 30.4Source: DHS reports for specified countries.*Refers to modern methods, except for use by wealth qu<strong>in</strong>tiles, where all methods are <strong>in</strong>cluded.** Nauru has no rural sector.areas was found to be statistically significant, with higherodds of contraceptive use among rural women, even whencontroll<strong>in</strong>g for o<strong>the</strong>r covariates. In Solomon Isl<strong>and</strong>s <strong>the</strong>higher odds of use among rural dwellers did not rema<strong>in</strong>when education <strong>and</strong> o<strong>the</strong>r variables were controlled(Robertson, 2009).Ano<strong>the</strong>r measure of socio-economic status that is availablefrom DHS data sets is household wealth, as measured by<strong>the</strong> stock of physical assets <strong>in</strong> each household. This measurecan be seen as a proxy <strong>in</strong>dicator of <strong>in</strong>come, assum<strong>in</strong>g thatassets <strong>and</strong> <strong>in</strong>come are correlated. It would normally beexpected that women <strong>in</strong> wealthier households would bemore likely to use contraception given <strong>the</strong>ir greater accessto health services <strong>and</strong> <strong>the</strong> higher chance that <strong>the</strong>y wouldbe work<strong>in</strong>g <strong>in</strong> wage <strong>and</strong> salary occupations. As can be seen<strong>in</strong> Table 5, however, <strong>the</strong>re is no clear l<strong>in</strong>ear relationshipbetween household wealth <strong>and</strong> <strong>the</strong> use of contraception.78

Figuremarried at an older age compared with women who hadmarried while younger. When all women of reproductiveage were compared, it was also found that married womenhad statistically significantly higher odds of us<strong>in</strong>g moderncontraceptives than s<strong>in</strong>gle women (Robertson, 2009).There was also some association between employmentstatus <strong>and</strong> contraceptive use, with “unemployed” womenless likely to be us<strong>in</strong>g contraception.Contraceptive use is an imperfect <strong>in</strong>dicator of <strong>the</strong> successof family plann<strong>in</strong>g programmes, although it is reasonableto assume that <strong>the</strong>re is a l<strong>in</strong>k between <strong>the</strong>m. However,prelim<strong>in</strong>ary analysis of DHS data on contraceptiveuse has produced unexpected results. The associationbetween contraceptive use <strong>and</strong> education, for example isweak. It is normally <strong>the</strong> case that educated women aremore knowledgeable about family plann<strong>in</strong>g, are moreconfident <strong>in</strong> us<strong>in</strong>g contraception <strong>and</strong> more motivated tolimit <strong>the</strong>ir fertility. In <strong>the</strong> <strong>Pacific</strong> <strong>the</strong>se l<strong>in</strong>kages appear tobe weak (House, 1999b), although <strong>the</strong>y can be discerned<strong>in</strong> some countries (Papua New Gu<strong>in</strong>ea <strong>and</strong> Samoa, forexample). Similarly, o<strong>the</strong>r socio-economic <strong>in</strong>dicators, suchas household wealth <strong>and</strong> rural-urban residence, are weaklyassociated with <strong>the</strong> use of contraception. That some <strong>Pacific</strong>countries exhibit higher contraceptive use <strong>in</strong> rural areas ascompared with urban areas is puzzl<strong>in</strong>g <strong>and</strong> needs deeperstudy.On <strong>the</strong> o<strong>the</strong>r h<strong>and</strong>, <strong>the</strong> effects of religion <strong>and</strong> age are aswould be expected, with Catholic <strong>and</strong> younger women lesslikely to be us<strong>in</strong>g contraception. Similarly, contact witha health facility or nurse is associated with higher use ofcontraception, as might be expected. Parity also has a clearrelationship with contraceptive use, with women hav<strong>in</strong>gfive children be<strong>in</strong>g more likely to use contraception thanthose with three or four.Relationship between fertility<strong>and</strong> mortalityClassical demographic transition <strong>the</strong>ory places strongemphasis on mortality decl<strong>in</strong>e, particularly of <strong>in</strong>fantmortality, as a cause of fertility decl<strong>in</strong>e. Traditional highfertility regimes, it is argued, were <strong>in</strong>tended to ensurea sufficient number of surviv<strong>in</strong>g children to providehousehold labour <strong>and</strong> parental support <strong>in</strong> old age.As already noted, <strong>in</strong> pre-contact times it is likely thatmortality was not as high <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> as it later becameafter <strong>in</strong>itial outside contact. The importation of foreigndiseases elevated mortality, which <strong>in</strong> turn necessitated apronatalist policy if depopulation was to be avoided. Thus<strong>Pacific</strong> countries eventually approximated <strong>the</strong> demographicconditions presupposed by transition <strong>the</strong>ory. Under <strong>the</strong>secircumstances, mortality decl<strong>in</strong>e was seen as a preconditionfor fertility decl<strong>in</strong>e.Figure 5 presents a cross-country comparison, show<strong>in</strong>gthat <strong>the</strong>re is a clear relationship between mortality <strong>and</strong>fertility levels <strong>in</strong> <strong>the</strong> <strong>Pacific</strong>, as measured by life expectancy<strong>and</strong> <strong>the</strong> total fertility rate, respectively 15 . As life expectancyFigure5Relationship between life expectancy <strong>and</strong> total fertility rate <strong>in</strong> <strong>Pacific</strong> isl<strong>and</strong> countries5.04.54.0TFR3.53.02.5R 2 = 0.25552.01.51.050.0 55.0 60.0 65.0 70.0 75.0 80.0Life expectancySource: Tables 2 <strong>and</strong> 3.80

Figure<strong>in</strong>creases, TFR decreases. However, <strong>in</strong> spite of a generaltrend <strong>in</strong> this direction, <strong>the</strong>re are a number of countries(<strong>in</strong>clud<strong>in</strong>g some <strong>in</strong> which fertility decl<strong>in</strong>e has stalled) thatdo not fit <strong>the</strong> general pattern. These are countries that haverelatively high life expectancy but also high fertility. Thesecountries are clustered <strong>in</strong> <strong>the</strong> top right corner of Figure5. Ano<strong>the</strong>r group of countries is clustered at <strong>the</strong> bottomright corner of <strong>the</strong> graph. These are <strong>the</strong> countries that fit<strong>the</strong> pattern expected by transition <strong>the</strong>ory. There are nocountries that occupy <strong>the</strong> lower left corner of <strong>the</strong> graph,which would signal low fertility <strong>and</strong> low life expectancy. In<strong>the</strong> set of countries shown <strong>in</strong> <strong>the</strong> graph, a life expectancyof about 70 years is required before replacement fertilityis achieved, but a life expectancy of 70 years does notguarantee that fertility will be at or anywhere nearreplacement level. In o<strong>the</strong>r words, high life expectancymay be a necessary condition for low fertility, but it is nota sufficient condition.A similar argument follows from Figure 6, which shows<strong>the</strong> relationship between fertility <strong>and</strong> <strong>in</strong>fant mortality, asmeasured by TFR <strong>and</strong> <strong>the</strong> <strong>in</strong>fant mortality rate (IMR),respectively. None of <strong>the</strong> countries that have a TFR under3 have an IMR above 20 per 1,000, but several countrieswith an IMR of about 20 per 1,000 have TFRs between 3<strong>and</strong> 4. Similarly, two clusters of countries can be observed<strong>in</strong> <strong>the</strong> graph – those below <strong>the</strong> trend l<strong>in</strong>e that fulfil <strong>the</strong>expectations of <strong>the</strong> classical transition <strong>the</strong>ory <strong>and</strong> thoseclustered above <strong>the</strong> trend l<strong>in</strong>e that do not fit <strong>the</strong>oreticalexpectations. Thus, it can be concluded that, while anIMR of 20 per 1,000 or less is a necessary condition forlow fertility, it is not a sufficient condition. In fact, whatis strik<strong>in</strong>g about <strong>the</strong> graph is that, among countries with aTFR <strong>in</strong> <strong>the</strong> range 3.0-4.5, <strong>the</strong> <strong>in</strong>fant mortality rate rangesextremely widely, from a low of 10 per 1,000 to a high of55 per 1,000.Cross-country comparison suggests that, while <strong>the</strong>re is abroad general association between mortality <strong>and</strong> fertilitylevels, high fertility cannot be expla<strong>in</strong>ed by high mortalityalone, whe<strong>the</strong>r measured by overall life expectancy or by<strong>the</strong> <strong>in</strong>fant mortality rate. There is a significant cluster ofcountries that have higher fertility than would be expectedon <strong>the</strong> basis of <strong>the</strong>ir mortality level.Fertility levels <strong>and</strong> development<strong>in</strong>dicators: macrolevelA full explanation for <strong>the</strong> slowdown <strong>in</strong> fertility decl<strong>in</strong>e<strong>in</strong> some countries <strong>and</strong> periods over <strong>the</strong> past 10-20 yearswould require a detailed analysis of development patterns<strong>and</strong> trends, which is beyond <strong>the</strong> scope of this paper.Never<strong>the</strong>less, it is important to assess, to <strong>the</strong> extent possible,whe<strong>the</strong>r <strong>the</strong> relationship between contraceptive use <strong>and</strong>socio-economic factors at <strong>the</strong> microlevel are also observedat <strong>the</strong> macrolevel – as reflected <strong>in</strong> st<strong>and</strong>ard development<strong>in</strong>dicators. This is particularly important from a programmeperspective, because family plann<strong>in</strong>g programmes cannotbe expected to address broad development conditions.If <strong>the</strong> relationship between economic <strong>in</strong>dicators <strong>and</strong>contraceptive use, for example, is weak, it may suggest that<strong>the</strong>re is scope for programmes to address non-economicissues, such as knowledge, perceptions <strong>and</strong> availability offamily plann<strong>in</strong>g.Figure6Relationship between <strong>in</strong>fant mortality <strong>and</strong> fertility <strong>in</strong> <strong>Pacific</strong> countries5.04.5R 2 = 0.51654.03.5TFR3.02.52.01.51.00.0 10.0 20.0 30.0 40.0 50.0 60.0Source: Tables 2 <strong>and</strong> 3.IMR81

As previously mentioned most <strong>Pacific</strong> isl<strong>and</strong> countriesreached <strong>the</strong>ir peak fertility <strong>in</strong> <strong>the</strong> 1960s, but <strong>in</strong> twocountries, Federated States of Micronesia <strong>and</strong> SolomonIsl<strong>and</strong>s, peak fertility was not reached until <strong>the</strong> mid-1970s<strong>and</strong> at a high level (TFR: 6.9 <strong>and</strong> 7.3, respectively). In<strong>the</strong>se countries fertility decl<strong>in</strong>e has been more gradualthan <strong>in</strong> countries <strong>in</strong> which <strong>the</strong> TFR peaked <strong>in</strong> <strong>the</strong> 1960s.Countries that reached peak fertility <strong>in</strong> <strong>the</strong> 1960s generallyexperienced a very rapid <strong>in</strong>itial decl<strong>in</strong>e until <strong>the</strong> mid tolate 1970s when <strong>the</strong> pace of decl<strong>in</strong>e slowed <strong>and</strong> <strong>the</strong> TFRlevelled off between 4.5 <strong>and</strong> 5. As already noted, some of<strong>the</strong>se countries also experienced a second slowdown <strong>in</strong> <strong>the</strong>1990s.It is difficult to determ<strong>in</strong>e with precision if <strong>the</strong> fertilityplateaus that have occurred at different stages of <strong>the</strong>fertility transition <strong>in</strong> some <strong>Pacific</strong> isl<strong>and</strong> countries canbe attributed to <strong>the</strong> strength or even existence of familyplann<strong>in</strong>g programmes. Systematic <strong>and</strong> comparative datameasur<strong>in</strong>g <strong>the</strong> “strength” of family plann<strong>in</strong>g programmesthrough time are <strong>in</strong> any case not available for <strong>the</strong> <strong>Pacific</strong>.In some countries, <strong>the</strong> <strong>in</strong>itial establishment of a familyplann<strong>in</strong>g programme engendered a backlash by <strong>the</strong> RomanCatholic Church with or without <strong>the</strong> support of traditionalleaders. Kiribati appears to be an extreme case of this but<strong>the</strong>re was also an element of demographic rivalry presentbetween Catholics <strong>and</strong> Protestants.Fertility decl<strong>in</strong>es have also cont<strong>in</strong>ued l<strong>in</strong>early <strong>in</strong> somecountries <strong>and</strong> territories without an obvious plateaueven while contraceptive prevalence rates appear tohave rema<strong>in</strong>ed unchanged for many years – a situationrepresented well by <strong>the</strong> Cook Isl<strong>and</strong>s <strong>and</strong> Fiji 16 . Themost susta<strong>in</strong>ed fertility decl<strong>in</strong>es have occurred <strong>in</strong> <strong>the</strong> non<strong>in</strong>dependentterritories of French Polynesia, Guam, NewCaledonia <strong>and</strong> <strong>the</strong> Nor<strong>the</strong>rn Mariana Isl<strong>and</strong>s, which havenot had organized family plann<strong>in</strong>g programmes comparablewith those established <strong>in</strong> Fiji, Kiribati or Tonga.In some countries it is apparent that historical factors haveplayed a part. In Papua New Gu<strong>in</strong>ea, for example, fertilitydecl<strong>in</strong>e stalled after <strong>in</strong>dependence <strong>in</strong> 1975. One reason forthis was that <strong>the</strong> rate of decl<strong>in</strong>e <strong>in</strong> <strong>in</strong>fant mortality alsoslowed due to <strong>the</strong> weaken<strong>in</strong>g of health delivery systems –<strong>in</strong> particular <strong>the</strong> abolition of regular government patrols <strong>in</strong>remote areas that had been a feature of <strong>the</strong> colonial period.The fertility plateaus <strong>in</strong> Samoa <strong>and</strong> Tonga have stretchedover a period of 20-25 years, dur<strong>in</strong>g which time familyplann<strong>in</strong>g programmes have received vary<strong>in</strong>g amounts ofsupport from governments <strong>and</strong> donors.The relevance of socio-economic factors can be questioned<strong>in</strong> <strong>the</strong> light of <strong>the</strong> lack of, or weak associations between,contraceptive use <strong>and</strong> <strong>the</strong> socio-economic status of DHSrespondents. Presumably, macrolevel variables reflectsocial change only to <strong>the</strong> extent that <strong>the</strong>y are evident<strong>in</strong> <strong>the</strong> microlevel behaviour of <strong>in</strong>dividuals. The DHSresults appear to question <strong>the</strong> effect of broader social <strong>and</strong>economic conditions at <strong>the</strong> level of <strong>the</strong> <strong>in</strong>dividual <strong>and</strong>family. Never<strong>the</strong>less, it is important to consider <strong>the</strong> socioeconomicfactors that may have played a contribut<strong>in</strong>g role<strong>in</strong> fertility decl<strong>in</strong>e, or its absence. It is important to note,however, that st<strong>and</strong>ard macrolevel development <strong>in</strong>dicatorsdo not necessarily capture <strong>the</strong> dimensions of socio-economicchange that are relevant to socio-economic <strong>the</strong>ories offertility change (Bryant, 2007). At <strong>the</strong> <strong>in</strong>dividual or familylevel, <strong>in</strong>centives to reduce fertility may be just as strong,or stronger, when economic conditions are worsen<strong>in</strong>g aswhen conditions are improv<strong>in</strong>g <strong>in</strong> as much as a strategy offertility limitation may be aimed at ensur<strong>in</strong>g that familywelfare does not deteriorate fur<strong>the</strong>r.Potential cross-country macroeconomic variables that maybe l<strong>in</strong>ked to fertility are per capita <strong>in</strong>come (GDP) <strong>and</strong> <strong>the</strong>proportion of <strong>the</strong> population below <strong>the</strong> poverty l<strong>in</strong>e. Afull set of data for all <strong>Pacific</strong> countries is not available for<strong>the</strong>se variables, but <strong>the</strong> data for those countries hav<strong>in</strong>g <strong>the</strong>available statistics are plotted <strong>in</strong> Figures 7 <strong>and</strong> 8. In <strong>the</strong>case of GDP per capita measured accord<strong>in</strong>g to purchas<strong>in</strong>gpower parity (PPP), <strong>the</strong> trend is certa<strong>in</strong>ly <strong>in</strong> <strong>the</strong> expecteddirection: as GDP per capita <strong>in</strong>creases, TFR decl<strong>in</strong>es 17 , butit cannot be concluded that <strong>the</strong>re is a necessary relationshipbetween per capita <strong>in</strong>come <strong>and</strong> TFR <strong>in</strong> this group ofcountries. Among <strong>the</strong> countries with a TFR between 4.0<strong>and</strong> 4.5, GDP per capita ranges from US$ 1,500 to 4,300.Conversely, among countries with per capita GDP aboveUS$ 3,500, <strong>the</strong> TFR ranges from 2.6 to 4.2. Thus, it isnot possible to specify <strong>the</strong> level of GDP per capita thatis necessary to achieve a given fertility rate among <strong>the</strong>secountries.Similarly, <strong>the</strong> percentage of <strong>the</strong> population liv<strong>in</strong>g below <strong>the</strong>“basic needs” poverty l<strong>in</strong>e is very weakly l<strong>in</strong>ked to <strong>the</strong> levelof fertility. Although TFR tends to rise with <strong>the</strong> proportionof <strong>the</strong> population below <strong>the</strong> poverty l<strong>in</strong>e, countries <strong>in</strong> whichTFR is about 4.0 <strong>and</strong> above have poverty levels rang<strong>in</strong>gfrom about 20 per cent to over 40 per cent. While povertymay be l<strong>in</strong>ked to family size at <strong>the</strong> household level, thisrelationship does not show up clearly at <strong>the</strong> country level.If GDP per capita is only loosely related to TFR, <strong>the</strong>npresumably contraceptive use, as one of <strong>the</strong> “proximatedeterm<strong>in</strong>ants” of fertility (Bongaarts, 1978), will also beloosely related to GDP per capita. As Figure 9 shows,contraceptive use rises with per capita GDP, largelybecause two countries at <strong>the</strong> upper end of <strong>the</strong> contraceptiveprevalence range are also at <strong>the</strong> upper end of <strong>the</strong> GDPper capita range. Never<strong>the</strong>less, countries with CPRs (formodern methods) between 25 <strong>and</strong> 30 per cent amongmarried women can be found right across <strong>the</strong> per capitaGDP scale from about US$ 1,500 to over US$ 4,000.82

FigureFigureFigure7Relationship between total fertility rate <strong>and</strong> GDP per capita <strong>in</strong> eight <strong>Pacific</strong> countries5.04.54.0TFR3.53.0R 2 = 0.16662.52.01000 1500 2000 2500 3000 3500 4000 4500GDP per Capita PPPSource: Tables 2 <strong>and</strong> 3.Figure8Relationship between TFR <strong>and</strong> poverty rate <strong>in</strong> 11 <strong>Pacific</strong> countries5.0Total fertility rate4.54.03.53.0R 2 = 0.01812.52.00.0 10.0 20.0 30.0 40.0 50.0 60.0Percent below poverty l<strong>in</strong>eSource: Tables 2 <strong>and</strong> 3.Never<strong>the</strong>less, it is notable that two corners of <strong>the</strong> graphare unoccupied: <strong>the</strong>re are no countries with a per capitaGDP above US$ 3,000 <strong>and</strong> a CPR below 25 per cent.Conversely, <strong>the</strong>re is no country with per capita GDP belowUS$ 3,500 with a CPR above 35 per cent. In this groupof countries, a relatively high per capita GDP may be anecessary condition to achieve a CPR above 40 per cent,but it is not a sufficient one.If TFR <strong>and</strong> CPR are both loosely associated with per capitaGDP <strong>in</strong> cross-country comparisons, it would presumablyfollow that TFR <strong>and</strong> CPR are also ra<strong>the</strong>r loosely related.That this is <strong>the</strong> case <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> can be seen from Figure10. While <strong>the</strong>re is an apparent association between <strong>the</strong>two variables <strong>in</strong> <strong>the</strong> expected direction (higher CPR isassociated with lower TFR), <strong>the</strong>re are outliers that do notfit <strong>the</strong> trend. On one h<strong>and</strong>, <strong>the</strong>re are no countries with aTFR below 3.0 <strong>and</strong> a CPR below 44 per cent, so a relatively83

FigureFigure945Relationship between total fertility rate <strong>and</strong> GDP per capita <strong>in</strong> eight <strong>Pacific</strong> countriesContraceptive prevalence rate403530252015R 2 = 0.2076101000 1500 2000 2500 3000 3500 4000 4500GDP per Capita PPPSource: Tables 2 <strong>and</strong> 3.high (<strong>in</strong> <strong>the</strong> context of <strong>the</strong>se countries) CPR contributesto low fertility. On <strong>the</strong> o<strong>the</strong>r, <strong>the</strong>re are two countries <strong>in</strong> <strong>the</strong>group with a CPR near <strong>the</strong> upper end of <strong>the</strong> range (about40%) that also have high TFRs between 4.0 <strong>and</strong> 5.0.The forego<strong>in</strong>g analysis, although rudimentary <strong>in</strong> terms ofprecise statistical measures of association, suggests thatdevelopment <strong>in</strong>dicators expla<strong>in</strong> some of <strong>the</strong> variationbetween <strong>the</strong> countries <strong>in</strong> terms of contraceptive use<strong>and</strong> fertility levels, but also leave much of <strong>the</strong> varianceunexpla<strong>in</strong>ed. From a broad cross-country perspective,higher GDP per capita <strong>and</strong> a lower proportion of <strong>the</strong>population <strong>in</strong> poverty are associated with lower fertility<strong>and</strong> higher contraceptive use, but <strong>the</strong> relationships aresufficiently weak that <strong>the</strong>re is no guarantee that an<strong>in</strong>crease <strong>in</strong> per capita <strong>in</strong>come or a reduction <strong>in</strong> povertywould necessarily produce higher contraceptive use orlower fertility. These weak associations at <strong>the</strong> macrolevel,essentially complement <strong>the</strong> f<strong>in</strong>d<strong>in</strong>gs of DHS at <strong>the</strong>microlevel where it was found that <strong>the</strong> associations betweencontraceptive use <strong>and</strong> <strong>in</strong>dividual socio-economic variables,such as completed education <strong>and</strong> household wealth, wereweak.Age patterns <strong>and</strong> gender issuesThe ma<strong>in</strong> issue with regard to family plann<strong>in</strong>g <strong>and</strong> age <strong>in</strong><strong>the</strong> <strong>Pacific</strong> is <strong>the</strong> low use of contraception among teenagers<strong>and</strong> result<strong>in</strong>g levels of teenage fertility. By <strong>the</strong> st<strong>and</strong>ards of<strong>the</strong> least developed countries as a group, <strong>the</strong> <strong>Pacific</strong> isl<strong>and</strong>sregion is not characterized by high teenage fertility rates,but some countries have quite high levels. In <strong>the</strong> region asa whole, <strong>the</strong> teenage fertility rate is somewhat higher than<strong>in</strong> South-East <strong>Asia</strong> but lower than <strong>in</strong> South-Central <strong>Asia</strong>.The teenage fertility rate currently ranges from 9 <strong>in</strong> Wallis<strong>and</strong> Futuna Isl<strong>and</strong>s to 127 <strong>in</strong> Marshall Isl<strong>and</strong>s (Table 3).A dist<strong>in</strong>ctive feature of teenage fertility <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> is<strong>the</strong> lack of a clear relationship between teenage fertilityrates <strong>and</strong> TFR. As illustrated <strong>in</strong> Figure 11, <strong>the</strong> associationbetween TFR <strong>and</strong> <strong>the</strong> teenage fertility rate is extremelyloose when <strong>the</strong> two “outliers” are removed from <strong>the</strong> sample 18 .Although <strong>the</strong>re is a slight tendency for teenage fertility todecl<strong>in</strong>e with TFR, it is unlikely to be statistically significant.If <strong>the</strong> l<strong>in</strong>e between relatively “high” <strong>and</strong> relatively “low”teenage fertility rates is set arbitrarily at 45 per 1,000, itis clear from Figure 10 that “high” teenage fertility can befound <strong>in</strong> countries with a TFR rang<strong>in</strong>g from 4.7 to 1.6,<strong>and</strong> “low” teenage fertility can be found <strong>in</strong> countries witha TFR rang<strong>in</strong>g from 4.5 to 1.9. This suggests that teenagefertility is determ<strong>in</strong>ed by a different set of factors thanfertility <strong>in</strong> general. A plausible explanation is that socioculturalfactors play a larger role <strong>in</strong> teenage fertility thangeneral fertility. In particular, <strong>the</strong> barriers that restrictaccess to contraceptive <strong>in</strong>formation <strong>and</strong> services are muchgreater for teenagers than for older women. Teenagers arealso more likely to be unmarried, <strong>and</strong> sexual activity beforemarriage is still not broadly acceptable, even though it iswidely practised 19 .84

FigureFigureFigure10Relationship between total fertility rate <strong>and</strong> contraceptive prevalence rate <strong>in</strong> 12 <strong>Pacific</strong> countries5.04.54.0TFR3.53.0R 2 = 0.01812.52.010 15 20 25 30 35 40 45 50Contraceptive prevalence rateSource: Tables 2-4.Figure115.0Relationship between total fertility rate <strong>and</strong> teenage fertility rate4.54.0R 2 = 0.0312Total fertility rate3.53.02.52.01.51.010 20 30 40 50 60 70 80 90Teenage fertility rateSource: Tables 2-4.Unmet need for family plann<strong>in</strong>g:recent evidenceConceptual issuesAs previously noted, <strong>the</strong> ICPD Programme of Actionrecommends that “Government goals for family plann<strong>in</strong>gshould be def<strong>in</strong>ed <strong>in</strong> terms of unmet need for <strong>in</strong>formation<strong>and</strong> services”. Subsequently, ICPD+5 recommended that“Where <strong>the</strong>re is a gap between contraceptive use <strong>and</strong> <strong>the</strong>proportion of <strong>in</strong>dividuals express<strong>in</strong>g a desire to space orlimit <strong>the</strong>ir families, countries should attempt to close thisgap by at least 50 per cent by 2005, 75 per cent by 2010<strong>and</strong> 100 per cent by 2050” (United Nations, 1999, para.58). The concept of “gap” comes from early generationKAP studies from which <strong>the</strong> term “KAP-gap” was co<strong>in</strong>edto refer to a situation whereby a woman expressed a desireto limit or space births but was not us<strong>in</strong>g any form ofcontraception. Clos<strong>in</strong>g this gap entirely by 2050 was anextremely ambitious goal.85

The concept of “unmet need” has undergone fur<strong>the</strong>rref<strong>in</strong>ement <strong>in</strong> recent years with <strong>in</strong>creas<strong>in</strong>gly encompass<strong>in</strong>gdef<strong>in</strong>itions of <strong>the</strong> categories of women who can beconsidered as hav<strong>in</strong>g an unmet need. The current def<strong>in</strong>itionof unmet need accord<strong>in</strong>g to <strong>the</strong> United Nations PopulationDivision is:Unmet need for family plann<strong>in</strong>g is <strong>the</strong>number of women with unmet need forfamily plann<strong>in</strong>g expressed as a percentageof women of reproductive age who aremarried or <strong>in</strong> union. Women with anunmet need are those who are fecund<strong>and</strong> sexually active but are not us<strong>in</strong>g anymethod of contraception, <strong>and</strong> report notwant<strong>in</strong>g any more children or want<strong>in</strong>g todelay <strong>the</strong> birth of <strong>the</strong>ir next child (UnitedNations Department of Economic <strong>and</strong>Social Affairs, 2009).This def<strong>in</strong>ition is identical to that used <strong>in</strong> Demographic<strong>and</strong> Health Surveys. The method of computation requiresthat surveys identify women who are married or <strong>in</strong> a sexualunion <strong>in</strong> various statuses requir<strong>in</strong>g a complex branch<strong>in</strong>gprocess based upon answers to questions appear<strong>in</strong>g atvarious po<strong>in</strong>ts <strong>in</strong> <strong>the</strong> DHS questionnaire.Women who are excluded from <strong>the</strong> numerator <strong>in</strong>cludethose who are:(a) Us<strong>in</strong>g contraception to delay <strong>the</strong>ir next birth;(b) Us<strong>in</strong>g contraception to stop childbear<strong>in</strong>g;(c) Currently pregnant or amenorrheic <strong>and</strong> <strong>the</strong> pregnancywas:(i) Intended;(ii) Due to method failure;(d) Infecund (accord<strong>in</strong>g to an objective set of criteria);(e) Want a child with<strong>in</strong> <strong>the</strong> next two years.By a process of elim<strong>in</strong>ation, a residual is obta<strong>in</strong>ed that<strong>in</strong>cludes women who:(a) Are not us<strong>in</strong>g contraception;(b) Are not pregnant or amenorrheic;(c) Do not want ano<strong>the</strong>r child or do not want it with<strong>in</strong> <strong>the</strong>next two years;(d) Are pregnant or amenorrheic <strong>and</strong>(i) Did not want <strong>the</strong> child;(ii) Wanted <strong>the</strong> child but at a later date;(e) Are unsure about want<strong>in</strong>g <strong>the</strong> child at a later date.The denom<strong>in</strong>ator is all women who are married or <strong>in</strong> asexual union 20 .The concept of unmet need def<strong>in</strong>ed by <strong>the</strong>se criteriais considered to be consistent with a rights-based,voluntaristic approach to family plann<strong>in</strong>g because it is <strong>the</strong>respondent herself who states whe<strong>the</strong>r she wishes to haveano<strong>the</strong>r child, or have a child later, or did not want to have<strong>the</strong> child with whom she is currently pregnant, <strong>and</strong> not<strong>the</strong> state or a family plann<strong>in</strong>g worker. However, <strong>the</strong> processof measurement is complex <strong>and</strong> presupposes that womenhave a high level of awareness about <strong>the</strong>ir own state ofm<strong>in</strong>d with regard to childbear<strong>in</strong>g, someth<strong>in</strong>g that may notnecessarily be <strong>the</strong> case.The concept of unmet need also produces anomalies thatare difficult to <strong>in</strong>terpret. One anomaly arises from <strong>the</strong> factthat women who want more children, or wanted <strong>the</strong> childwith whom <strong>the</strong>y are currently pregnant, or who becamepregnant while us<strong>in</strong>g a contraceptive method, or are<strong>in</strong>fecund are <strong>in</strong>cluded <strong>in</strong> <strong>the</strong> denom<strong>in</strong>ator when calculat<strong>in</strong>g<strong>the</strong> percentage of women hav<strong>in</strong>g an unmet need. Oneresult of this is that where a high proportion of womenwant ano<strong>the</strong>r child or more children than <strong>the</strong>y currentlyhave, unmet need for family plann<strong>in</strong>g may be low. Thisdoes not necessarily mean that family plann<strong>in</strong>g servicesare unavailable or not used by those women who do wantto space or limit childbear<strong>in</strong>g, but some proportion of <strong>the</strong>women with an unmet need may not be us<strong>in</strong>g contraceptionbecause of <strong>the</strong>ir <strong>in</strong>ability to obta<strong>in</strong> contraception forwhatever reason. Thus, <strong>the</strong> measure confounds threequite different circumstances: one <strong>in</strong> which women havedifficulty obta<strong>in</strong><strong>in</strong>g contraception (result<strong>in</strong>g <strong>in</strong> high unmetneed); ano<strong>the</strong>r <strong>in</strong> which only a small proportion of womenactually want to control <strong>the</strong>ir childbear<strong>in</strong>g (result<strong>in</strong>g <strong>in</strong>low unmet need); <strong>and</strong> one <strong>in</strong> which a high proportion ofwomen who want to limit childbear<strong>in</strong>g are able to obta<strong>in</strong><strong>and</strong> use <strong>the</strong> means to do so.As Bhushan (1997) has po<strong>in</strong>ted out, “unmet need can below <strong>in</strong> two entirely different sett<strong>in</strong>gs: (1) <strong>in</strong> places wheremotivation for fertility regulation is low; <strong>and</strong> (2) <strong>in</strong> placeswhere motivation for fertility regulation is high but it iseasy to implement one’s preferences”. This proposition canbe verified by compar<strong>in</strong>g unmet need <strong>in</strong> Solomon Isl<strong>and</strong>s(7.7% accord<strong>in</strong>g to recent DHS estimates shown <strong>in</strong> Table7), with that <strong>in</strong> <strong>the</strong> United States, which has a reportedunmet need of 7 per cent (Guttmacher Institute) 21 .86

Although <strong>the</strong> unmet need for family plann<strong>in</strong>g is similar <strong>in</strong>both countries, <strong>the</strong>ir fertility circumstances are completelydifferent. In Solomon Isl<strong>and</strong>s <strong>the</strong> contraceptive prevalencerate is 27 per cent (Table 4), whereas <strong>in</strong> <strong>the</strong> United States itis 69 per cent. Similarly, <strong>the</strong> total fertility rate <strong>in</strong> SolomonIsl<strong>and</strong>s is 4.6, whereas <strong>in</strong> <strong>the</strong> United States it is 2.1.In ano<strong>the</strong>r respect <strong>the</strong> two countries are similar, whichis to be expected, given <strong>the</strong> similar level of unmet need:<strong>in</strong> <strong>the</strong> United States, 89 per cent of <strong>the</strong> dem<strong>and</strong> forfamily plann<strong>in</strong>g is met; <strong>in</strong> Solomon Isl<strong>and</strong>s, 76 per centof <strong>the</strong> dem<strong>and</strong> for family plann<strong>in</strong>g is met (Table 8). Theproportion of dem<strong>and</strong> met <strong>in</strong> <strong>the</strong> two countries is roughlysimilar because, although <strong>the</strong> proportion of womenof childbear<strong>in</strong>g age who wish to limit births is muchhigher <strong>in</strong> <strong>the</strong> United States than <strong>in</strong> Solomon Isl<strong>and</strong>s, ahigh proportion of those women are able to meet <strong>the</strong>ircontraceptive needs. In Solomon Isl<strong>and</strong>s, a much smallerproportion of women of childbear<strong>in</strong>g age wish to regulate<strong>the</strong>ir childbear<strong>in</strong>g, but a similar proportion of <strong>the</strong>se womenis also able to meet <strong>the</strong>ir contraceptive needs.The implication of <strong>the</strong>se considerations is that statisticson unmet need must be <strong>in</strong>terpreted with caution <strong>and</strong> used<strong>in</strong> comb<strong>in</strong>ation with o<strong>the</strong>r measures of dem<strong>and</strong> for familyplann<strong>in</strong>g services.TableTable7VariablePercentage of currently married women (15-49 years of age) with an unmet need for familyplann<strong>in</strong>g <strong>in</strong> selected <strong>Pacific</strong> isl<strong>and</strong> countries, by socio-economic characteristics*Tuvalu2007Nauru2007Marshall Isl<strong>and</strong>s2007Solomon Isl<strong>and</strong>s2007Samoa 2009Kiribati2008Papua NewGu<strong>in</strong>ea2006‡Age group15-19 -- -- 33.2 15.0 -- 36.5 29.520-24 23.8 36.6 12.5 14.8 41.5 30.5 29.825-29 22.2 31.1 9.3 15.3 41.9 26.3 37.730-34 30.9 23.7 7.6 15.1 41.5 32.2 42.235-39 23.7 17.5 2.8 8.5 46.4 26.6 48.040-44 24.3 -- 1.4 2.3 46.2 29.7 61.445-49 20.2 -- 0.0 0.7 53.8 19.5 76.815-49 24.2 23.5 8.1 7.7 45.6 28.2 44.1ResidenceUrban 25.5 na 7.3 8.2 45.4 31.3 42.1Rural 23.1 na 9.6 11.6 45.6 25.3 44.3EducationNo education na na na 12.1 na 0.0 51.4Primary or less 20.5 na 9.0 11.6 54.8 25.5 43.5Secondary 27.6 23.5 7.6 10.1 45.4 30.3 30.0More than secondary+ 22.9 -- 8.9 3.0 43.2 26.2 naWealthQu<strong>in</strong>tile 1 (highest) 22.6 27.6 6.2 6.0 41.4 31.0 naQu<strong>in</strong>tile 2 25.8 19.3 4.6 9.8 43.6 31.5 naQu<strong>in</strong>tile 3 26.2 31.1 9.1 15.4 48.1 26.6 naQu<strong>in</strong>tile 4 22.7 20.8 11.1 10.4 47.7 26.9 naQu<strong>in</strong>tile 5 (lowest) 23.3 17.2 14.1 14.5 46.8 24.4 naSource: DHS reports for specified countries.*Note that <strong>the</strong> method of estimat<strong>in</strong>g unmet need <strong>in</strong> Papua New Gu<strong>in</strong>ea is not identical to <strong>the</strong> method used <strong>in</strong> <strong>the</strong> o<strong>the</strong>r countries.In Papua New Gu<strong>in</strong>ea <strong>the</strong> figures refer to <strong>the</strong> unmet need for stopp<strong>in</strong>g <strong>and</strong> not spac<strong>in</strong>g. Also, some o<strong>the</strong>r categories of unmet needare excluded. The Papua New Gu<strong>in</strong>ea figures are <strong>the</strong>refore underestimates when compared with <strong>the</strong> o<strong>the</strong>r countries. In all o<strong>the</strong>rcountries, <strong>the</strong> figures given are <strong>the</strong> sum of <strong>the</strong> unmet need for spac<strong>in</strong>g <strong>and</strong> <strong>the</strong> unmet need for stopp<strong>in</strong>g.‡Women who are undecided as to whe<strong>the</strong>r <strong>the</strong>y want ano<strong>the</strong>r child or responded “don’t know” are considered to have an unmet needfor contraception <strong>in</strong> Papua New Gu<strong>in</strong>ea. If <strong>the</strong>se women are excluded, <strong>the</strong> proportion of women with an unmet need is much lower(29.8%)87

TableTable8Percentage of <strong>the</strong> total dem<strong>and</strong> for family plann<strong>in</strong>g that is satisfied <strong>in</strong> selected <strong>Pacific</strong> isl<strong>and</strong>countries, by socio-economic characteristics (currently married women)*Variable Tuvalu 2007 Nauru 2007MarshallIsl<strong>and</strong>s 2007SolomonIsl<strong>and</strong>s 2007Samoa2009Kiribati2008Papua NewGu<strong>in</strong>ea 2006Age group15-19 -- -- 43.0 56.6 -- 5.0 37.020-24 46.3 42.5 68.8 62.9 35.2 37.6 44.225-29 54.7 51.6 81.7 62.8 37.4 47.0 41.830-34 49.8 62.7 86.4 71.0 45.4 45.3 41.435-39 61.2 68.7 95.4 84.0 42.7 51.8 36.240-44 62.0 -- 97.6 94.6 41.4 46.9 29.445-49 58.8 -- 100.0 98.5 30.7 41.5 16.315-49 55.8 60.3 84.6 75.6 38.6 44.2 36.5ResidenceUrban 54.5 na 85.4 78.1 39.9 38.0 42.8Rural 56.8 na 83.4 75.3 38.4 50.0 35.7EducationNo education na na -- 71.0 Na 100.0 23.9Primary or less 62.2 na 84.8 75.7 27.2 49.4 37.2Secondary 50.1 61.0 85.1 75.9 39.5 41.1 39.7More than secondary+57.7 -- 81.8 93.8 39.5 39.3 54.0WealthQu<strong>in</strong>tile 1 (highest) 56.9 57.1 87.7 84.6 46.1 40.2 naQu<strong>in</strong>tile 2 50.4 67.2 91.1 79.2 35.8 34.7 naQu<strong>in</strong>tile 3 55.5 49.9 82.8 70.3 37.7 43.0 naQu<strong>in</strong>tile 4 61.9 65.3 80.0 75.6 36.1 46.0 naQu<strong>in</strong>tile 5 (lowest) 53.0 64.1 75.4 70.0 37.6 57.0 naSource: DHS reports for specified countries.Note: -- means number <strong>in</strong> sample too small.*In Papua New Gu<strong>in</strong>ea, women who want more children are excluded from <strong>the</strong> calculation.Unmet need <strong>and</strong> socio-economicfactors at <strong>the</strong> microlevelIn <strong>the</strong> <strong>Pacific</strong>, unmet need by country among marriedwomen ranges from 7.7 per cent <strong>in</strong> Solomon Isl<strong>and</strong>s to45.6 per cent <strong>in</strong> Samoa (Table 7). Marshall Isl<strong>and</strong>s <strong>and</strong>Solomon Isl<strong>and</strong>s seem to be <strong>in</strong> a group of <strong>the</strong>ir own,with much lower levels of unmet need (8.1 <strong>and</strong> 7.7%,respectively) compared with <strong>the</strong> o<strong>the</strong>r countries. As alreadynoted, Solomon Isl<strong>and</strong>s has a low level of unmet needbecause fertility preferences rema<strong>in</strong> high. This may alsobe <strong>the</strong> case <strong>in</strong> Marshall Isl<strong>and</strong>s, although that country hasone of <strong>the</strong> highest CPRs <strong>in</strong> <strong>the</strong> region (42.4%). SolomonIsl<strong>and</strong>s has <strong>the</strong> highest TFR <strong>in</strong> <strong>the</strong> region but <strong>the</strong> lowestlevel of unmet need.Patterns of unmet need by age vary widely betweencountries. For several countries (Kiribati, Nauru <strong>and</strong>Samoa) <strong>the</strong>re are <strong>in</strong>sufficient married women aged 15-19<strong>in</strong> <strong>the</strong> sample to provide a valid measure of unmet need. InKiribati, Marshall Isl<strong>and</strong>s <strong>and</strong> Solomon Isl<strong>and</strong>s, this agegroup has <strong>the</strong> highest rate of unmet need. In <strong>the</strong> countrieswith low unmet need, <strong>the</strong> highest levels are found <strong>in</strong>younger age groups <strong>and</strong> <strong>the</strong> lowest <strong>in</strong> older age groups.In Kiribati, Papua New Gu<strong>in</strong>ea, Samoa <strong>and</strong> Tuvalu <strong>the</strong>differences between age groups is not large. In Papua NewGu<strong>in</strong>ea <strong>and</strong> Samoa, <strong>the</strong> highest levels of unmet need are <strong>in</strong><strong>the</strong> 45-49 age group.A surpris<strong>in</strong>g f<strong>in</strong>d<strong>in</strong>g <strong>in</strong> Table 7 is that unmet need is similar<strong>in</strong> urban <strong>and</strong> rural areas with<strong>in</strong> countries. Although unmetneed is slightly higher <strong>in</strong> rural areas <strong>in</strong> four countries, <strong>the</strong>differences are small. In Kiribati <strong>and</strong> Tuvalu unmet need ishigher <strong>in</strong> urban than rural areas. The relationship betweeneducation <strong>and</strong> unmet need is also quite different <strong>in</strong> eachcountry. The highest levels of unmet need are among88

women with only primary education <strong>in</strong> Samoa (54.8%)<strong>and</strong> women with no education <strong>in</strong> Papua New Gu<strong>in</strong>ea(51.4%). In Solomon Isl<strong>and</strong>s, <strong>the</strong> highest level of unmetneed is also among women with no education or onlyprimary education.There is no clear relationship between unmet need <strong>and</strong>household wealth. Only <strong>in</strong> Marshall Isl<strong>and</strong>s is unmet needhighest <strong>in</strong> <strong>the</strong> poorest fifth of <strong>the</strong> population. Elsewhereunmet need is highest <strong>in</strong> <strong>the</strong> middle wealth qu<strong>in</strong>tile, exceptfor Kiribati where <strong>the</strong> second highest qu<strong>in</strong>tile has <strong>the</strong>highest unmet need.In summary, as was <strong>the</strong> case with CPR, unmet need isnot strongly associated with socio-economic factors at <strong>the</strong>microlevel on a cross-country basis. While unmet need isgenerally higher <strong>in</strong> rural areas, this is not true <strong>in</strong> all countries.Similarly, <strong>in</strong> some countries unmet need is higher amongwomen with secondary education but <strong>in</strong> o<strong>the</strong>r countriesuneducated women have higher unmet need. Fur<strong>the</strong>rmore,nei<strong>the</strong>r high nor low wealth is associated with unmetneed. The strongest relationship <strong>in</strong> most countries is age,although it is not l<strong>in</strong>ear. In Marshall Isl<strong>and</strong>s <strong>and</strong> SolomonIsl<strong>and</strong>s, countries with <strong>the</strong> lowest level of unmet need,<strong>the</strong> highest levels were found <strong>in</strong> younger age groups. Thiswas also <strong>the</strong> case <strong>in</strong> Kiribati <strong>and</strong> Nauru with much higheroverall unmet need.Ano<strong>the</strong>r measure of <strong>the</strong> extent to which <strong>the</strong> family plann<strong>in</strong>gneeds of a country or subgroups with<strong>in</strong> a country are be<strong>in</strong>gmet is <strong>the</strong> “total dem<strong>and</strong>” for family plann<strong>in</strong>g. This is <strong>the</strong>sum of women currently us<strong>in</strong>g contraception <strong>and</strong> thosewho have an unmet need. The proportion of <strong>the</strong> totaldem<strong>and</strong> that is met is current users divided by <strong>the</strong> totalof users <strong>and</strong> non-users. Where unmet need is low, it canbe expected that <strong>the</strong> proportion of <strong>the</strong> total dem<strong>and</strong> thatis met will be high. This can be confirmed with referenceto <strong>the</strong> <strong>Pacific</strong> isl<strong>and</strong> countries with <strong>the</strong> recent DHS (Table8). The two countries with <strong>the</strong> lowest level of unmet need(Marshall Isl<strong>and</strong>s <strong>and</strong> Solomon Isl<strong>and</strong>s) have <strong>the</strong> highestproportion of total dem<strong>and</strong> satisfied – 84.6 per cent <strong>and</strong>75.6 per cent, respectively – as might be expected.As was found with o<strong>the</strong>r fertility <strong>and</strong> contraceptive<strong>in</strong>dicators, <strong>the</strong> percentage of total dem<strong>and</strong> for contraceptionthat is satisfied is not clearly associated with <strong>the</strong> socioeconomiccharacteristics of women at <strong>the</strong> microscale. Tosome extent, <strong>the</strong> proportion of dem<strong>and</strong> satisfied is higher<strong>in</strong> urban than rural areas, but not <strong>in</strong> all countries. Womenwith a primary or lower level of education are more likelyto have lower proportions of <strong>the</strong>ir total dem<strong>and</strong> satisfied,but aga<strong>in</strong> this is not true <strong>in</strong> all countries. In general, as with<strong>the</strong> o<strong>the</strong>r <strong>in</strong>dicators, women younger than 30 years of agehave a smaller proportion of <strong>the</strong>ir total dem<strong>and</strong> satisfied,thus demographic factors have a stronger impact thansocio-economic ones.Expla<strong>in</strong><strong>in</strong>g patterns of unmet needAs Bhushan (1997), Casterl<strong>in</strong>e <strong>and</strong> S<strong>in</strong>d<strong>in</strong>g (2000), <strong>and</strong>o<strong>the</strong>rs have po<strong>in</strong>ted out, from a programme perspective<strong>the</strong> key issue <strong>in</strong> respond<strong>in</strong>g to unmet need is to identify<strong>the</strong> country-specific causes of it. As Casterl<strong>in</strong>e <strong>and</strong> S<strong>in</strong>d<strong>in</strong>galso note, <strong>the</strong>re is a temptation for policymakers to addressunmet need by focus<strong>in</strong>g almost exclusively on improv<strong>in</strong>gaccess to services, but lack of access is not always <strong>the</strong>primary reason for unmet need. Detailed research maybe required to uncover <strong>the</strong> actual reasons among variousgroups of women.Although DHS are not generally f<strong>in</strong>ely adapted to <strong>the</strong>specific country <strong>in</strong> which <strong>the</strong>y are conducted, <strong>the</strong>ir resultsprovide a useful po<strong>in</strong>t of departure for more detailedresearch on <strong>the</strong> underly<strong>in</strong>g causes of unmet need. Ast<strong>and</strong>ard DHS question asked of currently married womenwho are not us<strong>in</strong>g contraception is whe<strong>the</strong>r <strong>the</strong>y <strong>in</strong>tendto use contraception <strong>in</strong> <strong>the</strong> future. The responses to thisquestion <strong>in</strong> seven <strong>Pacific</strong> countries are shown <strong>in</strong> Table 9.Ra<strong>the</strong>r than employ <strong>the</strong> st<strong>and</strong>ard DHS format, however,<strong>the</strong> data <strong>in</strong> Table 9 have been arranged accord<strong>in</strong>g to<strong>the</strong> previously mentioned “ready, will<strong>in</strong>g, <strong>and</strong> able”conceptualization of Lesthaeghe <strong>and</strong> V<strong>and</strong>erhoeft. Becausewomen who are already practis<strong>in</strong>g contraception can beconsidered as fulfill<strong>in</strong>g all three conditions, <strong>the</strong>y are excludedfrom <strong>the</strong> table. The two rema<strong>in</strong><strong>in</strong>g categories of womenare those who ei<strong>the</strong>r are unable to use contraception or areunwill<strong>in</strong>g to do so. The <strong>in</strong>ability to use contraception maybe caused by lack of knowledge, <strong>the</strong> difficulty of locat<strong>in</strong>g asource, or <strong>the</strong> lack of money to pay for transportation orfor <strong>the</strong> method itself.Unwill<strong>in</strong>gness to practise contraception arises from anumber of factors, rang<strong>in</strong>g from religious objections,spousal opposition to fear of side effects <strong>and</strong> general healthconcerns. A third category “not specified” is <strong>in</strong>cluded toshow <strong>the</strong> extent to which respondents give o<strong>the</strong>r reasonsor are unable to give a response.It is clear from Table 9 that lack of knowledge of, oraccess to, contraception is a significant impediment tocontraceptive use only <strong>in</strong> Papua New Gu<strong>in</strong>ea, where 50.9per cent of women who say that <strong>the</strong>y do not <strong>in</strong>tend to usecontraception <strong>in</strong> <strong>the</strong> future give this reason. Only <strong>in</strong> Nauru(12.7) <strong>and</strong> Solomon Isl<strong>and</strong>s (13.5) does <strong>the</strong> percentageof women cit<strong>in</strong>g this reason rise above a few percentagepo<strong>in</strong>ts.It appears that <strong>in</strong>ability to access contraception is not amajor cause of unmet need <strong>in</strong> most of <strong>the</strong> <strong>Pacific</strong> countriesrecently conduct<strong>in</strong>g a DHS. That a majority of women <strong>in</strong>Papua New Gu<strong>in</strong>ea would cite this reason is underst<strong>and</strong>ablegiven <strong>the</strong> low level of female literacy, low urbanization89

TableTable9Percentage of reasons for lack of <strong>in</strong>tention to use contraception <strong>in</strong> <strong>the</strong> future among currentlymarried women who are not currently us<strong>in</strong>g contraception, selected <strong>Pacific</strong> isl<strong>and</strong> countriesCategory/reasonsTuvalu2007Nauru2007MarshallIsl<strong>and</strong>s2007SolomonIsl<strong>and</strong>s2007Samoa2009Kiribati2008Papua NewGu<strong>in</strong>ea2006Unable (a)Lack of knowledge/knows no 0.5 10.1 0.5 8.7 1.4 3.7 43.4methodAccess difficult/knows no source 0.0 2.5 0.0 4.2 0.2 0.2 6.9Too expensive/costs too much 0.0 0.0 0.0 0.6 0.5 0.0 0.6Total (a) 0.5 12.7 0.5 13.5 2.1 4.0 50.9Unwill<strong>in</strong>g (w)Religious opposition 1.6 22.8 0.0 6.1 0.5 37.1 9.6Husb<strong>and</strong>/partner opposed 5.5 1.3 1.4 3.9 2.1 5.3 4.8O<strong>the</strong>rs opposed 0.0 0.0 0.9 1.2 0.0 0.5 0.0Respondent opposed 7.7 25.3 10.3 7.5 70.2 6.9 0.0Health concerns 5.5 5.1 15.5 7.1 17.5 9.0 0.0Fear of side effects 62.1 19.0 42.7 46.4 2.1 14.6 13.8Inconvenient to use 0.5 2.5 8.9 0.3 0.0 0.5 0.0Interferes with body’s normal 9.3 6.3 3.3 3.6 3.7 3.2 0.0processTotal (w) 92.3 82.3 83.1 76.1 96.3 51.9 28.2Not specifiedO<strong>the</strong>r reasons 3.3 1.3 12.7 2.8 0.5 15.6 16.1Don’t know 3.8 2.5 1.9 7.0 1.1 1.6 4.9Miss<strong>in</strong>g/non-response 0.0 1.3 1.9 0.6 0.0 1.6 0.0Total not specified 7.1 5.1 16.4 10.4 1.6 17.2 21.0TOTAL 100.0 100.0 100.0 100.0 100.0 100.0 100.0(N) (182) (79) (213) (644) (561) (377) (1,030)a/w ratio 0.01 0.15 0.01 0.18 0.02 0.07 1.80Source: DHS reports for specified countries.Note: Excludes women who are past menopause or have had a hysterectomy, have <strong>in</strong>frequent sex, are <strong>in</strong>fecund or subfecund, or wantas many children as possible. The group of women <strong>in</strong>cluded <strong>in</strong> <strong>the</strong> table is not <strong>the</strong> same as those who currently have an unmet needfor contraception because some of <strong>the</strong> women who currently have an unmet need may <strong>in</strong>tend to use contraception <strong>in</strong> <strong>the</strong> future,<strong>in</strong> which case <strong>the</strong>y would be excluded from this table. Women with an unmet need who do not <strong>in</strong>tend to use contraception <strong>in</strong> <strong>the</strong>future would be <strong>in</strong>cluded <strong>in</strong> this table.<strong>and</strong> <strong>the</strong> extreme isolation of many rural villages <strong>in</strong> thatcountry. To some extent <strong>the</strong>se characteristics are alsopresent <strong>in</strong> Solomon Isl<strong>and</strong>s, <strong>and</strong> this would expla<strong>in</strong> why<strong>the</strong> proportion of women cit<strong>in</strong>g lack of access as a reasonfor not us<strong>in</strong>g contraception is second highest after PapuaNew Gu<strong>in</strong>ea.In o<strong>the</strong>r countries, however, <strong>the</strong> majority of women who donot <strong>in</strong>tend to use contraception <strong>in</strong> <strong>the</strong> future are “unwill<strong>in</strong>g”to do so because of some form of opposition (<strong>the</strong>ir own oro<strong>the</strong>rs) to family plann<strong>in</strong>g or concerns about health <strong>and</strong>side effects. In Samoa <strong>and</strong> Tuvalu, more than 90 per cent ofrespondents report <strong>the</strong>se concerns, whereas only 28.2 percent of women <strong>in</strong> Papua New Gu<strong>in</strong>ea do. The proportionof women who provide o<strong>the</strong>r (unspecified) reasons or “don’tknow” is low <strong>in</strong> Nauru, Samoa <strong>and</strong> Tuvalu, but higher <strong>in</strong><strong>the</strong> o<strong>the</strong>r countries, especially Papua New Gu<strong>in</strong>ea.The f<strong>in</strong>al row of Table 9 shows <strong>the</strong> ratio of ability/will<strong>in</strong>gness as an explanation for <strong>the</strong> lack of <strong>in</strong>tention touse contraception. In six out of <strong>the</strong> seven countries thisratio is low, show<strong>in</strong>g that unwill<strong>in</strong>gness, not <strong>in</strong>ability, is <strong>the</strong>ma<strong>in</strong> factor underly<strong>in</strong>g <strong>the</strong> unmet need for contraception,aside from fertility preferences. The exception is, as alreadynoted, Papua New Gu<strong>in</strong>ea, where difficulty of access is <strong>the</strong>ma<strong>in</strong> barrier to <strong>the</strong> use of contraception.90

Of those who are “unwill<strong>in</strong>g” to use contraception, a fearof side effects is <strong>the</strong> predom<strong>in</strong>ant reason given <strong>in</strong> threecountries. In <strong>the</strong> o<strong>the</strong>r countries, some form of oppositionis <strong>the</strong> ma<strong>in</strong> reason. When fear of side effects is comb<strong>in</strong>edwith health concerns or “<strong>in</strong>terferes with <strong>the</strong> body’s normalprocesses”, issues relat<strong>in</strong>g to health <strong>and</strong> side effects accountfor <strong>the</strong> largest number of responses among women who donot <strong>in</strong>tend to use contraception. In Kiribati <strong>and</strong> Samoa,however, opposition to family plann<strong>in</strong>g is <strong>the</strong> predom<strong>in</strong>antresponse. In Samoa 70.2 per cent of women who do not<strong>in</strong>tend to use contraception <strong>in</strong> <strong>the</strong> future mentioned<strong>in</strong>dividual opposition to family plann<strong>in</strong>g as <strong>the</strong> reason.However, <strong>in</strong> no country did husb<strong>and</strong>’s opposition accountfor more than 5.5 per cent of <strong>the</strong> responses. Religiousopposition to family plann<strong>in</strong>g was significant only <strong>in</strong>Kiribati <strong>and</strong> Nauru, countries that have a large Catholicpopulation.Several prelim<strong>in</strong>ary conclusions may be drawn from <strong>the</strong>sedata: (a) lack of access to contraceptives does not appearto be <strong>the</strong> ma<strong>in</strong> cause of high unmet need, o<strong>the</strong>r than <strong>in</strong>Papua New Gu<strong>in</strong>ea, which is a somewhat special case.This is consistent with o<strong>the</strong>r f<strong>in</strong>d<strong>in</strong>gs <strong>in</strong> DHS that showthat knowledge of contraceptive methods is relatively high<strong>and</strong> most people know where to obta<strong>in</strong> <strong>the</strong>m; (b) <strong>the</strong>pr<strong>in</strong>ciple cause of unmet need is not <strong>the</strong> unavailability ofcontraceptive methods but <strong>the</strong> unwill<strong>in</strong>gness of women touse <strong>the</strong>m; (c) <strong>the</strong> ma<strong>in</strong> reason that women are unwill<strong>in</strong>g touse contraception has to do with <strong>the</strong> methods <strong>the</strong>mselves<strong>and</strong> <strong>the</strong>ir impact (real or perceived) on women’s health or<strong>the</strong> physical or psychological discomfort that <strong>the</strong> methodsmight cause; (d) opposition to contraception by husb<strong>and</strong>s oro<strong>the</strong>r persons is a negligible factor but religious oppositionis significant <strong>in</strong> some countries; (e) opposition on <strong>the</strong> partof <strong>the</strong> respondent herself is very significant <strong>in</strong> Samoa <strong>and</strong>somewhat significant <strong>in</strong> Nauru, but not elsewhere. (InSamoa, <strong>the</strong>re is a possibility that <strong>the</strong> very high proportionof “respondent opposed” may be a result of poor <strong>in</strong>terviewmethods, particularly <strong>in</strong>sufficient prob<strong>in</strong>g).Programme implications of <strong>the</strong>f<strong>in</strong>d<strong>in</strong>gs of Demographic <strong>and</strong>Health SurveysOpposition to family plann<strong>in</strong>gThe implications of <strong>the</strong> DHS results discussed abovedepend on <strong>the</strong> country <strong>in</strong> question, as <strong>the</strong>re is considerablevariation between countries. The first po<strong>in</strong>t to be madeis that DHS results need to be supplemented by fur<strong>the</strong>rfocused social research. The f<strong>in</strong>d<strong>in</strong>g that 70 per cent ofwomen <strong>in</strong> Samoa who do not <strong>in</strong>tend to use contraception<strong>in</strong> <strong>the</strong> future mention that <strong>the</strong>y are “opposed” to familyplann<strong>in</strong>g is a clear example. Before plann<strong>in</strong>g <strong>in</strong>terventionsto address such opposition, it is important to determ<strong>in</strong>e ifthis is a valid result or ra<strong>the</strong>r a consequence of <strong>in</strong>terviewmethods. It is possible, for example, that <strong>in</strong>terviewersoverused this broad category <strong>and</strong> did not dist<strong>in</strong>guishbetween <strong>the</strong> various reasons why women could be opposed.In itself, “opposition” on <strong>the</strong> part of <strong>the</strong> respondent is notvery <strong>in</strong>formative. In Nauru, respondent opposition wasalso significant, but unlike <strong>in</strong> Samoa, religious oppositionwas also an important reason for not <strong>in</strong>tend<strong>in</strong>g to usecontraception. In Kiribati, religious opposition was also<strong>the</strong> primary reason for women be<strong>in</strong>g unwill<strong>in</strong>g to usecontraception – substantially overshadow<strong>in</strong>g health issuesor fear of side effects.Religious opposition to family plann<strong>in</strong>g is a difficult issueto address as all <strong>in</strong>dividuals have <strong>the</strong> right to practise<strong>the</strong>ir religion <strong>and</strong> follow its precepts. It is not <strong>the</strong> role offamily plann<strong>in</strong>g providers to change religious views. S<strong>in</strong>cemost religious opposition <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> comes from <strong>the</strong>Catholic Church, <strong>the</strong> issue to be <strong>in</strong>vestigated is whe<strong>the</strong>rrespondents understood that “natural” family plann<strong>in</strong>g isacceptable to <strong>the</strong> Church. The “ovulation” method is taughtby family plann<strong>in</strong>g nurses <strong>in</strong> most countries, even thoughit is understood that this method it has a high failure rate.Side effects <strong>and</strong> health concernsIt is clear that <strong>the</strong> primary issue that needs to be addressed<strong>in</strong> most countries where unmet need is high is <strong>the</strong>perceived health consequences of contraception, <strong>in</strong>clud<strong>in</strong>g<strong>the</strong> question of “side effects”. That some women experienceside effects, especially with hormonal methods <strong>and</strong> IUDs,is <strong>in</strong>disputable. Whe<strong>the</strong>r <strong>the</strong> women who cite fear of sideeffects have actually experienced <strong>the</strong>m <strong>the</strong>mselves or arerespond<strong>in</strong>g to generally held beliefs with<strong>in</strong> <strong>the</strong> community,however, cannot be determ<strong>in</strong>ed from DHS. Fur<strong>the</strong>r<strong>in</strong>vestigation, possibly us<strong>in</strong>g focus group methods, mightbe needed to clarify this question. In small communities,one or two bad experiences with a contraceptive are likelyto become well known throughout a community, rais<strong>in</strong>g<strong>the</strong> fear level even higher 22 . More generalized concernsmay well be based on <strong>in</strong>correct <strong>in</strong>formation, such as claimsthat a method could result <strong>in</strong> sterility. Studies are neededthat focus on what women <strong>and</strong> men actually know aboutvarious methods, <strong>in</strong>clud<strong>in</strong>g how <strong>the</strong>y work <strong>and</strong> what <strong>the</strong>irpotential health consequences might be. Only when <strong>the</strong>basis of women’s fears can be identified will it be possible todesign programmes to address <strong>the</strong>m, although forewarn<strong>in</strong>gwomen about <strong>the</strong> possibility of side effects can reduce <strong>the</strong>likelihood of discont<strong>in</strong>uation.Where unmet need is low due to family size preferences,<strong>the</strong> central question is whe<strong>the</strong>r it is <strong>the</strong> function of a91

family plann<strong>in</strong>g programme to attempt to change familysize preferences. ICPD championed <strong>in</strong>dividual sovereigntyover family size decisions <strong>and</strong> promoted <strong>in</strong>dividual needsover demographic targets 23 . This would appear to rule out<strong>the</strong> promotion of small families <strong>in</strong> general by governments,<strong>in</strong>clud<strong>in</strong>g family plann<strong>in</strong>g workers. However, familyplann<strong>in</strong>g workers obviously have a role to play <strong>in</strong> promot<strong>in</strong>g<strong>the</strong> concept of birth spac<strong>in</strong>g <strong>in</strong> <strong>the</strong> <strong>in</strong>terest of ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g<strong>the</strong> health of mo<strong>the</strong>rs <strong>and</strong> children. As Bhushan (1997)po<strong>in</strong>ted out, however, <strong>the</strong>re is someth<strong>in</strong>g of a paradox <strong>in</strong><strong>the</strong> concept of unmet need: “[O]<strong>the</strong>r th<strong>in</strong>gs be<strong>in</strong>g equal,<strong>in</strong>crease <strong>in</strong> contraceptive use decreases unmet need,whereas <strong>in</strong>crease <strong>in</strong> potential dem<strong>and</strong> <strong>in</strong>creases unmetneed”. Thus, <strong>the</strong> effort to promote child-spac<strong>in</strong>g amongwomen who do not already have an unmet need for spac<strong>in</strong>gwill <strong>in</strong>crease unmet need by <strong>in</strong>creas<strong>in</strong>g potential dem<strong>and</strong>– unless <strong>the</strong> additional unmet need created is immediatelycompensated for by an <strong>in</strong>crease <strong>in</strong> contraceptive use.This essentially br<strong>in</strong>gs <strong>the</strong> issue back to <strong>the</strong> reasons whywomen who currently have an unmet need do not <strong>in</strong>tendto use contraception <strong>in</strong> <strong>the</strong> future. An <strong>in</strong>crease <strong>in</strong> dem<strong>and</strong>without address<strong>in</strong>g current health concerns might beconsidered counterproductive 24 .AccessIn situations such as those found <strong>in</strong> Papua New Gu<strong>in</strong>ea,where a large component of unmet need is related to lackof knowledge <strong>and</strong> lack of access, <strong>the</strong> policy implications areclearer. As noted previously, <strong>in</strong> <strong>the</strong> 2006 DHS of PapuaNew Gu<strong>in</strong>ea, 43.4 per cent of currently married womenwho said that <strong>the</strong>y did not <strong>in</strong>tend to use contraception<strong>in</strong> <strong>the</strong> future <strong>in</strong>dicated that <strong>the</strong>y had no knowledge of amethod of contraception, as compared with 14.4 per centwho mentioned some form of opposition <strong>and</strong> 13.8 percent who mentioned fear of side effects. Clearly, <strong>in</strong> PapuaNew Gu<strong>in</strong>ea <strong>the</strong>re is a need to exp<strong>and</strong> knowledge of familyplann<strong>in</strong>g, but, as already noted, exp<strong>and</strong><strong>in</strong>g knowledge hasto go h<strong>and</strong> <strong>in</strong> h<strong>and</strong> with <strong>in</strong>creas<strong>in</strong>g services <strong>and</strong> supplies,as well as address<strong>in</strong>g opposition <strong>and</strong> side effects. It wouldappear that <strong>the</strong> reverse is also true: exp<strong>and</strong><strong>in</strong>g supplies<strong>and</strong> services without improv<strong>in</strong>g <strong>the</strong> quality of couples’<strong>and</strong> <strong>in</strong>dividuals’ knowledge about methods would notnecessarily <strong>in</strong>crease contraceptive use.Target<strong>in</strong>g specific groups with anunmet needBecause fertility preferences change through time, it hasbeen argued (Casterl<strong>in</strong>e <strong>and</strong> S<strong>in</strong>d<strong>in</strong>g, 2000) that <strong>in</strong>dividualscan move <strong>in</strong> <strong>and</strong> out of <strong>the</strong> state of unmet need, mak<strong>in</strong>g itimpossible to monitor which <strong>in</strong>dividuals have an unmetneed at a specific po<strong>in</strong>t <strong>in</strong> time. These authors argue thatit is <strong>in</strong>appropriate to expect health <strong>and</strong> family plann<strong>in</strong>gworkers to monitor <strong>the</strong> fertility preferences of <strong>in</strong>dividuals.The approach <strong>the</strong>y advocate is for programme managersto “be well <strong>in</strong>formed about <strong>the</strong> societal-specific causes ofunmet need <strong>and</strong>, accord<strong>in</strong>gly, develop <strong>in</strong>terventions toovercome those obstacles”. However, <strong>the</strong>y also acknowledgethat <strong>the</strong> socio-economic characteristics of persons withunmet need may be more stable than <strong>the</strong> status of specific<strong>in</strong>dividuals whose circumstances change through time.Accord<strong>in</strong>gly, <strong>the</strong>re is a case for develop<strong>in</strong>g programmesthat are aimed at those groups that are more likely to havean unmet need than o<strong>the</strong>r groups.Until recent DHS were conducted <strong>in</strong> <strong>the</strong> <strong>Pacific</strong>, it wouldhave been reasonable to assume that women liv<strong>in</strong>g <strong>in</strong> rural<strong>and</strong> remote areas would be much more likely to have anunmet need for family plann<strong>in</strong>g than women liv<strong>in</strong>g <strong>in</strong>urban centres. In <strong>the</strong> <strong>Pacific</strong> <strong>the</strong> term “rural” residence oftenimplies outer-isl<strong>and</strong>s that suffer from costly <strong>and</strong> <strong>in</strong>frequenttransport, poor health services (<strong>in</strong>clud<strong>in</strong>g difficulties <strong>in</strong>reta<strong>in</strong><strong>in</strong>g staff <strong>and</strong> keep<strong>in</strong>g stocks of medic<strong>in</strong>e up to date).However DHS results <strong>in</strong>dicate that <strong>the</strong>re is no strictdeterm<strong>in</strong>ism between rural <strong>and</strong> urban residence <strong>in</strong> crosscountrycomparison, whe<strong>the</strong>r <strong>the</strong> <strong>in</strong>dicator employed isCPR or <strong>the</strong> percentage of women with an unmet need. Asalready noted, <strong>in</strong> some countries unmet need is higher <strong>in</strong>urban areas than <strong>in</strong> rural areas <strong>and</strong> this is also true of CPR.In some countries <strong>the</strong>re is little difference. It is notable that<strong>in</strong> <strong>the</strong> two countries with <strong>the</strong> highest unmet need (PapuaNew Gu<strong>in</strong>ea <strong>and</strong> Samoa), <strong>the</strong>re is no apparent differencebetween rural <strong>and</strong> urban areas 25 .On <strong>the</strong> basis of such data, it is not possible to say thatfamily plann<strong>in</strong>g programmes are generally weaker <strong>in</strong> ruralthan urban areas. The only possible generalization from<strong>the</strong> data is that each country is different <strong>and</strong> programmesneed to be tailored to specific national circumstances.As with rural-urban differences, it would have beenreasonable on logical grounds to assume that <strong>the</strong> moreeducated women would have lower unmet need <strong>and</strong>higher contraceptive use. This expectation arises from <strong>the</strong>probability that <strong>the</strong> more educated women would havemore knowledge of family plann<strong>in</strong>g methods <strong>and</strong> be morelikely employed <strong>in</strong> paid work outside <strong>the</strong> home. However<strong>the</strong> association between education <strong>and</strong> reproductivebehaviour was already questioned <strong>in</strong> earlier KAP studiesconducted <strong>in</strong> <strong>the</strong> <strong>Pacific</strong>. The 1995 KAP study carriedout <strong>in</strong> Vanuatu found that unmet need for effective familyplann<strong>in</strong>g among currently married (or <strong>in</strong> union) womenwas 49.1 per cent for women with college or universityeducation <strong>and</strong> 49.7 per cent for women who had “no92

school<strong>in</strong>g” (House, 1999a). When all methods (both<strong>in</strong>effective <strong>and</strong> effective) were <strong>in</strong>cluded, unmet need amongwomen with only primary education (30.9%) was virtuallyidentical to that of women with some college or universityeducation (30.8%). After look<strong>in</strong>g at several <strong>in</strong>dicators offertility behaviour, House (1999a) concluded: “… fertilityseems to have a limited response to <strong>in</strong>creas<strong>in</strong>g educationat this stage of Vanuatu’s development <strong>and</strong> demographictransition”. This f<strong>in</strong>d<strong>in</strong>g foreshadowed by more than adecade <strong>the</strong> f<strong>in</strong>d<strong>in</strong>gs of <strong>the</strong> recent DHS <strong>in</strong> seven countries,which produced similar results.To some extent, however, <strong>the</strong> actual associations betweeneducation <strong>and</strong> unmet need vary between countries. InPapua New Gu<strong>in</strong>ea, women with no education havemuch higher unmet need than women with secondaryeducation; <strong>in</strong> Samoa, women with only primary educationhave higher unmet need than women with more than asecondary level, so <strong>in</strong> <strong>the</strong>se countries <strong>the</strong> relationship is<strong>in</strong> <strong>the</strong> expected direction. Aga<strong>in</strong>, <strong>the</strong> programme responsewould have to be tailored to <strong>the</strong> particular circumstancesof each country.The ICPD Programme of Action recommended that<strong>in</strong> seek<strong>in</strong>g to assess <strong>the</strong> extent of unmet need for goodqualityfamily plann<strong>in</strong>g services, countries should “payparticular attention to vulnerable <strong>and</strong> underserved groups”.As <strong>the</strong> analysis <strong>in</strong> this paper has shown, DHS do not fullyaccomplish this task <strong>in</strong> all sett<strong>in</strong>gs <strong>and</strong> additional researchus<strong>in</strong>g both quantitative <strong>and</strong> qualitative methods is needed.There is little doubt, however, that young, unmarriedpeople are both “vulnerable” <strong>and</strong> “underserved”. To someextent this is evident <strong>in</strong> <strong>the</strong> teenage fertility rate, whichis high <strong>in</strong> some countries <strong>and</strong> does not appear to follow<strong>the</strong> general fertility trend. Recourse to illegal abortion byyoung people is ano<strong>the</strong>r <strong>in</strong>dicator, although statistical dataare hard to come by 26 .Commodity securityCommodity security plansReproductive health commodity security (RHCS) hasreceived a great deal of attention <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> isl<strong>and</strong>sover <strong>the</strong> past decade. In 2003, <strong>Pacific</strong> m<strong>in</strong>isters of healthagreed to <strong>the</strong> Reproductive Health Commodity SecurityPlan of Action for <strong>the</strong> region. The Regional Workshop onRHCS was subsequently conducted <strong>in</strong> 2004 for healthpersonnel from <strong>Pacific</strong> isl<strong>and</strong> countries. In 2008, <strong>Pacific</strong>m<strong>in</strong>isters of health endorsed <strong>the</strong> <strong>Pacific</strong> Policy Frameworkfor Achiev<strong>in</strong>g Universal Access to Reproductive HealthServices <strong>and</strong> Commodities. Dur<strong>in</strong>g <strong>the</strong> period 2005-2008,<strong>the</strong> UNFPA <strong>Pacific</strong> Sub-regional Office <strong>in</strong> Fiji carried outdetailed assessments of <strong>the</strong> status of reproductive healthcommodity security <strong>in</strong> 10 <strong>Pacific</strong> isl<strong>and</strong> countries. Some of<strong>the</strong>se assessments were follow-ups on earlier assessmentsconducted with<strong>in</strong> <strong>the</strong> previous five years, thus changesthrough time have also been assessed. Evidence-basedGuidel<strong>in</strong>es <strong>in</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> for Health Personnel havealso been prepared for several <strong>Pacific</strong> isl<strong>and</strong> countries,which also cover commodity security <strong>and</strong> related topics.These assessments have been comprehensive, cover<strong>in</strong>g <strong>the</strong>full range of issues connected with commodity security,<strong>in</strong>clud<strong>in</strong>g <strong>the</strong> follow<strong>in</strong>g:Legislative framework <strong>and</strong> its impact on contraceptiveavailability <strong>and</strong> quality controlPolicy framework <strong>and</strong> <strong>the</strong> level of politicalcommitmentCoord<strong>in</strong>ation between components of <strong>the</strong> healthsystem, NGOs, <strong>and</strong> o<strong>the</strong>rsLogistical systems for manag<strong>in</strong>g stockMethods of forecast<strong>in</strong>g <strong>and</strong> mak<strong>in</strong>g procurementarrangementsInclusion of contraceptives on “essential drugs list”Ma<strong>in</strong>tenance of records <strong>and</strong> compilation of statisticsSupervisionThe quality <strong>and</strong> scope of <strong>the</strong>se assessments is somewhatvariable <strong>and</strong> <strong>the</strong>refore <strong>the</strong> results are not easily summarized.In general, much less attention has been paid to <strong>the</strong>situation <strong>in</strong> rural areas or outer isl<strong>and</strong>s, ma<strong>in</strong>ly because of<strong>the</strong> lack of, or high costs associated with, transportation<strong>and</strong> <strong>the</strong> limited amount of time available to <strong>the</strong> assessors.The results of <strong>the</strong>se assessments cannot be discussed <strong>in</strong>detail here, but <strong>the</strong> overall impression <strong>the</strong>y give is that <strong>the</strong>reare no significant legislative barriers to <strong>the</strong> purchase orsupply of contraceptives <strong>in</strong> <strong>the</strong>se countries <strong>and</strong> <strong>the</strong> overallpolicy stance of governments is positive. Some countriesstill have regulations <strong>in</strong> place that require a husb<strong>and</strong>’ssignature before a tubal ligation procedure can be carriedout, <strong>and</strong> this requirement is seen by some women to bea constra<strong>in</strong>t upon <strong>the</strong>ir reproductive rights, but suchregulations are undergo<strong>in</strong>g review. While “stockouts” (asituation which occurs when <strong>the</strong> dem<strong>and</strong> or requirementfor an item cannot be fulfilled from <strong>the</strong> current <strong>in</strong>ventory)are reported <strong>in</strong> most countries, <strong>the</strong>re are no precise figureson how frequently <strong>the</strong>se occur <strong>and</strong> to what extent womenare unprotected aga<strong>in</strong>st unwanted pregnancy <strong>and</strong> for howlong. In most countries, contraceptives have been placedon <strong>the</strong> “essential medic<strong>in</strong>e list” <strong>in</strong> order to guarantee <strong>the</strong>security of supplies.93

As far as <strong>the</strong> supply of contraceptive commodities isconcerned, <strong>the</strong> general arrangement <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> is thatUNFPA purchases <strong>and</strong> pays for contraceptives <strong>and</strong> o<strong>the</strong>rsupplies <strong>and</strong> equipment on behalf of governments fordistribution by government-operated health facilities,usually public health centres or cl<strong>in</strong>ics or, <strong>in</strong> larger centres,a dedicated reproductive health cl<strong>in</strong>ic attached to a hospitalor o<strong>the</strong>r health facility. In one or two countries, UNFPApurchases commodities on behalf of <strong>the</strong> government ona “third party” procurement arrangement, with <strong>the</strong> costscovered <strong>in</strong> <strong>the</strong> government budget. Ano<strong>the</strong>r modalityof purchase <strong>and</strong> supply is through NGOs, often <strong>Family</strong>Health Associations (FHA) affiliated with IPPF. FHAsobta<strong>in</strong> supplies through IPPF, generally at low or no cost.F<strong>in</strong>ally, <strong>in</strong> some countries, contraceptives are available <strong>in</strong>pharmacies which purchase <strong>the</strong>ir supplies from normalwholesale suppliers based overseas. Because of its highHIV prevalence rate, Papua New Gu<strong>in</strong>ea is a somewhatspecial case with several <strong>in</strong>ternational donors provid<strong>in</strong>gcondoms. O<strong>the</strong>r contraceptives <strong>and</strong> commodities areprovided through <strong>the</strong> health budget <strong>and</strong> <strong>the</strong> <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Association.In general, <strong>the</strong> distribution <strong>and</strong> dispens<strong>in</strong>g of contraceptives<strong>in</strong> <strong>the</strong> develop<strong>in</strong>g <strong>Pacific</strong> countries is based upon a threetiersystem:(a) Government-operated public health facilities associatedwith maternal <strong>and</strong> child health services or reproductivehealth cl<strong>in</strong>ics. Services are generally free <strong>and</strong> suppliesare provided by UNFPA.(b) <strong>Family</strong> Health Associations (<strong>Family</strong> WelfareAssociations <strong>in</strong> some countries) affiliated with IPPF<strong>and</strong> with supplies <strong>and</strong> commodities furnished by IPPF.O<strong>the</strong>r NGOs (such as YWCA or generic youth clubs)also distribute contraceptives <strong>and</strong> provide reproductivehealth services. In some countries NGOs are suppliedby <strong>the</strong> government, with UNFPA be<strong>in</strong>g <strong>the</strong> ultimatesupplier.(c) Private pharmacies <strong>and</strong>/or doctors <strong>in</strong> private practicewho dispense contraceptives ei<strong>the</strong>r on an over-<strong>the</strong>counterbasis or by means of prescription. Theseoutlets tend to be concentrated <strong>in</strong> urban areas.Although <strong>the</strong>re are shortcom<strong>in</strong>gs <strong>in</strong> <strong>the</strong> reliability ofcontraceptive supplies <strong>and</strong> <strong>the</strong>re is room for improv<strong>in</strong>glogistical arrangements, commodity security has greatlyimproved <strong>in</strong> recent years <strong>and</strong> <strong>the</strong> prospects for fur<strong>the</strong>rimprovement rema<strong>in</strong> quite good. As <strong>in</strong> so many o<strong>the</strong>rareas to do with <strong>the</strong> delivery of health services, PapuaNew Gu<strong>in</strong>ea is a special case. This arises from <strong>the</strong> fact thatPapua New Gu<strong>in</strong>ea rema<strong>in</strong>s a predom<strong>in</strong>antly rural, villagesociety. A significant proportion of village-based healthfacilities (aid posts) have closed <strong>in</strong> recent years due to <strong>the</strong>difficulty of ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g staff, law-<strong>and</strong>-order problems<strong>and</strong> <strong>the</strong> shortages of supplies. The extreme remotenessof so many rural villages makes commodity security verydifficult to achieve.Supply cha<strong>in</strong> <strong>and</strong> logisticsmanagementEnsur<strong>in</strong>g a secure, timely <strong>and</strong> reliable supply of contraceptivesfor all persons who wish to use <strong>the</strong>m is a strategy thathas received substantial technical <strong>and</strong> f<strong>in</strong>ancial supportover <strong>the</strong> past several years <strong>in</strong> <strong>Pacific</strong> isl<strong>and</strong> countries. Thekey organizations provid<strong>in</strong>g it are: UNFPA, AustralianAgency for <strong>International</strong> Development (AusAID), NewZeal<strong>and</strong> Agency for <strong>International</strong> Development (NZAid)<strong>and</strong> IPPF.As a result of this support, contraceptive choice hasbroadened from oral contraceptives, condoms <strong>and</strong><strong>in</strong>jectables to <strong>in</strong>clude emergency contraceptive pills,implants <strong>and</strong> female condoms. Tubal ligations are performed<strong>in</strong> many countries <strong>in</strong> urban areas, <strong>and</strong> vasectomies <strong>in</strong> a fewcountries, although dem<strong>and</strong> for <strong>the</strong> latter is low.Reproductive health policies <strong>and</strong>strategiesThe <strong>in</strong>corporation of reproductive health, <strong>in</strong>clud<strong>in</strong>g familyplann<strong>in</strong>g, <strong>in</strong>to national <strong>and</strong> subnational developmentplans <strong>and</strong> sector plans is well advanced <strong>in</strong> most <strong>Pacific</strong>isl<strong>and</strong> countries, but sexual health <strong>and</strong> family plann<strong>in</strong>g<strong>in</strong>itiatives target<strong>in</strong>g specific groups are less evident. Nearlyall develop<strong>in</strong>g <strong>Pacific</strong> isl<strong>and</strong> countries <strong>and</strong> territories(<strong>the</strong> Cook Isl<strong>and</strong>s, <strong>the</strong> Federated States of Micronesia,Fiji, Kiribati, Marshall Isl<strong>and</strong>s, Nauru, Samoa, SolomonIsl<strong>and</strong>s, Tonga, Tuvalu <strong>and</strong> Vanuatu) have developed or are<strong>in</strong> <strong>the</strong> process of develop<strong>in</strong>g national reproductive healthpolicies <strong>and</strong> strategies <strong>in</strong> which voluntary <strong>and</strong> rights-basedfamily plann<strong>in</strong>g is a core component. As DHS surveys arerecent <strong>and</strong> as yet not fully analysed, it has not been possibleto target specific groups, o<strong>the</strong>r than adolescents, whoseneeds are addressed largely by <strong>Family</strong> Health Associationsor o<strong>the</strong>r NGOs.Fund<strong>in</strong>g sourcesUNFPA is <strong>the</strong> primary fund<strong>in</strong>g source for contraceptivecommodities <strong>and</strong> o<strong>the</strong>r reproductive health supplies <strong>in</strong><strong>the</strong> smaller <strong>Pacific</strong> isl<strong>and</strong> countries. UNFPA has beenadvocat<strong>in</strong>g, with very limited success, for many yearsamong m<strong>in</strong>isters of health to <strong>in</strong>clude funds <strong>in</strong> <strong>the</strong>ir ownhealth budgets for <strong>the</strong> purchase of contraceptives. Largerisl<strong>and</strong> countries, such as Fiji <strong>and</strong> Papua New Gu<strong>in</strong>ea,purchase <strong>the</strong> bulk of <strong>the</strong>ir supplies through <strong>the</strong>ir own94

udgets, supplemented by donor fund<strong>in</strong>g – particularly <strong>in</strong>Papua New Gu<strong>in</strong>ea where <strong>the</strong> HIV epidemic has reacheda serious level (Hayes, 2007).L<strong>in</strong>kages to o<strong>the</strong>r reproductivehealth issuesHIV <strong>and</strong> o<strong>the</strong>r sexually transmitted<strong>in</strong>fectionsAs <strong>in</strong> many o<strong>the</strong>r parts of <strong>the</strong> world, a large proportionof <strong>the</strong> population <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> will never come <strong>in</strong>tocontact with HIV or o<strong>the</strong>r STI health services, despitesignificant numbers of people be<strong>in</strong>g at risk of STIs due to<strong>the</strong>ir practice of unsafe sex. Self-referral for STIs or HIVrema<strong>in</strong>s relatively uncommon <strong>and</strong> is usually restricted tosymptomatic <strong>in</strong>dividuals – however many cases of STI <strong>and</strong><strong>in</strong>deed <strong>the</strong> early stages of HIV rema<strong>in</strong> asymptomatic. Thispoor uptake of HIV/STI services rema<strong>in</strong>s problematic,facilitat<strong>in</strong>g fur<strong>the</strong>r transmission <strong>and</strong> caus<strong>in</strong>g significantimpacts on reproductive health – such as via neonataltransmission, reproductive system symptoms, <strong>in</strong>fertility<strong>and</strong> o<strong>the</strong>r STI-related morbidities. As such, l<strong>in</strong>kagesbetween HIV, family plann<strong>in</strong>g <strong>and</strong> broader sexual <strong>and</strong>reproductive health services provide multiple benefits ofexp<strong>and</strong>ed coverage of HIV/STI care, reduced HIV/STIrelatedmorbidity <strong>and</strong> mortality <strong>and</strong> improved reproductivehealth outcomes.It is thus relevant <strong>and</strong> advantageous to offer HIV- <strong>and</strong>o<strong>the</strong>r STI-related care <strong>in</strong> reproductive health sett<strong>in</strong>gs,such as family plann<strong>in</strong>g services. Specific promotion ofcondoms with<strong>in</strong> family plann<strong>in</strong>g, as <strong>the</strong> only currentlyeffective barrier contraceptive, also gives fur<strong>the</strong>r uniqueadvantages – dual protection (aga<strong>in</strong>st both unplannedpregnancy <strong>and</strong> HIV/STIs), <strong>and</strong> <strong>the</strong> reduced side effects ofa s<strong>in</strong>gle-use contraceptive that is required only dur<strong>in</strong>g <strong>the</strong>sex act itself. Long-act<strong>in</strong>g contraceptives have undesirableside effects for many people. Such contraceptives have tocont<strong>in</strong>ue to be taken by <strong>the</strong> user even dur<strong>in</strong>g periods ofsexual <strong>in</strong>activity.A converse benefit occurs where people liv<strong>in</strong>g with HIVor o<strong>the</strong>r STIs are provided with effective family plann<strong>in</strong>gadvice. As part of comprehensive prevention of parent–tochildtransmission (PPTCT), it is imperative that peopleliv<strong>in</strong>g with HIV are provided with contraception to ensurethat any result<strong>in</strong>g pregnancy is planned <strong>and</strong> preparedfor <strong>in</strong> consultation with <strong>the</strong>ir health-care providers.Contraceptive advice is thus a core part of comprehensiveHIV care (prong 2 of PPTCT). The presentation ofpersons to family plann<strong>in</strong>g cl<strong>in</strong>ics is also a good opportunityto promote HIV test<strong>in</strong>g, referr<strong>in</strong>g persons diagnosed withHIV for follow-up <strong>and</strong> management, <strong>and</strong> counsell<strong>in</strong>gpersons found to be free of HIV on how to stay HIVnegative <strong>and</strong> reduce risks of future <strong>in</strong>fection (prong 1 ofPPTCT).Barriers to l<strong>in</strong>kages of HIV with family plann<strong>in</strong>g <strong>and</strong>o<strong>the</strong>r sexual <strong>and</strong> reproductive health services do exist,however. Often <strong>the</strong>se services are set up <strong>in</strong> a very verticalmanner with separate fund<strong>in</strong>g streams <strong>and</strong> health-carestaff – sometimes <strong>in</strong> different localities. Time constra<strong>in</strong>ts<strong>and</strong> cl<strong>in</strong>ic layouts that are not user-friendly can alsoh<strong>in</strong>der delivery of HIV/STI counsell<strong>in</strong>g <strong>in</strong> familyplann<strong>in</strong>g sett<strong>in</strong>gs. There can be (spurious) ownershipissues between staff over which cl<strong>in</strong>ic is go<strong>in</strong>g to providewhich services – <strong>in</strong> reality <strong>the</strong>re is noth<strong>in</strong>g stopp<strong>in</strong>g bothHIV <strong>and</strong> family plann<strong>in</strong>g services from provid<strong>in</strong>g carefor both needs. Sometimes, family plann<strong>in</strong>g cl<strong>in</strong>ic staffare not completely familiar or comfortable with rais<strong>in</strong>gHIV <strong>and</strong> STI issues, preferr<strong>in</strong>g to limit <strong>the</strong>ir guidance topurely contraceptive matters. This is a missed opportunity.At <strong>the</strong> community level, <strong>the</strong> paucity of sex education <strong>and</strong>stigmatiz<strong>in</strong>g attitudes towards HIV <strong>and</strong> o<strong>the</strong>r STIs createan unsupportive environment which fur<strong>the</strong>r reduces <strong>the</strong>chance of HIV <strong>and</strong> STI care be<strong>in</strong>g ei<strong>the</strong>r sought out oreffectively delivered.Some good examples of fully <strong>in</strong>tegrated adolescent sexual<strong>and</strong> reproductive health services exist, where <strong>the</strong>se “onestopshops” furnish a comprehensive range of sexual <strong>and</strong>reproductive health, HIV/STI, drug <strong>and</strong> adolescentcounsell<strong>in</strong>g <strong>and</strong> awareness, toge<strong>the</strong>r with HIV/STIdiagnosis <strong>and</strong> treatment (or at least referral for treatmentif required). These adolescent sexual <strong>and</strong> reproductivehealth services take full advantage of <strong>the</strong> opportunityaris<strong>in</strong>g from a young person attend<strong>in</strong>g <strong>in</strong> order to ensurea holistic approach to sexual <strong>and</strong> reproductive health care,<strong>in</strong>clud<strong>in</strong>g both pregnancy <strong>and</strong> disease-prevention advice<strong>and</strong> services. Broader reproductive health services, such as<strong>the</strong> ma<strong>in</strong>stream family plann<strong>in</strong>g cl<strong>in</strong>ics with<strong>in</strong> outpatientcl<strong>in</strong>ics, would significantly benefit from a similar one-stopshopapproach. When develop<strong>in</strong>g primary health-careservices, <strong>the</strong>re is a need to tra<strong>in</strong> <strong>and</strong> promote delivery ofcomprehensive sexual <strong>and</strong> reproductive health care by publichealth centre staff, <strong>in</strong>clud<strong>in</strong>g comb<strong>in</strong>ed family plann<strong>in</strong>g<strong>and</strong> HIV/STI advice <strong>and</strong> treatment for patients.Strategies for streng<strong>the</strong>n<strong>in</strong>g national capacity to identify<strong>and</strong> implement l<strong>in</strong>kages for sexual <strong>and</strong> reproductive health<strong>and</strong> HIV are currently be<strong>in</strong>g developed <strong>in</strong> <strong>the</strong> FederatedStates of Micronesia <strong>and</strong> Vanuatu. These <strong>in</strong>clude pre- <strong>and</strong><strong>in</strong>-service tra<strong>in</strong><strong>in</strong>g <strong>in</strong> family plann<strong>in</strong>g <strong>and</strong> HIV counsell<strong>in</strong>g<strong>and</strong> test<strong>in</strong>g.95

Socio-cultural challenges tofamily plann<strong>in</strong>gThe dem<strong>and</strong> for <strong>and</strong> supply ofchildrenLarge family size as a cultural normThe decl<strong>in</strong>e <strong>in</strong> <strong>in</strong>fant <strong>and</strong> child mortality rates from <strong>the</strong> laten<strong>in</strong>eteenth <strong>and</strong> early twentieth century <strong>in</strong>creased <strong>the</strong> supplyof children likely to survive to adulthood, thus <strong>in</strong>creas<strong>in</strong>g<strong>the</strong> <strong>in</strong>centive to employ fertility controls with<strong>in</strong> marriage.The ab<strong>and</strong>onment of customary practices that had limitedfertility <strong>in</strong> <strong>the</strong> pre-contact period also contributed to an<strong>in</strong>creas<strong>in</strong>g potential supply of surviv<strong>in</strong>g children. Thereis no evidence to support <strong>the</strong> proposition that any <strong>Pacific</strong>isl<strong>and</strong> culture sought to produce as many children as wasphysiologically possible for a woman to bear, or as manyas “God provided”. In areas where <strong>in</strong>ter-tribal warfarewas endemic <strong>the</strong>re was a belief that <strong>the</strong>re is “strength <strong>in</strong>numbers”, <strong>and</strong> <strong>the</strong>se beliefs persist today <strong>in</strong> some areas(Pataki-Schweitzer, 1996). In pre-contact times, however,pregnancy <strong>and</strong> childhood were well understood by bothwomen <strong>and</strong> men to carry risks to health <strong>and</strong> life, thuswomen were disposed to avoid excessive childbear<strong>in</strong>g bywhatever means were available. From a male perspective,contact with women was potentially debilitat<strong>in</strong>g <strong>in</strong> any case,<strong>and</strong> mak<strong>in</strong>g women pregnant was considered “work”. 27Missionary teach<strong>in</strong>g did not stress large families as such butra<strong>the</strong>r that <strong>the</strong> decision on <strong>the</strong> number of children that awoman would bear was not hers to make but ra<strong>the</strong>r God’s.Interference with God’s will <strong>in</strong> such matters was s<strong>in</strong>ful.In those areas that had experienced a massive <strong>in</strong>crease<strong>in</strong> mortality follow<strong>in</strong>g <strong>the</strong> <strong>in</strong>troduction of unfamiliar<strong>in</strong>fectious diseases, missionary views were functional<strong>in</strong> ensur<strong>in</strong>g that such decimated populations recovered<strong>the</strong>ir numbers. However pronatalist attitudes rema<strong>in</strong>edstrong for several generations afterwards, long after futurepopulation growth <strong>and</strong> cultural survival had been assured.However, <strong>the</strong>re is a wide range of evidence that suggeststhat a family of three or four children is still generallypreferred among <strong>Pacific</strong> peoples, who cont<strong>in</strong>ue to live <strong>in</strong> <strong>the</strong>rural village universe, <strong>and</strong> this accounts for <strong>the</strong> low level of“unmet need” for family plann<strong>in</strong>g <strong>in</strong> some countries. In someareas it is still believed that a man is not fully mature <strong>and</strong>qualified to participate as a full member of <strong>the</strong> communityuntil he has produced three children. The possibility thatsome of <strong>the</strong>se children may f<strong>in</strong>d employment overseas or<strong>in</strong> local towns eases <strong>the</strong> resource constra<strong>in</strong>ts that operated<strong>in</strong> earlier times when l<strong>and</strong>-tenure systems limited accessto l<strong>and</strong> beyond that owned by k<strong>in</strong> groups. As is apparentfrom <strong>the</strong> current low levels of fertility <strong>in</strong> such territoriesas French Polynesia, New Caledonia <strong>and</strong> <strong>the</strong> Nor<strong>the</strong>rnMariana Isl<strong>and</strong>s, however, high fertility is no longer anecessary component of <strong>the</strong> <strong>Pacific</strong> isl<strong>and</strong>s way of life.However, such low fertility countries <strong>and</strong> territories alsohave state-funded social security arrangements that providepeople with an <strong>in</strong>come <strong>in</strong> <strong>the</strong>ir old age, thus reduc<strong>in</strong>g <strong>the</strong>need for <strong>the</strong>m to rely on children for f<strong>in</strong>ancial support afterretirement. As already mentioned, not all of those <strong>Pacific</strong>societies that have access to overseas labour markets havepersistently high fertility. The case of Indo-Fijians proves<strong>the</strong> po<strong>in</strong>t, although this group is unique <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> <strong>in</strong>hav<strong>in</strong>g very limited access to l<strong>and</strong> resources. Indo-Fijianshave rapidly reduced <strong>the</strong>ir average family size <strong>in</strong> order totake advantage of opportunities to educate <strong>the</strong>ir childrenfor overseas employment.Sexuality of adolescents <strong>and</strong> youngpeopleIn most <strong>Pacific</strong> cultures, young people between <strong>the</strong> ageof puberty <strong>and</strong> early adulthood were given considerablefreedom to experiment <strong>in</strong> matters of sex <strong>and</strong> sexuality,although <strong>the</strong>re is much variation across <strong>and</strong> with<strong>in</strong> cultures.A very widespread belief, remnants of which exist today, isthat a young woman will become pregnant only if she hasrepeated <strong>in</strong>tercourse with <strong>the</strong> same partner. Switch<strong>in</strong>g ofpartners, it was believed, would ensure that a pregnancywould not occur. In Tahiti (<strong>in</strong> French Polynesia), well <strong>in</strong>to<strong>the</strong> modern era, mo<strong>the</strong>rs advised <strong>the</strong>ir daughters not tostay with one boyfriend for this reason (Levy, 1973). It isalso not uncommon for young men to prefer to marry awoman who has already given birth as visible proof thatshe is fertile, thus guarantee<strong>in</strong>g additional children.Adolescent sexuality, however, rema<strong>in</strong>s a highly contestedarea <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> <strong>and</strong> attitudes are chang<strong>in</strong>g very slowly.The view that sexuality education <strong>and</strong> <strong>the</strong> supply ofcontraceptives to young, unmarried people will leadto promiscuity result<strong>in</strong>g <strong>in</strong> unwanted pregnancy <strong>and</strong>br<strong>in</strong>g shame to <strong>the</strong> family is still widespread. In <strong>the</strong><strong>Pacific</strong>, adolescent pregnancy generally occurs outsidemarriage, unlike <strong>in</strong> Africa or India where teenage birthsresult primarily from early age of marriage. Where oldergatekeepers, <strong>in</strong>clud<strong>in</strong>g public health nurses <strong>and</strong> privatepharmacy staff, believe that access to contraceptives by<strong>the</strong> unmarried is contrary to <strong>the</strong> moral order of society,adolescents will have difficulty practis<strong>in</strong>g safe sex <strong>and</strong>avoid<strong>in</strong>g unwanted pregnancy.Gender <strong>and</strong> family relationsGender equality is far from be<strong>in</strong>g achieved <strong>in</strong> <strong>the</strong> <strong>Pacific</strong>,although it is not clear to what extent <strong>the</strong> current statusof gender relations affects fertility levels, <strong>the</strong> use ofcontraception <strong>and</strong> <strong>the</strong> unmet need for family plann<strong>in</strong>g.96

In general, opposition from husb<strong>and</strong>s is not cited bywomen as a major cause of <strong>the</strong>ir unwill<strong>in</strong>gness to usecontraception. However, <strong>the</strong> prevalence of gender-basedviolence is very high <strong>in</strong> those countries where researchhas been conducted, <strong>and</strong> it is likely that coercive sexualrelations results <strong>in</strong> unwanted pregnancy.Socio-cultural research on male attitudes towardscontraception <strong>and</strong> family plann<strong>in</strong>g <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> is limited;thus, more such research is needed.Conclusions <strong>and</strong>recommendationsConclusionsThis paper has reviewed recent micro- <strong>and</strong> macrolevelevidence of relationships between fertility trends,contraceptive prevalence <strong>and</strong> unmet need for familyplann<strong>in</strong>g <strong>in</strong> <strong>Pacific</strong> isl<strong>and</strong> countries. The ma<strong>in</strong> conclusionsfrom this analysis are as follows.There is evidence that <strong>the</strong> fertility transition has“stalled” <strong>in</strong> several <strong>Pacific</strong> isl<strong>and</strong> countries. The totalfertility rate is currently about 4.0 <strong>in</strong> 9 countries <strong>and</strong> <strong>in</strong>some of <strong>the</strong>se countries fertility has hardly changed forover a decade or even longer. However, <strong>in</strong> several o<strong>the</strong>rcountries <strong>and</strong> territories, fertility decl<strong>in</strong>e has cont<strong>in</strong>uedunabated. With <strong>the</strong> exception of Fiji, <strong>the</strong> countries thathave experienced an un<strong>in</strong>terrupted fertility transitionto <strong>the</strong> replacement or near-replacement level are thosethat are <strong>in</strong> some form of political dependency withmetropolitan states 28 . The particular features of <strong>the</strong>sepolitical l<strong>in</strong>ks that are conducive to fertility decl<strong>in</strong>ehave not been exam<strong>in</strong>ed <strong>in</strong> this study, but it is probablethat a comb<strong>in</strong>ation of higher per capita <strong>in</strong>comes, <strong>the</strong>availability of private medical care <strong>and</strong> health <strong>in</strong>surance,higher levels of education <strong>and</strong> greater formal labourforce participation among women are key factors. 29Similarly, contraceptive prevalence rates <strong>in</strong> many <strong>Pacific</strong>countries have rema<strong>in</strong>ed below <strong>the</strong> average for <strong>the</strong> lessdeveloped regions of <strong>the</strong> world <strong>and</strong> have <strong>in</strong>creasedat a slow pace or not at all over <strong>the</strong> past decade ormore. In some countries it is likely that official ratesare understated due to <strong>the</strong> exclusion of private healthproviders from health m<strong>in</strong>istry statistics, but surveybasedestimates generally capture all sources of supply.Notwithst<strong>and</strong><strong>in</strong>g <strong>the</strong>se measurement issues, several<strong>Pacific</strong> countries appear to fit a common pattern of rapidtake-up of family plann<strong>in</strong>g on <strong>the</strong> <strong>in</strong>itial establishmentof a programme followed by a plateau that may lastfor many years. This paper has not exam<strong>in</strong>ed <strong>the</strong>historical evidence underly<strong>in</strong>g <strong>the</strong> levell<strong>in</strong>g-off of <strong>the</strong>rate contraceptive use, but it is likely that a comb<strong>in</strong>ationof factors is responsible, <strong>in</strong>clud<strong>in</strong>g <strong>the</strong> follow<strong>in</strong>g:A preference for a family size of 3-4 children as aresult of <strong>the</strong> need for old-age security <strong>in</strong> <strong>the</strong> absenceof alternative sources of supportDissatisfaction with <strong>the</strong> available methods ofcontraception <strong>and</strong> <strong>the</strong> limited range of alternativesActual or perceived side effects, particularly due tohormonal methods <strong>and</strong> IUDsThe <strong>in</strong>fluence of some churches whose doctr<strong>in</strong>es donot allow <strong>in</strong>terference with <strong>the</strong> natural function<strong>in</strong>gof <strong>the</strong> human body, which <strong>in</strong>cludes opposition tosterilization ei<strong>the</strong>r of men or womenIn several Melanesian countries, notably Papua NewGu<strong>in</strong>ea, Solomon Isl<strong>and</strong>s <strong>and</strong> Vanuatu, fertility decl<strong>in</strong>ehas been slow, but <strong>the</strong> use of modern contraception has<strong>in</strong>creased quite steadily over <strong>the</strong> past two decades, evenaga<strong>in</strong>st many obstacles. The slow pace of fertility decl<strong>in</strong>e<strong>in</strong> <strong>the</strong>se countries is related <strong>in</strong> part to <strong>the</strong> slow decl<strong>in</strong>e <strong>in</strong>family size preferences, although <strong>in</strong> Papua New Gu<strong>in</strong>ea,<strong>the</strong> gap between <strong>the</strong> “wanted” TFR (3.0) <strong>and</strong> “actual”TFR (4.4) is now 1.4 children, a significantly smallerlevel than it was 20 years ago. Limited access to healthservices <strong>in</strong> general – <strong>and</strong> reproductive health services <strong>in</strong>particular – is constra<strong>in</strong><strong>in</strong>g <strong>the</strong> use of family plann<strong>in</strong>g<strong>in</strong> that country.The cross-country relationships between fertility<strong>and</strong> socio-economic factors, such as GDP per capita(R2=0.017) 30 , <strong>and</strong> <strong>the</strong> proportion of <strong>the</strong> populationbelow <strong>the</strong> basic needs poverty l<strong>in</strong>e is weak (R2=0.018).Similarly, <strong>the</strong> contraceptive prevalence rate is onlyweakly associated with <strong>the</strong> level of GDP per capita(R2=0.208). TFR shows some association with <strong>in</strong>fantmortality (R2=0.5165), as transition <strong>the</strong>ory wouldpredict.At <strong>the</strong> microlevel, <strong>the</strong> expected relationship between <strong>the</strong>socio-economic status of women <strong>and</strong> contraceptive usewas not found <strong>in</strong> all countries. Although contraceptiveuse rises with education <strong>in</strong> some countries, <strong>in</strong> o<strong>the</strong>rs<strong>the</strong>re is an <strong>in</strong>verse relationship. However, <strong>the</strong> weight ofevidence suggests that women educated to <strong>the</strong> secondarylevel or beyond are more likely to use contraception thanwomen with little or no education.Similarly, rural-urban differences <strong>in</strong> contraceptive useare non-existent <strong>in</strong> some countries, while <strong>in</strong> o<strong>the</strong>rs <strong>the</strong>reverse of expectations is true, with higher contraceptiveuse be<strong>in</strong>g found <strong>in</strong> rural as compared with urban areas.This f<strong>in</strong>d<strong>in</strong>g is anomalous <strong>in</strong> <strong>the</strong> geographical contextof <strong>the</strong> <strong>Pacific</strong>.Contraceptive use is, however, closely l<strong>in</strong>ked to age<strong>and</strong> parity. Women aged 40 <strong>and</strong> older <strong>and</strong> women whoalready have had five or more children are much more97

likely to use contraception than younger, lower-paritywomen. There also appears to be an association betweencontraceptive use <strong>and</strong> contact with a health facility.The unmet need for family plann<strong>in</strong>g ranges from a lowof about 8 per cent <strong>in</strong> Marshall Isl<strong>and</strong>s <strong>and</strong> SolomonIsl<strong>and</strong>s to a high of 46 per cent <strong>in</strong> Samoa. Papua NewGu<strong>in</strong>ea is also at <strong>the</strong> high end of <strong>the</strong> range at 44 percent. Ow<strong>in</strong>g to <strong>the</strong> omission of some categories ofunmet need <strong>in</strong> <strong>the</strong> Papua New Gu<strong>in</strong>ea DHS, it is highlylikely that this country has <strong>the</strong> highest level of unmetneed among all those countries that have had a DHS <strong>in</strong>recent years.The determ<strong>in</strong>ants of unmet need for family plann<strong>in</strong>gvary considerably between countries but, o<strong>the</strong>r than<strong>in</strong> Papua New Gu<strong>in</strong>ea, lack of access, <strong>in</strong>clud<strong>in</strong>g lack ofknowledge <strong>and</strong> <strong>in</strong>ability to obta<strong>in</strong> services <strong>and</strong> supplies,is not <strong>the</strong> primary cause. The primary cause of unmetneed is “unwill<strong>in</strong>gness” to use <strong>the</strong> available methods ofcontraception. Unwill<strong>in</strong>gness to use contraception arisesfrom various types of “opposition”, ei<strong>the</strong>r for religiousor personal reasons or worries about side effects <strong>and</strong>o<strong>the</strong>r health concerns. Concerns about side effects <strong>and</strong><strong>the</strong> health risks associated with contraception are <strong>the</strong>s<strong>in</strong>gle-most important cause of unmet need <strong>in</strong> mostcountries. There is little doubt that such concerns areexacerbated <strong>in</strong> small village communities <strong>in</strong> which faceto-facecommunication dom<strong>in</strong>ates social relations 31 .Although <strong>the</strong> relationship is far from l<strong>in</strong>ear – <strong>in</strong> somecountries <strong>in</strong>verse – women with little or no educationtend to have higher levels of unmet need. The highestlevel of unmet need among any group <strong>in</strong> <strong>the</strong> countrieshav<strong>in</strong>g had a DHS was found among Samoan womenwith a primary or lower level of education (55%).The absence of close associations between socioeconomicfactors at ei<strong>the</strong>r <strong>the</strong> macro- or microlevels<strong>and</strong> contraceptive use, fertility levels <strong>and</strong> unmet needsuggests that <strong>the</strong> primary obstacle to <strong>in</strong>creased use offamily plann<strong>in</strong>g <strong>and</strong> <strong>the</strong> reduction of unmet need lies <strong>in</strong><strong>the</strong> socio-cultural systems of <strong>Pacific</strong> societies. Fur<strong>the</strong>rspecification of <strong>the</strong> precise nature of <strong>the</strong>se socioculturalfactors would require more detailed researchus<strong>in</strong>g qualitative methods ra<strong>the</strong>r than fixed-responsesurveys.RecommendationsHealth <strong>in</strong>formation systems should be redesigned tocapture all services dispens<strong>in</strong>g contraceptives, <strong>in</strong>clud<strong>in</strong>gboth public <strong>and</strong> private health services, <strong>in</strong> order toprovide a more accurate <strong>and</strong> complete measure ofcontraceptive use. The use of a dedicated reproductivehealth survey <strong>in</strong> selected countries should be employed<strong>in</strong> order to verify contraceptive use patterns <strong>and</strong> <strong>the</strong>irdeterm<strong>in</strong>ants.Fur<strong>the</strong>r analysis of DHS data should be undertaken tomore precisely identify <strong>the</strong> determ<strong>in</strong>ants of unmet needfor family plann<strong>in</strong>g <strong>and</strong> to resolve counter-<strong>in</strong>tuitivesurvey results. Such research needs to determ<strong>in</strong>e, amongo<strong>the</strong>r th<strong>in</strong>gs, whe<strong>the</strong>r concern about “side effects” arisesfrom personal experience or from second-h<strong>and</strong> reports.The socio-cultural obstacles to contraceptive useamong young, unmarried people (adolescents) <strong>and</strong>older women, both of which groups have special needs,should be reviewed.Qualitative studies should be conducted us<strong>in</strong>gappropriate methods, such as focus groups <strong>and</strong> <strong>in</strong>tensive<strong>in</strong>terviews, to determ<strong>in</strong>e <strong>the</strong> basis for opposition to <strong>the</strong>use of family plann<strong>in</strong>g. Such studies should measure<strong>the</strong> impact of reference groups with<strong>in</strong> <strong>the</strong> community,op<strong>in</strong>ion leaders <strong>and</strong> <strong>in</strong>fluential persons.Fur<strong>the</strong>r research should be conducted <strong>in</strong>to problems ofaccess <strong>in</strong> rural areas <strong>in</strong> those countries <strong>in</strong> which DHSresults suggest that unmet need is unaffected by urbanruralresidence.Qualitative studies should be conducted to developapproaches to family plann<strong>in</strong>g education for poor, <strong>and</strong>poorly educated, or illiterate women.Wherever possible, primary health services (asrecommended by <strong>the</strong> Eighth Meet<strong>in</strong>g of M<strong>in</strong>istersof Health for <strong>the</strong> <strong>Pacific</strong> Isl<strong>and</strong> Countries (WorldHealth Organization, 2010) ) should be streng<strong>the</strong>ned,particularly <strong>in</strong> rural areas, <strong>in</strong>clud<strong>in</strong>g <strong>the</strong> provision of<strong>in</strong>centives for health personnel to work <strong>in</strong> remote areas.It should be ensured that family plann<strong>in</strong>g servicesrema<strong>in</strong> free of cost.Cont<strong>in</strong>ue <strong>and</strong> if necessary exp<strong>and</strong> tra<strong>in</strong><strong>in</strong>g programmesfor reproductive health nurses to improve <strong>the</strong> qualityof counsell<strong>in</strong>g furnished to clients prior to adopt<strong>in</strong>g acontraceptive method.The central role of family plann<strong>in</strong>g <strong>in</strong> reproductivehealth programmes should be re<strong>in</strong>forced <strong>in</strong> policies <strong>and</strong>programmes.Efforts should be cont<strong>in</strong>ued to ensure that all servicedelivery po<strong>in</strong>ts have available <strong>the</strong> widest practicablechoice of contraceptive methods <strong>and</strong> that reproductivehealth nurses have <strong>the</strong> skills to provide comprehensive<strong>and</strong> accurate counsell<strong>in</strong>g.On a country-by-country basis greater use of outreach,<strong>in</strong>clud<strong>in</strong>g home visits, should be considered particularlyto follow up on women with health concerns. Methodsto encourage more frequent visits to health facilitiesshould be explored.Efforts to improve reproductive health commoditysecurity should be cont<strong>in</strong>ued <strong>and</strong> <strong>in</strong>tensified throughtra<strong>in</strong><strong>in</strong>g <strong>in</strong> logistics, <strong>in</strong>ventory management, warehous<strong>in</strong>getc.98

National champions should be identified as advocatesfor sexual <strong>and</strong> reproductive health, <strong>in</strong>clud<strong>in</strong>g familyplann<strong>in</strong>g, <strong>in</strong> all countries.Advocacy for gender equality <strong>and</strong> <strong>the</strong> rights of women<strong>and</strong> girls to achieve a high st<strong>and</strong>ard of sexual <strong>and</strong>reproductive health, <strong>in</strong>clud<strong>in</strong>g access to family plann<strong>in</strong>gmethods of <strong>the</strong>ir choice, should be cont<strong>in</strong>ued. Male<strong>in</strong>volvement <strong>in</strong> family plann<strong>in</strong>g decisions should beencouraged through appropriate tra<strong>in</strong><strong>in</strong>g.Access to a full range of sexual <strong>and</strong> reproductivehealth <strong>in</strong>formation, family plann<strong>in</strong>g services <strong>and</strong>commodities should be promoted for all women <strong>and</strong>men, especially young people, liv<strong>in</strong>g <strong>in</strong> peri-urban <strong>and</strong><strong>in</strong>formal settlements, rural areas <strong>and</strong> outer isl<strong>and</strong>s,<strong>and</strong> disadvantaged or marg<strong>in</strong>alized groups. Awarenessabout high-risk behaviour <strong>and</strong> culturally determ<strong>in</strong>edbehaviours that act as barriers to <strong>the</strong> use of servicesneeds to be improved.The extent to which family plann<strong>in</strong>g <strong>and</strong> sexual <strong>and</strong>reproductive health programmes are identify<strong>in</strong>g thosegroups that are disadvantaged <strong>in</strong> terms of access forreasons of cost, transportation or low levels of educationshould be assessed.Condom programm<strong>in</strong>g should cont<strong>in</strong>ue to be promoted,with a rapid needs assessment toolkit be<strong>in</strong>g developedfor condom programm<strong>in</strong>g <strong>and</strong> promot<strong>in</strong>g communitybaseddistribution through tra<strong>in</strong><strong>in</strong>g of peer educators<strong>and</strong> supply of commodities.Outreach should be improved for condom programm<strong>in</strong>g,particularly for young people most at risk, <strong>in</strong>volv<strong>in</strong>gparents <strong>and</strong> religious <strong>and</strong> cultural leaders, given <strong>the</strong>irstatus as gatekeepers <strong>in</strong> many <strong>Pacific</strong> societies, as wellas <strong>the</strong> young people <strong>the</strong>mselves.Programm<strong>in</strong>g efforts should seek to identify <strong>the</strong> mostat-risk young people. A network of susta<strong>in</strong>able NGOs,focus<strong>in</strong>g on behavioural change communication,provision of IEC materials <strong>and</strong> contraceptives, is needed<strong>in</strong> most countries. Social market<strong>in</strong>g techniques shouldalso be explored <strong>in</strong> different communities.Barriers to supply<strong>in</strong>g contraceptives to sexually activeadolescents need to be removed so as to enable <strong>the</strong>mto achieve <strong>the</strong>ir educational <strong>and</strong> life aspirations whiletak<strong>in</strong>g <strong>in</strong>to account <strong>the</strong>ir reproductive needs. Specificallytailored methods for provid<strong>in</strong>g contraceptives to youngpeople need to be designed <strong>in</strong> sett<strong>in</strong>gs where healthcareproviders <strong>and</strong> pharmacists are <strong>the</strong>mselves <strong>the</strong> ma<strong>in</strong>barriers fac<strong>in</strong>g young people <strong>in</strong> access<strong>in</strong>g <strong>the</strong> supplies<strong>and</strong> services <strong>the</strong>y need.End Note1 For fur<strong>the</strong>r details, see IPPF.org/en/where/CN.htm. Accessed on8 October 2010.2 Explanatory models of fertility frequently appear to take an“essentialist” position, presuppos<strong>in</strong>g that fertility decisions areessentially “economic”, “social” or “cultural” <strong>in</strong> nature. Howeverdiscipl<strong>in</strong>ary approaches merely provide different ways of look<strong>in</strong>g ataspects of a phenomenon, <strong>the</strong> essence of which cannot ultimatelybe captured by a s<strong>in</strong>gle model or group of models.3 The isl<strong>and</strong>s of Hawaii <strong>in</strong> <strong>the</strong> United States, <strong>and</strong> New Zeal<strong>and</strong>were orig<strong>in</strong>ally settled by Polynesians but are not <strong>in</strong>cluded <strong>in</strong> <strong>the</strong>def<strong>in</strong>ition of Polynesia for <strong>the</strong> purpose of this paper.4 In this paper a “stalled” transition is def<strong>in</strong>ed simply as a perioddur<strong>in</strong>g which little change <strong>in</strong> TFR is evident by visual <strong>in</strong>spectionof graphs. A more precise measure that <strong>in</strong>cludes assessment ofstatistical significance, as found <strong>in</strong> Bongaarts (2008), has not beenattempted, but is necessary before f<strong>in</strong>al conclusions can be drawn.5 It is important to note that abortion is legal <strong>in</strong> <strong>the</strong> Frenchterritories <strong>and</strong> <strong>in</strong> <strong>in</strong>corporated United States territories such asGuam. Elsewhere <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> abortion is illegal except to save<strong>the</strong> life of <strong>the</strong> mo<strong>the</strong>r. The extent of illegal abortion has not beenassessed statistically but is not uncommon <strong>in</strong> Fiji <strong>and</strong> Papua NewGu<strong>in</strong>ea.6 Bryant (2007) noted that <strong>the</strong> ability to enter labour marketsoutside <strong>the</strong> country may have reduced pressure to constra<strong>in</strong> fertility<strong>in</strong> Irel<strong>and</strong> <strong>and</strong> Japan <strong>in</strong> earlier periods <strong>and</strong> currently <strong>in</strong> Gaza <strong>and</strong><strong>the</strong> West Bank, <strong>and</strong> <strong>the</strong> Philipp<strong>in</strong>es. The present situation <strong>in</strong> Tonga<strong>and</strong> Samoa may be similar to <strong>the</strong>se examples.7 The existence of a population of nearly 800,000 people <strong>in</strong> <strong>the</strong> NewGu<strong>in</strong>ea highl<strong>and</strong>s became known only <strong>in</strong> <strong>the</strong> 1930s when m<strong>in</strong>eralprospectors ventured <strong>in</strong>to <strong>the</strong> area.8 Given that <strong>the</strong> separation of men <strong>and</strong> women was greatest whenwomen were most likely to be <strong>in</strong>fecund (dur<strong>in</strong>g menstruation <strong>and</strong>breastfeed<strong>in</strong>g, for example) <strong>the</strong> l<strong>in</strong>k between female pollution <strong>and</strong>population control is questionable (Faithorn, 1975).9 Women had less access to prote<strong>in</strong> <strong>in</strong> traditional times because menhad <strong>the</strong> first call on prote<strong>in</strong>, justified by <strong>the</strong>ir warrior status <strong>and</strong>higher prestige.10 Demographic transition <strong>the</strong>ory asserts that, <strong>in</strong> traditional orpre-<strong>in</strong>dustrial societies, population growth was slow because ahigh fertility rate was offset by a high mortality rate, whereas<strong>in</strong> <strong>in</strong>dustrial societies population growth is aga<strong>in</strong> low becauseboth fertility <strong>and</strong> mortality have fallen to low levels. Dur<strong>in</strong>g <strong>the</strong>transition from <strong>the</strong> first demographic regime to <strong>the</strong> second, <strong>the</strong> rateof population growth will be high.11 The possibility of <strong>the</strong> AIDS epidemic hav<strong>in</strong>g a negative effect onfund<strong>in</strong>g for family plann<strong>in</strong>g was recognized more than 20 yearsago (Black, 1989), but it would seem that such warn<strong>in</strong>gs wentunheeded. In <strong>the</strong> <strong>Pacific</strong> <strong>the</strong> ma<strong>in</strong> impact of <strong>the</strong> diversion of fundsto HIV/AIDS programmes has been felt <strong>in</strong> Papua New Gu<strong>in</strong>ea.12 This generalization excludes <strong>the</strong> dependent territories of <strong>the</strong>United States <strong>and</strong> France <strong>in</strong> which family plann<strong>in</strong>g is availablethrough a well-developed private medical system supported bygovernment <strong>and</strong> private health <strong>in</strong>surance.13 Data from unpublished records, Fiji Department of Health. Lee(1995) has po<strong>in</strong>ted out that, even 20 years previously, 10 per centof contraceptive users <strong>in</strong> Fiji were obta<strong>in</strong><strong>in</strong>g <strong>the</strong>ir supplies fromprivate sources.14 Tests of significance have yet to be carried out on <strong>the</strong>se associations.99

15 Tests of statistical significance have not been carried out on thisrelationship.16 Note <strong>the</strong> previously mentioned po<strong>in</strong>t that CPR is understated <strong>in</strong>countries with a significant private medical system.17 This assessment is based on visual <strong>in</strong>spection of <strong>the</strong> trend l<strong>in</strong>e. Theassociation rema<strong>in</strong>s to be tested for statistical significance.18 As previously noted, Wallis <strong>and</strong> Futuna Isl<strong>and</strong>s has a reportedteenage fertility rate of 9, similar to that of Western Europe. On <strong>the</strong>o<strong>the</strong>r h<strong>and</strong>, Marshall Isl<strong>and</strong>s has a rate of 127. These two extremeshave been removed from <strong>the</strong> sample of countries.19 The generalization advanced by Harris <strong>and</strong> Ross (1987) that <strong>in</strong>traditional societies marriage beg<strong>in</strong>s with childbear<strong>in</strong>g ra<strong>the</strong>r than<strong>the</strong> o<strong>the</strong>r way around is widely applicable <strong>in</strong> <strong>Pacific</strong> isl<strong>and</strong> societies,even though this is not consistent with cultural norms <strong>and</strong> values.20 Unmet need can also be calculated, <strong>and</strong> <strong>in</strong>creas<strong>in</strong>gly is, for allwomen of reproductive age regardless of <strong>the</strong>ir marital status. In thispaper only currently married women are <strong>in</strong>cluded <strong>in</strong> <strong>the</strong> numerator<strong>and</strong> denom<strong>in</strong>ator. If all women of reproductive age are <strong>in</strong>cluded,some method of exclud<strong>in</strong>g women who are not sexually active mustbe applied. O<strong>the</strong>rwise, unmet need will tend to be overstated.21 This is <strong>the</strong> percentage of women at risk of an un<strong>in</strong>tendedpregnancy but not us<strong>in</strong>g contraceptives.22 As Sk<strong>in</strong>ner (2008) notes, <strong>in</strong> matters of contraceptive complications<strong>in</strong> small communities, “bad news travels fast” <strong>and</strong> even one badexperience can have a significant impact on confidence among o<strong>the</strong>rwomen.23 The pr<strong>in</strong>ciple of <strong>in</strong>dividual sovereignty <strong>in</strong> family size choices hadalready been established <strong>in</strong> earlier <strong>in</strong>ternational conferences onpopulation.24 Chung (2000) argued that promot<strong>in</strong>g <strong>the</strong> knowledge <strong>and</strong> useof contraception among adolescents while fail<strong>in</strong>g to makecontraceptives easily available is unethical.25 Although a test of statistical significance has not been carried outas yet, for all <strong>in</strong>tents <strong>and</strong> purposes <strong>the</strong>re is no difference betweenurban <strong>and</strong> rural CPR <strong>and</strong> unmet need <strong>in</strong> Samoa: national, rural<strong>and</strong> urban rates are 46, 46 <strong>and</strong> 45 per cent, respectively.26 A clue to <strong>the</strong> extent of illegal abortion is <strong>the</strong> number of womenadmitted to hospital suffer<strong>in</strong>g from complications aris<strong>in</strong>g fromabortion. In Papua New Gu<strong>in</strong>ea, 23 per cent of gynaecologyadmissions to <strong>the</strong> Port Moresby General Hospital <strong>in</strong> 2001 wereassociated with complications aris<strong>in</strong>g from illegal abortions (Hayes,2002).27In many areas <strong>in</strong> Papua New Gu<strong>in</strong>ea it was believed, <strong>and</strong> to someextent still is, that repeated acts of sexual <strong>in</strong>tercourse are requiredto “build up” a baby. This is <strong>the</strong> basis for a belief among youth thatpregnancy cannot result from one act of sexual <strong>in</strong>tercourse.28 American Samoa is an exception to this generalization. TFR <strong>in</strong>American Samoa is similar to that of neighbour<strong>in</strong>g Samoa.29 Legal abortion no doubt contributes to lower fertility <strong>in</strong> some of<strong>the</strong>se countries <strong>and</strong> territories.30 Note that GDP data were not available for <strong>the</strong> dependentterritories, thus bias<strong>in</strong>g <strong>the</strong> relationship between fertility <strong>and</strong> GDP.31 “Quality concerns voiced among FP-seek<strong>in</strong>g consumers seems totravel rapidly <strong>and</strong> widely (bad news travels fast) <strong>and</strong> if not followedup could threaten <strong>the</strong> credibility <strong>and</strong> acceptance of goods, mayharm <strong>the</strong> reputation of RH services, <strong>and</strong> affect public confidence <strong>in</strong><strong>the</strong> health supply cha<strong>in</strong>” (Sk<strong>in</strong>ner, 2008).ReferencesAshford, L. (2003). 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BangladeshBangladeshThe Bangladesh <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Programme:Achievements, Gaps <strong>and</strong> <strong>the</strong> Way ForwardBarkat-e-Khuda* <strong>and</strong> Samiha Barkat #* Barkat-e-Khuda, Professor, Department of Economics, <strong>and</strong> Chairman, Bureau of Economic Research,University of Dhaka, Bangladesh. E-mail: barkatek@yahoo.com.#Samiha Barkat. MPH103

104

BackgroundAs is <strong>the</strong> case <strong>in</strong> many develop<strong>in</strong>g countries, Bangladeshcan trace its official family plann<strong>in</strong>g (FP) programmeback several decades, i.e. to 1960, although voluntary FPprogramme efforts had started even earlier <strong>in</strong> <strong>the</strong> early1950s. S<strong>in</strong>ce that time, <strong>the</strong> programme has gone throughdifferent phases. It achieved commendable success until <strong>the</strong>mid-1990s; however, <strong>the</strong> pace of success slowed <strong>the</strong>reafterow<strong>in</strong>g to <strong>the</strong> erosion of political will <strong>and</strong> commitment to <strong>the</strong>programme. Not surpris<strong>in</strong>gly, <strong>the</strong>refore, <strong>the</strong> pace of successhas slowed, result<strong>in</strong>g <strong>in</strong> a stall<strong>in</strong>g <strong>and</strong>/or near stagnation <strong>in</strong>fertility decl<strong>in</strong>e <strong>in</strong> Bangladesh. Although <strong>the</strong>re has been nochange <strong>in</strong> official policy regard<strong>in</strong>g <strong>the</strong> need to conta<strong>in</strong> <strong>the</strong>rate of population growth, <strong>the</strong> commitment of <strong>the</strong> politicalleadership has weakened considerably. This, <strong>in</strong> turn, hasaffected <strong>the</strong> commitment of <strong>the</strong> officials concerned withprogramme implementation.In 1994, <strong>the</strong> United Nations organized <strong>the</strong> <strong>International</strong>Conference on Population <strong>and</strong> Development (ICPD)<strong>in</strong> Cairo. The Programme of Action (POA) adopted bythat Conference recommended, among o<strong>the</strong>r th<strong>in</strong>gs, thatgovernments should meet <strong>the</strong> family plann<strong>in</strong>g needs of<strong>the</strong>ir populations as soon as possible <strong>and</strong> should, <strong>in</strong> allcases by <strong>the</strong> year 2015, seek to provide universal accessto a full range of safe <strong>and</strong> reliable family plann<strong>in</strong>g services(for example, see UNFPA, 1995). ICPD accorded dueimportance to women's health <strong>and</strong> rights, <strong>and</strong> accord<strong>in</strong>gly,made FP part of <strong>the</strong> overall reproductive health (RH)agenda. However, ICPD failed to clearly operationalizehow FP was to be made an <strong>in</strong>tegral part of <strong>the</strong> RHprogramme, especially <strong>in</strong> countries such as Bangladesh,which has two health (RH) agenda. However, ICPDfailed to clearly operationalize how FP was to be made an<strong>in</strong>tegral part of <strong>the</strong> RH programme, especially <strong>in</strong> countriessuch as Bangladesh, which has two separate directorates –<strong>the</strong> Directorate General of Health Services (DGHS) <strong>and</strong><strong>the</strong> Directorate General of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> (DGFP) –offer<strong>in</strong>g RH services <strong>in</strong>dependently of each o<strong>the</strong>r, withoutany effective coord<strong>in</strong>ation <strong>and</strong> cooperation between <strong>the</strong>two directorates.The purpose of <strong>the</strong> present case study on Bangladeshis to review <strong>the</strong> status of <strong>the</strong> country’s FP programme,<strong>in</strong>clud<strong>in</strong>g <strong>the</strong> knowledge <strong>and</strong> practice of contraception<strong>and</strong> <strong>the</strong> service delivery system. The study (a) identifiesachievements of <strong>the</strong> Bangladesh FP programme; (b)highlights various gaps faced by <strong>the</strong> programme; <strong>and</strong> (c)identifies Bangladesh-specific strategies for renewed focus<strong>and</strong> <strong>in</strong>creased <strong>in</strong>vestment <strong>in</strong> FP.A review of (a) relevant documents, strategies <strong>and</strong>assessment reports, all of which have been referenced<strong>in</strong> <strong>the</strong> present paper, <strong>and</strong> (b) <strong>the</strong> 2007 BangladeshDemographic <strong>and</strong> Health Survey (BDHS) <strong>and</strong> earlierBDHSs <strong>and</strong> predecessor surveys for <strong>the</strong> period 1975-2007 was undertaken <strong>in</strong> order to obta<strong>in</strong> an <strong>in</strong>-depthunderst<strong>and</strong><strong>in</strong>g of <strong>the</strong> Bangladesh FP programme. Inaddition, <strong>in</strong>terviews were held with relevant stakeholders,such as officials from <strong>the</strong> M<strong>in</strong>istry of Health <strong>and</strong> <strong>Family</strong>Welfare (MOHFW), <strong>the</strong> Directorate General of <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> (DGFP), <strong>in</strong>ternational donors <strong>and</strong> bilateralagencies, non-governmental organizations (NGOs) <strong>and</strong><strong>the</strong> private sector.Country sett<strong>in</strong>gDemographic challengesBangladesh is <strong>the</strong> seventh most populous country <strong>in</strong> <strong>the</strong>world <strong>and</strong> <strong>the</strong> fifth largest <strong>in</strong> <strong>Asia</strong>, with a population ofabout 160 million people. The annual rate of populationgrowth currently is about 1.4 per cent; <strong>in</strong> o<strong>the</strong>r words,about 2 million new faces are added to <strong>the</strong> populationannually. Accord<strong>in</strong>g to government estimates, <strong>the</strong>population of Bangladesh under vary<strong>in</strong>g assumptions willrange from about 170 million to 184 million by 2020, <strong>and</strong>from 218 million to 294 million by 2050 (Government ofBangladesh (GOB), 2006a). Accord<strong>in</strong>g to United Nationsestimates, <strong>the</strong> population of Bangladesh is projected(under <strong>the</strong> medium variant) to <strong>in</strong>crease to 185.6 millionby 2020, <strong>and</strong> fur<strong>the</strong>r to 222.5 million by 2050 (UnitedNations, 2010).Bangladesh is <strong>the</strong> most densely populated country <strong>in</strong> <strong>the</strong>world, with <strong>the</strong> exception of some small isl<strong>and</strong> states. Itspopulation density of around 1,000 persons per squarekilometre is projected to <strong>in</strong>crease (under <strong>the</strong> mediumvariant) to 1,289 persons per sq km by 2020, <strong>and</strong> fur<strong>the</strong>rto 1,545 persons per sq km by 2050 (United Nations,2010).About one third of <strong>the</strong> total population is younger than15 years of age, <strong>and</strong> <strong>the</strong> elderly population (60 years <strong>and</strong>older) accounts for about 6 per cent of <strong>the</strong> total population,<strong>in</strong>dicat<strong>in</strong>g a high dependency ratio. The elderly populationis projected to rise to 8.2 per cent <strong>and</strong> 21.2 per cent of <strong>the</strong>total population <strong>in</strong> 2020 <strong>and</strong> 2050 respectively. Women <strong>in</strong><strong>the</strong> reproductive age group are projected to <strong>in</strong>crease from55.8 per cent of <strong>the</strong> total population <strong>in</strong> 2010 to 56.7 percent <strong>in</strong> 2020, <strong>and</strong> <strong>the</strong>n decl<strong>in</strong>e to 45.9 per cent <strong>in</strong> 2050(United Nations, 2010).Accord<strong>in</strong>g to <strong>the</strong> 1974 census, only 9 per cent of <strong>the</strong>population at that time lived <strong>in</strong> urban areas; that proportiondoubled to 18 per cent <strong>in</strong> 1988. Currently, about 30 percent of <strong>the</strong> total population lives <strong>in</strong> urban areas. By 2025,<strong>the</strong> urban population is projected to <strong>in</strong>crease to 40 per centof <strong>the</strong> total population; by 2031, <strong>the</strong> urban population105

Figurewill exceed <strong>the</strong> rural population; <strong>and</strong> by 2051, <strong>the</strong> urbanpopulation will account for 64 per cent of <strong>the</strong> country’stotal population (GOB, 2006a).Dhaka, <strong>the</strong> capital of Bangladesh, is today one of <strong>the</strong>world’s largest metropolises. From a population of about14 million people now, Dhaka is expected to become <strong>the</strong>fourth largest city <strong>in</strong> <strong>the</strong> world, with a population of 23million by 2015 (Brockerhoff, 2000). Also, o<strong>the</strong>r smallertowns <strong>in</strong> Bangladesh have grown <strong>in</strong> size. While <strong>the</strong> annualgrowth rate of <strong>the</strong> rural population is about 1 per cent, it isabout 5 per cent for <strong>the</strong> urban population (United NationsPopulation Division, 1998).Dur<strong>in</strong>g <strong>the</strong> 1960s, fertility was quite high, with <strong>the</strong> totalfertility rate (TFR) exceed<strong>in</strong>g 7 children per woman. TFRdecl<strong>in</strong>ed to 6.3 <strong>in</strong> 1975, <strong>and</strong> rema<strong>in</strong>ed above 6.0 until 1981(Clel<strong>and</strong> et al., 1994). Between 1989 <strong>and</strong> 1993/94, TFRdecl<strong>in</strong>ed sharply from 5.1 to 3.4. However, <strong>the</strong> decl<strong>in</strong>e wasmuch slower <strong>the</strong>reafter; it stalled at about 3.3 dur<strong>in</strong>g <strong>the</strong>period 1994-2000. Thereafter, TFR decl<strong>in</strong>ed slowly to 3.0<strong>in</strong> <strong>the</strong> period 2001-2003, reach<strong>in</strong>g 2.7 <strong>in</strong> 2007 (see Figure1 <strong>and</strong> Table 1).There has been an extremely high level of adolescent fertility<strong>in</strong> Bangladesh s<strong>in</strong>ce <strong>the</strong> mid-1990s, with <strong>the</strong> adolescentfertility rate be<strong>in</strong>g one of <strong>the</strong> highest <strong>in</strong> <strong>the</strong> world. Onethird of adolescent married women aged 15-19 years havebegun childbear<strong>in</strong>g. Childbear<strong>in</strong>g among adolescents ishigher: (a) <strong>in</strong> rural than urban areas; (b) among those withno education than those with education; <strong>and</strong> (c) amongthose <strong>in</strong> <strong>the</strong> lowest wealth qu<strong>in</strong>tile than those <strong>in</strong> <strong>the</strong>higher wealth qu<strong>in</strong>tiles (NIPORT, Mitra <strong>and</strong> Associates<strong>and</strong> ORC Macro, 1994; 2005; <strong>and</strong> NIPORT, Mitra <strong>and</strong>Associates <strong>and</strong> Macro <strong>International</strong>, 2009).There are sharp differentials <strong>in</strong> fertility levels. Fertility islower <strong>in</strong> urban than rural areas by about half a child; lower<strong>in</strong> Khulna <strong>and</strong> Rajshahi divisions (where replacement ornear replacement-level fertility has been reached) than<strong>in</strong> Sylhet <strong>and</strong> Chittagong divisions (with TFRs rang<strong>in</strong>gbetween 3.2 <strong>and</strong> 3.7); lower among educated women(women who completed secondary or who have highereducation have reached near replacement-level fertility,or a TFR of 2.3) compared with a TFR of 3.0 amongwomen with no education; lower among women <strong>in</strong> <strong>the</strong>highest wealth qu<strong>in</strong>tile (who have reached replacementlevelfertility) than those <strong>in</strong> <strong>the</strong> lowest wealth qu<strong>in</strong>tile(TFR of 3.2) (NIPORT, Mitra <strong>and</strong> Associates <strong>and</strong> Macro<strong>International</strong>, 2009). Also, fertility is lower among limiters<strong>and</strong> spacers, those with access to mass media than thosewithout, ever-users of FP methods, work<strong>in</strong>g women,women belong<strong>in</strong>g to l<strong>and</strong>ed households, <strong>and</strong> thosebelong<strong>in</strong>g to households with an electricity connection,which is an <strong>in</strong>dicator not only of <strong>the</strong> economic conditionof <strong>the</strong> household but also its level of monetization (Khuda,2004; Neaz et al., 2004).There has been a slow but steady rise over <strong>the</strong> past 25years <strong>in</strong> <strong>the</strong> age at which Bangladeshi women marry, froma median age at marriage of 14.1 years for women now <strong>in</strong><strong>the</strong>ir late forties to 16.4 years for women now <strong>in</strong> <strong>the</strong>ir earlytwenties. 1 The median age at marriage is about two yearslower than <strong>the</strong> legal m<strong>in</strong>imum age at marriage for females.The median age at marriage is positively associated with<strong>the</strong> level of education <strong>and</strong> wealth status (NIPORT, Mitra<strong>and</strong> Associates <strong>and</strong> Macro <strong>International</strong>, 2009).Bangladeshi women beg<strong>in</strong> childbear<strong>in</strong>g early. On average,women have about one quarter of <strong>the</strong>ir children beforereach<strong>in</strong>g 20 years of age, more than half of <strong>the</strong>ir childrendur<strong>in</strong>g <strong>the</strong>ir twenties, <strong>and</strong> one fifth dur<strong>in</strong>g <strong>the</strong>ir thirties.The median age of women at <strong>the</strong> time of <strong>the</strong>ir first birthis only about 18 years. It is one year higher <strong>in</strong> urban (19years) than rural areas (18 years), about four years higheramong educated women (21 years) than those with noeducation (17 years), <strong>and</strong> two years higher among women<strong>in</strong> <strong>the</strong> highest wealth qu<strong>in</strong>tile (19 years) than those <strong>in</strong> <strong>the</strong>lowest wealth qu<strong>in</strong>tile (NIPORT, Mitra <strong>and</strong> Associates<strong>and</strong> Macro <strong>International</strong>, 2009).Figure1Trends <strong>in</strong> <strong>the</strong> total fertility rate <strong>in</strong> Bangladesh: 1975-200776.3655.14.3433.4 3.3 3.33 32.72101975 1989 1991 1993-94 1996-97 1999-2000 2001-03 2004 2007106

TableTable2Budgeted amount <strong>and</strong> actual expenditure under <strong>the</strong> family plann<strong>in</strong>g <strong>and</strong> reproductive healthprogramme: 2003/04-2010/11 (In “000,000” taka)Development budget:Period Budget ExpenditureFiscal year Govt. Total Govt.Directproject aidExpenditureas % of budget2003/04 13,984 45,717 13,090 21,572 34,662 75.822004/05 8,400 38,178 6,779 27,123 33,902 88.792005/06 7,767 43,655 6,952 23,825 30,777 70.502006/07 7,844 56,641 6,441 41,589 48,030 84.792007/08 9,724 32,899 8,453 19,107 27,560 83.772008/09 12,557 50,957 11,054 20,306 31,360 61.542009/10 13,225 56,220 12,590 34,086 46,676 83.02Total2010/11 19,906 53,081 19,906 33,175 53,081Revenue budget:Fiscal yearRevised budgetActualexpenditureExpenditure as % of revised budget2003/04 30,539.05 30,263.14 99.092004/05 42,557.80 39,075.46 91.812005/06 51,484.29 46,239.95 89.812006/07 62,629.01 59,602.34 95.162007/08 62,840.71 61,566.17 97.972008/09 73,694.66 63,364.74 85.982009/10 79,397.59 78,691.18 99.112010/11 97,829.32 ------- ------Source: Directorate General of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>.<strong>the</strong> two most common misconceptions about <strong>the</strong> humanimmunodeficiency virus – that HIV can be transmittedby mosquito bites <strong>and</strong> that a person can become <strong>in</strong>fectedby shar<strong>in</strong>g food with someone who is HIV-positive – only6 per cent of ever-married women <strong>and</strong> 14 per cent of evermarriedmen were found to have comprehensive knowledgeof HIV/AIDS (NIPORT, Mitra <strong>and</strong> Associates <strong>and</strong>Macro <strong>International</strong>, 2009).It is clear that Bangladesh is fac<strong>in</strong>g a serious demographiccrisis <strong>in</strong> terms of its grow<strong>in</strong>g population size <strong>and</strong> density,<strong>the</strong> proportion of <strong>the</strong> population younger than 15 yearsof age, <strong>the</strong> <strong>in</strong>creas<strong>in</strong>g number of married women <strong>in</strong> <strong>the</strong>reproductive age group, <strong>the</strong> stall<strong>in</strong>g <strong>and</strong>/or near stagnation<strong>in</strong> fertility decl<strong>in</strong>e, <strong>the</strong> extremely high level of adolescentfertility, <strong>the</strong> sharp differentials <strong>in</strong> fertility by socioeconomiccharacteristics of <strong>the</strong> women, <strong>the</strong> low femaleage at marriage, early childbear<strong>in</strong>g, <strong>and</strong> high neonatal<strong>and</strong> maternal mortality. Such demographic challengesplace enormous burdens on <strong>the</strong> limited resources of <strong>the</strong>country <strong>in</strong>sofar as poverty reduction <strong>and</strong> efforts to tackleenvironmental <strong>and</strong> climate change are concerned. Also,<strong>the</strong>se factors are seen as h<strong>in</strong>der<strong>in</strong>g efforts to achieve o<strong>the</strong>rreproductive goals, <strong>in</strong>clud<strong>in</strong>g a reduction <strong>in</strong> maternalmortality.Socio-economic changesMajor socio-economic changes have taken place <strong>in</strong>Bangladesh over <strong>the</strong> past two decades – both on <strong>the</strong> positive<strong>and</strong> negative sides – affect<strong>in</strong>g fertility norms <strong>and</strong> behaviour.Changes <strong>in</strong> <strong>the</strong> positive direction <strong>in</strong>clude <strong>in</strong>creases <strong>in</strong>female education, employment, women’s empowerment<strong>and</strong> access to mass media; changes <strong>in</strong> <strong>the</strong> negative direction<strong>in</strong>clude <strong>in</strong>creas<strong>in</strong>g l<strong>and</strong>lessness, shr<strong>in</strong>k<strong>in</strong>g employmentopportunities <strong>in</strong> <strong>the</strong> agricultural sector, cont<strong>in</strong>u<strong>in</strong>g high<strong>in</strong>cidence of poverty <strong>and</strong> grow<strong>in</strong>g urbanization.The education sector <strong>in</strong> Bangladesh has witnessedconsiderable improvements. The literacy rate of <strong>the</strong> adultpopulation aged 15 years <strong>and</strong> older <strong>in</strong>creased from 45 percent <strong>in</strong> 1995 to 51 per cent <strong>in</strong> 2006, with <strong>the</strong> rate be<strong>in</strong>ghigher among males (59%) than females (49%), <strong>and</strong> higher108

<strong>in</strong> urban (67%) than rural areas (49%). Between 1985 <strong>and</strong>2005, primary school enrolment <strong>in</strong>creased by about twotimes (from 10 million to 16 million) <strong>and</strong> secondary schoolenrolment <strong>in</strong>creased almost three-fold from 2.6 million to7.4 million (Government of Bangladesh (GOB), 2009).Income per capita is only about US$ 700 annually, withsharp <strong>in</strong>equity <strong>in</strong> <strong>in</strong>come distribution. A large proportion(31.5%) of <strong>the</strong> population lives below <strong>the</strong> poverty l<strong>in</strong>e(GOB, 2011). The poverty is more acute <strong>in</strong> rural areas <strong>and</strong>urban slums than elsewhere. The current government hasplaced elim<strong>in</strong>ation of poverty <strong>and</strong> <strong>in</strong>equity at <strong>the</strong> forefrontof its development strategy. In <strong>the</strong> FY 2010/11 budget, <strong>the</strong>government allocated 14.8 per cent of <strong>the</strong> total development<strong>and</strong> non-development budget <strong>and</strong> 2.5 per cent of totalGDP for social security <strong>and</strong> social empowerment (GOB,2010a). The aim is to br<strong>in</strong>g down <strong>the</strong> poverty rate from40 per cent <strong>in</strong> 2008 to 15 per cent by 2021. The socialsafety net measures also partly address <strong>the</strong> needs of <strong>the</strong>elderly population by provid<strong>in</strong>g a select number of suchbeneficiaries with a monthly allowance of Tk. 300 (US$ 1= almost 75 taka) (Khuda, 2011).There has been a considerable rise <strong>in</strong> <strong>the</strong> HumanDevelopment Index (HDI). Accord<strong>in</strong>g to Bongaarts <strong>and</strong>Watk<strong>in</strong>s (1996), HDI for Bangladesh rose by 45.5 percent between 1960 <strong>and</strong> 1980. Between 1980 <strong>and</strong> 2007, it<strong>in</strong>creased by 1.86 per cent per annum from 0.328 to 0.543,giv<strong>in</strong>g <strong>the</strong> country a rank of 146th out of 182 countries(UNDP, 2009).Because of ris<strong>in</strong>g population size, <strong>the</strong> l<strong>and</strong>-to-person ratiocont<strong>in</strong>ues to worsen. The size of <strong>the</strong> average farm is smallernow than previously had been <strong>the</strong> case, <strong>and</strong> l<strong>and</strong>lessnessis <strong>in</strong>creas<strong>in</strong>g as is <strong>the</strong> number of marg<strong>in</strong>al farmers. Thissituation has reduced <strong>the</strong> dem<strong>and</strong> for household labouron <strong>the</strong> farm. As a result, <strong>the</strong>re has been <strong>in</strong>creas<strong>in</strong>g ruralto-urbanmigration, especially to <strong>the</strong> capital city Dhaka(Alam <strong>and</strong> Khuda, 2010).The male labour force participation rate (LFPR) hasrema<strong>in</strong>ed almost unchanged at about 56 per cent from1974. However, <strong>the</strong> female LFPR, which was quitenegligible until 1985/86, <strong>in</strong>creased to 29 per cent of <strong>the</strong>total <strong>in</strong> 2005/06 (Khuda, 2010). Part of <strong>the</strong> <strong>in</strong>crease <strong>in</strong>female LFPR is due to changes <strong>in</strong> def<strong>in</strong>itions used <strong>in</strong> <strong>the</strong>different censuses <strong>and</strong> labour force surveys, while part of<strong>the</strong> <strong>in</strong>crease is real, reflect<strong>in</strong>g <strong>the</strong>ir <strong>in</strong>creased participation<strong>in</strong> <strong>the</strong> labour force. In 2006, <strong>the</strong> garment <strong>in</strong>dustry furnishedjobs for 4.5 million people <strong>in</strong> urban areas, 80 per cent ofwhom were females, mostly young <strong>and</strong> unmarried (ADB,2006). The number has <strong>in</strong>creased s<strong>in</strong>ce 2006 because offur<strong>the</strong>r expansion <strong>in</strong> <strong>the</strong> garment sector. There is evidenceof poverty-driven female employment, result<strong>in</strong>g frompoor household economic conditions <strong>and</strong> high rates offemale headship (Rahman, 1986; Safilios-Rothschild <strong>and</strong>Mahmood, 1989; BIDS, 1990; Rahman <strong>and</strong> Hossa<strong>in</strong>,1991).Notwithst<strong>and</strong><strong>in</strong>g that women <strong>in</strong> Bangladesh are adisadvantaged group, <strong>the</strong>ir status has improved. Ingeneral, women now have greater freedom of movement,an enhanced role <strong>in</strong> household decision-mak<strong>in</strong>g, relativefreedom from more patriarchal structures than before, <strong>and</strong><strong>in</strong>creased ability to use contraceptives (see, for example,Khuda et al., 1990a; 1990b; 1993b; Schuler <strong>and</strong> Hashemi,1994; Islam et al., 2000; <strong>and</strong> NIPORT, Mitra <strong>and</strong>Associates <strong>and</strong> Macro <strong>International</strong>, 2009).There has been a considerable <strong>in</strong>crease <strong>in</strong> access to massmedia, both pr<strong>in</strong>t <strong>and</strong> electronic. Ideational changesresult<strong>in</strong>g from <strong>in</strong>creased access to <strong>the</strong> media have fosteredmodern outlooks <strong>and</strong> attitudes <strong>in</strong> general <strong>and</strong> thoserelat<strong>in</strong>g to FP <strong>and</strong> RH <strong>in</strong> particular. The <strong>in</strong>fluence ofmodernization has helped to change <strong>the</strong> high fertilitynorms, even among <strong>the</strong> poor, who <strong>the</strong>mselves haveexperienced <strong>in</strong>creases <strong>in</strong> contraceptive use <strong>and</strong> decl<strong>in</strong>es <strong>in</strong>fertility over time, though much less so than <strong>the</strong> relativelywell-off. Among <strong>the</strong> poor, two forces operate to depressfertility norms. One is poverty-led because of <strong>the</strong> poor’s<strong>in</strong>ability to ma<strong>in</strong>ta<strong>in</strong> a large family, while one <strong>the</strong> o<strong>the</strong>r isaspiration-driven: people be<strong>in</strong>g imbued with modern ideas<strong>and</strong> attitudes (see also Caldwell et al., 1999; Khuda et al.,2001).<strong>Family</strong> plann<strong>in</strong>g programmeEvolution <strong>and</strong> developmentFP activities <strong>in</strong> Bangladesh have been carried out <strong>in</strong> threedist<strong>in</strong>ct phases. Phase 1 activities were largely voluntary,with <strong>the</strong> sett<strong>in</strong>g up of <strong>the</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Association <strong>in</strong>1953 by a group of dedicated social workers who realized<strong>the</strong> adverse consequences of rapid population growthon <strong>the</strong> society’s development efforts. Subsequently, <strong>the</strong>sevoluntary activities received some limited support from <strong>the</strong>government.Phase II activities began <strong>in</strong> 1960, with <strong>the</strong> governmenttak<strong>in</strong>g some broader steps to check <strong>the</strong> populationgrowth rate. Population control was made <strong>the</strong> officialpolicy <strong>in</strong> <strong>the</strong> First Five-Year Plan of Pakistan (1960-1965). A sizable cadre of FP personnel was recruited; anumber of cl<strong>in</strong>ics were set up; a tra<strong>in</strong><strong>in</strong>g-cum-research<strong>in</strong>stitute was established; <strong>and</strong> <strong>in</strong>formation, education<strong>and</strong> communication (IEC) activities emphasized cl<strong>in</strong>icbasedcounsel<strong>in</strong>g <strong>and</strong> dissem<strong>in</strong>ation of knowledge aboutcontraceptives by physicians <strong>and</strong> paramedics.Phase III activities were <strong>in</strong>itiated <strong>in</strong> 1973 with <strong>the</strong>109

Figurelaunch<strong>in</strong>g of <strong>the</strong> First Five-Year Plan of Bangladesh. ThePlan attached equal priority to population control <strong>and</strong> foodproduction. It marked <strong>the</strong> beg<strong>in</strong>n<strong>in</strong>g of a multisectoral <strong>and</strong>broad-based population control <strong>and</strong> FP programme <strong>in</strong> <strong>the</strong>country. At a meet<strong>in</strong>g of <strong>the</strong> National Population <strong>Council</strong><strong>in</strong> June 1976, population was declared as <strong>the</strong> number oneproblem for <strong>the</strong> country. The government emphasized <strong>the</strong>urgency of mak<strong>in</strong>g <strong>the</strong> FP programme an <strong>in</strong>tegral partof <strong>the</strong> development process. The base of <strong>the</strong> programmewas broadened by <strong>in</strong>tegrat<strong>in</strong>g maternal <strong>and</strong> child health(MCH) activities. O<strong>the</strong>r positive developments <strong>in</strong>cluded<strong>the</strong> recruitment <strong>and</strong> tra<strong>in</strong><strong>in</strong>g of fieldworkers; <strong>the</strong><strong>in</strong>troduction <strong>and</strong> subsequent availability of menstrualregulation services; <strong>the</strong> sett<strong>in</strong>g up of mobile sterilizationteams; <strong>the</strong> establishment of upazila (subdistrict) MCHcl<strong>in</strong>ics; <strong>the</strong> streng<strong>the</strong>n<strong>in</strong>g of IEC activities; <strong>the</strong> <strong>in</strong>volvementof multisectoral m<strong>in</strong>istries; <strong>and</strong> <strong>the</strong> <strong>in</strong>volvement of NGOs<strong>and</strong> <strong>the</strong> private sector. The programme was fur<strong>the</strong>rstreng<strong>the</strong>ned <strong>in</strong> subsequent plans. 2Programme after <strong>the</strong><strong>International</strong> Conference onPopulation <strong>and</strong> DevelopmentFollow<strong>in</strong>g ICPD, <strong>the</strong> government formed a nationalcommittee <strong>and</strong> developed <strong>the</strong> National Plan of Action forimplementation of <strong>the</strong> goals set <strong>in</strong> <strong>the</strong> ICPD Programmeof Action. Under <strong>the</strong> <strong>in</strong>tegrated approach of population<strong>and</strong> development, national policies on population, health,women, maternal health, HIV/AIDS <strong>and</strong> sexuallytransmitted diseases, children, <strong>the</strong> environment, food <strong>and</strong>nutrition were formulated; <strong>and</strong> strategies were developedfor economic growth, poverty reduction <strong>and</strong> socialdevelopment, reproductive health, population, health <strong>and</strong>nutrition (UNFPA/MOHFW/GOB, 2005).Major changes had been tak<strong>in</strong>g place <strong>in</strong> <strong>the</strong> FP <strong>and</strong> RHprogramme <strong>in</strong> Bangladesh even before ICPD. Follow<strong>in</strong>g<strong>the</strong> ICPD Programme of Action, however, <strong>in</strong>tegration ofFP with<strong>in</strong> <strong>the</strong> RH programme was fur<strong>the</strong>r streng<strong>the</strong>ned.In 1996, MOHFW published its Strategic Directions for<strong>the</strong> Bangladesh National <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Programme:1995-2005, which focused on a client-oriented approach toexp<strong>and</strong> high-quality FP services <strong>and</strong> achieve replacementlevelfertility by 2010 (GOB, 1996). In <strong>the</strong> 2004 populationpolicy it was recognized that <strong>the</strong> high rate of populationgrowth <strong>and</strong> <strong>the</strong> resultant <strong>in</strong>crease <strong>in</strong> population sizeadversely affected <strong>the</strong> pace of development; thus, <strong>the</strong> policyemphasized <strong>the</strong> need for <strong>the</strong> o<strong>the</strong>r m<strong>in</strong>istries concernedwith population-related activities to become <strong>in</strong>volved. The2004 population policy is currently be<strong>in</strong>g revised <strong>in</strong> l<strong>in</strong>ewith <strong>the</strong> government’s <strong>in</strong>tention to implement a broadbasedresponse to <strong>the</strong> population crisis faced by <strong>the</strong> country.The goals of <strong>the</strong> draft revised 2010 population policy areto focus on improv<strong>in</strong>g <strong>the</strong> status of FP <strong>and</strong> maternal <strong>and</strong>child health, <strong>in</strong>clud<strong>in</strong>g RH services, <strong>and</strong> to improve <strong>the</strong>liv<strong>in</strong>g st<strong>and</strong>ard of <strong>the</strong> people.MOHFW is responsible primarily for provid<strong>in</strong>g <strong>the</strong>people of Bangladesh with health, population <strong>and</strong> nutritionservices through its two directorates – DGHS <strong>and</strong>DGFP – <strong>and</strong> one project, <strong>the</strong> National Nutrition Project.The M<strong>in</strong>istry’s activities are supplemented by those ofmany NGOs <strong>and</strong> <strong>the</strong> private sector, <strong>in</strong>clud<strong>in</strong>g <strong>the</strong> SocialMarket<strong>in</strong>g Company. DGFP provides <strong>the</strong> follow<strong>in</strong>g typesof services through its field-based network <strong>and</strong> facility-Figure2Trends <strong>in</strong> <strong>the</strong> CPR <strong>in</strong> Bangladesh: 1975-200770Percent6053.858.155.8504039.944.635.249.241.543.447.347.53025.330.823.231.22019.118.413.8107.75.001975 1983 1985 1989 1991 1993- 1996- 1999- 2003- 20071994 1997 2000 2004TotalModern Methods110

ased service delivery po<strong>in</strong>ts, <strong>the</strong> Maternal <strong>and</strong> ChildWelfare Centres (MCWCs): FP, exp<strong>and</strong>ed programmeon immunization, antenatal care, postnatal care, normalvag<strong>in</strong>al deliveries, Caesarean-section deliveries, behaviouralchange communication, adolescent RH services, menstrualregulation, screen<strong>in</strong>g for <strong>and</strong> treatment of sexuallytransmitted <strong>in</strong>fection (STI), <strong>and</strong> STI prevention through<strong>the</strong> provision of condoms. DGHS affords preventive <strong>and</strong>curative health-care services, <strong>in</strong>clud<strong>in</strong>g management of <strong>the</strong>HIV/AIDS programme with fund<strong>in</strong>g from <strong>the</strong> GlobalFund to Fight AIDS, Tuberculosis <strong>and</strong> Malaria, with no<strong>in</strong>volvement of DGFP <strong>in</strong> <strong>the</strong> latter programme underwhich it imports condoms separately <strong>and</strong> distributes thosefree of charge, unlike <strong>in</strong> <strong>the</strong> FP programme where a dozencondoms are sold for Tk. 1.20. The National NutritionProject manages <strong>the</strong> country’s nutrition programme.The Health <strong>and</strong> Population Sector Programme (HPSP)was formulated as part of <strong>the</strong> Fifth Five-Year Plan (1998-2003), keep<strong>in</strong>g <strong>in</strong> view <strong>the</strong> pr<strong>in</strong>ciples of <strong>the</strong> Health <strong>and</strong>Population Sector Strategy, which called for a s<strong>in</strong>gle <strong>and</strong><strong>in</strong>tegrated sector for both health <strong>and</strong> population (GOB,1998). The ma<strong>in</strong> objective of HPSP was to ensure universalaccess to essential health-care services of acceptable quality<strong>and</strong> to fur<strong>the</strong>r slow <strong>the</strong> population growth rate. TheEssential Services Package, delivered through differentlevels of <strong>the</strong> primary health-care system (community, union,upazilla <strong>and</strong> district levels), <strong>in</strong>corporated RH services,<strong>in</strong>clud<strong>in</strong>g FP; child health <strong>and</strong> immunization; control ofselected communicable diseases; limited curative care <strong>and</strong>behavioural change communications. The HPSP targetswere not achieved (Streatfield et al., 2003). The Health,Nutrition <strong>and</strong> Population Sector Programme (HNPSP)was launched <strong>in</strong> 2003 (GOB, 2004a). Adolescent healthbecame a major part of <strong>the</strong> Essential Services Package underHNPSP, <strong>the</strong> targets of which are to: (a) <strong>in</strong>crease CPR from54 per cent <strong>in</strong> 2003 to 72 per cent by 2011; (b) reduce <strong>the</strong>discont<strong>in</strong>uation rate of contraception from 44.5 per cent <strong>in</strong>2007 to 20 per cent by 2011; <strong>and</strong> (c) <strong>in</strong>crease <strong>the</strong> uptake oflonger-act<strong>in</strong>g <strong>and</strong> permanent methods – voluntary surgicalcontraception: 1,750,000; IUDs: 2,300,000; <strong>and</strong> implants:1,050,000 (GOB, 2008a). However, <strong>the</strong> targets are quiteoverambitious, <strong>and</strong> hence are not likely to be achieved.With one year left of HNPSP, <strong>the</strong> M<strong>in</strong>istry has begun <strong>the</strong>process of design<strong>in</strong>g its next five-year health, population<strong>and</strong> nutrition programme. The Health, Population <strong>and</strong>Nutrition Sector Strategic Plan (HPNSSP) has identified<strong>the</strong> key <strong>in</strong>terventions required to accelerate <strong>the</strong> pace of<strong>the</strong> health, population <strong>and</strong> nutrition sector, so that it willbecome more responsive to clients’ needs, more efficient<strong>in</strong> <strong>the</strong> delivery of services <strong>and</strong> more effective <strong>in</strong> provid<strong>in</strong>gkey services for poor people. It is proposed that various FP<strong>in</strong>terventions would be revitalized to achieve replacementlevelfertility by 2016 by giv<strong>in</strong>g priority to: (a) efforts todelay age at marriage <strong>and</strong> age of childbear<strong>in</strong>g; <strong>and</strong> (b)<strong>in</strong>crease <strong>the</strong> use of long-term <strong>and</strong> permanent methods(GOB, 2010b).In recogniz<strong>in</strong>g <strong>the</strong> threats posed by HIV/AIDS, <strong>the</strong>government developed a comprehensive policy on HIV/AIDS <strong>and</strong> STD-related issues <strong>in</strong> 1997 <strong>in</strong> order to furnishnecessary guidance <strong>and</strong> support <strong>in</strong> address<strong>in</strong>g <strong>the</strong>seissues. MOHFW has overall responsibility for HIV/AIDS programmes, <strong>and</strong> o<strong>the</strong>r related m<strong>in</strong>istries supportits activities. There is an STD/AIDS network consist<strong>in</strong>gof more than 135 NGOs <strong>and</strong> private organizations,which is work<strong>in</strong>g actively to coord<strong>in</strong>ate <strong>and</strong> streng<strong>the</strong>nHIV/AIDS-related activities. HIV/AIDS <strong>and</strong> STDsurveillance was set up <strong>in</strong> 1998 to monitor trends <strong>in</strong>HIV <strong>in</strong>fection <strong>and</strong> risk behaviours for HIV transmissionamong <strong>the</strong> most vulnerable population groups (<strong>in</strong>ject<strong>in</strong>gdrug users, commercial sex workers <strong>and</strong> men who have sexwith men) <strong>and</strong> among <strong>the</strong> bridg<strong>in</strong>g population (transportworkers). Targeted <strong>in</strong>terventions are be<strong>in</strong>g implementedwith high-risk <strong>and</strong> bridg<strong>in</strong>g population groups (UNFPA/MOHFW/GOB, 2005).AchievementsThe Bangladesh <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Programme has become asocial movement. It received <strong>the</strong> country’s highest politicalcommitment until <strong>the</strong> mid-1990s. The programme has<strong>the</strong> support of <strong>the</strong> elite, <strong>in</strong>clud<strong>in</strong>g journalists (Khuda et al.,1994a). Also, <strong>the</strong> role of religious leaders is, by <strong>and</strong> large,positive (Khuda, 2004).Knowledge of FP methods is almost universal amongBangladeshi couples. In <strong>the</strong> context of such a favourablepolitical <strong>and</strong> religious environment, <strong>the</strong> FP programme<strong>in</strong> Bangladesh achieved commendable success until <strong>the</strong>mid-1990s. From only about 4 per cent of married couplesus<strong>in</strong>g FP <strong>in</strong> <strong>the</strong> 1960s (Sirageld<strong>in</strong> et al., 1975; Stoeckel <strong>and</strong>Chowdhury, 1973; Azhar <strong>and</strong> Hardee, 1977), CPR slowly<strong>in</strong>creased dur<strong>in</strong>g <strong>the</strong> 1970s (K<strong>in</strong>gdom of Ne<strong>the</strong>rl<strong>and</strong>s,1978; Mia et al., 1978; Bhuiyan, 1980; Khan et al., 1977;Khan, 1981; Khuda, 1981). In 1993/94, CPR <strong>in</strong>creasedto 44.6 per cent, i.e. an almost six-fold <strong>in</strong>crease comparedwith 1975. Thereafter, <strong>the</strong> rate of <strong>in</strong>crease slowed, <strong>and</strong> <strong>in</strong>fact decl<strong>in</strong>ed from 58 per cent <strong>in</strong> 2004 to 56 per cent <strong>in</strong>2007 (see Figure 2 <strong>and</strong> Table 1).The achievements until <strong>the</strong> mid-1990s can be attributed tostrong political will <strong>and</strong> commitment s<strong>in</strong>ce <strong>the</strong> launch<strong>in</strong>gof <strong>the</strong> First Five-Year Plan of Bangladesh until <strong>the</strong> mid-1990s, <strong>the</strong> <strong>in</strong>crease <strong>in</strong> <strong>the</strong> dem<strong>and</strong> for FP services, <strong>the</strong>provision of such services by <strong>the</strong> FP programme, <strong>and</strong>socio-economic development (for example, see Clel<strong>and</strong> etal., 1994; Caldwell et al., 1999; Khuda et al., 2001; <strong>and</strong>UNFPA, 2010).111

Programmatic gapsPolicy environmentThe overall political environment <strong>in</strong> <strong>the</strong> country is farless supportive of a broad-based approach to conta<strong>in</strong><strong>in</strong>g<strong>the</strong> rate of population growth <strong>in</strong> <strong>the</strong> country (see alsoAlaudd<strong>in</strong> et al., 2010). Indeed, s<strong>in</strong>ce <strong>the</strong> mid-1990s,<strong>the</strong>re has been erosion <strong>in</strong> political will <strong>and</strong> commitmentof successive governments to tackle <strong>the</strong> problem (Khuda<strong>and</strong> Barkat, 2010). This is clearly <strong>the</strong> major gap, becauseall o<strong>the</strong>r gaps discussed below are due to lack of politicalwill <strong>and</strong> commitment, which <strong>in</strong> turn has adversely affectedprogramme implementation at different levels. Based on<strong>the</strong> family plann<strong>in</strong>g programme effort studies conducted <strong>in</strong>several countries, <strong>in</strong>clud<strong>in</strong>g Bangladesh, <strong>in</strong> 1999, 2004 <strong>and</strong>2009, <strong>the</strong> overall policy score <strong>in</strong> Bangladesh has decl<strong>in</strong>edbetween 1999 <strong>and</strong> 2009 (see Appendix Table 1).Slow<strong>in</strong>g <strong>the</strong> rate of <strong>in</strong>crease <strong>in</strong> <strong>the</strong>contraceptive prevalence rateBetween 1975 <strong>and</strong> 1989, CPR <strong>in</strong>creased from about 8 percent to 31 per cent, i.e. a 1.6 per cent <strong>in</strong>crease per year.Between 1989 <strong>and</strong> 1991, <strong>the</strong>re was a sharp <strong>in</strong>crease <strong>in</strong>CPR from 31 per cent to 40 per cent, i.e. a 4.5 per cent<strong>in</strong>crease per year. Thereafter, <strong>the</strong> rate of <strong>in</strong>crease <strong>in</strong> CPRslowed. Between 1993/94 <strong>and</strong> 2004, CPR <strong>in</strong>creased from45 per cent to 58 per cent, i.e. a 1.3 per cent <strong>in</strong>crease peryear. Worse still, CPR decl<strong>in</strong>ed from 58 per cent <strong>in</strong> 2004to 56 per cent <strong>in</strong> 2007. A similar pattern emerges if <strong>the</strong>trend <strong>in</strong> <strong>the</strong> use of modern methods is observed: such userema<strong>in</strong>ed almost unchanged between 2004 <strong>and</strong> 2007 (seeFigure 2 <strong>and</strong> Table 1). Data from <strong>the</strong> <strong>International</strong> Centrefor Diarrhoeal Disease Research, Bangladesh (ICDDR, B)<strong>in</strong> <strong>the</strong> Matlab area, which had a considerably higher CPRthan <strong>the</strong> national rate over <strong>the</strong> few past years, also show adecl<strong>in</strong><strong>in</strong>g trend <strong>in</strong> CPR, from over 70 per cent <strong>in</strong> 2004/05to 56.6 per cent <strong>in</strong> 2007 <strong>and</strong> fur<strong>the</strong>r decl<strong>in</strong><strong>in</strong>g to 54.4 percent <strong>in</strong> 2008 (ICDDR, B, 2010). The slow<strong>in</strong>g <strong>in</strong> <strong>the</strong> rateof <strong>in</strong>crease <strong>in</strong> CPR is a matter of concern, given <strong>the</strong> needto accelerate <strong>the</strong> rate of <strong>in</strong>crease <strong>in</strong> CPR to achieve <strong>the</strong>desired reduction <strong>in</strong> fertility.The decl<strong>in</strong>e <strong>in</strong> <strong>the</strong> rate of <strong>in</strong>crease <strong>in</strong> CPR <strong>and</strong> <strong>the</strong> decl<strong>in</strong>e<strong>in</strong> CPR between 2004 <strong>and</strong> 2007 is due to <strong>the</strong> follow<strong>in</strong>ggaps <strong>in</strong> <strong>the</strong> programme: (a) erosion <strong>in</strong> political will <strong>and</strong>commitment, (b) failure on <strong>the</strong> part of <strong>the</strong> 1994 ICPD toclearly operationalize how FP was to be made an <strong>in</strong>tegralpart of <strong>the</strong> RH programme, (c) various organizationalweaknesses of <strong>the</strong> programme, (d) variations <strong>in</strong>contraceptive use by region <strong>and</strong> place of residence, (e) lowcontraceptive use among young married women, (f ) lownumber of fieldworker visitations, (g) decl<strong>in</strong><strong>in</strong>g trend <strong>in</strong> <strong>the</strong>relative share of longer-act<strong>in</strong>g <strong>and</strong> permanent FP methods,(h) a high discont<strong>in</strong>uation rate, <strong>and</strong> (i) ris<strong>in</strong>g unmet needfor contraception <strong>and</strong> high future <strong>in</strong>tention to use FP.Inadequate coverage, low quality <strong>and</strong><strong>in</strong>appropriate method mixInadequate <strong>and</strong> <strong>in</strong>efficient servicedelivery:FP service delivery suffers from various constra<strong>in</strong>ts.These <strong>in</strong>clude, for example, <strong>in</strong>adequate fund<strong>in</strong>g by <strong>the</strong>government; <strong>in</strong>adequate staff<strong>in</strong>g; lack of a regular, reliable<strong>and</strong> un<strong>in</strong>terrupted supply of contraceptives; scarce <strong>and</strong><strong>in</strong>consistent behavioural change communication messages;lack of strong technical <strong>and</strong> managerial leadership; <strong>and</strong><strong>the</strong> limited role of NGOs <strong>and</strong> <strong>the</strong> private sector, with <strong>the</strong>exception of <strong>the</strong> Social Market<strong>in</strong>g Company (SMC). All<strong>the</strong>se result <strong>in</strong> a general lack of access to good-quality FPservices, especially <strong>in</strong> <strong>the</strong> low-perform<strong>in</strong>g areas.Fieldworkers are a critical part of <strong>the</strong> FP programme.Their role <strong>in</strong>volves advocacy, motivation <strong>and</strong> supply<strong>in</strong>g/resupply<strong>in</strong>g FP methods. They visit women at <strong>the</strong>ir homesto motivate <strong>the</strong>m about us<strong>in</strong>g FP, teach <strong>the</strong>m about FPpractices, provide women with contraceptives, help restock<strong>the</strong>m on a regular basis <strong>and</strong> make referrals for longeract<strong>in</strong>g<strong>and</strong> permanent methods. However, only 21 percent of <strong>the</strong> married women surveyed <strong>in</strong> <strong>the</strong> 2007 BDHSreported hav<strong>in</strong>g been visited by a FP fieldworker (84% of<strong>the</strong>m by government fieldworkers <strong>and</strong> only 16% by NGOfieldworkers), which represented a sharp decl<strong>in</strong>e from 43per cent <strong>in</strong> 1993/94 (see Table 1). More than 85 per centof <strong>the</strong> young (15-19 years) <strong>and</strong> older women (45-49 years)did not receive any visit from a fieldworker. Chittagonghad <strong>the</strong> lowest fieldworker home visitation rate (14%),followed by Sylhet (18%) compared with Rajshahi (26%)<strong>and</strong> Khulna (24%). The rate was lowest among womenwith no liv<strong>in</strong>g children (7%). Also, it was low among pillusers (36%), followed by IUD <strong>and</strong> <strong>in</strong>jectable users (29%)<strong>and</strong> condom users (24%).The public sector programme is faced with <strong>the</strong> problem ofa shortage of fieldworkers, i.e. <strong>Family</strong> Welfare Assistants(FWAs). Over <strong>the</strong> past several years, <strong>the</strong>ir numbers havedecl<strong>in</strong>ed, because fresh recruitment had been on hold. Themajority of fieldworkers, recruited two to three decades ago,will be retir<strong>in</strong>g <strong>in</strong> <strong>the</strong> next 2-3 years. The problem is fur<strong>the</strong>rcompounded by <strong>the</strong> fact that FWAs, who were orig<strong>in</strong>allyrecruited to serve an average of 600 households per FWA,are now responsible for almost double that number. Inaddition, <strong>the</strong>y are now responsible for a broader array ofhealth <strong>in</strong>formation <strong>and</strong> services (such as supply<strong>in</strong>g oralrehydration salts, vitam<strong>in</strong> A capsules, <strong>and</strong> health educationon ante- <strong>and</strong> pre-natal care, newborn care, nutrition, <strong>and</strong>adolescent health), <strong>the</strong>reby divert<strong>in</strong>g <strong>the</strong>ir time away fromFP service delivery activities.112

Most FWAs who were recruited two to three decadesago have not received adequate follow-up tra<strong>in</strong><strong>in</strong>g, <strong>and</strong>hence, are unable to counsel clients effectively about <strong>the</strong>side effects of different FP methods <strong>and</strong> successfully matchclients to different methods, based on <strong>the</strong>ir reproductivelife-cycle needs. It is, <strong>the</strong>refore, not surpris<strong>in</strong>g that asizeable proportion of older, high-parity women cont<strong>in</strong>ueto use oral pills ra<strong>the</strong>r than switch to longer-act<strong>in</strong>g <strong>and</strong>permanent methods. Fur<strong>the</strong>r, <strong>the</strong> very high <strong>and</strong> ris<strong>in</strong>g ratesof discont<strong>in</strong>uation among users <strong>in</strong>dicate that <strong>the</strong> servicesare of poor quality.The public sector is <strong>the</strong> predom<strong>in</strong>ant source of supply ofFP methods, provid<strong>in</strong>g contraceptives to half of all users,although its contribution to FP provision has decl<strong>in</strong>ed byseven percentage po<strong>in</strong>ts <strong>in</strong> 2007 compared to 2004. Thepublic sector is <strong>the</strong> predom<strong>in</strong>ant source for female <strong>and</strong> malesterilization, <strong>in</strong>jectables <strong>and</strong> implants, while <strong>the</strong> privatesector is <strong>the</strong> predom<strong>in</strong>ant source of oral pills <strong>and</strong> condoms.Of pill users, 45 per cent <strong>in</strong> 2007 used SMC br<strong>and</strong>scompared with 52 per cent who used <strong>the</strong> governmentsuppliedbr<strong>and</strong>. Condoms sold by SMC accounted forover 60 per cent of <strong>the</strong> total market share, with <strong>the</strong> publicsector account<strong>in</strong>g for 17 per cent; <strong>the</strong> rema<strong>in</strong>der wassupplied by private sources <strong>and</strong> o<strong>the</strong>rs (NIPORT, Mitra<strong>and</strong> Associates <strong>and</strong> Macro <strong>International</strong>, 2009). Theoverall services score has decl<strong>in</strong>ed between 2004 <strong>and</strong> 2009(see Appendix Table 1).Low contraceptive use among youngmarried women:Women younger than 20 years of age – adolescents –accounted for 13 per cent of <strong>the</strong> married women <strong>in</strong>terviewed<strong>in</strong> <strong>the</strong> 2007 BDHS, less than 42 per cent of whom usedcontraception <strong>and</strong> only 38 per cent of whom used modernmethods. Of those us<strong>in</strong>g modern methods, 78 per centwere us<strong>in</strong>g <strong>the</strong> pill. Compared with national rates, CPR<strong>and</strong> <strong>the</strong> use of modern methods among adolescent femaleswere lower – 25 per cent <strong>and</strong> 21 per cent respectively.Given <strong>the</strong> disproportionately high share of such females <strong>in</strong><strong>the</strong> total fertility rate (23%), low contraceptive use amongyoung married women is a major gap <strong>in</strong> <strong>the</strong> programme.Regional variations <strong>in</strong> contraceptiveuse:There are pronounced regional variations <strong>in</strong> contraceptiveuse <strong>in</strong> Bangladesh. CPR <strong>and</strong> use of modern methods aremore than twice as high <strong>in</strong> Rajshahi division (66% <strong>and</strong>57% respectively) compared with Sylhet division (32% <strong>and</strong>25% respectively).CPR varies by place of residence. It is higher <strong>in</strong> urban(62%) than rural areas (54%), although <strong>the</strong> urban-ruralgap has been narrow<strong>in</strong>g s<strong>in</strong>ce 1996/97. The urban-ruralgap is primarily due to higher use of condoms <strong>in</strong> urbanareas (9.5%) than <strong>in</strong> rural ones (3%). With<strong>in</strong> urban areas,CPR is lower <strong>in</strong> slums than <strong>in</strong> non-slum areas (NIPORT,MEASURE DHS, ICDDR, B <strong>and</strong> ACPR, 2008).The variations <strong>in</strong> contraceptive use by region <strong>and</strong> by placeof residence <strong>in</strong>dicate limited access to, <strong>and</strong> availability of,FP services across different regions of <strong>the</strong> country. This isdue also to <strong>the</strong> lack of adequate <strong>and</strong> effective behaviouralchange communication campaigns <strong>in</strong> <strong>the</strong> underservedareas of <strong>the</strong> country.Decl<strong>in</strong><strong>in</strong>g share of longer-act<strong>in</strong>g <strong>and</strong>permanent methods:Over time, <strong>the</strong> relative share of modern methods has<strong>in</strong>creased, although <strong>the</strong> relative use of longer-act<strong>in</strong>g <strong>and</strong>permanent methods has decl<strong>in</strong>ed. Global experienceshows that <strong>the</strong> most successful FP programmes arecharacterized by considerably high use of longer-act<strong>in</strong>g<strong>and</strong> permanent methods (for example, see UNFPA, 2010).Modern methods account for over 85 per cent of overallcontraceptive use. The pill cont<strong>in</strong>ues to be <strong>the</strong> most popularFP method, used by 28.5 per cent of currently marriedwomen, followed by <strong>in</strong>jectables (7%), sterilization (5.7%),<strong>and</strong> condoms (4.5%) (NIPORT, Mitra <strong>and</strong> Associates<strong>and</strong> Macro <strong>International</strong>, 2009).With <strong>the</strong> <strong>in</strong>crease <strong>in</strong> use of short-term methods, especially<strong>the</strong> pill, <strong>the</strong> contraceptive method mix has changed overtime. For example, <strong>the</strong> pill now accounts for 60 per cent ofmodern method use compared with 48 per cent <strong>in</strong> 1994.Similarly, <strong>in</strong>jectables now account for 15 per cent of modernmethod use compared with 12 per cent <strong>in</strong> 1994. In sharpcontrast, <strong>the</strong> relative share of longer-act<strong>in</strong>g <strong>and</strong> permanentmethods decl<strong>in</strong>ed from 32 per cent of modern methoduse <strong>in</strong> 1994 to only 14 per cent <strong>in</strong> 2007. As previouslynoted, Bangladeshi women beg<strong>in</strong> early childbear<strong>in</strong>g, <strong>and</strong>have more than half of <strong>the</strong>ir children dur<strong>in</strong>g <strong>the</strong>ir twenties<strong>and</strong> one fifth dur<strong>in</strong>g <strong>the</strong>ir thirties. In 2007, <strong>the</strong> median ageof sterilized women was quite high (27 years), which hasrema<strong>in</strong>ed unchanged s<strong>in</strong>ce 1993 (NIPORT, Mitra <strong>and</strong>Associates <strong>and</strong> Macro <strong>International</strong>, 2009). High medianage for sterilization <strong>and</strong> early pregnancies pose majorproblems <strong>in</strong> ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g small <strong>and</strong> healthy families.The change <strong>in</strong> <strong>the</strong> contraceptive method mix hasimplications for <strong>the</strong> FP programme <strong>in</strong> respect of relianceon fieldworkers, especially among <strong>the</strong> poor, rural women,<strong>and</strong> on restocks of modern temporary methods, as well ason overall programme susta<strong>in</strong>ability. Also, <strong>the</strong> extremelylow frequency of fieldworker home visitation, especially<strong>in</strong> areas with low CPR, among women with one or noliv<strong>in</strong>g child <strong>and</strong> among condom <strong>and</strong> pill users, adds anew dimension to <strong>the</strong> problem. In addition, <strong>the</strong> change <strong>in</strong>method mix has implications for <strong>the</strong> women <strong>the</strong>mselves.113

FigureAbout one fifth of married women aged 35 years <strong>and</strong> older<strong>and</strong> over one quarter of those with three or more surviv<strong>in</strong>gchildren rely on <strong>the</strong> pill. Rely<strong>in</strong>g on <strong>the</strong> pill ra<strong>the</strong>r thanaccept<strong>in</strong>g longer-act<strong>in</strong>g <strong>and</strong> permanent methods poses amajor problem for <strong>the</strong> efficiency of <strong>the</strong> programme.Under <strong>the</strong> Mayer Hashi Project, funded by USAID, <strong>the</strong>goal is to achieve 5 million voluntary sterilization clientsover <strong>the</strong> four-year project period (May 2009 to September2013). The target is unlikely to be achieved because of<strong>the</strong> lack of prerequisite conditions, such as shortage oftra<strong>in</strong>ed providers. The achievements <strong>in</strong> longer-act<strong>in</strong>g <strong>and</strong>permanent methods are below <strong>the</strong> targets (GOB, 2008a),<strong>and</strong> this has been fur<strong>the</strong>r confirmed by <strong>the</strong> concernedDGFP officials. The Mayer Hashi Project is implementedby EngenderHealth <strong>in</strong> collaboration with DGFP.Figure 3 shows <strong>the</strong> trend <strong>in</strong> longer-act<strong>in</strong>g <strong>and</strong> permanentmethod performance <strong>in</strong> <strong>the</strong> national programme. Thetotal number of voluntary sterilization cases <strong>in</strong>creasedfrom about 70,000 for <strong>the</strong> period from October 2002to September 2003 to about 300,000 dur<strong>in</strong>g <strong>the</strong> periodOctober 2009 to September 2010; however, <strong>the</strong> numbersdecl<strong>in</strong>ed dur<strong>in</strong>g <strong>the</strong> periods October 2005 to September2006 <strong>and</strong> October 2001 to September 2008. The numberof IUD acceptors <strong>in</strong>creased from fewer than 200,000 dur<strong>in</strong>g<strong>the</strong> period October 2002 to September 2003 to around350,000 dur<strong>in</strong>g <strong>the</strong> period October 2008 to September2009, but <strong>the</strong>n decl<strong>in</strong>ed to around 200,000 dur<strong>in</strong>g <strong>the</strong>period October 2009 to September 2010. The number ofimplant acceptors <strong>in</strong>creased from over 50,000 dur<strong>in</strong>g <strong>the</strong>period October 2002 to September 2003 to over 200,000dur<strong>in</strong>g <strong>the</strong> period October 2008 to September 2009, but<strong>the</strong>n decl<strong>in</strong>ed to 50,000 from October 2008. The decl<strong>in</strong>e<strong>in</strong> <strong>the</strong> use of <strong>the</strong> different longer-act<strong>in</strong>g <strong>and</strong> permanentmethods between October 2002 <strong>and</strong> September 2010 islargely due to such methods be<strong>in</strong>g out of stock <strong>and</strong> to <strong>the</strong>shortage of tra<strong>in</strong>ed providers, equipment, <strong>in</strong>frastructure<strong>and</strong> f<strong>in</strong>ance. Fur<strong>the</strong>r, <strong>the</strong> dem<strong>and</strong> for longer-act<strong>in</strong>g <strong>and</strong>permanent methods is affected by <strong>the</strong> poor quality ofservices <strong>in</strong> <strong>the</strong> public sector <strong>and</strong> lack of promotional efforts.Overall, <strong>the</strong> quality of health <strong>and</strong> FP services cont<strong>in</strong>ues tobe low, <strong>and</strong> this disproportionately hurts <strong>the</strong> poor (WorldBank, 2010).High discont<strong>in</strong>uation rate:A key concern for FP programmes overly-dependent ontemporary modern methods is <strong>the</strong> rate of discont<strong>in</strong>uation<strong>and</strong> <strong>the</strong> clients’ reasons for discont<strong>in</strong>uation. Over half(56.5%) of <strong>the</strong> users stopped us<strong>in</strong>g a method with<strong>in</strong> 12months of start<strong>in</strong>g its use <strong>in</strong> 2007, up from 48 per cent <strong>in</strong>1993/94 (see Table 1). The discont<strong>in</strong>uation rate was highestamong condom users (76%), followed by those practis<strong>in</strong>gwithdrawal (67%), us<strong>in</strong>g <strong>the</strong> pill (54%), <strong>in</strong>jectables (53%)<strong>and</strong> IUD (33%). Most users drop out because of methodfailure, side effects, health reasons, or because <strong>the</strong>y want tobecome pregnant. Dropp<strong>in</strong>g out on account of side effects<strong>and</strong> method failure <strong>in</strong>dicates that FP services are of lowquality. Such a high drop-out rate implies huge systemlosses for <strong>the</strong> programme.Ris<strong>in</strong>g unmet need <strong>and</strong> high future<strong>in</strong>tention to use family plann<strong>in</strong>gRis<strong>in</strong>g unmet need for contraception:Unmet need for contraception <strong>in</strong>creased from 11 per cent<strong>in</strong> 2004 to 17 per cent <strong>in</strong> 2007 (see Table 1). Fur<strong>the</strong>r, ifthose us<strong>in</strong>g traditional methods of FP (8% <strong>in</strong> 2007)Figure3Trend of National LA/PM Performance (October 2002 - September 2010)400000350000300000250000200000150000100000500000Tubectomy Vasectomy Total VSC IUD ImplantOct-02 to Sep-0335003407567575918370755972Oct-03 to Sep-04624994719110969019866984977Oct-04 to Sep-058490159222144123210878107137Oct-05 to Sep-06684325672012515225390451386Oct-06 to Sep-071066089839520500319659911164Oct-07 to Sep-0810251587559190074269112211069Oct-08 to Sep-0912471612646225117833612653896Oct-09 to Sep-1012814315612828427121920949683114

are considered, unmet need for effective methods ofcontraception was 25 per cent <strong>in</strong> 2007. Unmet need has<strong>in</strong>creased across all age groups, all educational groups, <strong>in</strong>both rural <strong>and</strong> urban areas, <strong>and</strong> <strong>in</strong> all geographic regionsof <strong>the</strong> country. Unmet need is highest <strong>in</strong> Sylhet division(26%), <strong>and</strong> lowest <strong>in</strong> Khulna <strong>and</strong> Rajshahi divisions (12%).Unmet need is higher among limiters (11%) than spacers(7%). The <strong>in</strong>crease <strong>in</strong> unmet need reflects problems withfieldworker home visitations, <strong>the</strong> supply of FP methods<strong>and</strong> services, <strong>and</strong>/or an actual <strong>in</strong>crease <strong>in</strong> <strong>the</strong> dem<strong>and</strong> forFP.High future <strong>in</strong>tention to use: A large majority (70%)of <strong>the</strong> non-users <strong>in</strong> <strong>the</strong> 2007 BDHS reported that <strong>the</strong>ywanted to use FP <strong>in</strong> <strong>the</strong> future (see Table 1). The highproportion of non-users who <strong>in</strong>tended to practise FP <strong>in</strong><strong>the</strong> future created both a challenge <strong>and</strong> an opportunity for<strong>the</strong> programme to be able to provide <strong>the</strong>m with access togood-quality FP services.Gaps <strong>in</strong> contraceptive securityThe term “commodity security” is used to describe a situationwhere every person will<strong>in</strong>g to practise FP is able to choose,obta<strong>in</strong> <strong>and</strong> use good-quality FP methods at <strong>the</strong> right time<strong>and</strong> <strong>in</strong> <strong>the</strong> right place. The “six rights” pr<strong>in</strong>ciples are: rightcommodities, right quantities, right conditions, right place,right time <strong>and</strong> right prices (GOB, 2010c). Contraceptivesecurity exists when <strong>the</strong> follow<strong>in</strong>g four conditions are metby <strong>the</strong> programme: (a) <strong>the</strong> programme has <strong>the</strong> ability toaccurately estimate its contraceptive requirements; (b) ithas or has coord<strong>in</strong>ated <strong>the</strong> necessary fund<strong>in</strong>g to procurecontraceptives; (c) it has <strong>the</strong> technical capacity to procurecontraceptives on a timely basis; <strong>and</strong> (d) it is able to ensure<strong>the</strong> availability of contraceptives <strong>and</strong> <strong>the</strong>ir reliable deliveryto <strong>the</strong> end-users for <strong>the</strong> medium- to long-term future. Of<strong>the</strong> four essential conditions for achiev<strong>in</strong>g contraceptivesecurity, <strong>the</strong> ability to procure commodities has been <strong>the</strong>most difficult for Bangladesh (GOB, 2004b).The contraceptive requirements of Bangladesh are metby <strong>the</strong> public sector, SMC, <strong>the</strong> private sector <strong>and</strong> NGOs.Except for <strong>the</strong> private sector, <strong>the</strong> public sector, with grantsfrom development partners <strong>and</strong> loans from <strong>the</strong> WorldBank/<strong>International</strong> Development Association (IDA), isprocur<strong>in</strong>g contraceptives for <strong>the</strong> public sector <strong>and</strong> NGOs.SMC currently receives commodities directly from donors<strong>and</strong> procures some products us<strong>in</strong>g <strong>the</strong> sales proceeds fromdonated contraceptives.Before 1998, most contraceptives were supplied to <strong>the</strong>Bangladesh FP programme by donors (Department for<strong>International</strong> Development, KfW Entwicklungsbank,CIDA, UNFPA <strong>and</strong> USAID). Under HPSP, with abudget of approximately US$ 3 billion provided by <strong>the</strong>government, <strong>the</strong> World Bank <strong>and</strong> a pool of developmentpartners, about half of <strong>the</strong> funds were allocated for <strong>the</strong>procurement of goods <strong>and</strong> services. Procurement was to becarried out <strong>in</strong> l<strong>in</strong>e with IDA <strong>and</strong> World Bank procurementguidel<strong>in</strong>es. Ow<strong>in</strong>g to a lack of experience with<strong>in</strong> MOHFWregard<strong>in</strong>g such procurement guidel<strong>in</strong>es, <strong>the</strong> DevelopmentCredit Agreement called for MOHFW to contract a privateprocurement agency; however, this approach did not workout. Subsequently, <strong>the</strong> responsibility for procurementwas assigned to <strong>the</strong> two directorates, DGFP <strong>and</strong> DGHS.However, ow<strong>in</strong>g to <strong>the</strong> lack of prior experience of DGFP<strong>and</strong> DGHS with procurement <strong>and</strong> <strong>the</strong> lack of familiaritywith IDA <strong>and</strong> World Bank procurement guidel<strong>in</strong>es,<strong>the</strong> procurement process was <strong>in</strong>effective, lead<strong>in</strong>g toconsiderable delays <strong>in</strong> process<strong>in</strong>g orders <strong>and</strong> <strong>the</strong> deliveryof commodities. To address this problem, <strong>the</strong> DELIVERProject of USAID provided technical assistance to tra<strong>in</strong>procurement staff of DGFP <strong>and</strong> DGHS (USAID/DELIVER Project, 2008).The procurement <strong>and</strong> supply of goods under IDAguidel<strong>in</strong>es, Work Bank procedures <strong>and</strong> <strong>the</strong> government’sPublic Procurement Regulations <strong>in</strong>volve a complexprocess, tak<strong>in</strong>g between a year <strong>and</strong> a year <strong>and</strong> a half underideal conditions. The DGFP contraceptives procurementprocess, funded dur<strong>in</strong>g <strong>the</strong> cont<strong>in</strong>gency period (2003-2005), was <strong>in</strong>itiated <strong>in</strong> late 2005 <strong>and</strong> early 2006. The delay<strong>in</strong> cont<strong>in</strong>gency plan fund<strong>in</strong>g was accompanied by delaysencountered throughout <strong>the</strong> procurement process, result<strong>in</strong>g<strong>in</strong> delayed commodity deliveries <strong>and</strong> eventual “stock-outs” 4of condoms, IUDs, <strong>in</strong>jectables <strong>and</strong> implant contraceptives.There was a shortfall of 247 million condoms betweenFebruary <strong>and</strong> March 2008; 614,000 IUDs betweenMay <strong>and</strong> June 2007; <strong>and</strong> 20 million <strong>in</strong>jectables betweenNovember <strong>and</strong> December 2006 (USAID/DELIVER,2008). Such shortfalls led to high discont<strong>in</strong>uation ratesamong users; <strong>and</strong> <strong>the</strong> method-mix, be<strong>in</strong>g dom<strong>in</strong>atedby temporary methods, resulted <strong>in</strong> a high <strong>in</strong>cidence ofun<strong>in</strong>tended <strong>and</strong> unwanted pregnancies. Accord<strong>in</strong>g to<strong>the</strong> 2007 BDHS, 3 <strong>in</strong> 10 births <strong>in</strong> Bangladesh are ei<strong>the</strong>runwanted or mistimed <strong>and</strong> wanted later, with no changefrom 2004 (NIPORT, Mitra <strong>and</strong> Associates <strong>and</strong> Macro<strong>International</strong>, 2009). The overall availability score decl<strong>in</strong>edbetween 2004 <strong>and</strong> 2009 (see Appendix Table 1).O<strong>the</strong>r constra<strong>in</strong>ts on <strong>the</strong> availability of contraceptivemethods <strong>in</strong>clude: (a) a considerable shortage of tra<strong>in</strong>edproviders hamper<strong>in</strong>g provision of tubal ligation, no-scalpelvasectomy <strong>and</strong> IUDs; (b) non-availability of <strong>the</strong> emergencycontraceptive pill, <strong>the</strong>refore leav<strong>in</strong>g menstrual regulation<strong>and</strong> abortion as <strong>the</strong> only back-up method for method <strong>and</strong>/or user failure; (c) non-availability of progest<strong>in</strong>-only pill;(d) stock-out of <strong>in</strong>jectables; <strong>and</strong> (e) stock-out of implants.With technical assistance from donors, Bangladeshhas developed large, successful supply cha<strong>in</strong>s for both115

MOHFW <strong>and</strong> NGOs, <strong>and</strong> separately for SMC. However,about half of <strong>the</strong> upazilas still do not have proper storagefacilities, <strong>and</strong> generally keep <strong>the</strong>ir supplies <strong>in</strong> a smallroom <strong>in</strong> Upazila Health Complexes or at Upazila ParisadBuild<strong>in</strong>gs (subdistrict adm<strong>in</strong>istrative complex), where it isnot possible to follow basic storage pr<strong>in</strong>ciples. Fur<strong>the</strong>r, <strong>the</strong><strong>in</strong>crease <strong>in</strong> contraceptive requirements could result <strong>in</strong> <strong>the</strong>warehous<strong>in</strong>g system experienc<strong>in</strong>g a shortage of space.The government undertook a number of measures tosimplify <strong>and</strong> modernize <strong>the</strong> public procurement policy<strong>and</strong> procedures <strong>in</strong> order to m<strong>in</strong>imize delays. Despite thoseefforts, delays cont<strong>in</strong>ue to hamper <strong>the</strong> procurement process.Delays arise largely due to: (a) limited technical capacity of<strong>the</strong> DGFP <strong>and</strong> MOHFW officials <strong>and</strong> Tender EvaluationCommittee (TEC) members; (b) high staff turnover atDGFP <strong>and</strong> MOHFW; (c) considerable time <strong>in</strong>volvementfor <strong>the</strong> MOHFW <strong>and</strong> World Bank Review Process; <strong>and</strong>(d) lengthy time for decision-mak<strong>in</strong>g by MOHFW <strong>and</strong>World Bank officials.The high turnover of tra<strong>in</strong>ed procurement staff <strong>and</strong> seniormanagement staff creates a knowledge <strong>and</strong> experience gap,limit<strong>in</strong>g <strong>the</strong> capacity of <strong>the</strong> MOHFW/DGFP to carry outtimely <strong>and</strong> effective procurement. Also, <strong>the</strong> TEC membersdo not have <strong>the</strong> requisite knowledge for prepar<strong>in</strong>gacceptable bid evaluation reports.Lack of adequate supportfor behavioural changecommunicationCommunication is an <strong>in</strong>tegral part of <strong>the</strong> FP programme,facilitat<strong>in</strong>g exchange of <strong>in</strong>formation <strong>and</strong> ideas to promote<strong>and</strong> susta<strong>in</strong> behavioural changes among differentpopulation groups towards <strong>the</strong> small family size norm <strong>and</strong>promote <strong>the</strong> use of contraception.The Information, Education <strong>and</strong> Motivation Unit of DGFPprepares various types of communication materials, suchas posters, h<strong>and</strong>bills, billboards, short television serials,dramas, radio j<strong>in</strong>gles <strong>and</strong> advertisements; however, mostsuch materials are outdated <strong>and</strong> not tailored to meet <strong>the</strong>specific needs of different client groups. Also, <strong>the</strong>re is noseparate cadre of officials at <strong>the</strong> district level for behaviouralchange communication activities.The major behavioural change communication objectivesunder HNPSP <strong>in</strong>clude: (a) encourag<strong>in</strong>g users not todiscont<strong>in</strong>ue FP use without valid reasons <strong>and</strong> to cont<strong>in</strong>uewith <strong>the</strong> option to use o<strong>the</strong>r FP methods; (b) develop<strong>in</strong>gpositive attitudes among people about longer-act<strong>in</strong>g <strong>and</strong>permanent methods <strong>and</strong> promot<strong>in</strong>g male participation;(c) extend<strong>in</strong>g behavioural change communicationactivities to hard-to-reach areas, urban slum dwellers<strong>and</strong> disadvantaged population groups; <strong>and</strong> (d) <strong>in</strong>creas<strong>in</strong>gbehavioural change communication knowledge amongservice providers for better counsel<strong>in</strong>g <strong>and</strong> good-qualitycare services. The key strategies <strong>in</strong>clude: (a) streng<strong>the</strong>n<strong>in</strong>gbehavioural change communication <strong>in</strong>terventionsat service centres, (b) improv<strong>in</strong>g <strong>the</strong> <strong>in</strong>terpersonalcommunication skills of service providers, (c) develop<strong>in</strong>g<strong>and</strong> dissem<strong>in</strong>at<strong>in</strong>g appropriate messages us<strong>in</strong>g a media mix,(d) develop<strong>in</strong>g advocacy programmes for policymakers<strong>and</strong> o<strong>the</strong>r stakeholders, <strong>and</strong> (e) promot<strong>in</strong>g longer-act<strong>in</strong>g<strong>and</strong> permanent methods (GOB, 2008a). To achieve <strong>the</strong>goals <strong>and</strong> objectives outl<strong>in</strong>ed <strong>in</strong> HNPSP, <strong>the</strong> governmentdeveloped its Adolescent Reproductive Health Strategy(GOB, 2006b) <strong>and</strong> National Communication Strategy for<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> Reproductive Health (GOB, 2008b).Although such strategy documents, as well as <strong>the</strong> previousstrategy documents (for example, see Khuda et al., 1993a),are quite comprehensive, <strong>the</strong>ir implementation has hardlybegun. Accord<strong>in</strong>g to <strong>the</strong> DGFP officials concerned, <strong>the</strong>major constra<strong>in</strong>ts to implementation of such strategies<strong>in</strong>clude: (a) lack of adequate support from <strong>the</strong> higherlevel decision-makers, (b) <strong>in</strong>adequate fund<strong>in</strong>g, (c) lackof adequate numbers of tra<strong>in</strong>ed staff, <strong>and</strong> (d) <strong>the</strong> limitedcapacity of <strong>the</strong> DGFP pr<strong>in</strong>t<strong>in</strong>g press to pr<strong>in</strong>t differenttypes of behavioural change communication materials. Asa result, both FP users <strong>and</strong> service providers have not beenable to ga<strong>in</strong> access to relevant <strong>in</strong>formation from a coherentnational behavioural change communication programme,which promotes small family size norms, counters clients’mis<strong>in</strong>formation <strong>and</strong> misconceptions, provides clients with<strong>in</strong>formation regard<strong>in</strong>g where services are available, <strong>and</strong><strong>in</strong>forms couples about <strong>the</strong>ir FP options. Consequently,basic knowledge of FP methods is low. Provider knowledgeis relatively low, result<strong>in</strong>g <strong>in</strong> poor quality of service, which,<strong>in</strong> turn, leads to <strong>in</strong>effective use of FP methods, unwantedpregnancies <strong>and</strong> <strong>in</strong>creased use of menstrual regulation <strong>and</strong>abortion (see also Alaudd<strong>in</strong> et al., 2010).Limited fund<strong>in</strong>g <strong>and</strong> actualexpenditureTotal health expenditure (THE) was estimated at Tk.159.91 billion (US$ 2.32 billion) <strong>in</strong> 2007, up from Tk.73.8 billion (US$ 1.4 billion) <strong>in</strong> 2001 <strong>and</strong> Tk. 48.47billion (US$ 1.1 billion) <strong>in</strong> 1997. THE as a percentageof GDP was 2.7 per cent dur<strong>in</strong>g <strong>the</strong> period 1997-2000;it <strong>in</strong>creased to 3.4 per cent <strong>in</strong> 2007. Per capita spend<strong>in</strong>gon health <strong>in</strong>creased from Tk. 391 (US$ 9) <strong>in</strong> 1997 toTk. 1,111 (US$ 16) <strong>in</strong> 2007, one of <strong>the</strong> lowest levels <strong>in</strong><strong>the</strong> world. Bangladesh’s public expenditure constitutes 26per cent of THE, which is similar to that of India (25%).Private expenditure as a percentage of THE account for 74per cent <strong>in</strong> Bangladesh, 83 per cent <strong>in</strong> Pakistan <strong>and</strong> 52 percent <strong>in</strong> Sri Lanka (GOB, 2010d).116

Households pay <strong>the</strong> major share of health expenditures<strong>in</strong> Bangladesh; <strong>the</strong>ir relative share has <strong>in</strong>creased from57 per cent of THE <strong>in</strong> 1997 to 65 per cent <strong>in</strong> 2007.The government is <strong>the</strong> second largest f<strong>in</strong>anc<strong>in</strong>g agent,account<strong>in</strong>g for 26 per cent of THE <strong>in</strong> 2007, with its sharedecl<strong>in</strong><strong>in</strong>g from 36 per cent <strong>in</strong> 1997.For public sector f<strong>in</strong>anc<strong>in</strong>g, MOHFW serves as <strong>the</strong> primaryf<strong>in</strong>ancial <strong>in</strong>termediary of <strong>the</strong> government, receiv<strong>in</strong>g fundsfrom <strong>the</strong> M<strong>in</strong>istry of F<strong>in</strong>ance. Of <strong>the</strong> total amount ofpublic sector health f<strong>in</strong>anc<strong>in</strong>g, MOHFW’s share was Tk.40.1 billion (US$ 581 million), which is 97 per cent of <strong>the</strong>total public f<strong>in</strong>anc<strong>in</strong>g <strong>in</strong> 2007. MOHFW uses <strong>the</strong>se fundsprimarily by disburs<strong>in</strong>g <strong>the</strong>m to those units provid<strong>in</strong>ghealth care. In addition to its own providers, throughtransfers <strong>and</strong> grants-<strong>in</strong>-aid to NGOs, MOHFW supports<strong>the</strong> health, FP <strong>and</strong> maternal <strong>and</strong> child health activities ofNGOs (GOB, 2010d).The estimated budget for HNPSP (2003-2011) is Tk.3,738,411.05 lacs 5 , of which Tk. 2,081,764.52 lacs (56%)is from <strong>the</strong> government revenue budget, Tk. 629,911.82lacs (17%) from <strong>the</strong> government development budget,<strong>and</strong> Tk. 1,026,734.71 lacs (27%) from project aid. For<strong>the</strong> development budget, <strong>the</strong> government’s share is 38per cent <strong>and</strong> that of development partners is 62 per cent.Out of <strong>the</strong> development budget of Tk. 1,656,647, <strong>the</strong>share of <strong>the</strong> FP <strong>and</strong> maternal, child <strong>and</strong> RH programmeis Tk. 357,129 (22%) of <strong>the</strong> total development budget –Tk. 98,662 lacs (16%) from <strong>the</strong> government developmentbudget <strong>and</strong> Tk. 258,467 (25%) from project aid. Of <strong>the</strong>total amount allocated to <strong>the</strong> FP <strong>and</strong> maternal, child <strong>and</strong>RH programme, FP service delivery accounts for 56 percent, while it accounts for only 12 per cent of <strong>the</strong> totaldevelopment budget allocated to <strong>the</strong> health, population<strong>and</strong> nutrition sector (GOB, 2008a).Dur<strong>in</strong>g 2003/04 <strong>and</strong> 2009/10, actual expenditure from <strong>the</strong>revenue budget was over 90 per cent <strong>in</strong> most years, exceptfor 2005/06 <strong>and</strong> 2008/09. However, expenditure from<strong>the</strong> development budget did not follow any clear pattern,rang<strong>in</strong>g between 62 per cent <strong>in</strong> 2008/09 <strong>and</strong> 89 per cent <strong>in</strong>2004/05 (see Table 2). Thus, <strong>the</strong> allocation to <strong>the</strong> FP <strong>and</strong>maternal, child <strong>and</strong> RH programme is <strong>in</strong>adequate, <strong>and</strong> <strong>the</strong>programme is unable to spend <strong>the</strong> funds allocated to it,<strong>the</strong>reby not be<strong>in</strong>g able to achieve <strong>the</strong> desired programmeobjectives. Inefficiencies <strong>in</strong> public spend<strong>in</strong>g rema<strong>in</strong> <strong>the</strong>health sector’s most immediate challenge. Widespreadsystem <strong>in</strong>efficiencies, weak plann<strong>in</strong>g capacity <strong>and</strong> anoverly centralized approval process lead to underspend<strong>in</strong>gof available funds. Fur<strong>the</strong>r, weak accountability, limitedimplementation capacity <strong>and</strong> weak governance <strong>in</strong>evitablylead to underperformance <strong>in</strong> <strong>the</strong> delivery of public services(World Bank, 2010).The way forwardGiven <strong>the</strong> major gaps faced by <strong>the</strong> Bangladesh <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Programme discussed <strong>in</strong> <strong>the</strong> preced<strong>in</strong>g sectionof <strong>the</strong> present paper 6 <strong>and</strong> identification of <strong>the</strong> major<strong>in</strong>terventions of HPNSSP, <strong>the</strong>re is a need to adopt <strong>and</strong>effectively implement <strong>the</strong> follow<strong>in</strong>g strategies to reverse<strong>the</strong> slow<strong>in</strong>g down <strong>in</strong> <strong>the</strong> rate of <strong>in</strong>crease <strong>in</strong> CPR <strong>and</strong> <strong>the</strong>consequent stall<strong>in</strong>g <strong>and</strong>/or near stagnation <strong>in</strong> fertilitydecl<strong>in</strong>e.Need to develop a supportive <strong>and</strong>proactive policy environmentThere is no doubt <strong>the</strong> Bangladesh <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Programme has lost much of <strong>the</strong> focus <strong>and</strong> priority ithad received until <strong>the</strong> mid-1990s. To fully achieve itsdevelopment objectives <strong>and</strong> br<strong>in</strong>g about <strong>the</strong> desiredreduction <strong>in</strong> poverty levels, <strong>the</strong> government should givehigh priority to <strong>the</strong> FP <strong>and</strong> RH programme <strong>and</strong> makeit an <strong>in</strong>tegral part of its overall development agenda;o<strong>the</strong>rwise, <strong>the</strong> demographic challenges it faces will impedeits overall development goals <strong>and</strong> objectives. Hence, <strong>the</strong>reis clearly a need to develop a supportive <strong>and</strong> proactivepolicy environment by sensitiz<strong>in</strong>g <strong>the</strong> political leadership<strong>and</strong> o<strong>the</strong>r stakeholders about <strong>the</strong> grave dangers of <strong>the</strong>cont<strong>in</strong>ued relatively high population growth rate <strong>in</strong> <strong>the</strong>country. Also, <strong>the</strong>re is a need for a more <strong>in</strong>clusive strategy,<strong>in</strong>volv<strong>in</strong>g greater <strong>in</strong>volvement <strong>and</strong> participation of allo<strong>the</strong>r m<strong>in</strong>istries concerned, NGOs, <strong>the</strong> private sector <strong>and</strong>professional groups. The political leadership should renewits commitment to conta<strong>in</strong> <strong>the</strong> rate of population growth,as it had until <strong>the</strong> mid-1990s, <strong>in</strong>stead of putt<strong>in</strong>g <strong>the</strong> issueon <strong>the</strong> backburner.With <strong>the</strong> end<strong>in</strong>g of HNPSP <strong>in</strong> June 2011, <strong>the</strong>government was <strong>in</strong>volved <strong>in</strong> design<strong>in</strong>g its next five-yearHealth, Population <strong>and</strong> Nutrition Sector Strategic Plan(HPNSSP), which would conclude <strong>in</strong> 2016. That Planrecognizes <strong>the</strong> demographic challenges faced by <strong>the</strong>country. The overall objective is to achieve replacementlevel fertility by 2016. The Plan is aimed at rais<strong>in</strong>g CPR to75 per cent from 56 per cent <strong>in</strong> 2007 (GOB, 2010e). Thetarget appears ambitious, imply<strong>in</strong>g a 2 per cent <strong>in</strong>crease <strong>in</strong>CPR annually. However, given <strong>the</strong> considerable unmet needfor contraception, <strong>the</strong> target can be achieved, though withmajor modifications <strong>and</strong> overhaul<strong>in</strong>g of <strong>the</strong> programme.HPNSSP has identified a number of <strong>in</strong>terventions <strong>and</strong>modifications to <strong>the</strong> FP programme aimed at facilitat<strong>in</strong>ga fur<strong>the</strong>r decl<strong>in</strong>e <strong>in</strong> fertility. These <strong>in</strong>clude <strong>the</strong> need to:(a) promote <strong>in</strong>creased use of FP before <strong>the</strong> first birth; (b)provide better counsel<strong>in</strong>g on side effects; (c) hire additionalfieldworkers <strong>in</strong> low-perform<strong>in</strong>g regions; (d) hire, tra<strong>in</strong> <strong>and</strong>update programme personnel; (e) improve delivery ofFP as part of post-abortion care; (f ) use different servicedelivery approaches for different geographic regions; (g)117

segment <strong>the</strong> target population by specific characteristics;(h) promote use of longer-act<strong>in</strong>g <strong>and</strong> permanent methods;(ix) streng<strong>the</strong>n behavioural change communications; <strong>and</strong>(i) improve commodity security.Need to adopt a client-segmentedapproach to both behavioural changecommunications <strong>and</strong> family plann<strong>in</strong>gservice deliveryIt is clear that <strong>the</strong> “one-size-fits-all” approach has not beenwork<strong>in</strong>g. Hence, <strong>the</strong>re is need to develop a client-segmentedapproach to both behavioural change communications <strong>and</strong>FP service delivery to be able to motivate non-users to useFP; promote <strong>in</strong>creased contraceptive use among marriedadolescents to delay <strong>the</strong>ir first birth; promote contraceptiveuse <strong>in</strong> underserved areas, <strong>in</strong>clud<strong>in</strong>g urban slums; <strong>in</strong>crease<strong>the</strong> use of longer-act<strong>in</strong>g <strong>and</strong> permanent methods; <strong>and</strong>motivate, <strong>and</strong> provide methods of choice to, those withunmet need <strong>and</strong> those who <strong>in</strong>tend to practise FP <strong>in</strong> <strong>the</strong>future.Over two fifths of eligible couples <strong>in</strong> Bangladesh are notpractis<strong>in</strong>g contraception. The priority target groups<strong>in</strong>clude married adolescents; women aged 35 years <strong>and</strong>older; those <strong>in</strong> Sylhet <strong>and</strong> Chittagong divisions; those <strong>in</strong>urban slums; those with an unmet need for contraception,<strong>in</strong>clud<strong>in</strong>g those us<strong>in</strong>g traditional methods; non-users who<strong>in</strong>tend to practise FP <strong>in</strong> <strong>the</strong> future; <strong>and</strong> those who could bemotivated to adopt longer-act<strong>in</strong>g <strong>and</strong> permanent methods.It is, <strong>the</strong>refore, critical that <strong>the</strong> programme undertakeappropriate measures to motivate <strong>the</strong> priority targetgroups to start us<strong>in</strong>g FP by adopt<strong>in</strong>g a client-segmentedapproach to both behavioural change communications<strong>and</strong> FP service delivery. There should be a differentialor segmented approach to both behavioural changecommunications <strong>and</strong> service delivery. Priority should begiven to ensur<strong>in</strong>g that tra<strong>in</strong>ed providers are available tooffer good-quality FP services. Efforts should be made tomotivate men to practise male methods, as well as support<strong>the</strong>ir wives <strong>in</strong> <strong>the</strong> practice of contraception by develop<strong>in</strong>gappropriate behavioural change communication messages<strong>and</strong> campaigns to remove misconceptions about malemethods; orient<strong>in</strong>g <strong>and</strong> tra<strong>in</strong><strong>in</strong>g staff on male <strong>in</strong>volvement<strong>in</strong> RH <strong>and</strong> FP services; <strong>and</strong> provid<strong>in</strong>g services for malesat health centres, <strong>in</strong>clud<strong>in</strong>g mobile satellite cl<strong>in</strong>ics (forexample, see Ashraf et al., 1999). Major emphasis shouldbe given to implement <strong>the</strong> 2006 Adolescent ReproductiveHealth Strategy <strong>and</strong> <strong>the</strong> 2008 National CommunicationStrategy for <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> Reproductive Health,with due emphasis given to: (a) sensitiz<strong>in</strong>g policymakers<strong>and</strong> <strong>the</strong> population as a whole to <strong>the</strong> dangers of <strong>the</strong>grow<strong>in</strong>g population <strong>and</strong> <strong>the</strong> need for smaller family sizes;(b) address<strong>in</strong>g <strong>and</strong> reduc<strong>in</strong>g high-risk pregnancies; (c)conduct<strong>in</strong>g <strong>in</strong>tensive behavioural change communicationcampaigns <strong>in</strong> low-perform<strong>in</strong>g areas, <strong>in</strong>clud<strong>in</strong>g urban slums;(d) motivat<strong>in</strong>g traditional method users to switch to moreeffective methods of contraception; <strong>and</strong> (e) motivat<strong>in</strong>gusers of temporary methods to use more effective methodsof contraception, especially longer-act<strong>in</strong>g <strong>and</strong> permanentmethods among older clients (see also Alaudd<strong>in</strong> et al.,2010).Need to improve access to, <strong>and</strong> <strong>the</strong>quality of, family plann<strong>in</strong>g servicesIn view of <strong>the</strong> high discont<strong>in</strong>uation rate of contraceptiveuse, it is essential to improve <strong>the</strong> access to, <strong>and</strong> qualityof, FP services. By provid<strong>in</strong>g good-quality services, <strong>the</strong>programme can take advantage of satisfied clients <strong>in</strong>addition to fieldworkers <strong>in</strong> order to advocate for FPmethods among non-users. It is also imperative thatcouples have access to good-quality FP services. Effortsshould be made to: (a) ensure that tra<strong>in</strong>ed providers areavailable to offer good-quality FP services; (b) <strong>in</strong>crease <strong>the</strong>number of follow-up visits to improve <strong>the</strong> cont<strong>in</strong>uation<strong>and</strong> effectiveness rates of commodity-based methods; (c)provide better counsel<strong>in</strong>g on side effects; (d) provide anappropriate mix of methods for spac<strong>in</strong>g <strong>and</strong> limit<strong>in</strong>g births;(e) improve delivery of FP as part of post-abortion care;<strong>and</strong> (vi) ensure that <strong>the</strong>re is no stock-out of FP methods.Public-private partnerships should be streng<strong>the</strong>ned totake advantage of <strong>the</strong> exist<strong>in</strong>g private sector networks <strong>in</strong><strong>the</strong> distribution/sales of contraceptives, successful supplycha<strong>in</strong>systems, <strong>and</strong> well-tra<strong>in</strong>ed providers.Need to streng<strong>the</strong>n service deliveryCurrently, exist<strong>in</strong>g health-care facilities are underutilized,<strong>the</strong>re is a lack of adequately tra<strong>in</strong>ed personnel, <strong>and</strong> prioritysegments of <strong>the</strong> population are neglected. To improve <strong>the</strong>current FP programme <strong>and</strong> achieve <strong>the</strong> desired CPR, it iscritical that service delivery be streng<strong>the</strong>ned adequately.Efforts should be made to: (a) maximize <strong>the</strong> use of exist<strong>in</strong>gtra<strong>in</strong>ed personnel, health-care facilities, equipment<strong>and</strong> services for promotion of FP methods, <strong>in</strong>clud<strong>in</strong>glonger-act<strong>in</strong>g <strong>and</strong> permanent methods; (b) give adequateemphasis to various priority segments of <strong>the</strong> population;(c) remove <strong>in</strong>ternal conflicts between <strong>the</strong> medical <strong>and</strong>non-medical personnel with<strong>in</strong> DGFP; <strong>and</strong> (d) ensurebetter coord<strong>in</strong>ation <strong>and</strong> l<strong>in</strong>kages between DGFP <strong>and</strong>DGHS. The latter two measures are critical for revers<strong>in</strong>g<strong>the</strong> decl<strong>in</strong><strong>in</strong>g trend <strong>in</strong> <strong>the</strong> relative share of longer-act<strong>in</strong>g<strong>and</strong> permanent methods, as well as rais<strong>in</strong>g <strong>the</strong> overallCPR <strong>in</strong> <strong>the</strong> country. Also, MOHFW should work <strong>in</strong> closecollaboration with <strong>the</strong> M<strong>in</strong>istry of Local Government, <strong>the</strong>Urban Primary Health Care Project, <strong>the</strong> Bangladesh RuralAdvancement Committee <strong>and</strong> SMC <strong>in</strong> extend<strong>in</strong>g servicedelivery <strong>in</strong> urban slums.118

Effective public-private partnerships should also bestreng<strong>the</strong>ned to assist <strong>the</strong> government <strong>in</strong> its efforts toimprove <strong>the</strong> current FP programme. The private (forprofit) sector can play an important role <strong>in</strong> provid<strong>in</strong>g goodquality<strong>and</strong> accessible FP services at affordable prices, as isevident from <strong>the</strong> role played by SMC. O<strong>the</strong>r private sectororganizations can also be encouraged to sell contraceptivesat affordable prices, <strong>and</strong> <strong>the</strong>reby contribute to public sectorefforts. If necessary, <strong>the</strong> government <strong>and</strong>/or donors shouldfurnish f<strong>in</strong>ancial <strong>and</strong> commodity support to those privatesector organizations as is <strong>the</strong> case with SMC. Currently,<strong>the</strong> role of <strong>the</strong> commercial sector is largely limited to oralpills <strong>and</strong> condoms; however, it is time to encourage privatesector hospitals <strong>and</strong> cl<strong>in</strong>ics to provide <strong>the</strong> population <strong>in</strong><strong>the</strong> middle- <strong>and</strong> higher-<strong>in</strong>come brackets with temporaryas well as longer-act<strong>in</strong>g <strong>and</strong> permanent methods. If serviceproviders from private health-care facilities are providedwith <strong>the</strong> necessary tra<strong>in</strong><strong>in</strong>g on <strong>the</strong> st<strong>and</strong>ard service deliveryprotocols on longer-act<strong>in</strong>g <strong>and</strong> permanent methods, itwill help <strong>the</strong> public sector efforts <strong>in</strong> <strong>in</strong>creas<strong>in</strong>g <strong>the</strong> useof such methods among <strong>the</strong> upper- <strong>and</strong> middle-<strong>in</strong>comegroups. The role of NGOs, which played a pioneer<strong>in</strong>g <strong>and</strong>laudable role <strong>in</strong> <strong>the</strong> past, needs to be redef<strong>in</strong>ed. With only16 per cent of women be<strong>in</strong>g visited by NGO fieldworkers,<strong>and</strong> NGOs account<strong>in</strong>g for only 4-6 per cent of CPR,NGOs need to be repositioned to serve different functionswhich <strong>the</strong> public sector is not adequately equipped to dealwith, such as serv<strong>in</strong>g underserved areas <strong>and</strong> carry<strong>in</strong>g outspecialized tasks, such as tra<strong>in</strong><strong>in</strong>g <strong>and</strong> behavioural changecommunications.Need to improve commodity securityIt is critical that <strong>the</strong> FP programme ensure a consistent<strong>and</strong> un<strong>in</strong>terrupted supply of a broad range of FP methods,as well as product varieties with<strong>in</strong> methods. As previouslynoted, DGFP’s procurement capacity is not yet up to <strong>the</strong>desired level. Therefore, technical procurement capacity <strong>in</strong>MOHFW/DGFP needs to be fur<strong>the</strong>r enhanced. Also, acha<strong>in</strong> of accountability with<strong>in</strong> DGFP needs to be developedfor timely procurement of FP methods. The HPNSSP preappraisalmission recommended that, among o<strong>the</strong>r th<strong>in</strong>gs,<strong>the</strong> most efficient arrangement for manag<strong>in</strong>g procurementfunctions across <strong>the</strong> seven procur<strong>in</strong>g entities should beidentified, <strong>and</strong> a procurement process<strong>in</strong>g plan developedto ensure timely submission of <strong>the</strong> operational plans <strong>and</strong>procurement plans each year (GOB, 2010f ).Ow<strong>in</strong>g to dependence on <strong>the</strong> support of developmentpartners, coord<strong>in</strong>ation among <strong>the</strong> stakeholders concernedis needed <strong>in</strong> order to achieve contraceptive security<strong>in</strong> Bangladesh. Therefore, a coord<strong>in</strong>ation mechanismamong development partners needs to be developed for<strong>the</strong> purpose of jo<strong>in</strong>tly advocat<strong>in</strong>g government leadership<strong>in</strong> develop<strong>in</strong>g <strong>and</strong> implement<strong>in</strong>g policies, practices <strong>and</strong>procedures relat<strong>in</strong>g to <strong>the</strong> timely procurement <strong>and</strong> supplyof contraceptives. For this purpose, DGFP established<strong>the</strong> Logistics Coord<strong>in</strong>ation Forum, which is supposed tomeet quarterly to review consumption, stock, pipel<strong>in</strong>e <strong>and</strong>procurement status; however, this forum has not met on aregular basis <strong>in</strong> <strong>the</strong> past. Hence, it should be ensured thatthis forum meets regularly to take stock of <strong>the</strong> exist<strong>in</strong>gsituation <strong>and</strong> provide remedial measures as necessary.Based on <strong>the</strong> current consumption trends <strong>and</strong> projectedrequirements for contraceptives <strong>in</strong> <strong>the</strong> period 2011-2015,<strong>the</strong> estimated cost of contraceptives for Bangladesh isabout US$ 55.6 million (Tk. 3,836.4 million) <strong>in</strong> 2011,which is projected to <strong>in</strong>crease to US$ 62.6 million (Tk.4,319.4 million) <strong>in</strong> 2015 (GOB, 2010c). To reduce <strong>the</strong>f<strong>in</strong>ancial burden on <strong>the</strong> public sector <strong>and</strong> on developmentpartners, <strong>the</strong> costs of contraceptives should be sharedby all <strong>the</strong> implement<strong>in</strong>g partners <strong>in</strong> <strong>the</strong> programme,<strong>in</strong>clud<strong>in</strong>g NGOs, SMC, <strong>the</strong> private sector <strong>and</strong> <strong>the</strong> endusers, especially those belong<strong>in</strong>g to <strong>the</strong> middle- <strong>and</strong> upper<strong>in</strong>comegroups.Emphasis should also be given to <strong>the</strong> local productionof contraceptives. Currently, <strong>the</strong>re are two condommanufacturers <strong>in</strong> Bangladesh: one <strong>in</strong> <strong>the</strong> private sector(<strong>the</strong> Bangla-German Latex Company Limited) <strong>and</strong> <strong>the</strong>o<strong>the</strong>r <strong>in</strong> <strong>the</strong> public sector, run <strong>and</strong> managed by EssentialDrugs Company Limited. The pharmaceutical companyOrganon Bangladesh is produc<strong>in</strong>g oral pills <strong>in</strong> limitedquantities; <strong>the</strong>se are sold <strong>in</strong> <strong>the</strong> market at a higher pricecompared with <strong>the</strong> products offered by SMC. Preferencefor local manufacturers dur<strong>in</strong>g <strong>the</strong> process of public sectorprocurement would encourage <strong>the</strong> growth of <strong>the</strong> privatesector <strong>in</strong> manufactur<strong>in</strong>g contraceptives <strong>in</strong> Bangladesh.With <strong>the</strong> requirement for contraceptives <strong>in</strong>creas<strong>in</strong>g,<strong>the</strong> country’s warehous<strong>in</strong>g system is likely to experiencea shortage of space. It is <strong>the</strong>refore imperative that anassessment be made of storage needs for all tiers of <strong>the</strong>supply cha<strong>in</strong>, at least for <strong>the</strong> next decade.The need to improve programmeefficiencyThe current FP programme is <strong>in</strong>efficient because of anumber of factors. These <strong>in</strong>clude low staff morale, absenceof career plann<strong>in</strong>g, staff vacancies, <strong>in</strong>adequate tra<strong>in</strong><strong>in</strong>g,staff be<strong>in</strong>g overburdened with various non-FP activities,poor monitor<strong>in</strong>g <strong>and</strong> supervision, lack of leadership <strong>and</strong>management, limited fund<strong>in</strong>g, weak implementationcapacity, <strong>and</strong> non-<strong>in</strong>volvement of <strong>the</strong> o<strong>the</strong>r m<strong>in</strong>istriesconcerned. All <strong>the</strong>se have resulted <strong>in</strong> considerable systemloss.Efforts are <strong>the</strong>refore needed to: (a) address various humanresources issues by giv<strong>in</strong>g top priority to <strong>the</strong> recruitment119

of additional workers both to fill exist<strong>in</strong>g vacant posts <strong>and</strong>to recruit additional staff, especially <strong>in</strong> <strong>the</strong> low-perform<strong>in</strong>gareas, <strong>in</strong> order to meet <strong>the</strong> needs of <strong>the</strong> <strong>in</strong>creas<strong>in</strong>g numberof eligible couples; (b) reth<strong>in</strong>k <strong>the</strong> role of DGFP <strong>in</strong>provid<strong>in</strong>g good-quality FP-related activities, as was <strong>the</strong>case until <strong>the</strong> early 1990s, ra<strong>the</strong>r than be<strong>in</strong>g <strong>in</strong>volved <strong>in</strong>various non-FP activities, <strong>the</strong>reby enabl<strong>in</strong>g DGFP toachieve its primary goal of <strong>in</strong>creas<strong>in</strong>g CPR <strong>and</strong> <strong>the</strong> use oflonger-act<strong>in</strong>g <strong>and</strong> permanent methods <strong>in</strong> br<strong>in</strong>g<strong>in</strong>g about<strong>the</strong> desired reduction <strong>in</strong> fertility; (c) enhance tra<strong>in</strong><strong>in</strong>gcapacity (NIPORT is primarily responsible for <strong>the</strong>tra<strong>in</strong><strong>in</strong>g of fieldworkers <strong>and</strong> paramedics, <strong>and</strong> undertakesprogrammatic research, both of which, <strong>and</strong> especially<strong>the</strong> former, has rema<strong>in</strong>ed largely underutilized) so thatprogramme personnel could receive <strong>the</strong> necessary tra<strong>in</strong><strong>in</strong>g;(d) improve staff morale through better job security, careerplann<strong>in</strong>g <strong>and</strong> compensation packages; (e) promote taskshift<strong>in</strong>gamong health-care workers; (f ) tra<strong>in</strong> supervisors<strong>and</strong> managers who could provide guidance to o<strong>the</strong>r staff;<strong>and</strong> (vii) stop mak<strong>in</strong>g frequent transfers of programmepersonnel.The government has decided to recruit 10,000 additionalFWAs, 655 additional <strong>Family</strong> Welfare Visitors (FWVs)<strong>and</strong> 400 additional doctors; however, <strong>the</strong> recruitmentprocess could take over a year to be completed at <strong>the</strong>earliest. After <strong>the</strong>y are recruited, <strong>the</strong>y need to go throughtra<strong>in</strong><strong>in</strong>g before <strong>the</strong>y can beg<strong>in</strong> <strong>the</strong>ir work. Regard<strong>in</strong>gFWVs, <strong>the</strong> <strong>in</strong>itial tra<strong>in</strong><strong>in</strong>g period is 18 months <strong>in</strong> duration,followed by 6 months of midwifery tra<strong>in</strong><strong>in</strong>g. Tra<strong>in</strong><strong>in</strong>gof o<strong>the</strong>r staff is also needed to build <strong>and</strong> enhance <strong>the</strong>ircapacity, especially those deal<strong>in</strong>g with behavioural changecommunications <strong>and</strong> procurement. The programmeshould address <strong>the</strong> issue of its <strong>in</strong>adequate tra<strong>in</strong><strong>in</strong>g capacityby tra<strong>in</strong><strong>in</strong>g its exist<strong>in</strong>g tra<strong>in</strong>ers; hire new skilled tra<strong>in</strong>ers;update its tra<strong>in</strong><strong>in</strong>g curriculum, protocols <strong>and</strong> manuals; <strong>and</strong>fully utilize its tra<strong>in</strong><strong>in</strong>g <strong>in</strong>frastructure <strong>and</strong> facilities. Also, itshould be ensured that <strong>the</strong> tra<strong>in</strong>ed staff are not transferredto perform o<strong>the</strong>r jobs, <strong>the</strong>reby not only reduc<strong>in</strong>g wastageof time <strong>and</strong> resources spent on tra<strong>in</strong><strong>in</strong>g but also improv<strong>in</strong>gprogramme implementation.Action should also be taken to ensure active participationof <strong>the</strong> m<strong>in</strong>istries concerned that are m<strong>and</strong>ated to carryout various population-related activities, <strong>and</strong> encouragegreater participation of communities, NGOs <strong>and</strong> <strong>the</strong>private sector <strong>in</strong> provid<strong>in</strong>g <strong>and</strong>/or shar<strong>in</strong>g <strong>the</strong> cost of FPsupplies <strong>and</strong> services.As previously noted, overall health expenditure is onlyabout 3 per cent of GDP, with a relatively smallerportion go<strong>in</strong>g to <strong>the</strong> FP <strong>and</strong> RH programme. Hence,<strong>the</strong> budgetary allocation to <strong>the</strong> overall health sectorneeds to be <strong>in</strong>creased, with a higher share earmarkedfor <strong>the</strong> FP <strong>and</strong> RH programme. However, <strong>the</strong> f<strong>in</strong>ancialperformance of <strong>the</strong> sector shows that, while on one h<strong>and</strong><strong>the</strong> sector has not been able to fully utilize its funds from<strong>the</strong> government <strong>and</strong> development partners because of itsweak implementation capacity, on <strong>the</strong> o<strong>the</strong>r <strong>the</strong> servicesit provides are underfunded; hence, additional fund<strong>in</strong>gis needed. This situation calls for a reexam<strong>in</strong>ation of <strong>the</strong>programme strategies along two l<strong>in</strong>es: (a) how to moreefficiently utilize <strong>the</strong> funds allocated by <strong>the</strong> government<strong>and</strong> development partners; <strong>and</strong> (b) how to <strong>in</strong>crease<strong>the</strong> f<strong>in</strong>ancial resource base for <strong>the</strong> programme. Hence,programme implementation capacity needs to be enhanced<strong>in</strong> order to ensure more efficient use of available resources<strong>and</strong> avoid leakages <strong>in</strong> <strong>the</strong> system, <strong>and</strong> <strong>the</strong>reby, improveprogramme efficiency (see also GOB, 2010f ). With regardto <strong>in</strong>creas<strong>in</strong>g <strong>the</strong> f<strong>in</strong>ancial resource base for <strong>the</strong> overallhealth programme, three sets of budget estimates have beenprepared for HPNSSP (2011-2016): (a) Tk. 41,440.12crore 7 (US$ 6,005.81 million), which is 2.5 times higherthan <strong>the</strong> estimated cost of HNPSP (2003-2011); (b) Tk.31,848.54 crore (US$ 4,615.73 million), almost double<strong>the</strong> size of <strong>the</strong> development budget of HNPSP; <strong>and</strong> (c)Tk. 25,702.00 crore (US$ 3,724.93 million), over 60 percent higher than <strong>the</strong> development budget of HNPSP(GOB, 2010e). The FP <strong>and</strong> RH programme is projectedto receive allocations of only 16 per cent, 21.6 per cent <strong>and</strong>22.2 per cent respectively under <strong>the</strong> high, medium <strong>and</strong> lowscenarios. In addition to <strong>the</strong> government, <strong>the</strong> HNP sectoris currently be<strong>in</strong>g supported by 16 development partners<strong>in</strong> <strong>the</strong> form of both pooled <strong>and</strong> non-pooled parallelfund<strong>in</strong>g. The three estimated HNPSSP budgets depicta picture of <strong>the</strong> total development budget outlay. Thegovernment is projected to share <strong>the</strong> burden of 35 per centof <strong>the</strong> resource requirement, <strong>and</strong> expects <strong>the</strong> developmentpartners to contribute <strong>the</strong> rema<strong>in</strong><strong>in</strong>g 65 per cent of <strong>the</strong>development budget requirement for implementation ofHNPSSP (GOB, 2010e). The support of developmentpartners will be aligned with <strong>the</strong> sector programme <strong>and</strong> itscomponents. They will f<strong>in</strong>ance part of <strong>the</strong> overall MOHFWprogramme <strong>and</strong> budget, <strong>in</strong>clud<strong>in</strong>g technical assistance.The pre-appraisal mission has identified, among o<strong>the</strong>rs,<strong>the</strong> follow<strong>in</strong>g steps <strong>in</strong> relation to <strong>the</strong> budget for <strong>the</strong> nextprogramme: (a) <strong>the</strong> total MOHFW budget requirementfor <strong>the</strong> programme (2011-2016) should <strong>in</strong>clude both <strong>the</strong>revenue <strong>and</strong> development budgets; (b) MOHFW willscrut<strong>in</strong>ize <strong>the</strong> operational plan budget submitted by <strong>the</strong>l<strong>in</strong>e directors <strong>in</strong> l<strong>in</strong>e with <strong>the</strong> goals, objectives, priorities<strong>and</strong> reform areas of <strong>the</strong> programme, <strong>and</strong> rationalize <strong>the</strong>total development budget requirements, based on realistic<strong>in</strong>creases <strong>in</strong> resource envelopes <strong>and</strong> <strong>the</strong> fund<strong>in</strong>g gap; <strong>and</strong>(c) based on <strong>the</strong> rationalized budget <strong>and</strong> availability offunds <strong>in</strong>dicated by <strong>the</strong> development partners, MOHFWwill suggest options for mitigat<strong>in</strong>g <strong>the</strong> fund<strong>in</strong>g gap, if any(GOB, 2010f ).120

ConclusionThe Bangladesh <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Programme was <strong>in</strong>itiatedby <strong>the</strong> government to reduce <strong>the</strong> rate of population growth.The programme made great progress until <strong>the</strong> mid-1990s,but, ow<strong>in</strong>g to erosion <strong>in</strong> political will <strong>and</strong> commitment<strong>and</strong> certa<strong>in</strong> systemic issues, <strong>the</strong> programme has s<strong>in</strong>ce <strong>the</strong>nbeen lagg<strong>in</strong>g beh<strong>in</strong>d. The rate of <strong>in</strong>crease <strong>in</strong> CPR amongmarried couples has slowed considerably s<strong>in</strong>ce <strong>the</strong>n,<strong>and</strong> <strong>in</strong>deed, decl<strong>in</strong>ed between 2004 <strong>and</strong> 2007. Amongthose us<strong>in</strong>g FP, most are opt<strong>in</strong>g for short-term methodsra<strong>the</strong>r than longer-act<strong>in</strong>g <strong>and</strong> permanent methods. Thecurrent programme is <strong>in</strong>efficient <strong>and</strong> <strong>in</strong>effective. Thereis an <strong>in</strong>adequate number of tra<strong>in</strong>ed providers <strong>and</strong> a lackof effective measures to improve job satisfaction. Also,<strong>the</strong>re have been problems with stock-outs of FP methods.Fur<strong>the</strong>rmore, <strong>the</strong>re is limited fund<strong>in</strong>g available for <strong>the</strong>programme; <strong>and</strong> worse still, <strong>the</strong> funds are not fully utilizeddue to weak implementation capacity.To achieve <strong>the</strong> desired <strong>in</strong>crease <strong>in</strong> CPR <strong>and</strong> fertilitydecl<strong>in</strong>e, <strong>the</strong> government should undertake a number ofmeasures. First <strong>and</strong> foremost, <strong>the</strong> political leadershipshould make a renewed commitment to conta<strong>in</strong> <strong>the</strong>country’s population growth rate. Second, <strong>the</strong> systemicproblems affect<strong>in</strong>g <strong>the</strong> programme should be addressedon an urgent basis. Third, <strong>the</strong> role of DGFP <strong>in</strong> provid<strong>in</strong>ggood-quality FP-related services needs to be rethought, aswas <strong>the</strong> case until <strong>the</strong> early 1990s, ra<strong>the</strong>r than <strong>in</strong>volv<strong>in</strong>gDGFP <strong>in</strong> various non-FP activities, which would <strong>the</strong>rebyenable it to achieve its primary goal of <strong>in</strong>creas<strong>in</strong>g CPR<strong>and</strong> <strong>the</strong> use of longer-act<strong>in</strong>g <strong>and</strong> permanent methods <strong>in</strong>br<strong>in</strong>g<strong>in</strong>g about <strong>the</strong> desired reduction <strong>in</strong> fertility. Fourth,both access to, <strong>and</strong> <strong>the</strong> quality of, FP services should beimproved by tra<strong>in</strong><strong>in</strong>g workers, <strong>in</strong>creas<strong>in</strong>g fieldworkervisitations, enhanc<strong>in</strong>g worker morale <strong>and</strong> job satisfaction,<strong>and</strong> ensur<strong>in</strong>g that <strong>the</strong>re is no stock-out. Fifth, servicedelivery <strong>and</strong> programme efficiency should be enhancedby mak<strong>in</strong>g better use of exist<strong>in</strong>g <strong>in</strong>frastructure, resources<strong>and</strong> personnel of both DGFP <strong>and</strong> DGHS to reach out to<strong>the</strong> underserved population groups. Sixth, effective publicprivatepartnerships should be established to maximize <strong>the</strong>use of exist<strong>in</strong>g resources, personnel <strong>and</strong> networks. Seventh,greater emphasis should be given to fur<strong>the</strong>r improv<strong>in</strong>g <strong>the</strong>child survival rate <strong>and</strong> <strong>the</strong> overall status of women, <strong>and</strong><strong>the</strong>reby promote FP use among non-users. Eighth, femaleeducation should be made a national priority to empowerwomen, which would deter <strong>the</strong>m from hav<strong>in</strong>g more than<strong>the</strong> desired number of children <strong>and</strong> offer <strong>the</strong>m attractivealternatives to childbear<strong>in</strong>g. F<strong>in</strong>ally, issues relat<strong>in</strong>g tobetter governance <strong>and</strong> accountability should receive highpriority.The government should re-evaluate its exist<strong>in</strong>g FPprogramme, <strong>and</strong> adopt <strong>and</strong> effectively implement <strong>the</strong>strategies proposed above to make <strong>the</strong> programme moreefficient <strong>and</strong> susta<strong>in</strong>able. This would help accelerate <strong>the</strong>rate of <strong>in</strong>crease <strong>in</strong> CPR <strong>and</strong> ultimately achieve populationstabilization with<strong>in</strong> <strong>the</strong> shortest possible time. Provisionof good-quality FP services could save <strong>the</strong> lives of mo<strong>the</strong>rs<strong>and</strong> children. FP could prevent as many as one <strong>in</strong> everythree maternal deaths by enabl<strong>in</strong>g women to delaychildbear<strong>in</strong>g, avoid un<strong>in</strong>tended pregnancies <strong>and</strong> abortions,<strong>and</strong> stop childbear<strong>in</strong>g when <strong>the</strong>y have reached <strong>the</strong>irdesired family size. Thus, provision of good-quality FPservices could help Bangladesh achieve <strong>the</strong> targets underMillennium Development Goal 5 (improve maternalhealth). Moreover, FP use could help reduce poverty <strong>and</strong>promote economic growth by improv<strong>in</strong>g family wellbe<strong>in</strong>g,rais<strong>in</strong>g female productivity <strong>and</strong> lower<strong>in</strong>g fertility(for example, see UNFPA, 2010). F<strong>in</strong>ally, <strong>the</strong> governmentshould reposition <strong>the</strong> FP <strong>and</strong> RH programme as part ofits overall development agenda; o<strong>the</strong>rwise, its developmentobjectives will not be fully achieved to <strong>the</strong> detriment of <strong>the</strong>country as a whole.End Note1 In Bangladesh, about 50 per cent of <strong>the</strong> females younger than20 years of age are married compared with 33 per cent <strong>in</strong> India,25 per cent <strong>in</strong> Pakistan, <strong>and</strong> a much smaller percentage <strong>in</strong> o<strong>the</strong>rdevelop<strong>in</strong>g countries (GOB, 2004).2 For a more elaborate discussion of <strong>the</strong> evolution <strong>and</strong> developmentof <strong>the</strong> FP programme <strong>in</strong> Bangladesh, see Khuda, 1981 <strong>and</strong> 1984;Khuda et al., 1992, 1993a; Khuda <strong>and</strong> Barkat 1994; Khuda <strong>and</strong>Anwar, 2004; Khuda <strong>and</strong> Barkat, 2010; <strong>and</strong> Clel<strong>and</strong> et al., 1994.4 situation <strong>in</strong> which <strong>the</strong> dem<strong>and</strong> or requirement for an item cannotbe fulfilled from <strong>the</strong> current <strong>in</strong>ventory.5 lac is equal to 100,000.6 See also Khuda <strong>and</strong> Barkat, 1994; Khuda et al., 1994a, 1994 b <strong>and</strong>Khuda et al., 1997; Khuda <strong>and</strong> Anwar, 2004; Khuda <strong>and</strong> Barkat,2010; <strong>and</strong> UNFPA, 2010.7 1 crore is equal to 10 million.AcknowledgementsThe ma<strong>in</strong> f<strong>in</strong>d<strong>in</strong>gs of <strong>the</strong> draft paper were shared dur<strong>in</strong>gmeet<strong>in</strong>gs with officials concerned from <strong>the</strong> Governmentof Bangladesh, development partners, non-governmentalorganizations <strong>and</strong> <strong>the</strong> private sector. We are <strong>in</strong>debted to<strong>the</strong>m for <strong>the</strong>ir valuable feedback <strong>and</strong> useful comments. Weare especially <strong>in</strong>debted to Mr. Humayun Kabir, Secretary,M<strong>in</strong>istry of Health <strong>and</strong> <strong>Family</strong> Welfare (MOHFW), <strong>and</strong>his colleagues; Begum Dilruba, Additional Secretary <strong>and</strong>Director General, <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>, <strong>and</strong> her colleagues;<strong>and</strong> representatives of <strong>the</strong> World Bank, <strong>the</strong> Canadian<strong>International</strong> Development Agency (CIDA), <strong>the</strong> UKDepartment for <strong>International</strong> Development (UKAID), <strong>the</strong>United Nations Population Fund (UNFPA), <strong>the</strong> UnitedStates Agency for <strong>International</strong> Development (USAID),121

AppendixTable11999 scores:<strong>Family</strong> plann<strong>in</strong>g programme effort scores: 1999, 2004 <strong>and</strong> 2009Country Total Policy Services Evaluation AvailabilityBangladesh 56.9 70.2 48.8 55.0 57.6Cambodia 48.5 46.2 49.6 62.2 42.2Ch<strong>in</strong>a 77.2 87.4 70.9 73.2 79.1India 49.7 62.2 38.9 46.8 58.0Indonesia 69.3 77.7 68.3 77.7 56.0Iran (Islamic Republic of ) 62.2 57.2 58.5 72.2 71.7Lao People’s DemocraticRepublic40.5 46.5 38.9 35.2 38.9Malaysia 65.6 72.2 59.1 75.9 65.7Nepal 51.8 61.2 46.3 53.7 50.1Pakistan 46.1 49.9 42.0 49.6 48.1Philipp<strong>in</strong>es 49.7 52.5 45.0 54.7 53.9Sri Lanka 47.4 55.5 46.1 33.3 46.3Thail<strong>and</strong> 71.2 72.2 66.2 74.0 79.6Viet Nam 66.7 83.0 56.9 54.7 72.22004 scoresCountry Total Policy Services Evaluation AvailabilityBangladesh 64.4 66.8 62.4 59.9 67.5Cambodia 46.0 48.2 46.0 41.4 45.4Ch<strong>in</strong>a 71.3 81.9 71.1 66.1 61.8India 48.7 65.1 41.4 39.7 47.4Indonesia 56.4 63.4 56.5 57.5 47.8Malaysia 62.9 62.5 61.5 68.3 63.4Myanmar 31.8 29.7 31.0 36.6 33.8Nepal 57.4 62.3 53.8 59.5 57.5Pakistan 55.2 63.8 54.4 48.1 49.8Philipp<strong>in</strong>es 46.9 48.2 43.8 59.5 45.5Thail<strong>and</strong> 66.8 61.8 65.7 65.8 74.8Viet Nam 72.5 82.3 66.8 63.5 75.92009 scoresCountry Total Policy Services Evaluation AvailabilityAfghanistan 50.7 56.0 51.6 53.4 41.8Bangladesh 56.4 61.1 53.1 49.5 60.2Cambodia 55.8 59.9 58.5 51.1 48.2Ch<strong>in</strong>a 72.9 83.0 74.8 75.4 56.7India 53.5 59.0 51.0 55.8 50.7Indonesia 59.9 68.6 56.9 67.3 52.3Malaysia 62.2 61.9 58.8 74.1 63.8Myanmar 28.1 22.3 26.1 33.7 35.9Nepal 56.8 58.4 55.0 48.3 62.0Pakistan 45.7 59.6 42.5 45.3 35.9Philipp<strong>in</strong>es 29.8 35.7 28.8 34.5 23.1Sri Lanka 55.4 55.0 55.2 62.7 53.0Viet Nam 71.1 77.8 67.4 63.3 73.8Sources: John Ross <strong>and</strong> Ellen Smith. The <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Effort Index: 1999, 2004, <strong>and</strong> 2009, Wash<strong>in</strong>gton, D.C.: Futures Group,Health Policy Initiative, Task Order 1, 2010; John Ross, John Stover <strong>and</strong> Demi Adelaja. “<strong>Family</strong> plann<strong>in</strong>g programs <strong>in</strong> 2004: new assessments”,<strong>International</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Perspectives, 2007, 33(1):22–30; <strong>and</strong> J.A. Ross <strong>and</strong> J. Stover. “The family plann<strong>in</strong>g programeffort <strong>in</strong>dex: 1999 cycle”, <strong>International</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Perspectives, 2001, 27(3):119–129.122

<strong>the</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Association of Bangladesh (FPAB),<strong>the</strong> Social Market<strong>in</strong>g Company (SMC) <strong>and</strong> <strong>the</strong> Smil<strong>in</strong>gSun Project for <strong>the</strong>ir valuable <strong>and</strong> <strong>in</strong>sightful comments.Several <strong>in</strong>dividuals provided us with various usefuldocuments. 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National Institute for Population Research <strong>and</strong> Tra<strong>in</strong><strong>in</strong>g(NIPORT), Mitra <strong>and</strong> Associates <strong>and</strong> Macro<strong>International</strong> Inc. (1994). Bangladesh Demographic<strong>and</strong> Health Survey 1993-1994, Dhaka.__________ (1997). Bangladesh Demographic <strong>and</strong> HealthSurvey 1996-1997, Dhaka.__________ (2009). Bangladesh Demographic <strong>and</strong> HealthSurvey: 2007, Dhaka.Neaz A., Ahmed Al-Sabir <strong>and</strong> M.A. Khan (2004).Review <strong>and</strong> identification of gaps <strong>in</strong> <strong>the</strong> currentknowledge <strong>and</strong> underst<strong>and</strong><strong>in</strong>g on <strong>the</strong> level<strong>in</strong>gof total fertility rate <strong>in</strong> Bangladesh, Centre forIntegrated Development Studies, Dhaka, unpublishedmanuscript.NIPORT, Mitra <strong>and</strong> Associates <strong>and</strong> ORC <strong>International</strong>(2001). Bangladesh Demographic <strong>and</strong> Health Survey,1999-2000, Dhaka.NIPORT, Mitra <strong>and</strong> Associates <strong>and</strong> ORC Macro (2005).Bangladesh Demographic <strong>and</strong> Health Survey 2004,Dhaka.NIPORT, MEASURE, ICDDR, B <strong>and</strong> ACPR(Associates for Community <strong>and</strong> Research) (2008).Bangladesh Urban Health Survey 2006, Dhaka.Rahman, H.Z. <strong>and</strong> M.B. Hossa<strong>in</strong> (1991). Reth<strong>in</strong>k<strong>in</strong>gPoverty: Dimension, Process, Option, Dhaka:Bangladesh Institute of Development Studies.Rahman, R.I. (1986). The Wage Employment Market forRural Women <strong>in</strong> Bangladesh. Bangladesh Instituteof Development Studies, Research Monograph 6,Dhaka.Ross, John <strong>and</strong> Ellen Smith (2010). The <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Effort Index: 1999, 2004 <strong>and</strong> 2009, Wash<strong>in</strong>gton,D.C.: Futures Group, Health Policy Initiative, TaskOrder 1.Ross, John, John Stover <strong>and</strong> Demi Adelaja (2007).“<strong>Family</strong> plann<strong>in</strong>g programs <strong>in</strong> 2004: newassessments”, <strong>International</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Perspectives, 33(1):22–30Ross, J.A. <strong>and</strong> J. Stover (2001). “The family plann<strong>in</strong>gprogram effort <strong>in</strong>dex: 1999 cycle”, <strong>International</strong> <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Perspectives, 27(3):119-129.Safilios-Rothshild, C. <strong>and</strong> S. Mahmood (1989). Women'sRoles <strong>in</strong> Agriculture—Present Trends <strong>and</strong> Potentials forGrowth: Agriculture Sector Review, Dhaka: UNDP<strong>and</strong> UNIFEM.Schuler, S.R. <strong>and</strong> S.M. Hashemi (1994). “Creditprograms, women's empowerment, <strong>and</strong> contraceptiveuse <strong>in</strong> rural Bangladesh”, Studies <strong>in</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>,25(2):65-76.Sirageld<strong>in</strong>, I., M. Hossa<strong>in</strong> <strong>and</strong> M.T.Ca<strong>in</strong> (1975). “<strong>Family</strong>plann<strong>in</strong>g <strong>in</strong> Bangladesh: an empirical <strong>in</strong>vestigation”,Bangladesh Development Studies, Dhaka.Stoeckel, J. <strong>and</strong> M.A. Chowdhury (1973). InfantMortality <strong>and</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>in</strong> Rural Bangladesh,Dhaka: Oxford University Press Limited.Streatfield, K., A. Mercer, A.B. Siddique, Z.U.A.Khan <strong>and</strong> A. Ashraf (2003). Health <strong>and</strong> PopulationSector Programme 1998-2003, Bangladesh: Status ofPerformance Indicators 2002, Dhaka: ICDDR, B.United Nations Development Programme (UNDP)(2009). Human Development Report, 2009, New York.United Nations Population Division (1998). WorldUrbanization Prospects: The 1996 Revision, New York.__________ (2010). World Urbanization Prospects: The2008 Revision, New York.United Nations Population Fund (UNFPA)(1995).National Perspectives on Population <strong>and</strong> Development,New York.__________ (2010). Revitaliz<strong>in</strong>g <strong>the</strong> National <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Programme <strong>in</strong> Bangladesh: TowardsReplacement Level Fertility <strong>and</strong> <strong>the</strong> Achievement ofMDGs 4 <strong>and</strong> 5 by 2015, Dhaka.__________ <strong>and</strong> MOHFW, GOB (2005). Ten Yearsafter ICPD: Bangladesh Perspectives, Dhaka.USAID/DELIVER Project (2008). Bangladesh:Government of Bangladesh Contraceptive ProcurementBottleneck Study—Full Report, Arl<strong>in</strong>gton, VA: JohnSnow, Inc.World Bank (2010). Bangladesh Country AssistanceStrategy—2011-2014, Dhaka.125

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IndiaIndia<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> Fertility <strong>in</strong> IndiaAnrudh K. Ja<strong>in</strong>* <strong>and</strong> Aparna Ja<strong>in</strong> #* Anrudh K. Ja<strong>in</strong>, Population <strong>Council</strong>, New York.#Aparna Ja<strong>in</strong>, Johns Hopk<strong>in</strong>s University Bloomberg School of Public Health, Baltimore, Maryl<strong>and</strong>, UnitedStates.127

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IntroductionThe use of contraceptive methods <strong>in</strong> India <strong>in</strong>creased from13 per cent <strong>in</strong> 1971 to 56 per cent <strong>in</strong> 2005/06, <strong>and</strong> fertilitydecl<strong>in</strong>ed from about 6 births per woman <strong>in</strong> <strong>the</strong> 1960s <strong>and</strong>1970s to about 2.7 births <strong>in</strong> 2004. This decl<strong>in</strong>e of morethan 3 births per woman represents about 85 per centof <strong>the</strong> decl<strong>in</strong>e required to reach replacement fertility: 2.1births per woman. The rise <strong>in</strong> contraceptive use <strong>and</strong> <strong>the</strong>pace of fertility decl<strong>in</strong>e, however, has not been uniformthroughout <strong>the</strong> country. Progress at <strong>the</strong> national levelmasks important differentials among subgroups of <strong>the</strong>population. For example, <strong>the</strong> gap <strong>in</strong> contraceptive use <strong>and</strong>fertility between <strong>the</strong> sou<strong>the</strong>rn <strong>and</strong> <strong>the</strong> nor<strong>the</strong>rn states ofIndia observed <strong>in</strong> <strong>the</strong> 1970s cont<strong>in</strong>ues to exist. Fertility <strong>in</strong>six major states is at or below <strong>the</strong> replacement level <strong>and</strong> itis close to <strong>the</strong> replacement level <strong>in</strong> ano<strong>the</strong>r four states. It is<strong>in</strong> four nor<strong>the</strong>rn states only that fertility is more than threebirths per woman (IIPS, 2007). There are o<strong>the</strong>r disparities<strong>in</strong> contraceptive use <strong>and</strong> fertility between <strong>the</strong> poor <strong>and</strong> <strong>the</strong>rich, <strong>and</strong> between <strong>the</strong> educated <strong>and</strong> <strong>the</strong> uneducated. While<strong>the</strong> country has also made tremendous progress <strong>in</strong> termsof economic growth, <strong>the</strong>se disparities <strong>in</strong> contraceptive use<strong>and</strong> fertility have important implications for <strong>the</strong> futureof <strong>the</strong> country. The purpose of this study is to review <strong>the</strong>current status of <strong>the</strong> family plann<strong>in</strong>g programme <strong>in</strong> India,to document <strong>the</strong> persist<strong>in</strong>g <strong>in</strong>equalities <strong>in</strong> contraceptiveuse <strong>and</strong> fertility <strong>and</strong> to assess <strong>the</strong> factors responsible forregional <strong>in</strong>equalities.The fertility behaviour of couples is <strong>in</strong>fluenced by <strong>the</strong>irown characteristics <strong>and</strong> <strong>the</strong>ir residential environment: aparticular country; a state, or a district with<strong>in</strong> a country;<strong>and</strong> urban or rural areas with<strong>in</strong> a district. It is difficultto summarize this vast literature. However, at <strong>the</strong> risk ofoversimplification, it can be said that couples have childrenbecause <strong>the</strong>y want or need <strong>the</strong>m. Some prefer large familiesto ensure security <strong>in</strong> old age, to secure additional assistance<strong>in</strong> domestic <strong>and</strong> agricultural activities, or to support <strong>the</strong>upbr<strong>in</strong>g<strong>in</strong>g of o<strong>the</strong>r sibl<strong>in</strong>gs. This implies that couplesprefer large families to enhance <strong>the</strong>ir own well-be<strong>in</strong>g now<strong>and</strong> later <strong>in</strong> life. A shift <strong>in</strong> value from this self-<strong>in</strong>terest to<strong>the</strong> well-be<strong>in</strong>g of children is believed to <strong>in</strong>itiate tradeoffsbetween <strong>the</strong> quantity <strong>and</strong> quality of children <strong>and</strong> between<strong>the</strong> cost <strong>and</strong> benefits of children. These tradeoffs lead to adesire for smaller families. This shift <strong>in</strong> th<strong>in</strong>k<strong>in</strong>g is facilitatedby a couple’s education, diffusion of ideas through massmedia, contact with o<strong>the</strong>r families benefit<strong>in</strong>g from smallerfamilies <strong>and</strong> <strong>the</strong> macro-level conditions to which <strong>the</strong>y areexposed.Factors such as education do not affect fertility directly.Their <strong>in</strong>fluence on fertility is transmitted through fourma<strong>in</strong> proximate determ<strong>in</strong>ants: marriage, post-partumamenorrhoea <strong>and</strong> abst<strong>in</strong>ence, abortion <strong>and</strong> use ofcontraception (Bongaarts, 1978). Age at marriage risesslowly <strong>and</strong> its fertility-<strong>in</strong>hibit<strong>in</strong>g effect is usually cancelledout by <strong>the</strong> fertility-enhanc<strong>in</strong>g effect of reductions <strong>in</strong>post-partum amenorrhoea <strong>and</strong> abst<strong>in</strong>ence associatedwith modernization. While <strong>the</strong> use of abortion servicessuppresses fertility, its availability is limited <strong>in</strong> manysocieties. In brief, fertility is ma<strong>in</strong>ly determ<strong>in</strong>ed by <strong>the</strong>use of contraception. In recogniz<strong>in</strong>g this fact, develop<strong>in</strong>gcountries <strong>in</strong>itiated family plann<strong>in</strong>g programmes that offerservices <strong>and</strong> <strong>in</strong>formation about contraceptive methods tocouples who wanted to regulate <strong>the</strong>ir fertility.The demographic literature <strong>and</strong> <strong>in</strong>ternational populationconferences have focused on how <strong>the</strong> fertility transition willoccur: through <strong>in</strong>vestment <strong>in</strong> family plann<strong>in</strong>g programmesor dependence on economic development. Some arguedthat economic development would ultimately lead tofertility decl<strong>in</strong>e as it did <strong>in</strong> North America <strong>and</strong> WesternEurope. O<strong>the</strong>rs argued that family plann<strong>in</strong>g programmeswould decrease fertility even <strong>in</strong> poorer sett<strong>in</strong>gs as seen <strong>in</strong>Bangladesh <strong>and</strong> Ghana (Phillips et al., 1988, Debpuur etal., 2002). These two oppos<strong>in</strong>g positions were evident at<strong>the</strong> 1974 <strong>and</strong> 1984 <strong>in</strong>ternational population conferences.At <strong>the</strong> World Population Conference <strong>in</strong> Bucharest <strong>in</strong> 1974,develop<strong>in</strong>g countries argued for “development” be<strong>in</strong>g <strong>the</strong>best contraceptive, whereas developed countries argued for<strong>the</strong> importance of family plann<strong>in</strong>g programmes. By <strong>the</strong> timeof <strong>the</strong> <strong>International</strong> Conference on Population <strong>in</strong> MexicoCity <strong>in</strong> 1984 <strong>the</strong> two sides had switched <strong>the</strong>ir positions.Many studies conducted prior to <strong>the</strong> <strong>International</strong>Conference on Population <strong>and</strong> Development (ICPD) <strong>in</strong>Cairo <strong>in</strong> 1994, however, <strong>in</strong>dicated that <strong>the</strong> best resultswould be obta<strong>in</strong>ed by a good family plann<strong>in</strong>g programmeimplemented under conditions of a good social sett<strong>in</strong>g (forexample, see Bongaarts et al., 1990; Ja<strong>in</strong>, 1985; Cutright,1983; Mauld<strong>in</strong> <strong>and</strong> Berelson, 1978; <strong>and</strong> Freedman <strong>and</strong>Berelson, 1976). This was also reflected <strong>in</strong> <strong>the</strong> discourse of<strong>the</strong> 1994 conference.The ma<strong>in</strong> message imbedded <strong>in</strong> <strong>the</strong> ICPD Programmeof Action <strong>in</strong>cluded two elements: provide contraceptivemethods with<strong>in</strong> <strong>the</strong> context of reproductive health <strong>and</strong>advance women’s equality <strong>in</strong> education, health <strong>and</strong> economicopportunities. With<strong>in</strong> <strong>the</strong> context of fertility transition,<strong>the</strong>se two recommended actions are consistent with <strong>the</strong>reduction of unwanted fertility through <strong>the</strong> provision ofcontraceptive services <strong>and</strong> reduction of wanted fertility,with improvements <strong>in</strong> equality <strong>in</strong> education, health <strong>and</strong>economic conditions (for a comparison of populationpolicies pre- <strong>and</strong> post-ICPD, see Ja<strong>in</strong>, 1998a; <strong>and</strong> for <strong>the</strong>evolution of population policies <strong>and</strong> <strong>the</strong> role of differentactors, see Ja<strong>in</strong> 1998b).The deliberations with<strong>in</strong> countries on population issueshas affected <strong>the</strong> <strong>in</strong>ternational discourse. At <strong>the</strong> same time<strong>the</strong> outcome of <strong>the</strong> <strong>in</strong>ternational conferences <strong>in</strong>fluencedpopulation policies <strong>and</strong> programmes <strong>in</strong> develop<strong>in</strong>g129

The Government of India liberalized its abortion policiesunder <strong>the</strong> Medical Term<strong>in</strong>ation of Pregnancy (MTP)Act <strong>in</strong> 1971. While services for safe abortions are stilllimited, efforts are under way to <strong>in</strong>troduce medicalabortion technology. The m<strong>in</strong>imum age at marriage forgirls was officially raised to 18 years <strong>in</strong> 1978. The meanage at marriage <strong>in</strong> 2007 was estimated at 20.6 years for <strong>the</strong>entire country. It ranged from about 19.5 years <strong>in</strong> Biharto about 22.8 years <strong>in</strong> Kerala (see Table 1). Applicationof <strong>the</strong> Bongaarts (1978) model of proximate determ<strong>in</strong>antsto NFHS data <strong>in</strong>dicates that total fertility <strong>in</strong> India isdeterm<strong>in</strong>ed ma<strong>in</strong>ly by <strong>the</strong> level of contraceptive methoduse ( Ja<strong>in</strong>, 1997; Visaria, 2002).The family plann<strong>in</strong>g programme <strong>in</strong> India has undergonevarious phases s<strong>in</strong>ce its reorganization <strong>in</strong> 1966. Theprogramme <strong>in</strong>itially offered services for vasectomy,tubectomy, IUD <strong>and</strong> <strong>the</strong> Nirodh condom. The government<strong>in</strong>itiated a social market<strong>in</strong>g programme <strong>in</strong> 1968, underwhich Nirodh condoms were sold at a subsidized pricethrough six commercial market<strong>in</strong>g companies (see Ja<strong>in</strong>,1973). In <strong>the</strong> early 1970s, however, <strong>the</strong> programme startedpromot<strong>in</strong>g vasectomies <strong>and</strong> used <strong>in</strong>centives through <strong>the</strong>camp approach 1 . Incentives, dis<strong>in</strong>centives <strong>and</strong> even forcewere used to promote vasectomies dur<strong>in</strong>g <strong>the</strong> emergencyperiod of <strong>the</strong> mid-1970s. A hiatus followed <strong>the</strong> emergencyperiod <strong>and</strong> later <strong>the</strong>re was renewed emphasis on <strong>in</strong>centivesfor women, method-specific targets <strong>and</strong> <strong>in</strong>centives forproviders to promote female sterilization (for <strong>in</strong>formationon <strong>the</strong> evolution of <strong>the</strong> family plann<strong>in</strong>g programme <strong>in</strong> India,see Visaria <strong>and</strong> Chari, 1998; <strong>and</strong> Harkavy <strong>and</strong> Roy, 2007).Follow<strong>in</strong>g <strong>the</strong> 1994 ICPD, <strong>the</strong> government elim<strong>in</strong>atedmethod-specific targets <strong>in</strong> April 1996 <strong>and</strong> changed <strong>the</strong>programme to promote wider choice among methods <strong>and</strong>address broader reproductive health issues <strong>in</strong> October1997 (see Visaria et al., 1999; <strong>and</strong> Donaldson, 2001).However, services <strong>and</strong> <strong>the</strong> uptake of methods o<strong>the</strong>r thansterilization rema<strong>in</strong>ed limited. S<strong>in</strong>ce <strong>the</strong>n <strong>the</strong> programmehas focused more on reproductive health issues.Recently, <strong>the</strong>re has been a renewed focus on populationissues. At <strong>the</strong> National Population Commission meet<strong>in</strong>g<strong>in</strong> October 2010, strategies were discussed which wereaimed at achiev<strong>in</strong>g population stabilization by 2045,a goal first set <strong>in</strong> <strong>the</strong> country’s 2000 population policy.The M<strong>in</strong>istry of Health <strong>and</strong> <strong>Family</strong> Welfare formulateda strategy consist<strong>in</strong>g of four elements: (a) to establisha division that focuses on population stabilization, to<strong>in</strong>crease access to services through <strong>the</strong> private sector<strong>and</strong> to undertake advocacy efforts; (b) to establish postpartumcentres <strong>in</strong> all areas; (c) to <strong>in</strong>crease <strong>the</strong> supply ofcontraceptives at <strong>the</strong> doorstep of each village through <strong>the</strong>Accredited Social Health Activists; <strong>and</strong> (d) to enhancecompensation for women undergo<strong>in</strong>g sterilization. O<strong>the</strong>rsteps reported 2 by <strong>the</strong> M<strong>in</strong>ister <strong>and</strong> <strong>the</strong> Secretary of Health<strong>and</strong> <strong>Family</strong> Welfare <strong>in</strong>cluded exp<strong>and</strong><strong>in</strong>g choice through <strong>the</strong>availability of <strong>in</strong>jectables, <strong>in</strong>creas<strong>in</strong>g compensation to Rs.1,500 (US$ 1 = 46 rupees) for vasectomies, <strong>and</strong> align<strong>in</strong>gcash <strong>in</strong>centives <strong>in</strong> 250 districts with high fertility <strong>and</strong> highmaternal mortality.The health <strong>and</strong> family plann<strong>in</strong>g programme <strong>in</strong> Indiais primarily f<strong>in</strong>anced from <strong>in</strong>ternal resources. TheGovernment of India allocated approximately US$ 31.5billion for <strong>the</strong> eleventh five-year plan beg<strong>in</strong>n<strong>in</strong>g on 1 April2007 <strong>and</strong> end<strong>in</strong>g on 31 March 2012. In addition, about US$400 million per year was allocated from non-plan budgets.States also allocated funds from <strong>the</strong>ir own resources. Of<strong>the</strong> few donors currently active <strong>in</strong> this sector, <strong>the</strong> ma<strong>in</strong>ones are: <strong>the</strong> United Nations Population Fund (UNFPA);United States Agency for <strong>International</strong> Development(USAID); Department for <strong>International</strong> Development(DFID); United Nations Children’s Fund (UNICEF);<strong>and</strong> Bill & Mel<strong>in</strong>da Gates Foundation. Donors primarilysupport special projects <strong>in</strong> four nor<strong>the</strong>rn states: DFID,Bill & Mel<strong>in</strong>da Gates Foundation, UNICEF <strong>and</strong> UNFPA<strong>in</strong> Bihar; USAID <strong>in</strong> Rajasthan; DFID <strong>and</strong> UNICEF <strong>in</strong>Madhya Pradesh; <strong>and</strong> UNFPA, UNICEF, USAID <strong>and</strong>Bill & Mel<strong>in</strong>da Gates Foundation <strong>in</strong> Uttar Pradesh.Availability <strong>and</strong> quality of servicesData on <strong>the</strong> availability <strong>and</strong> <strong>the</strong> quality of services are quitesparse. Services for contraceptive methods are providedthrough a hierarchical system of fixed facilities consist<strong>in</strong>gof subcentres, primary health centres (PHCs) <strong>and</strong>community health centres (CHCs), first referral units <strong>and</strong>district hospitals. Community health workers – AuxiliaryMidwives, Accredited Social Health Activists <strong>and</strong>Anganwadi workers – facilitate <strong>the</strong> use of various health<strong>and</strong> family plann<strong>in</strong>g services by l<strong>in</strong>k<strong>in</strong>g women <strong>in</strong> <strong>the</strong>ircommunities to <strong>the</strong>se fixed facilities. A subcentre furnishesbasic/m<strong>in</strong>imum health services to a population of about5,000; a PHC furnishes preventive <strong>and</strong> curative health <strong>and</strong>family plann<strong>in</strong>g services to a population of about 30,000;<strong>and</strong> a CHC provides a population of about 120,000 withspecialist <strong>and</strong> general health <strong>and</strong> family plann<strong>in</strong>g services.Table 2 presents data from <strong>the</strong> 2003 facility survey on stafftra<strong>in</strong><strong>in</strong>g <strong>and</strong> service availability through <strong>the</strong>se facilities. Veryfew staff at <strong>the</strong>se units received any tra<strong>in</strong><strong>in</strong>g with<strong>in</strong> threeyears of <strong>the</strong> survey. Paramedical staff <strong>in</strong> about half of <strong>the</strong>10,000 PHCs surveyed received tra<strong>in</strong><strong>in</strong>g <strong>in</strong> IUD <strong>in</strong>sertionwith<strong>in</strong> that three-year period <strong>and</strong> staff <strong>in</strong> only 10-15 percent of PHCs received any tra<strong>in</strong><strong>in</strong>g <strong>in</strong> sterilization <strong>and</strong>MTP (abortion) services. Contraceptive methods, such asNirodh condoms, pills <strong>and</strong> IUDs, were available <strong>in</strong> about131

TableTable2Indicators of tra<strong>in</strong><strong>in</strong>g <strong>and</strong> availability of contraceptives for various units provid<strong>in</strong>g services <strong>in</strong> IndiaItemsDistricthospitalsFirst referralunitsCommunityHealth CentresPrimaryHealthCentresSubcentresNumbers 370 1882 1625 9688 18385Percentage of units with at least one doctor/staff received tra<strong>in</strong><strong>in</strong>g with<strong>in</strong> 3 years <strong>in</strong>:a. Any sterilization 26.6 14.0 9.6b. NSVi 10.8c. Tubal ligation 14.6d.MTPii 68.8 54.4 44.4 14.6e. IUD <strong>in</strong>sertion 56.2iii 1.2iii% units <strong>in</strong> which some stocks were available on <strong>the</strong> day of visita. Nirodh 73.8 72.8 70.0 59.1 96.3ivb.Oral pills 68.9 69.6 67.0 58.4 96.6ivc. IUD 73.5 73.4 70.2 56.3 96.0iv% units which provided services with<strong>in</strong> 3 months prior to survey:a. MTP services 6.1b. Male sterilization 8.7c. Female sterilization 37.9d. IUDs <strong>in</strong>serted 65.1 75.0e. Condoms distributed 86.2f. Pills distributed 92.2Access 73.0a. Villages with<strong>in</strong> 10 km from PHC 74.2b.Villages with<strong>in</strong> 6 km from SC 73.0Source: 2003 Facility Survey Phase II (IIPS, 2005). i. NSV: No scalpel vasectomy, ii. MTP: Medical term<strong>in</strong>ation of pregnancyiii. Paramedical staff, iv. Regular supply60-70 per cent of <strong>the</strong>se units. Very few of PHCs providedany services for sterilization or MTP <strong>in</strong> <strong>the</strong> three monthsprior to survey. The situation with subcentres appears to bebetter, but it is not clear whe<strong>the</strong>r <strong>the</strong>se data represent a truepicture or normative responses to <strong>the</strong> survey questions. Itis difficult to believe that 96 per cent of <strong>the</strong> subcentres hada regular supply of Nirodh condoms, pills <strong>and</strong> IUDs; <strong>and</strong>that 75 per cent of <strong>the</strong> subcentres <strong>in</strong>serted IUDs with<strong>in</strong>three months prior to <strong>the</strong> survey.Table 3 summarizes selected <strong>in</strong>dicators of family plann<strong>in</strong>gservices from District Level Household <strong>and</strong> Facility Survey(DLHS)-2 <strong>and</strong> DLHS-3. About 71 per cent of villages hada subcentre with<strong>in</strong> 3 km <strong>and</strong> a PHC with<strong>in</strong> 10 km. Accessto <strong>the</strong>se facilities was not uniform across states: it wasmuch better <strong>in</strong> Kerala (99.8%) <strong>and</strong> Tamil Nadu (83.7%)<strong>in</strong> comparison with Madhya Pradesh (57.0%). Outreachof workers was also limited: only 10 per cent of <strong>the</strong> womensurveyed <strong>in</strong> DLHS-2 were visited at <strong>the</strong>ir home with<strong>in</strong> 3months prior to <strong>the</strong> survey, <strong>and</strong> 12 per cent of <strong>the</strong> nonuserswere advised to adopt a contraceptive method. Therewere some m<strong>in</strong>or variations among states <strong>in</strong> terms of <strong>the</strong>outreach of workers.A review of <strong>the</strong> literature (Koenig et al., 2000) highlightedseveral systematic shortcom<strong>in</strong>gs of <strong>the</strong> programme:restricted choice, limited <strong>in</strong>formation provided to clients,poor technical st<strong>and</strong>ards <strong>and</strong> low levels of follow-up <strong>and</strong>cont<strong>in</strong>uity of care. The situation has not changed muchs<strong>in</strong>ce <strong>the</strong>n. For example, sterilized women <strong>in</strong> 2002/04received limited <strong>in</strong>formation <strong>and</strong> services: about 29 percent were told about ano<strong>the</strong>r method or about side effects,<strong>and</strong> about 31 per cent received a follow-up visit from ahealth worker. Even <strong>in</strong> a state such as Kerala only 15 percent of <strong>the</strong> sterilized women received a follow up visit <strong>and</strong>21 per cent were told about side effects (see Table 3).132

TableTable3Indicators of family plann<strong>in</strong>g services from DLHS-2 <strong>and</strong> DLHS-3States% of ruralhouseholdpopulationwith anyhealthfacilityawith<strong>in</strong><strong>the</strong> village% ofwomenvisitedat homewith<strong>in</strong> 3monthsprior tosurvey b% of nonusersevertold oradvised toadopt contraceptivemethodToldabouto<strong>the</strong>rmethods(Choice)Receiveda follow-upvisit bya healthworkerWere toldaboutside effects% villageswithsubcentrewith<strong>in</strong> 3km% villageswith PHCwith<strong>in</strong> 10kmSource DLHS-2 DLHS-2 DLHS-2 DLHS-2 DLHS-2 DLHS-2 DLHS-3 DLHS-3Sou<strong>the</strong>rnAndhra Pradesh 55.7 13.2 5.9 22.0 34.0 18.5 62.1 67.9Karnataka 46.2 17.7 16.9 39.0 47.5 49.8 66.1 77.9Kerala 90.3 12.2 11.1 36.6 14.9 21.2 99.8 94.9Tamil Nadu 55.0 17.9 6.8 46.3 37.3 53.2 83.7 78.5Nor<strong>the</strong>rnBihar 37.3 2.1 16.3 21.5 7.9 20.5 74.2 70.6Madhya Pradesh 33.0 5.5 20.2 24.0 33.0 21.7 57.0 55.6Rajasthan 66.2 10.2 29.6 53.3 31.5 34.5 72.4 66.2Uttar Pradesh 36.8 11.2 16.5 20.0 26.3 25.9 75.9 77.8O<strong>the</strong>r LargeAssam 51.1 3.1 4.5 61.4 6.2 67.4 83.1 68.3Gujarat 52.3 12.8 6.4 23.8 49.6 38.8 63.3 70.8Haryana 64.3 3.1 18.5 21.8 41.1 34.9 77.0 82.3Maharashtra 46.1 14.2 13.9 26.2 30.7 22.4 61.5 64.9Orissa 45.5 5.5 8.0 23.4 61.5 28.1 80.7 83.6Punjab 54.9 2.5 9.6 31.8 45.0 47.9 79.5 78.3West Bengal 56.0 12.5 13.6 12.9 13.6 85.5 86.3All-India 50.4 10.0 11.7 28.9 31.2 29.3 71.4 71.2Source: 2002-2004 DLHS-2 (IIPS, 2006) <strong>and</strong> 2007/08 DLHS-3 (IIPS, 2010).a. Health facility <strong>in</strong>cludes subcentre, primary health centre, community health centre, government hospital or dispensary.c. Visited by a doctor, ANM/LHV, or male health worker.Contraceptive use <strong>in</strong> IndiaContraceptive use at <strong>the</strong> nationallevelThe contraceptive prevalence rate (CPR) <strong>in</strong> India<strong>in</strong>creased from about 13 per cent <strong>in</strong> 1971 to 41 per cent<strong>in</strong> 1992/93 <strong>and</strong> to 56 per cent <strong>in</strong> 2005/06 (see Figure 1).The method mix has been skewed s<strong>in</strong>ce <strong>the</strong> beg<strong>in</strong>n<strong>in</strong>g <strong>and</strong>started to become more skewed <strong>in</strong> <strong>the</strong> 1980s (47% of usersdepended upon sterilization <strong>in</strong> 1970 <strong>and</strong> more than 60%<strong>in</strong> <strong>the</strong> 1980s; see Figure 2). While <strong>the</strong> method-specifictargets were elim<strong>in</strong>ated <strong>in</strong> 1996, <strong>the</strong> method mix rema<strong>in</strong>edquite skewed towards female sterilization: <strong>the</strong> majority ofcontraceptive users depend upon sterilization – primarilyfemale sterilization. However, <strong>the</strong>re is some evidence<strong>in</strong>dicat<strong>in</strong>g that <strong>the</strong> use of spac<strong>in</strong>g <strong>and</strong> traditional methods<strong>in</strong>creased <strong>in</strong> recent years. For example, <strong>the</strong> proportion ofsterilization users among all method users decl<strong>in</strong>ed from 76per cent <strong>in</strong> 1992/93 <strong>and</strong> 75 per cent <strong>in</strong> 1998/99 to 68 percent <strong>in</strong> 2005/06, suggest<strong>in</strong>g some effect of <strong>the</strong> elim<strong>in</strong>ationof targets on exp<strong>and</strong>ed method choice (Figure 2).133

FigureFigureFigure1Contraceptive prevalence <strong>in</strong> India:1970 to 2005/06Figure2Method mix <strong>in</strong> India from 1970 to 2005/06Differentials <strong>in</strong> contraceptiveprevalenceWhile contraceptive use has <strong>in</strong>creased at <strong>the</strong> nationallevel as well as <strong>in</strong> all subgroups, this <strong>in</strong>crease has notbeen uniform. The demographic, social <strong>and</strong> economiccharacteristics of <strong>the</strong> women sampled <strong>in</strong> <strong>the</strong> three NFHSsurveys conducted <strong>in</strong> 1992/93, 1998/99 <strong>and</strong> 2005/06are presented <strong>in</strong> Table 4. Table 5 shows <strong>the</strong> proportionof women us<strong>in</strong>g any contraceptive method (<strong>in</strong>clud<strong>in</strong>gtraditional), those us<strong>in</strong>g sterilization (male <strong>and</strong> female) <strong>and</strong><strong>the</strong> proportion of sterilization use among all contraceptiveusers by <strong>the</strong>ir characteristics for <strong>the</strong> three NFHS rounds.Table 6 presents <strong>the</strong> adjusted odds ratios (ORs) <strong>and</strong> 95 percent confidence <strong>in</strong>tervals (CIs) of contraceptive methoduse for <strong>the</strong>se covariates. Important trends are highlightedbelow 3 .DemographicThe odds of contraceptive method use <strong>in</strong>creased with<strong>in</strong>creas<strong>in</strong>g women’s age, parity <strong>and</strong> number of liv<strong>in</strong>g sons<strong>in</strong> all three rounds of NFHS. Contraceptive use <strong>in</strong>creasedover time <strong>in</strong> all categories of age, parity <strong>and</strong> liv<strong>in</strong>g sons;however, <strong>the</strong> rate of <strong>in</strong>crease was not uniform. The oddsratios decreased for some age groups, reflect<strong>in</strong>g an <strong>in</strong>crease<strong>in</strong> contraceptive use among youth (from 7.1% <strong>in</strong> 1992/93to 13.0% <strong>in</strong> 2005/06; see Table 5). Conversely, <strong>the</strong> odds134

TableTableCharacteristics of <strong>the</strong> NFHS sample <strong>in</strong>4India: 1993-2005CharacteristicsPercentage distribution1992/93 1998/99 2005/06RegionSouth 22.8 24.0 21.8North 40.8 39.3 40.8Large 33.0 32.9 33.7Small 3.4 3.8 3.7ResidenceUrban 26.1 26.2 30.7Rural 73.9 73.8 69.3EducationNone 61.1 52.8 47.2Primary 16.1 16.8 15.4Secondary 19.0 22.0 31.5Higher 3.5 8.2 5.9Miss<strong>in</strong>g 0.3 0.2 0ReligionH<strong>in</strong>du 82.2 81.8 81.4Muslim 11.9 12.5 13.2Sikh 1.9 1.6 1.7Ja<strong>in</strong> 0.4 0.3Christian 2.3 2.5 2.2O<strong>the</strong>r 1.7 1.1 1.1Miss<strong>in</strong>g 0.1WealthLowest 19.2 19.3 18.7Second 19.7 19.9 19.9Middle 20.1 20.0 20.1Fourth 20.4 20.1 20.4Highest 20.7 20.6 21.0Household structureNuclear 93.2 98.1 48.6Non-nuclear 6.3 1.9 45.2Miss<strong>in</strong>g 0.6 0.0 6.2EmployedCash 11.6 24.2 27.5K<strong>in</strong>d 19.8 13.2 15.3Not employed 68.6 62.6 57.2RadioNo 71.9 61.5 68.1Yes 28.1 38.5 31.9Miss<strong>in</strong>g 0.0 0.0 0.0TelevisionNo 63.2 55.7 53.0Yes 36.8 44.3 47.0CharacteristicsPercentage distribution1992/93 1998/99 2005/06NewspaperNo 81.5 53.0Yes 18.5 47.0Miss<strong>in</strong>g 0.0Contact with Health/FP workerNo 86.8 79.4Yes 13.2 20.6Miss<strong>in</strong>g 0.0 0.0Age15-19 10.6 9.6 7.220-24 20.7 19.0 1825-29 19.9 20.4 19.930-34 16.5 17.1 17.735-39 13.8 14.4 15.640-44 10.4 11.2 12.545-49 8.2 8.3 9.1Parity0 11.7 10.7 10.11 14.5 14.2 14.92 18.3 21.1 253 17.9 19.4 19.64+ 37.7 34.6 30.4Desire< 2 years 12.9 14.8 12.62+ years 19.6 13.3 11.7Undecided 3.0 3.1 2.3No more 56.9 63.6 70.5Up to God 1.5 0.0Infecund 3.8 3.5 2.8Miss<strong>in</strong>g 3.9 0.1 0.1# of liv<strong>in</strong>g sons0 27.3 25.6 25.41 31.6 33.6 35.92+ 41.1 40.8 38.7# of child deaths0 72.1 75.3 78.11 17.3 16.2 14.92+ 10.6 8.6 6.9Miss<strong>in</strong>g 0.0 0.0 0.0Total: % 100.0 100.0 100.0Wt. N 84328 84682 93089135

TableTable5Indicators of contraceptive use <strong>and</strong> method mix, by women’s characteristics <strong>in</strong> India: 1992/93-2005/06CharacteristicsPercentage users of anymethodaSterilized as % of all usersSterilized as % of all users1992/93 1997/98 2005/06 1992/93 1997/98 2005/06 1992/93 1997/98 2005/06RegionSouth 50.9 57.9 65.2 43.5 52.1 59.0 85.5 90.0 90.5North 25.6 32.1 44.3 20.1 23.5 27.5 78.5 73.2 62.1Large 51.4 59.8 64.9 36.1 40.0 39.2 70.2 66.9 60.4Small 50.6 54.8 58.9 26.1 30.5 28.0 51.6 55.7 47.5ResidenceUrban 51.1 58.2 64.0 33.7 37.8 38.8 65.9 64.9 60.6Rural 37.1 44.7 53.0 29.9 35.4 38.1 80.6 79.2 71.9EducationNone 33.7 42.1 52.1 29.3 35.8 40.8 86.9 85.0 78.3Primary 50.6 54.4 60.1 40.0 43.3 44.7 79.1 79.6 74.4Secondary 51.5 54.6 59.4 30.9 36.0 35.0 60.0 65.9 58.9Higher 58.8 57.8 64.3 16.9 22.6 19.6 28.7 39.1 30.5Miss<strong>in</strong>g 40.2 55.2 47.7 30.4 18.2 16.8 75.6 33.0 35.2ReligionH<strong>in</strong>du 41.8 49.3 57.8 36.1 38.3 41.0 86.4 77.7 70.9Muslim 27.8 37.0 45.7 16.1 20.4 21.8 57.9 55.1 47.7Sikh 57.5 65.2 66.5 32.9 31.8 32.1 57.2 48.8 48.3Ja<strong>in</strong> - 65.1 75.4 - 43.7 41.8 - 67.1 55.4Christian 48.6 52.4 57.6 34.0 38.6 41.5 70.0 73.7 72.0O<strong>the</strong>r 50.0 58.5 53.8 36.1 46.9 44.2 72.2 80.2 82.2Miss<strong>in</strong>g - 50.2 54.2 - 35.8 30.1 - 71.3 55.5WealthLowest 28.1 33.8 42.2 23.5 27.2 30.5 83.6 80.5 72.3Second 31.1 39.3 51.1 25.5 32.0 37.9 82.0 81.4 74.2Middle 39.2 49.0 56.8 33.2 41.0 42.7 84.7 83.7 75.2Fourth 46.1 55.0 62.5 36.3 42.3 43.8 78.7 76.9 70.1Highest 57.8 63.1 67.5 35.3 37.3 36.3 61.1 59.1 53.8Household structureNuclear 41.3 48.6 63.0 31.4 36.3 45.6 76.0 74.7 72.4Non-nuclear 31.8 28.9 52.7 24.0 21.1 33.6 75.5 73.0 63.8Miss<strong>in</strong>g 39.6 34.8 30.6 32.2 21.0 15.9 81.3 60.3 52.0EmployedCash 41.4 55.3 63.6 37.3 47.1 49.7 90.1 85.2 78.1K<strong>in</strong>d 48.2 47.4 52.7 40.6 41.6 41.8 84.2 87.8 79.3Not employed 38.4 45.7 53.8 27.0 30.6 32.0 70.3 67.0 59.5RadioNo 35.4 44.5 55.4 28.7 34.5 39.6 81.1 77.5 71.5Yes 54.4 54.2 58.2 36.5 38.4 35.6 67.1 70.8 61.2Miss<strong>in</strong>g 18.4 17.0 66.5 18.2 3.1 47.3 98.9 18.2 71.1136

TelevisionNo 35.8 41.0 49.8 28.6 33.3 36.9 79.9 81.2 74.1Yes 49.1 57.3 63.7 34.9 39.5 39.9 71.1 68.9 62.6Miss<strong>in</strong>g 15.7 19.4 66.7 15.7 3.6 61.5 100.0 18.6 92.2NewspaperNo - 45.7 49.8 - 36.1 36.9 - 79.0 74.1Yes - 59.5 63.7 - 35.5 39.9 - 59.7 62.6Miss<strong>in</strong>g - 35.4 66.7 - 24.7 61.5 - 69.8 92.2Contact with Health/FP workerNo - 47.7 58.2 - 35.7 40.6 - 74.8 69.8Yes - 51.6 49.2 - 38.5 29.8 - 74.6 60.6Miss<strong>in</strong>g - 0.0 0.0 - 0.0 0.0 - 0.0 0.0Age15-19 7.1 8.1 13.0 1.3 1.5 1.1 18.3 18.5 8.520-24 21.0 26.1 33.4 10.9 13.4 13.6 51.9 51.3 40.725-29 42.3 49.3 56.4 29.3 34.0 33.9 69.3 69.0 60.130-34 55.8 62.8 70.4 43.8 47.1 48.0 78.5 75.0 68.235-39 62.0 67.4 73.1 50.3 54.1 54.1 81.1 80.3 74.040-44 56.2 64.9 68.7 49.0 55.6 55.5 87.2 85.7 80.845-49 45.8 57.2 63.2 42.1 52.1 57.0 91.9 91.1 90.2Parity0 4.2 4.4 7.5 0.5 0.4 0.3 11.9 9.1 4.01 18.3 22.5 32.6 2.5 2.7 3.2 13.7 12.0 9.82 44.0 56.7 68.0 27.6 38.9 45.6 62.7 68.6 67.13 57.4 66.1 73.9 48.3 55.4 59.7 84.1 83.8 80.84+ 51.1 57.2 63.2 44.6 48.1 48.3 87.3 84.1 76.4Desire< 2 years 7.0 7.5 11.1 0 0 0 0.0 0.0 0.02+ years 11.2 15.2 26.7 0 0 0 0.0 0.0 0.0Undecided 5.3 8.1 11.6 0 0 0 0.0 0.0 0.0No more 65.5 70.2 72.9 54.3 56.6 54.4 82.9 80.6 74.6Up to God - 6.0 - - 0 0 - 0.0 -Infecund 2.5 1.6 4.0 0 0 0 0.0 0.0 0.0Miss<strong>in</strong>g 2.7 20.9 15.2 0 0 0 0.0 0.0 0.0# of liv<strong>in</strong>g sons0 14.7 18.3 26.1 5.8 7.9 10.0 39.5 43.2 38.31 41.0 50.6 61.1 27.4 34.1 38.4 66.8 67.4 62.82+ 57.9 65.0 71.7 50.3 55.2 56.9 86.9 84.9 79.4# of child deaths0 40.6 47.8 56.4 29.3 34.3 37.4 72.2 71.8 66.31 43.3 52.1 58.3 36.4 43.2 43.9 84.1 82.9 75.32+ 37.2 44.6 51.1 32.7 37.3 37.3 87.9 83.6 73.0Total 40.7 48.2 56.3 30.9 36.0 38.3 75.9 74.7 68.0a. Includes traditional methods.b. Includes female <strong>and</strong> male sterilization.137

TableTable6Adjusted odds ratios for contraceptive use, by characteristics <strong>in</strong> India: 1992/93–2005/061992/933 1998/99 2005/06OR OR 95% CI OR 95% CI OR 95% CIEducationNone 1.00 1.00 1.00Primary 1.74 (1.64 - 1.85) 1.40 (1.31 - 1.49) 1.39 (1.30 - 1.48)Secondary 1.90 (1.75 - 2.06) 1.51 (1.41 - 1.63) 1.40 (1.30 - 1.50)Higher 2.37 (1.97 - 2.86) 1.48 (1.31 - 1.67) 1.62 (1.42 - 1.84)Lowest 1.00 1.00 1.00Second 1.21 (1.13 - 1.31) 1.25 (1.16 - 1.34) 1.43 (1.32 - 1.55)Middle 1.52 (1.40 - 1.66) 1.65 (1.52 -1.79) 1.68 (1.53 - 1.83)Fourth 1.74 (1.59 - 1.90) 1.91 (1.74 - 2.10) 1.94 (1.76 - 2.13)Highest 2.12 (1.86 -2.42) 2.09 (1.86 - 2.33) 1.99 (1.78 - 2.24)Employed (<strong>in</strong> k<strong>in</strong>d) 1.00 1.00 1.00Employed (cash) 1.24 (1.14 - 1.35) 1.37 (1.27 - 1.49) 1.45 (1.34 -1.57)Unemployed 0.74 (0.69 - 0.80) 0.77 (0.72 - 0.83) 0.91 (0.84 - 0.98)Non-nuclear 0.95 (0.86 - 1.06) 0.71 (0.60 - 0.83) 0.96 (0.91 -1.00)Nuclear 1.00 1.00 1.00No 1.00 1.00 1.00Yes 1.14 (1.06 - 1.23) 1.14 (1.07 - 1.20) 0.99 (0.93 - 1.05)No 1.00 1.00 1.00Yes 1.21 (1.14 -1.28) 1.31 (1.24 - 1.38) 1.39 (1.32 -1.47)No - 1.00 1.00Yes 1.08 (0.99 - 1.17) 1.14 (1.05 -1.23)No - 1.00 1.00Yes 1.16 (1.08 - 1.24) 0.72 (0.68 - 0.77)Rural 1.00 1.00 1.00Urban 0.93 (0.86 - 1.01) 1.01 (0.94 - 1.08) 1.02 (0.94 -1.10)H<strong>in</strong>du 1.00 1.00 1.00Muslim 0.52 (0.48 - 0.58) 0.58 (0.52 - 0.64) 0.53 (0.48 - 0.60)Sikh 1.26 (1.12 - 1.42) 1.23 (1.07 - 1.42) 0.81 (0.68 - 0.96)Ja<strong>in</strong> - 0.95 (0.63 - 1.45) 1.23 (0.78 - 1.94)Christian 0.89 (0.78 - 1.03) 0.88 (0.76 - 1.01) 0.68 (0.59 - 0.79)O<strong>the</strong>r 1.10 (0.92 - 1.31) 1.30 (1.00 - 1.69) 0.72 (0.59 - 0.88)Scheduled Caste 1.00 1.00 1.00Scheduled Tribe 1.13 (1.01 - 1.27) 0.95 (0.85 - 1.06) 0.92 (0.82 -1.03)O<strong>the</strong>r Backward- 1.02 (0.94 - 1.09) 0.90 (0.83 - 0.97)ClassO<strong>the</strong>r 1.21 (1.11 -1.31) 1.26 (1.16 - 1.36) 1.16 (1.06 - 1.26)Age15-19 1.00 1.00 1.0020-24 1.15 (1.02 - 1.29) 1.26 (1.10 - 1.43) 1.09 (0.95 - 1.24)25-29 1.61 (1.43 - 1.81) 2.00 (1.75 - 2.30) 1.55 (1.35 - 1.78)30-34 2.02 (1.80 -2.27) 2.88 (2.50 - 3.32) 2.25 (1.94 - 2.60)35-39 2.32 (2.07 - 2.61) 3.19 (2.75 - 3.69) 2.33 (2.00 - 2.71)40-44 1.89 (1.67 - 2.14) 3.17 (2.71 - 3.70) 1.90 (1.63 - 2.22)138

45-49 1.43 (1.24 - 1.64) 2.44 (2.10 - 2.84) 1.58 (1.35 - 1.86)Parity0 1.00 1.00 1.001 2.49 (2.16 - 2.86) 2.30 (1.96 - 2.71) 2.52 (2.20 - 2.88)2 2.97 (2.55 - 3.46) 3.74 (3.18 - 4.41) 5.17 (4.49 -5.94)3 4.01 (3.48 - 4.61) 4.43 (3.70 - 5.29) 6.08 (5.25 - 7.05)4+ 3.11 (2.69 - 3.61) 2.98 (2.47 - 3.60) 4.24 (3.63 - 4.96)# of liv<strong>in</strong>g sons0 1.00 1.00 1.001 1.22 (1.12 - 1.33) 1.34 (1.25 -1.44) 1.45 (1.35 - 1.55)2+ 1.76 (1.62 - 1.91) 1.85 (1.72 - 1.99) 2.13 (1.97 - 2.29)# of child deaths0 1.00 1.00 1.001 0.82 (0.77 - 0.87) 0.88 (0.83 - 0.94) 0.80 (0.75 - 0.85)2+ 0.62 (0.58 - 0.67) 0.66 (0.61 - 0.71) 0.61 (0.56 - 0.67)Deesire of childbear<strong>in</strong>gWith<strong>in</strong> two years 1.00 1.00 1.00After two years 1.51 (1.38 - 1.65) 2.17 (1.94 - 2.44) 3.14 (2.82 -3.51)Unsure of tim<strong>in</strong>g/ 0.68 (0.55 - 0.84) 0.86 (0.71 - 1.05) 0.80 (0.66 - 0.97)undecidedWants no more 10.88 (9.94 - 11.90) 10.51 (9.42 - 11.73) 6.66 (6.02 - 7.37)a. In <strong>the</strong> 1992/93 <strong>and</strong> 1998/99 surveys, <strong>the</strong> variable used was <strong>the</strong> presence of mo<strong>the</strong>r-<strong>in</strong>-law, presumably at <strong>the</strong> time of <strong>the</strong> survey.Nuclear represents no presence, <strong>and</strong> non-nuclear represents presence of mo<strong>the</strong>r-<strong>in</strong>-law.b. In <strong>the</strong> 2005/06 survey, <strong>the</strong> variable represents whe<strong>the</strong>r respondents were visited by an ANM, LHV, Anganwadi, or communityhealth worker <strong>in</strong> <strong>the</strong> past three months. In <strong>the</strong> 1998/99 survey, respondents reported if <strong>the</strong>y were visited by a family plann<strong>in</strong>g(FP) worker <strong>in</strong> last 12 months.ratios <strong>in</strong>creased from 1992/93 to 1998/99 to 2005/06for parity <strong>and</strong> number of liv<strong>in</strong>g sons. Women with twoor more liv<strong>in</strong>g sons <strong>in</strong> 1992/93 were 1.76 times (95%CI:1.62 – 1.91) more likely to use a contraceptive methodcompared with women without any liv<strong>in</strong>g sons (see Table6). The odds of us<strong>in</strong>g contraceptive methods among womenwith two or more liv<strong>in</strong>g sons <strong>in</strong>creased to 1.85 (95%CI:1.72 – 1.99) <strong>in</strong> 1998/99 <strong>and</strong> 2.13 (95%CI: 1.97-2.29) <strong>in</strong>2005/06. This means that women with two or more liv<strong>in</strong>gsons were 85 per cent more likely to use contraception <strong>in</strong>1998/99 <strong>and</strong> more than twice as likely to do so <strong>in</strong> 2005/06when compared with women with no liv<strong>in</strong>g sons.About 78 per cent of women <strong>in</strong> 2005/06 experienced nochild death 4 , 15 per cent experienced <strong>the</strong> death of onechild <strong>and</strong> <strong>the</strong> rema<strong>in</strong><strong>in</strong>g 7 per cent experienced <strong>the</strong> deathof 2 or more children (see Table 4). The situation relatedto child death improved between 1992/93 <strong>and</strong> 2005/06(Table 4). As expected it was significantly less likely that awoman would use a contraceptive method if one or moreof her children died. Women with one child death wereabout 20 per cent less likely to use contraception <strong>and</strong> thosewith 2 or more child deaths were 40 per cent less likelyto use contraception as compared with those without anychild death. The odds ratios reflect<strong>in</strong>g <strong>the</strong> effect of childdeath on contraceptive use rema<strong>in</strong>ed relatively constantacross <strong>the</strong> three survey years (Table 6).In terms of fertility desire, women who desired to haveano<strong>the</strong>r child after two years were significantly morelikely to use contraception as compared with those whodesired to have ano<strong>the</strong>r child with<strong>in</strong> two years. The oddsratio among women who desired ano<strong>the</strong>r birth after twoyears, however, <strong>in</strong>creased from 1.51 (95%CI: 1.38-1.65)<strong>in</strong> 1992/93 to 3.14 (95%CI: 2.82 – 3.51) <strong>in</strong> 2005/06,<strong>in</strong>dicat<strong>in</strong>g an <strong>in</strong>crease <strong>in</strong> <strong>the</strong> use of contraception forspac<strong>in</strong>g over time. Women who were undecided or wereunsure of tim<strong>in</strong>g were less likely to use contraception <strong>and</strong>those who wanted no more children 5 were more likely touse contraception.Education of womenThe education of women improved over <strong>the</strong> three roundsof surveys: about 61 per cent of women had no education<strong>in</strong> 1992/93, <strong>and</strong> that number decl<strong>in</strong>ed to 47 per cent<strong>in</strong> 2005/06. About 15 per cent of women surveyed <strong>in</strong>2005/06 had some primary-level education, 31 percent had some secondary-level education <strong>and</strong> about 6139

FigureFigure3Contraceptive prevalence <strong>in</strong> states <strong>in</strong> India: 1992/93 to 2005/06per cent had higher education (Table 4). Contraceptiveuse <strong>in</strong>creased with <strong>in</strong>creas<strong>in</strong>g education. The effect ofeducation on contraceptive use, however, decreasedbetween 1992/92 <strong>and</strong> 2005/06. This is shown by adecrease over time <strong>in</strong> <strong>the</strong> odds ratios of contraceptive usefor all education levels compared with no education (Table6). Among more highly educated women <strong>the</strong> odds ratiosdecreased from 2.37 (95%CI: 1.97 - 2.86) <strong>in</strong> 1992/93to1.62 (95%CI: 1.42-1.82) <strong>in</strong> 2005/06. This decreaserepresents a strik<strong>in</strong>g <strong>in</strong>crease <strong>in</strong> contraceptive use amongwomen with no education, from 34 per cent <strong>in</strong> 1992/93to 52 per cent <strong>in</strong> 2005/06 (see Table 5). Fur<strong>the</strong>rmore, <strong>the</strong>proportion us<strong>in</strong>g sterilization among all users decreasedacross education groups over time, <strong>in</strong>dicat<strong>in</strong>g <strong>the</strong> spread ofspac<strong>in</strong>g methods. The use of sterilization among womenwith higher education was already low <strong>in</strong> 1992/93 <strong>and</strong>rema<strong>in</strong>ed about <strong>the</strong> same <strong>in</strong> 2005/06 (28.7% <strong>in</strong> 1992/93<strong>and</strong> 30.5% <strong>in</strong> 2005/06).EconomicTwo variables – employment 6 <strong>and</strong> wealth qu<strong>in</strong>tiles –were used to capture <strong>the</strong> <strong>in</strong>fluence of economic factorson contraceptive use. About 57 per cent of <strong>the</strong> womensurveyed <strong>in</strong> 2005/06 were not employed dur<strong>in</strong>g <strong>the</strong> 12months prior to <strong>the</strong> survey, 15 per cent were employed butreceived compensation <strong>in</strong> k<strong>in</strong>d <strong>and</strong> <strong>the</strong> rema<strong>in</strong><strong>in</strong>g 28 percent received compensation <strong>in</strong> cash for <strong>the</strong>ir employment.In comparison, only 12 per cent of women surveyed <strong>in</strong>1992/93 were employed dur<strong>in</strong>g <strong>the</strong> 12 months prior to <strong>the</strong>survey <strong>and</strong> received compensation <strong>in</strong> cash (see Table 4).Employed women who received cash were significantlymore likely to use contraception while unemployedwomen were significantly less likely to use contraception ascompared with those who were employed but paid <strong>in</strong> k<strong>in</strong>d.The difference between unemployed <strong>and</strong> those employedbut paid <strong>in</strong> k<strong>in</strong>d decreased over time but <strong>the</strong> effect of cashemployment on contraceptive use <strong>in</strong>creased. As shown <strong>in</strong>Table 6, <strong>the</strong> odds ratio for those employed <strong>and</strong> paid <strong>in</strong> cash<strong>in</strong>creased from 1.24 (95%CI: 1.14 – 1.35) <strong>in</strong> 1992/93to 1.45 (95%CI: 1.34 – 1.57) <strong>in</strong> 2005/06; <strong>and</strong> <strong>the</strong> oddsratios for those who were unemployed <strong>in</strong>creased from0.74 (95%CI: 0.69 – 0.80) to 0.91 (95%CI: 0.84 – 0.98).By 2005/06, 64 per cent of employed women work<strong>in</strong>gfor cash were us<strong>in</strong>g contraception compared with 54 percent of unemployed women <strong>and</strong> 53 per cent of employedwomen paid <strong>in</strong> k<strong>in</strong>d (Table 5).While <strong>the</strong> use of contraception among women from <strong>the</strong>lowest wealth qu<strong>in</strong>tile rose from 28 per cent <strong>in</strong> 1992/93 to42 per cent <strong>in</strong> 2005/06, wealth <strong>in</strong>equalities <strong>in</strong> contraceptiveuse persisted (Table 5). The use of contraception <strong>in</strong>creasedwith household wealth qu<strong>in</strong>tiles <strong>in</strong> all three years. Women<strong>in</strong> <strong>the</strong> highest wealth qu<strong>in</strong>tile were twice as likely to usecontraception as women <strong>in</strong> <strong>the</strong> lowest wealth qu<strong>in</strong>tile. Theodds ratio among <strong>the</strong> highest wealth qu<strong>in</strong>tile was 1.99(95%CI: 1.78-2.24) <strong>in</strong> 2005/06. The effect of wealth oncontraceptive use rema<strong>in</strong>ed relatively constant over time.Media exposureExposure to television, newspapers <strong>and</strong> radio was usedto show <strong>the</strong> effect of mass media on contraceptive use.The use of contraception among women exposed totelevision or newspapers was higher than among those notexposed to <strong>the</strong>se channels of communication. The odds140

of contraceptive use <strong>in</strong> 2005/06 among those exposedto television was 1.39 (95%CI: 1.32 – 1.47) <strong>and</strong> amongthose exposed to newspapers was 1.14 (95%CI: 1.05-1.23) <strong>in</strong> comparison to those not exposed to television ornewspapers (see Table 6). The effect of newspapers <strong>in</strong> partreflected <strong>the</strong> effect of education, while television is probablyeffective <strong>in</strong> all segments of <strong>the</strong> society. Exposure to radiodid not seem to have a significant effect on contraceptiveuse.O<strong>the</strong>r variables of <strong>in</strong>terestWhile <strong>the</strong> use of contraception <strong>in</strong> rural areas <strong>in</strong>creasedfrom 37 per cent <strong>in</strong> 1992/93 to 53 per cent <strong>in</strong> 2005/06,rural women rema<strong>in</strong>ed less likely to use contraception thanurban women <strong>in</strong> all three years. However, this differencecould be expla<strong>in</strong>ed by <strong>the</strong> difference <strong>in</strong> <strong>the</strong>ir o<strong>the</strong>rcharacteristics. This is shown by <strong>the</strong> fact that <strong>the</strong> oddsratio is nei<strong>the</strong>r statistically significant <strong>in</strong> 1998/99 (0.98;95%CI: 0.91-1.05) nor <strong>in</strong> 2005/06 (1.00; 95%CI: 0.93-1.08).Women who lived <strong>in</strong> non-nuclear households wereless likely to use contraception than those who lived <strong>in</strong>nuclear households. However, <strong>the</strong> odds ratios were notstatistically significant. While women who were contactedby a family plann<strong>in</strong>g worker <strong>in</strong> 1998/99 were more likelyto use contraception, <strong>the</strong> odds ratio was not statisticallysignificant. In 2005/06, women who were contacted by ahealth worker were less likely to use contraception thanthose who were not <strong>and</strong> <strong>the</strong> odds ratio was also significant.This contact, however, reflected contact for any healthproblem, <strong>in</strong>clud<strong>in</strong>g <strong>the</strong> health of children.Regional differences <strong>in</strong> contraceptiveuseAs mentioned previously, while <strong>the</strong> guidel<strong>in</strong>es for<strong>the</strong> services were uniform across states, <strong>the</strong> actualimplementation varied among states because of differences<strong>in</strong> <strong>the</strong> availability of human resources, as well as issuesrelated to governance. These differences <strong>in</strong> serviceenvironments along with <strong>the</strong> differences <strong>in</strong> <strong>the</strong> socialsett<strong>in</strong>gs of states are manifested <strong>in</strong> state-level variations <strong>in</strong>contraceptive prevalence. For example, <strong>the</strong> percentage ofcouples protected by contraception <strong>in</strong> 1972/73 varied from7 per cent among states with a poor social sett<strong>in</strong>g <strong>and</strong> weakprogramme effort to 21 per cent among states with a goodsocial sett<strong>in</strong>g <strong>and</strong> strong programme effort (Freedman <strong>and</strong>Berelson, 1976). These state-level differences cont<strong>in</strong>uetoday.Contraceptive use <strong>in</strong> 1992/93 varied from about 20 percent <strong>in</strong> Uttar Pradesh to 63 per cent <strong>in</strong> Kerala, <strong>and</strong> from 34per cent <strong>in</strong> Bihar to 71 per cent <strong>in</strong> West Bengal <strong>in</strong> 2005/06(for changes <strong>in</strong> contraceptive use among states over time,see Figure 3). In 1992/93, only one state had contraceptiveuse greater than 60 per cent; by 2005/06, this number<strong>in</strong>creased to 12 large <strong>and</strong> small states. Four of <strong>the</strong> largeH<strong>in</strong>di-speak<strong>in</strong>g states <strong>in</strong> <strong>the</strong> nor<strong>the</strong>rn part of <strong>the</strong> countrycont<strong>in</strong>ued to have lower use of contraception than states<strong>in</strong> <strong>the</strong> sou<strong>the</strong>rn part <strong>and</strong> many o<strong>the</strong>r large states. To study<strong>the</strong>se variations fur<strong>the</strong>r, we divided 29 Indian states <strong>in</strong>tofour regions: north 7 , south 8 , o<strong>the</strong>r large states 9 <strong>and</strong> smallstates10. These groups consisted of about 40.8 per cent,21.8 per cent, 33.7 per cent, <strong>and</strong> 3.7 per cent, respectively,of <strong>the</strong> weighted sample of women <strong>in</strong> 2005/06 (see Table4).The contraceptive gap between nor<strong>the</strong>rn <strong>and</strong> sou<strong>the</strong>rnstates narrowed between 1992/93 <strong>and</strong> 2005/06. Amongnor<strong>the</strong>rn states CPR <strong>in</strong>creased by approximately 18percentage po<strong>in</strong>ts, from 26 per cent <strong>in</strong> 1992/933 to 44 percent <strong>in</strong> 2005/06 (see Table 5). A similar <strong>in</strong>crease of about14 percentage po<strong>in</strong>ts dur<strong>in</strong>g this period was observed <strong>in</strong><strong>the</strong> sou<strong>the</strong>rn states. Interest<strong>in</strong>gly among all contraceptiveusers <strong>the</strong> percentage sterilized decreased <strong>in</strong> <strong>the</strong> nor<strong>the</strong>rnstates but <strong>in</strong>creased <strong>in</strong> <strong>the</strong> sou<strong>the</strong>rn states over <strong>the</strong> threesurveys, <strong>in</strong>dicat<strong>in</strong>g <strong>the</strong> use of more permanent methods <strong>in</strong><strong>the</strong> south <strong>and</strong> more spac<strong>in</strong>g methods <strong>in</strong> <strong>the</strong> north (Table5).Table 7 presents <strong>the</strong> crude <strong>and</strong> adjusted odds ratios ofcontraceptive use by region. The odds of contraceptive useamong women <strong>in</strong> o<strong>the</strong>r large states were not significantlydifferent than among those liv<strong>in</strong>g <strong>in</strong> <strong>the</strong> sou<strong>the</strong>rn states.The odds of contraceptive use among women <strong>in</strong> small stateswere slightly lower than among women <strong>in</strong> sou<strong>the</strong>rn states.The odds of contraceptive use among women <strong>in</strong> nor<strong>the</strong>rnstates were lowest among all regions <strong>in</strong> all survey years.However, <strong>the</strong> gap between <strong>the</strong> nor<strong>the</strong>rn <strong>and</strong> sou<strong>the</strong>rnstates narrowed over time. This is <strong>in</strong>dicated by an <strong>in</strong>crease<strong>in</strong> <strong>the</strong> crude odds ratio for <strong>the</strong> north region from 0.332(95%CI: 0.310 – 0.355) <strong>in</strong> 1992/93 to 0.425 (95%CI:0.396 – 0.455) <strong>in</strong> 2005/06. Interest<strong>in</strong>gly <strong>the</strong> odds ratio for<strong>the</strong> north region <strong>in</strong> 2005/06 decreased slightly from 0.425(95%CI: 0.396 – 0.455) to 0.406 (95%CI: 0.373 – 0.442)after adjust<strong>in</strong>g for each respondent’s demographic, social<strong>and</strong> economic characteristics. While <strong>the</strong> difference between<strong>the</strong> crude <strong>and</strong> adjusted odds ratio was not significantstatistically, this unexpected result could <strong>in</strong>dicate thatwomen <strong>in</strong> nor<strong>the</strong>rn states have made greater progress <strong>in</strong>terms of contraceptive use than what would be expectedon <strong>the</strong> basis of <strong>the</strong>ir characteristics. This programme <strong>and</strong>occurred despite stronger son preference <strong>in</strong> <strong>the</strong> northcompared with <strong>the</strong> south.To assess which demographic, social <strong>and</strong> economiccovariates are contribut<strong>in</strong>g to this unexpected phenomenon,separate logistic models were run for <strong>the</strong> north <strong>and</strong> southregions. Table 8 presents <strong>the</strong> odds ratios separately for141

TableTable7Adjusted <strong>and</strong> crude odds ratios for contraceptive use, by region <strong>in</strong> India: 1992/93–2005/06Region 1992/93 1998/99 2005/06OR 95% CI OR 95% CI OR 95% CISouth 1.00 1.00 1.00CrudeNorth 0.332 (0.310 - 0.355) 0.343 (0.322 - 0.366) 0.425 (0.396 - 0.455)Large 1.022 (0.956 - 1.093) 1.082 (1.015 - 1.152) 0.990 (0.924 - 1.060)Small 0.988 (0.923 - 1.056) 0.884 (0.825 - 0.947) 0.765 (0.712 - 0.822)South 1.00 1.00 1.00AdjustedaNorth 0.403 (0.373 - 0.435) 0.323 (0.300 - 0.349) 0.406 (0.373 - 0.442)Large 1.040 (0.961 - 1.125) 1.080 (0.994 - 1.174) 0.984 (0.901 - 1.075)Small 0.769 (0.703 - 0.841) 0.582 (0.537 - 0.631) 0.528 (0.480 - 0.581)a. Adjusted for <strong>the</strong> demographic, social <strong>and</strong> economic characteristics <strong>in</strong>cluded <strong>in</strong> Table 6.TableTable8Adjusted odds ratios for contraceptive use, by characteristics for north <strong>and</strong> south regions <strong>in</strong> India:2005/06NorthSouthOR 95% CI OR 95% CIEducationNone 1.00 1.00Primary 1.32 (1.18 - 1.48) 0.83 (0.71 - 0.97)Secondary 1.44 (1.27 - 1.62) 0.92 (0.78 - 1.07)Higher 1.80 (1.40 - 2.32) 1.42 (1.04 - 1.95)Wealth <strong>in</strong>dexLowest 1.00 1.00Second 1.28 (1.15 - 1.43) 1.80 (1.45 - 2.25)Middle 1.39 (1.22 - 1.58) 1.93 (1.53 - 2.43)Fourth 1.70 (1.47 - 1.97) 2.73 (2.14 - 3.49)Highest 2.23 (1.85 - 2.70) 3.04 (2.27 - 4.07)Employment statusEmployed (<strong>in</strong> k<strong>in</strong>d) 1.00 1.00Employed (cash) 1.20 (1.07 - 1.35) 1.20 (0.95 - 1.51)Unemployed 0.84 (0.75 - 0.93) 0.84 (0.67 - 1.05)Household structureNon-nuclear 1.07 (1.00 - 1.16) 0.88 (0.78 - 0.99)Nuclear 1.00 1.00RadioNo 1.00 1.00Yes 1.10 (1.00 - 1.21) 0.79 (0.69 - 0.90)TelevisionNo 1.00 1.00Yes 1.56 (1.42 - 1.72) 1.06 (0.93 - 1.20)142

NewspaperNo 1.00 1.00Yes 1.15 (1.00 -1.34) 1.30 (1.08 - 1.56)Contact with Health/FP workerNo 1.00 1.00Yes 0.68 (0.61 - 0.74) 0.73 (0.63 - 0.84)ResidenceRural 1.00 1.00Urban 1.30 (1.14 - 1.48) 0.78 (0.65 - 0.94)ReligionMuslim 0.42 (0.36 - 0.49) 0.53 (0.42 - 0.67)H<strong>in</strong>du 1.00 1.00Sikh 1.63 (1.10 - 2.42) -Ja<strong>in</strong> 1.14 (0.65 - 2.00) 0.74 (0.19 - 2.97)Christian 0.45 (0.27 - 0.72) 1.03 (0.76 - 1.40)O<strong>the</strong>r 0.34 (0.22 - 0.53) 1.17 (0.21 - 6.40)EthnicityScheduled Caste 1.00 1.00Scheduled Tribe 1.24 (1.03 - 1.50) 1.23 (0.86 - 1.75)O<strong>the</strong>r Backward Class 1.17 (1.04 - 1.31) 1.06 (0.88 - 1.28)O<strong>the</strong>r 1.12 (0.98 - 1.29) 1.70 (1.36 - 2.12)Age15-19 1.00 1.0020-24 1.05 (0.84 - 1.30) 2.10 (1.36 - 3.22)25-29 1.49 (1.19 - 1.87) 2.85 (1.84 - 4.43)30-34 2.48 (1.96 - 3.15) 3.14 (2.01 - 4.89)35-39 2.38 (1.86 - 3.04) 2.61 (1.67 - 4.08)40-44 1.96 (1.52 - 2.53) 1.87 (1.18 - 2.96)45-49 1.83 (1.41 - 2.38) 1.63 (1.03 - 2.58)Parity0 1.00 1.001 1.73 (1.34 - 2.23) 4.12 (2.74 - 6.19)2 2.55 (1.97 - 3.31) 24.14 (15.85 - 36.75)3 3.24 (2.48 - 4.24) 35.21 (22.30 - 55.59)4+ 2.65 (2.00 - 3.50) 27.76 (17.34 - 44.45)# of liv<strong>in</strong>g sons0 1.00 1.001 1.83 (1.59 - 2.10) 1.34 (1.16 - 1.54)2+ 3.50 (3.03 - 4.05) 1.59 (1.36 - 1.87)# of child deaths0 1.00 1.001 0.86 (0.78 - 0.94) 0.78 (0.65 - 0.93)2+ 0.70 (0.62 - 0.79) 0.62 (0.45 - 0.83)Desire for childbear<strong>in</strong>gWith<strong>in</strong> two years 1.00 1.00After two years 3.27 (2.68 - 3.99) 4.92 (3.72 - 6.50)Unsure of tim<strong>in</strong>g /undecided 0.46 (0.30 - 0.73) 1.63 (1.02 - 2.60)Wants no more /sterilized 5.40 (4.50 - 6.48) 21.12 (16.48 - 27.08)143

<strong>the</strong> north <strong>and</strong> <strong>the</strong> south regions. Several characteristicscont<strong>in</strong>ue to have a strong <strong>in</strong>fluence on contraceptive use <strong>in</strong><strong>the</strong> north, whereas <strong>the</strong>ir effect <strong>in</strong> <strong>the</strong> south has weakened.For example, <strong>the</strong> odds ratio <strong>in</strong> <strong>the</strong> north <strong>in</strong>creased wi<strong>the</strong>ducation, whereas <strong>the</strong> differences <strong>in</strong> odds ratios amongwomen with no education, primary- or secondary-leveleducation <strong>in</strong> <strong>the</strong> south disappeared. Similarly, <strong>the</strong> effect of<strong>the</strong> number of liv<strong>in</strong>g sons <strong>in</strong> <strong>the</strong> south was much weakerthan <strong>in</strong> <strong>the</strong> north. The odds ratio among women with twoor more liv<strong>in</strong>g sons <strong>in</strong> <strong>the</strong> north was 3.50 (95%CI: 3.03 –4.05) <strong>in</strong> comparison with 1.59 (95%CI: 1.36 – 1.87) <strong>in</strong> <strong>the</strong>south. Urban women <strong>in</strong> <strong>the</strong> north were 30 per cent morelikely to use contraception than rural women, whereasurban women <strong>in</strong> <strong>the</strong> south were 22 per cent less likely touse contraception than rural women.Table 9 shows <strong>the</strong> odds ratio for <strong>the</strong> north compared with<strong>the</strong> south adjusted for various comb<strong>in</strong>ations of respondentcharacteristics <strong>in</strong> 2005/06 <strong>and</strong> 1992/93. Adjust<strong>in</strong>g foreducation only <strong>in</strong> 2005/06 <strong>in</strong>creased <strong>the</strong> odds ratio<strong>in</strong> <strong>the</strong> north from 0.425 to 0.438. This means that, ifwomen <strong>in</strong> <strong>the</strong> north had <strong>the</strong> same education as women <strong>in</strong><strong>the</strong> south, <strong>the</strong> gap <strong>in</strong> contraceptive use between <strong>the</strong> tworegions would decrease. After adjust<strong>in</strong>g for education,employment, residence <strong>and</strong> household wealth, <strong>the</strong> oddsratio for <strong>the</strong> north <strong>in</strong> 2005/06 fur<strong>the</strong>r <strong>in</strong>creased to 0.517.A comparable <strong>in</strong>crease was also observed for 1992/93.This <strong>in</strong>dicates that <strong>the</strong> contraceptive use gap between <strong>the</strong>two regions would decrease fur<strong>the</strong>r if women <strong>in</strong> <strong>the</strong> north<strong>and</strong> south had similar education, employment, residence<strong>and</strong> wealth distributions.In comparison, when adjust<strong>in</strong>g for only <strong>the</strong> number ofliv<strong>in</strong>g sons, <strong>the</strong> odds ratio for <strong>the</strong> north decreased from0.425 to 0.291 <strong>in</strong> 2005/06. This is not a new phenomenon.Adjustment for number of liv<strong>in</strong>g sons <strong>in</strong> 1992/93 decreased<strong>the</strong> odds ratio for <strong>the</strong> north from 0.332 to 0.247. Thismeans that, if women <strong>in</strong> <strong>the</strong> north have <strong>the</strong> same numberof liv<strong>in</strong>g sons as those <strong>in</strong> <strong>the</strong> south, <strong>the</strong> gap <strong>in</strong> contraceptiveuse between <strong>the</strong> two regions would become even wider.This happens because women <strong>in</strong> <strong>the</strong> south have a muchhigher contraceptive prevalence rate than those <strong>in</strong> <strong>the</strong> northfor each category of number of liv<strong>in</strong>g sons. Contraceptiveuse <strong>in</strong> <strong>the</strong> south <strong>in</strong>creases from 36 per cent among womenwith no son to 72 per cent among women with one sonto 85 per cent among women with two or more sons (seeTable 10). The comparative figures for women <strong>in</strong> <strong>the</strong> northare 13 per cent among women with no son, 44 per centamong those with one son <strong>and</strong> 61 per cent among womenwith two or more sons.The decrease between <strong>the</strong> crude odds ratio of 0.425 <strong>and</strong>adjusted odds ratio of 0.406 appears to be due to <strong>the</strong>adjustment made for <strong>the</strong> number of liv<strong>in</strong>g sons. Thismeans that women <strong>in</strong> <strong>the</strong> north have higher contraceptiveuse than would be expected on <strong>the</strong> basis of <strong>the</strong> stronger sonpreference <strong>in</strong> <strong>the</strong>se states. This could certa<strong>in</strong>ly be <strong>the</strong> effectof <strong>the</strong> family plann<strong>in</strong>g programme <strong>in</strong> <strong>the</strong>se states becausean adjustment for o<strong>the</strong>r factors would have decreased <strong>the</strong>gap between <strong>the</strong> north <strong>and</strong> <strong>the</strong> south 11 .In brief, <strong>the</strong> gap <strong>in</strong> contraceptive use between <strong>the</strong> north <strong>and</strong><strong>the</strong> south has decreased over <strong>the</strong> years. It would fur<strong>the</strong>rdecrease with improvements <strong>in</strong> such factors as education<strong>and</strong> employment of women. However, <strong>the</strong> progress couldbe hampered by a stronger son preference <strong>in</strong> <strong>the</strong> norththan <strong>in</strong> <strong>the</strong> south.Fertility decl<strong>in</strong>e <strong>in</strong> IndiaPrior to 1971 India’s total fertility rate (TFR) rema<strong>in</strong>edconstant at a high level. The Panel on India constitutedby <strong>the</strong> Committee on Population <strong>and</strong> Demography of <strong>the</strong>United States National Research <strong>Council</strong> estimated TFRat 5.7 births per woman dur<strong>in</strong>g <strong>the</strong> period 1961-1971 <strong>and</strong>at 5.6 dur<strong>in</strong>g <strong>the</strong> period 1970-1972 (Bhat et al., 1984).S<strong>in</strong>ce <strong>the</strong>n TFR decl<strong>in</strong>ed to 2.7 births: by about 2 birthsbetween 1971 <strong>and</strong> 1991 <strong>and</strong> by ano<strong>the</strong>r 0.7 births between1991 <strong>and</strong> 2004. The year 1997 provides a convenientreference po<strong>in</strong>t for assess<strong>in</strong>g <strong>the</strong> pace of fertility decl<strong>in</strong>es<strong>in</strong>ce it marks <strong>the</strong> elim<strong>in</strong>ation of method-specific targets<strong>and</strong> a shift to a broader reproductive health approach. Theaverage annual decl<strong>in</strong>e per year is estimated to be 1.92 percent with <strong>the</strong> target system (dur<strong>in</strong>g <strong>the</strong> period 1971-1997)<strong>in</strong> comparison with 0.50 per cent after <strong>the</strong> elim<strong>in</strong>ation of<strong>the</strong> target system (dur<strong>in</strong>g <strong>the</strong> period 1997-2004). NFHSdata would thus suggest a slowdown <strong>in</strong> fertility decl<strong>in</strong>eafter <strong>the</strong> elim<strong>in</strong>ation of <strong>the</strong> target system. However, TFRestimates from NFHS-2 may be less accurate than TFRestimates from NFHS-1 <strong>and</strong> NFHS-3 because CPR<strong>in</strong>creased by <strong>the</strong> same amount (about 6 percentage po<strong>in</strong>ts)between <strong>the</strong> first two rounds <strong>and</strong> between <strong>the</strong> second <strong>and</strong>third rounds of NFHS (Table 5).The percentage decl<strong>in</strong>e <strong>in</strong> TFR for major states <strong>and</strong>different periods is shown <strong>in</strong> Table 11. S<strong>in</strong>ce 1971, fertilitydecl<strong>in</strong>ed <strong>in</strong> all major states, which reflects <strong>the</strong> importanceof India’s family plann<strong>in</strong>g programme. Fertility decl<strong>in</strong>ed byat least 55 per cent <strong>in</strong> 11 states. Even <strong>in</strong> <strong>the</strong> nor<strong>the</strong>rn states<strong>the</strong> decl<strong>in</strong>e ranged from 34 per cent <strong>in</strong> Bihar to 41 per cent<strong>in</strong> Uttar Pradesh to 50 per cent <strong>in</strong> Madhya Pradesh <strong>and</strong>Rajasthan.Between 1971 <strong>and</strong> 1991, fertility decl<strong>in</strong>e ranged from 25per cent <strong>in</strong> Uttar Pradesh to 56 per cent <strong>in</strong> Kerala. Between1991 <strong>and</strong> 2004, TFR cont<strong>in</strong>ued to decl<strong>in</strong>e <strong>in</strong> all states; <strong>the</strong>percentage decl<strong>in</strong>e <strong>in</strong> TFR dur<strong>in</strong>g <strong>the</strong> period 1991-2004ranged from 4 per cent <strong>in</strong> Kerala <strong>and</strong> 5 per cent <strong>in</strong> Bihar to32 per cent <strong>in</strong> Haryana <strong>and</strong> Punjab. Moreover, TFR dur<strong>in</strong>gthis period decl<strong>in</strong>ed by at least 20 percentage po<strong>in</strong>ts <strong>in</strong> 10of <strong>the</strong> 15 states (see Table 11).144

TableTableAdjusted odds ratios for contraceptive use <strong>in</strong> north as compared with south after controll<strong>in</strong>g for9various characteristics <strong>in</strong> India: 1992/93 <strong>and</strong> 2005/06North compared with southCovariates2005/06 1992/93OR 95% CI OR 95% CIRegion: Crude 0.425 (0.396 - 0.455) 0.332 (0.310 - 0..355)Adjusted AOR AOREducation 0.438 (0.409 - 0.469) 0.374 (0.351 - 0.399)Education + Employment 0.465 (0.434 - 0.499) 0.408 (0.382 - 0.435)Education + Employment + Residence 0.476 (0.443 - 0.511) 0.416 (0.390 - 0.445)Education + Employment + Residence +Wealth0.517 (0.482 - 0.554) 0.449 (0.421 - 0.479)Parity 0.331 (0.305 - 0.359) 0.267 (0.247 - 0.289)# of liv<strong>in</strong>g sons 0.291 (0.268 - 0.315) 0.247 (0.229 - 0.267)# of child deaths 0.417 (0.389 - 0.447) 0.329 (0.307 - 0.352)The tim<strong>in</strong>g <strong>and</strong> pace of fertility decl<strong>in</strong>e varied acrossstates, suggest<strong>in</strong>g <strong>the</strong> importance of state-specific socialsett<strong>in</strong>gs. Fertility decl<strong>in</strong>e started earlier <strong>and</strong> decl<strong>in</strong>ed faster<strong>in</strong> sou<strong>the</strong>rn states that <strong>in</strong>vested <strong>in</strong> health <strong>and</strong> education.In nor<strong>the</strong>rn states that did not <strong>in</strong>vest adequately <strong>in</strong> health<strong>and</strong> education, fertility decl<strong>in</strong>ed later <strong>and</strong> at a slower pace.TFR <strong>in</strong> Kerala <strong>and</strong> Tamil Nadu had already decl<strong>in</strong>ed to4.7 by 1966, even before <strong>the</strong> reorganization of <strong>the</strong> familyplann<strong>in</strong>g programme, <strong>and</strong> reached <strong>the</strong> replacement level by1991 <strong>in</strong> Kerala <strong>and</strong> by 1997 <strong>in</strong> Tamil Nadu.The importance of social sett<strong>in</strong>g for fertility differentialsobserved <strong>in</strong> 2004 is illustrated by a classification of 15major states accord<strong>in</strong>g to <strong>the</strong>ir levels of <strong>in</strong>fant mortality <strong>and</strong>female education. When this is done by us<strong>in</strong>g data fromNFHS-3, we f<strong>in</strong>d that most of <strong>the</strong> states fall on a diagonal(see Table 12). States with a poorer social sett<strong>in</strong>g, i.e., withhigh <strong>in</strong>fant mortality <strong>and</strong> low female education, also havehigh fertility. This group <strong>in</strong>cludes Bihar, Rajasthan, MadhyaPradesh <strong>and</strong> Uttar Pradesh. At <strong>the</strong> o<strong>the</strong>r extreme areKerala <strong>and</strong> Tamil Nadu with TFRs of less than two births.These states also have a good social sett<strong>in</strong>g, i.e., low <strong>in</strong>fantmortality <strong>and</strong> high female education. The rema<strong>in</strong><strong>in</strong>g n<strong>in</strong>emajor states fall <strong>in</strong> between <strong>the</strong>se two extremes. There are afew exceptions. The states of Andhra Pradesh, Karnataka,Maharashtra <strong>and</strong> Punjab have achieved replacement-levelfertility at a slightly higher level of <strong>in</strong>fant mortality or aslightly lower level of female education. However, <strong>the</strong>re isno state with a good social sett<strong>in</strong>g <strong>and</strong> high fertility (for asimilar analysis of <strong>the</strong> NFHS-1 data, see Ja<strong>in</strong>, 1998c).Demographers have been <strong>in</strong>terested for quite a longtime <strong>in</strong> expla<strong>in</strong><strong>in</strong>g <strong>the</strong>se regional differences between <strong>the</strong>north <strong>and</strong> south. Dyson <strong>and</strong> Moore (1983) attributed <strong>the</strong>differences <strong>in</strong> demographic behaviour between <strong>the</strong> north<strong>and</strong> south to differences <strong>in</strong> <strong>the</strong> k<strong>in</strong>ship structure 12 <strong>and</strong>lower female autonomy <strong>in</strong> <strong>the</strong> north. Satia <strong>and</strong> Jejeebhoy(1991) attributed high fertility <strong>and</strong> low contraceptive use<strong>in</strong> <strong>the</strong> north to lower female education, lower economicopportunities for women, higher child mortality <strong>and</strong>deficiencies (limited availability <strong>and</strong> poor quality) <strong>in</strong> <strong>the</strong>implementation of <strong>the</strong> family plann<strong>in</strong>g programme. Earlyfertility transition <strong>in</strong> Kerala is attributed to more equitableachievement <strong>in</strong> female education <strong>and</strong> health or socialdevelopment (for additional policy <strong>in</strong>formation, see Nag,1984 <strong>and</strong> Krishnan, 1998). While fertility decl<strong>in</strong>e <strong>in</strong> TamilNadu is attributed to <strong>the</strong> social reform movement of powertransfer to lower caste <strong>in</strong>dividuals <strong>in</strong> <strong>the</strong> 1920s <strong>and</strong> 1930s,<strong>the</strong> movement itself is attributed to <strong>in</strong>creas<strong>in</strong>g literacy <strong>in</strong><strong>the</strong> state (Bhat, 1998). The family plann<strong>in</strong>g programmescerta<strong>in</strong>ly contributed to <strong>the</strong> acceleration of fertility decl<strong>in</strong>eafter reorganization of <strong>the</strong> programme <strong>in</strong> 1966.The experience of fertility decl<strong>in</strong>e <strong>in</strong> India po<strong>in</strong>ts to <strong>the</strong>synergistic effect of social development <strong>and</strong> <strong>the</strong> familyplann<strong>in</strong>g programme. Social development contributed tofertility decl<strong>in</strong>e by creat<strong>in</strong>g a desire for smaller families,while <strong>the</strong> family plann<strong>in</strong>g programme <strong>in</strong>creased accessto fertility-regulat<strong>in</strong>g methods, which helped couplesto transform <strong>the</strong>ir fertility desires <strong>in</strong>to practice. A betterhealth delivery system <strong>in</strong> states such as Kerala <strong>and</strong> TamilNadu also made it easier for <strong>the</strong> family plann<strong>in</strong>g programmeto make services for contraceptives widely available towomen <strong>and</strong> couples. A better education system <strong>in</strong> <strong>the</strong>sestates made it easier for <strong>the</strong> family plann<strong>in</strong>g programme torecruit <strong>the</strong> staff needed to provide such services. Moreover,better education also implied that a higher proportion ofwomen <strong>in</strong> <strong>the</strong>se states were exposed to <strong>the</strong> family plann<strong>in</strong>gmessages propagated by <strong>the</strong> family plann<strong>in</strong>g programmethrough mass media. For example, 57 per cent of women145

TableTable10Differences between north <strong>and</strong> south regions <strong>in</strong> India: 2005/06CharacteristicsResidencePercentage users ofany methodPercentagesterilizedSterilized as %of all usersOverall % distributionNorth South North South North South North SouthUrban 58.9 63.8 30.3 54.9 51.4 86.1 22.5 37.7Rural 40.0 66.0 26.7 61.4 66.8 93.1 77.5 62.3EducationNone 40.4 69.8 28.4 69.1 70.3 99.0 63.2 35.8Primary 46.0 68.1 30.6 65.8 66.5 96.6 2.4 17.3Secondary 51.1 61.0 25.1 51.9 49.1 85.1 20.0 39.5Higher 64.9 57.8 17.1 32.3 26.3 55.9 4.2 7.4Miss<strong>in</strong>g 38.8 0.0 35.7 0.0 92.0 0.0 0.0 0.0ReligionMuslim 30.1 57.6 9.8 48.4 32.6 84.0 13.3 11.0H<strong>in</strong>du 46.4 65.9 30.4 60.7 65.5 92.1 84.9 82.7Sikh 71.9 0.0 29.8 100.0 41.4 100.0 0.4 0.0Ja<strong>in</strong> 77.7 62.1 40.1 50.5 51.6 81.3 0.4 0.2Christian 37.6 67.9 15.4 54.8 41.0 80.7 0.4 6.0O<strong>the</strong>r 22.8 74.0 14.6 80.3 64.0 108.5 0.7 0.1Miss<strong>in</strong>g 50.1 80.3 17.4 65.0 34.7 80.9 0.1 0.0WealthLowest 33.2 58.2 23.2 57.8 69.9 99.3 28.2 8,6Second 39.6 65.9 26.8 64.8 67.7 98.3 24.2 15.9Middle 43.6 65.1 28.3 62.9 64.9 96.6 18.1 25.8Fourth 52.9 66.1 32.6 59.4 61.6 89.9 15.6 26.7Highest 65.8 66.2 30.8 50.5 46.8 76.3 13.9 23.0Household structureNuclear 49.2 72.4 32.3 67.1 65.7 92.7 43.0 56.6Non-nuclear 43.5 58.1 26.1 50.7 60.0 87.3 48.8 38.3Non-def<strong>in</strong>ed 22.8 37.8 11.2 31.6 49.1 83.6 8.1 5.1EmploymentCash 50.5 70.2 32.1 68.3 63.6 97.3 21.6 39.1In-k<strong>in</strong>d 43.2 70.6 35.7 65.6 82.6 92.9 22.7 8.1Not employed 42.3 60.6 22.5 52.6 53.2 86.8 55.7 52.7RadioNo 42.9 65.7 28.2 61.1 65.7 93.0 67.9 64.9Yes 47.1 64.1 26.1 55.1 55.4 86.0 32.1 35.1Miss<strong>in</strong>g 52.1 79.6 7.0 64.4 13.4 80.9 0.0 0.1TelevisionNo 37.3 64.7 25.7 61.1 68.9 94.4 63.0 42.9Yes 56.1 65.5 30.7 57.3 54.7 87.5 37.0 57.0Miss<strong>in</strong>g 0.0 96.6 0.0 96.6 0.0 100.0 0.0 0.0NewspaperNo 41.8 65.6 27.8 62.2 66.5 94.8 86.8 74.7146

Yes 60.9 63.8 26.1 49.3 42.9 77.3 13.2 25.3Miss<strong>in</strong>g 0.0 74.1 0.0 74.1 0.0 100.0 0.0 0.1Contact with Health/FP workerNo 46.6 66.5 30.1 60.6 64.6 91.1 78.4 82.0Yes 35.8 59.1 18.3 51.4 51.1 87.0 21.6 18.0Miss<strong>in</strong>g 0.0 0.0 0.0 0.0 0.0 0.0Age15-19 9.2 7.4 0.3 4.4 3.3 59.5 9.4 5.220-24 23.4 38.5 7.9 30.7 33.8 79.7 19.4 16.525-29 43.7 66.4 23.0 58.6 52.6 88.3 19.6 20.330-34 60.6 77.6 38.3 70.5 63.2 90.9 17.1 17,535-39 62.2 79.5 41.9 73.8 67.4 92.8 14.4 16.640-44 56.3 76.3 42.7 71.3 75.8 93.4 11.5 13.845-49 52.6 75.3 46.2 72.6 87.8 96.4 8.6 10.2Parity0 6.1 2.4 0.1 0.5 1.6 20.8 10.8 10.11 20.1 24.2 1.3 6.5 6.5 26.9 12.4 15.72 46.6 80.6 22.4 73.9 48.1 91.7 16.9 36.03 58.8 86.6 42.9 84.0 73.0 97.0 17.1 21.44+ 54.1 80.8 37.9 79.1 70.1 97.9 42.8 16.8Desire< 2 years 7.4 5.5 0.0 0.0 0.0 0.0 13.2 13.62+ years 19.4 19.9 0.0 0.0 0.0 0.0 14.9 7.1Undecided 4.1 14.8 0.0 0.0 0.0 0.0 2.5 2.1No more 61.3 84.4 42.0 79.6 68.5 94.3 65.6 74.1Up to God - - - - - - - -Infecund 2.3 6.2 0.0 0.0 0.0 0.0 3.7 3.0Miss<strong>in</strong>g 6.2 10.0 0.0 0.0 0.0 0.0 0.0 0.2# of liv<strong>in</strong>g sons0 12.9 35.8 1.8 27.5 14.0 76.8 24.0 29.01 43.0 71.6 21.7 64.5 50.5 90.1 29.3 41.52+ 61.1 85.1 44.4 82.2 72.7 96.6 46.7 29.4# of child deaths0 43.4 63.7 25.9 56.8 59.7 89.2 70.2 85.41 47.5 74.5 32.5 72.2 68.4 96.9 62.8 11.42+ 44.2 71.1 29.5 68.7 66.7 96.6 20.5 3.2Total 44.3 65.2 27.5 59.0 62.1 90.5 100.0 100.0Weighted N 37,955 20,341147

TableTable11 Total fertility rate <strong>and</strong> percentage decl<strong>in</strong>e, by states <strong>in</strong> India: 1996-2004StateIndiaPanelIndiaPanelTotal fertility rate (TFR)NFHS-1:1990/92NFHS-2:1996/98NFHS-3:2003/05Year 1966 1971 a 1991 1997 20041971to 1991Percentage decl<strong>in</strong>e <strong>in</strong> TFR1991to 20041971to 2004Sou<strong>the</strong>rn statesAndhra Pradesh 5.01 4.80 2.60 2.25 1.79 -46.0 -30.9 -62.7Karnataka 5.51 5.50 2.85 2.13 2.07 -48.2 -27.4 -62.4Kerala 4.70 4.49 2.00 1.96 1.93 -55.5 -3.5 -57.0Tamil Nadu 4.66 4.58 2.48 2.19 1.80 -45.9 -27.4 -60.7Nor<strong>the</strong>rn statesBihar 5.62 5.62 4.00 3.49 3.80 -28.8 -5.0 -32.4Madhya Pradesh 6.40 6.16 3.90 3.31 3.10 -36.7 -20.5 -49.7Rajasthan 6.34 6.38 3.63 3.78 3.21 -43.1 -11.6 -49.7Uttar Pradesh 6.45 6.45 4.82 3.99 3.80 -25.3 -21.2 -41.1O<strong>the</strong>r large statesAssam 6.85 6.35 3.53 2.31 2.42 -44.4 -31.4 -61.9Gujarat 5.83 5.97 2.99 2.72 2.42 -49.9 -19.1 -59.5Haryana 6.91 6.64 3.99 2.88 2.69 -39.9 -32.6 -59.5Maharashtra 5.29 4.92 2.86 2.52 2.11 -41.9 -26.2 -57.1Orissa 5.72 5.54 2.92 2.46 2.37 -47.3 -18.8 -57.2Punjab 5.52 5.57 2.92 2.21 1.99 -47.6 -31.8 -64.3West Bengal 5.93 5.93 2.92 2.29 2.27 -50.8 -22.3 -61.7All-India 5.72 5.60 3.39 2.85 2.68 -39.5 -20.9 -52.1Source: India Panel (Bhat et al., 1984); N FHS (IIPS 1995, 2000, 2007).a. Bihar <strong>and</strong> West Bengal TFR for 1966.<strong>in</strong> <strong>the</strong> sou<strong>the</strong>rn states were exposed to television <strong>and</strong> 25per cent to newspapers <strong>in</strong> comparison to 37 per cent <strong>and</strong>13 per cent <strong>in</strong> <strong>the</strong> nor<strong>the</strong>rn states (Table 10).The four lagg<strong>in</strong>g nor<strong>the</strong>rn states (Bihar, Uttar Pradesh,Rajasthan <strong>and</strong> Madhya Pradesh) may now be ready fora faster fertility transition because wanted fertility <strong>in</strong><strong>the</strong>se states is already close to <strong>the</strong> replacement level <strong>and</strong>because of <strong>the</strong> existence of a substantial unmet need forfamily plann<strong>in</strong>g 13 . What is needed now is wider accessto <strong>the</strong> means of fertility regulation <strong>and</strong> cont<strong>in</strong>uation of<strong>in</strong>vestment <strong>in</strong> education <strong>and</strong> health.ConclusionWhile socially just policies <strong>in</strong> education <strong>and</strong> health areimportant <strong>in</strong> <strong>the</strong>ir own right, we have shown here that<strong>the</strong>re is a synergistic effect of socially just policies <strong>in</strong>education <strong>and</strong> health <strong>and</strong> <strong>the</strong> family plann<strong>in</strong>g programmeon <strong>the</strong> differential pace of fertility decl<strong>in</strong>e among states <strong>in</strong>India. The fact that fertility decl<strong>in</strong>ed <strong>in</strong> all states reflects<strong>the</strong> importance of <strong>the</strong> family plann<strong>in</strong>g programme. Thefact that <strong>the</strong> tim<strong>in</strong>g <strong>and</strong> pace of fertility decl<strong>in</strong>e variesacross states reflects <strong>the</strong> importance of state-specific socialsett<strong>in</strong>gs.At <strong>the</strong> national level, contraceptive use rose from about 13per cent <strong>in</strong> <strong>the</strong> 1970s to 56 per cent <strong>in</strong> 2005/06 <strong>and</strong> fertilitydecl<strong>in</strong>ed from about 6 births per woman <strong>in</strong> <strong>the</strong> 1960s <strong>and</strong>1970s to about 2.7 <strong>in</strong> 2004. The implementation of <strong>the</strong>family plann<strong>in</strong>g programme has been a critical piece <strong>in</strong>this achievement. Method mix, however, rema<strong>in</strong>s skewedtowards female sterilization, <strong>and</strong> <strong>the</strong> quality of care alsorema<strong>in</strong>s poor. Even though more couples are us<strong>in</strong>g familyplann<strong>in</strong>g methods to space childbear<strong>in</strong>g, a more focused<strong>and</strong> concentrated effort is necessary to <strong>in</strong>crease <strong>the</strong>availability of o<strong>the</strong>r contraceptive methods <strong>and</strong> to improve<strong>the</strong> quality of care.Contraceptive use rose <strong>in</strong> all subgroups of <strong>the</strong> population:uneducated <strong>and</strong> educated, poor <strong>and</strong> rich, <strong>and</strong> rural <strong>and</strong>148

TableTable12 Conditions foster<strong>in</strong>g fertility decl<strong>in</strong>e <strong>in</strong> 15 major states <strong>in</strong> India, 2003-2005Female education(Percentage of marriedwomen <strong>in</strong> reproductiveages with at least primary-level education)High55 or moreInfant mortality rate(Infant deaths per 1,000 births)Medium35 to 54Low15 to 34LowLess than 45 per centMedium45 to 59 per centHigh60 percent or moreBihar (3.80)Uttar Pradesh (3.80)Rajasthan (3.21)Madhya Pradesh (3.10)Assam (2.42) Haryana (2.69)Orissa (2.37) Gujarat (2.42)West Bengal (2.27)Karnataka (2.07)Andhra(1.79)PradeshSource: NFHS-3 (IIPS, 2007).Note: Total fertility rate for each state is shown <strong>in</strong> paren<strong>the</strong>ses.Maharashtra (2.11) Kerala (1.93)Punjab (1.99) Tamil Nadu (1.80)urban. The rise <strong>in</strong> contraceptive use <strong>and</strong> <strong>the</strong> pace of fertilitydecl<strong>in</strong>e, however, has not been uniform throughout <strong>the</strong>country. Progress at <strong>the</strong> national level masks importantdifferentials among subgroups of <strong>the</strong> population14. Forexample, <strong>the</strong> gap <strong>in</strong> contraceptive use <strong>and</strong> fertility between<strong>the</strong> sou<strong>the</strong>rn <strong>and</strong> <strong>the</strong> nor<strong>the</strong>rn states observed <strong>in</strong> <strong>the</strong>1970s cont<strong>in</strong>ues to exist. Without <strong>the</strong> family plann<strong>in</strong>gprogramme, <strong>the</strong> gap <strong>in</strong> contraceptive use between nor<strong>the</strong>rn<strong>and</strong> sou<strong>the</strong>rn states would have been wider. The data showthat contraceptive use <strong>in</strong> <strong>the</strong> nor<strong>the</strong>rn states has <strong>in</strong>creasedover <strong>the</strong> past three decades, <strong>and</strong> <strong>the</strong> current level is higherthan what would have been expected on <strong>the</strong> basis of <strong>the</strong>stronger son preference. However, <strong>the</strong> gap <strong>in</strong> contraceptiveuse between nor<strong>the</strong>rn <strong>and</strong> sou<strong>the</strong>rn states would have beennarrower if nor<strong>the</strong>rn states had a similar social sett<strong>in</strong>g assou<strong>the</strong>rn states.The national fertility average <strong>in</strong> <strong>the</strong> future will dependupon what happens <strong>in</strong> four states, namely Bihar, MadhyaPradesh, Rajasthan <strong>and</strong> Uttar Pradesh, which, accord<strong>in</strong>g to<strong>the</strong> 2001 census, comprised a population of 366 million orabout 36 per cent of India’s total population 14 . Fertility hasdecl<strong>in</strong>ed <strong>in</strong> all <strong>the</strong>se states; TFR, however, rema<strong>in</strong>s highat around 3.1 <strong>in</strong> Madhya Pradesh, 3.2 Rajasthan <strong>and</strong> 3.8<strong>in</strong> Bihar <strong>and</strong> Uttar Pradesh. What happens <strong>in</strong> <strong>the</strong>se fourstates will determ<strong>in</strong>e what happens to <strong>the</strong> national averages.For example, trends <strong>in</strong> fertility decl<strong>in</strong>e <strong>in</strong> <strong>the</strong>se four stateswill have an impact on <strong>the</strong> pace of fertility decl<strong>in</strong>e at <strong>the</strong>national level, <strong>and</strong> improvements <strong>in</strong> female education <strong>and</strong>reductions <strong>in</strong> <strong>in</strong>fant <strong>and</strong> child mortality will <strong>in</strong>fluencewhen India will achieve Millennium Development Goals2 <strong>and</strong> 4 15 .A considerable unmet need for contraception exists<strong>in</strong> <strong>the</strong>se four states <strong>and</strong> wider access to <strong>the</strong> means offertility regulation is required. Fur<strong>the</strong>r streng<strong>the</strong>n<strong>in</strong>g of<strong>the</strong> ongo<strong>in</strong>g family plann<strong>in</strong>g programme will acceleratefertility decl<strong>in</strong>e <strong>in</strong> <strong>the</strong>se states by transform<strong>in</strong>g this unmetneed <strong>in</strong>to actual use, thus reduc<strong>in</strong>g unwanted fertility. Inaddition, <strong>in</strong>creased <strong>in</strong>vestments <strong>in</strong> education <strong>and</strong> health<strong>in</strong> <strong>the</strong>se states will accelerate fertility decl<strong>in</strong>e by improv<strong>in</strong>gwomen’s ability to regulate <strong>the</strong>ir own fertility.In sum, progress made <strong>in</strong> improv<strong>in</strong>g social development<strong>in</strong> addition to <strong>the</strong> progress made <strong>in</strong> streng<strong>the</strong>n<strong>in</strong>g <strong>the</strong>ongo<strong>in</strong>g family plann<strong>in</strong>g programme, especially <strong>in</strong> <strong>the</strong>previously mentioned four large nor<strong>the</strong>rn states, will notonly reduce fertility <strong>in</strong> <strong>the</strong>se states, it will also contributeto <strong>the</strong> future pace of fertility decl<strong>in</strong>e at <strong>the</strong> national level.This is a w<strong>in</strong>n<strong>in</strong>g comb<strong>in</strong>ation because of <strong>the</strong> mutuallyre<strong>in</strong>forc<strong>in</strong>g effects of <strong>in</strong>vestments <strong>in</strong> education, health<strong>and</strong> family plann<strong>in</strong>g programmes on reduc<strong>in</strong>g fertility aswell as achiev<strong>in</strong>g Millennium Development Goals 2 <strong>and</strong>4. The same, perhaps, can also be said about many o<strong>the</strong>rdevelop<strong>in</strong>g countries, especially <strong>in</strong> sub-Saharan Africa,that have high fertility, a poor social sett<strong>in</strong>g <strong>and</strong> weakfamily plann<strong>in</strong>g programmes.149

End Note1The first camp was successfully organized <strong>in</strong> 1970 <strong>in</strong> <strong>the</strong>Ernakulam district of Kerala state.2 Inaugural session of <strong>the</strong> <strong>Asia</strong>n Population Association Conference,New Delhi, on 16 November 2010.3All analyses used sample weights <strong>and</strong> were conducted us<strong>in</strong>g <strong>the</strong>STATA 10 Data Analysis <strong>and</strong> Statistical Software.4 The number of child deaths was constructed by subtract<strong>in</strong>g <strong>the</strong>number of liv<strong>in</strong>g children from parity.5This group also <strong>in</strong>cludes those who were sterilized.6The employment variable, constructed by comb<strong>in</strong><strong>in</strong>g two variables(respondent employed with<strong>in</strong> <strong>the</strong> past 12 months <strong>and</strong> paymenttype received), is divided <strong>in</strong>to three categories: employed for cash,employed for payment <strong>in</strong> k<strong>in</strong>d <strong>and</strong> unemployed. We used employedfor payment <strong>in</strong> k<strong>in</strong>d as <strong>the</strong> reference category.7Includes Bihar, Chhattisgarh, Jharkh<strong>and</strong>, Madhya Pradesh,Rajasthan, Uttaranchal <strong>and</strong> Uttar Pradesh.8Includes Andhra Pradesh, Karnataka, Kerala <strong>and</strong> Tamil Nadu.9 Includes Assam, Gujarat, Haryana, Maharashtra, Orissa, Punjab<strong>and</strong> West Bengal.10Includes <strong>the</strong> rema<strong>in</strong><strong>in</strong>g states.11It seems that adjustments for women’s social <strong>and</strong> economiccharacteristics more than compensated <strong>the</strong> effect of <strong>the</strong> adjustmentfor <strong>the</strong> liv<strong>in</strong>g sons <strong>in</strong> 1992/93, whereas <strong>the</strong> effect of liv<strong>in</strong>g sonsovershadowed <strong>the</strong> effect of o<strong>the</strong>r characteristics <strong>in</strong> 2005/06.12In <strong>the</strong> north, spouses are unrelated, females do not <strong>in</strong>herit property<strong>and</strong> males tend to take help from o<strong>the</strong>r males related by blood.In contrast, ideal or preferred marriages <strong>in</strong> <strong>the</strong> south are betweencross-cous<strong>in</strong>s, women sometime <strong>in</strong>herit property <strong>and</strong> males are alsolikely to take help from o<strong>the</strong>r males related by marriage.13Wanted fertility accord<strong>in</strong>g to NFHS-3 was 2.1 children perwoman <strong>in</strong> Madhya Pradesh; 2.2 <strong>in</strong> Rajasthan; 2.3 <strong>in</strong> Uttar Pradesh;<strong>and</strong> 2.4 <strong>in</strong> Bihar. 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(1973). “Market<strong>in</strong>g research <strong>in</strong> <strong>the</strong>Nirodh Program”, Studies <strong>in</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>,4(7):184-190.__________ (1985). “The impact of development <strong>and</strong>population policies on fertility <strong>in</strong> India”, Studies <strong>in</strong><strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>, 16(4):181-198.__________ (1997). “Consistency between contraceptiveuse <strong>and</strong> fertility <strong>in</strong> India”, Demography India, 26(1):19-36.__________ (1998a). “The future of population policies”,In: Anrudh Ja<strong>in</strong>, ed., Do Population Policies Matter?Fertility <strong>and</strong> Politics <strong>in</strong> Egypt, India, Kenya, <strong>and</strong> Mexico,New York: Population <strong>Council</strong>.__________ (1998b). “Population policies that matter”,150

In: Anrudh Ja<strong>in</strong>, ed., Do Population Policies Matter?Fertility <strong>and</strong> Politics <strong>in</strong> Egypt, India, Kenya, <strong>and</strong> Mexico,New York: Population <strong>Council</strong>._________(1998c). “Fertility transition <strong>in</strong> India:implications for social policies”, In: Mart<strong>in</strong>e George,Monica Das Gupta <strong>and</strong> L<strong>in</strong>coln C. Chen, eds.,Reproductive Change <strong>in</strong> India <strong>and</strong> Brazil, Delhi: OxfordUniversity Press.Koenig, Michael A., Gillian H.C. Foo <strong>and</strong> Ketan Joshi(2000). “Quality of care with<strong>in</strong> <strong>the</strong> Indian <strong>Family</strong>Welfare Programme: a review of recent evidence”,Studies <strong>in</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>, 31(1):1-18.Krishnan, T.N. (1998). “Social development <strong>and</strong> fertilityreduction <strong>in</strong> Kerala”, In: Mart<strong>in</strong>e George, Monica DasGupta <strong>and</strong> L<strong>in</strong>coln C. Chen, eds., Reproductive Change<strong>in</strong> India <strong>and</strong> Brazil, Delhi: Oxford University Press.Mauld<strong>in</strong>, W. Parker <strong>and</strong> Bernard Berelson (1978).“Conditions of fertility decl<strong>in</strong>e <strong>in</strong> develop<strong>in</strong>g countries,1965-75”, Studies <strong>in</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>. 9(3):89-147.Nag, Moni (1984). “Fertility differentials <strong>in</strong> Kerala<strong>and</strong> West Bengal: equity fertility hypo<strong>the</strong>sis asexplanation”, Economic <strong>and</strong> Political Weekly, Vol. XIX,No.1 (7 January): 33-41.Operations Research Group (n.d.). <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Practices <strong>in</strong> India: The First All-India Survey Report,Baroda, Gujarat, India: Operations Research Group(ORG).__________ (1990). <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Practices <strong>in</strong> India:Third All India Survey. Baroda, Gujarat, India: ORG.Phillips, James F., Ruth Simmons, Michael A. Koen<strong>in</strong>g<strong>and</strong> J. Chakraborty (1988). “Determ<strong>in</strong>ants ofreproductive change <strong>in</strong> a traditional society: evidencefrom Matlab, Bangladesh”, Studies <strong>in</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>,19(6):313-334.Registrar General, India (RGI (2009). Compendium ofIndia’s Fertility <strong>and</strong> Mortality Indicators based on <strong>the</strong>Sample Registration System (SRS): 1971-2007, NewDelhi: RGI.Satia, J.K. <strong>and</strong> Shireen J. Jejeebhoy (eds.) (1991). TheDemographic Challenge: A Study of Four Large IndianStates, Bombay: Oxford University Press.Visaria, Leela (2002). The Proximate Determ<strong>in</strong>antsof Fertility <strong>in</strong> India, India Project Work<strong>in</strong>g Paper,London: Department of Social Policy, London Schoolof Economics.__________ , Shireen Jeejabhoy <strong>and</strong> Tom Merrick(1999). “From family plann<strong>in</strong>g to reproductive health:challenges fac<strong>in</strong>g India”, <strong>International</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Perspectives, 25 (supplement): S44-S49.Visaria, Prav<strong>in</strong> <strong>and</strong> Vijaylaxmi Chari (1998). “India’spopulation policy <strong>and</strong> family plann<strong>in</strong>g program:yesterday, today <strong>and</strong> tomorrow”, In: Anrudh Ja<strong>in</strong>, ed.,Do Population Policies Matter? Fertility <strong>and</strong> Politics <strong>in</strong>Egypt, India, Kenya <strong>and</strong> Mexico, New York: Population<strong>Council</strong>.151

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MaldivesMaldivesThe Status of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> Reproductive Health<strong>in</strong> <strong>the</strong> Republic of Maldives, 2010Bhanu Bhakta Niraula*(The Population Policy of Maldives, MPND, 2005:8) supports reproductiverights of <strong>in</strong>dividuals <strong>and</strong> couples to decide freely <strong>and</strong> responsibly <strong>the</strong> number<strong>and</strong> spac<strong>in</strong>g of <strong>the</strong>ir children <strong>and</strong> create an environment for cost effectiveprovision of <strong>in</strong>formation <strong>and</strong> services that would enable <strong>the</strong>m to make<strong>in</strong>formed choices to achieve <strong>the</strong>ir reproductive <strong>in</strong>tentions.Population Policy of MaldivesWork<strong>in</strong>g draft, 2004* Country Director, Programmes <strong>and</strong> Operations, Brita<strong>in</strong> Nepal Medical Trust (BNMT), Kathm<strong>and</strong>u, Nepal.153

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Aim of <strong>the</strong> reportThe aim of <strong>the</strong> present report is to compile, review <strong>and</strong>analyse data <strong>and</strong> <strong>in</strong>formation on <strong>the</strong> status of familyplann<strong>in</strong>g (FP) <strong>in</strong> <strong>the</strong> Republic of Maldives dur<strong>in</strong>g<strong>the</strong> last three decades, based on <strong>in</strong>ternationally <strong>and</strong>nationally agreed targets <strong>and</strong> achievements, <strong>and</strong> <strong>the</strong>country’s progress towards meet<strong>in</strong>g <strong>the</strong> goals <strong>and</strong> targetsof <strong>the</strong> 1994 <strong>International</strong> Conference on Population <strong>and</strong>Development (ICPD) <strong>and</strong> <strong>the</strong> Millennium DevelopmentGoals (MDGs). Based on <strong>the</strong> review <strong>and</strong> analyses, <strong>the</strong>report presents recommendations on how <strong>the</strong> nationalFP programme <strong>in</strong> Maldives could be repositioned <strong>and</strong>moved forward. It should be noted that <strong>the</strong> study wasprepared at a time when Maldives was still <strong>in</strong> transition –politically <strong>and</strong> socially. The political changes that brought<strong>the</strong> new democratically elected President to power haveyet to stabilize. The stalemate between Parliament <strong>and</strong> <strong>the</strong>President’s office had not yet been resolved at <strong>the</strong> time ofwrit<strong>in</strong>g.MethodologyA variety of methods <strong>and</strong> materials have been used <strong>in</strong>prepar<strong>in</strong>g <strong>the</strong> report, namely a desk review of availabledocuments <strong>and</strong> visits to Malé, <strong>the</strong> capital of Maldives, to<strong>in</strong>teract with key stakeholders to obta<strong>in</strong> o<strong>the</strong>r necessary<strong>in</strong>formation to assist <strong>in</strong> <strong>the</strong> preparation of <strong>the</strong> report. Thedocuments reviewed <strong>in</strong>cluded key government policy <strong>and</strong>programme documents, policy statements <strong>and</strong> progressreports of <strong>the</strong> government on socio-economic <strong>and</strong>demographic <strong>in</strong>dicators, on Maldives’ progress <strong>in</strong> atta<strong>in</strong><strong>in</strong>gMDGs <strong>and</strong> its position vis-à-vis <strong>the</strong> Human DevelopmentIndex . In order to obta<strong>in</strong> a more <strong>in</strong>-depth underst<strong>and</strong><strong>in</strong>gof <strong>the</strong> situation, a visit to Maldives was conducted from 25September to 4 October 2010. Dur<strong>in</strong>g that period, a widespectrum of people represent<strong>in</strong>g various constituencieswere <strong>in</strong>terviewed. These <strong>in</strong>cluded <strong>the</strong> State M<strong>in</strong>ister ofHealth, <strong>the</strong> officiat<strong>in</strong>g permanent Secretary of Health, <strong>the</strong>Director General of <strong>the</strong> Center for Community Health<strong>and</strong> Disease Control, <strong>and</strong> o<strong>the</strong>r key government officials,United Nations country team members <strong>and</strong> representativesof various non-governmental organizations (NGOs).Past achievements <strong>in</strong> familyplann<strong>in</strong>g <strong>and</strong> reproductivehealthWhat was achieved under <strong>the</strong>programme <strong>in</strong> <strong>the</strong> past 30 yearsPopulation trends:Accord<strong>in</strong>g to <strong>the</strong> 2006 census, <strong>the</strong> population of <strong>the</strong>country was about 300,000 people liv<strong>in</strong>g <strong>in</strong> almost 200of Maldives’ <strong>in</strong>habited isl<strong>and</strong>s. As with o<strong>the</strong>r develop<strong>in</strong>gcountries, Maldives experienced periods of both sluggish<strong>and</strong> rapid population growth dur<strong>in</strong>g <strong>the</strong> past. Dur<strong>in</strong>g <strong>the</strong>first half of <strong>the</strong> twentieth century, population growth wasto a large extent balanced by high levels of both fertility<strong>and</strong> mortality, with an estimated population growth rate ofabout 1 per cent per annum (Chaudhury, 1996; <strong>and</strong> MPND,2002). However, as <strong>in</strong>dicated by global historical trends,<strong>the</strong> population started to grow more rapidly <strong>in</strong> <strong>and</strong> around<strong>the</strong> mid-1950s as high mortality began to decl<strong>in</strong>e due toimprovements <strong>in</strong> health conditions triggered by advances<strong>in</strong> medic<strong>in</strong>e <strong>and</strong> its wider availability. The population ofMaldives was estimated to be about 100,000 <strong>in</strong> 1966,<strong>the</strong> year it ga<strong>in</strong>ed <strong>in</strong>dependence. An official census wasconducted <strong>in</strong> 1977, <strong>and</strong> scientific estimates of populationgrowth rates were available only after that year.Table 1 shows <strong>the</strong> population trends <strong>in</strong> Maldivescover<strong>in</strong>g almost a century. Maldives experienced bothhigh fertility <strong>and</strong> high mortality regimes until <strong>the</strong> mid-TableTable1Census year, population, sex ratio <strong>and</strong> average annual growth rate, MaldivesCensus yearTotal population (N)Sex ratioAverage annual growth rate (%)1911 72,237 119 -1977 142,832 111 -1985 180, 088 108 3.201990 213,215 105 3.431995 244,814 104 2.732000 270,101 103 1.962006 298,968 103 1.69Source: MPND, 2007: Maldives, Population <strong>and</strong> Hous<strong>in</strong>g Census 2006.155

Figure1980s <strong>and</strong> experienced a rapid decl<strong>in</strong>e <strong>in</strong> subsequentyears, characteristics similar to those of o<strong>the</strong>r countriesexperienc<strong>in</strong>g socio-economic <strong>and</strong> demographic transitions.The population growth rate dur<strong>in</strong>g <strong>the</strong> <strong>in</strong>tercensal period2001-2006 was 1.69 per cent.Various data <strong>in</strong>dicate that fertility rates <strong>in</strong> Maldives beganto decl<strong>in</strong>e <strong>in</strong> <strong>the</strong> early 1990s (MPND, 2002), a trend thatbecame more rapid <strong>in</strong> recent years (Niyaaz, 2002; Naseemet al., 2004). Fertility analyses of recent censuses <strong>in</strong>dicatethat Maldives experienced one of <strong>the</strong> most rapid fertilitytransitions <strong>in</strong> <strong>the</strong> region. The 1990 <strong>and</strong> 1995 censusesreported total fertility rates (TFRs) of 6.4 <strong>and</strong> 5.7 childrenper woman. Total fertility estimates for 2000 <strong>and</strong> 2006stood at 2.8 <strong>and</strong> 2.1 respectively.The contraceptive prevalence rate (CPR) showed a steady<strong>in</strong>crease over <strong>the</strong> period 1985-2006 (see Figure 1). Before<strong>the</strong> official launch of <strong>the</strong> child-spac<strong>in</strong>g project <strong>in</strong> 1984,which formally <strong>in</strong>troduced FP services <strong>in</strong> <strong>the</strong> country, totalCPR (<strong>in</strong>clusive of traditional <strong>and</strong> modern methods) wasestimated to be about 10 per cent. By 1999 it had <strong>in</strong>creasedto 42 per cent; however, it fell <strong>in</strong> 2004 to 39 per cent <strong>and</strong><strong>in</strong> 2009 to 35 per cent. More scientific data on CPR beganto emerge from a 1999 Reproductive Health Basel<strong>in</strong>eSurvey which <strong>in</strong>dicated a CPR of 33 per cent for moderncontraceptive methods. Correspond<strong>in</strong>g data <strong>in</strong> <strong>the</strong> 2004RH survey showed a CPR of 34 per cent, <strong>and</strong> <strong>the</strong> firsteverdemographic survey conducted <strong>in</strong> Maldives <strong>in</strong> 2009recorded a CPR of 27 per cent for modern methods.In view of <strong>the</strong> small size of <strong>the</strong> population, mortalityestimates often lack consistency <strong>in</strong> estimates ofdemographic parameters. However, because Maldivesconducts a census every five years, <strong>the</strong> reliability of <strong>the</strong> datacannot be questioned. Commensurate with <strong>the</strong> decl<strong>in</strong>e <strong>in</strong>fertility, mortality decl<strong>in</strong>ed significantly dur<strong>in</strong>g <strong>the</strong> periodunder review, contribut<strong>in</strong>g to <strong>in</strong>creased expectation of lifeat birth. Table 2 shows <strong>the</strong> decl<strong>in</strong>e <strong>in</strong> <strong>the</strong> <strong>in</strong>fant mortalityrate (IMR), under-five mortality <strong>and</strong> maternal mortalityratio (MMR) over <strong>the</strong> years. Accord<strong>in</strong>g to <strong>the</strong> data,Maldives seems to have already achieved MDG Target 4 ofreduc<strong>in</strong>g <strong>the</strong> under-five mortality rate, as well as reduc<strong>in</strong>g<strong>in</strong>fant <strong>and</strong> child mortality at <strong>the</strong> aggregate level, <strong>and</strong> Target5 of reduc<strong>in</strong>g MMR.As a result of decl<strong>in</strong><strong>in</strong>g fertility <strong>and</strong> mortality, <strong>the</strong> populationage structure <strong>in</strong> Maldives has changed significantly, eventhough it is still relatively young. The chang<strong>in</strong>g age structureis depicted <strong>in</strong> Figure 2 <strong>and</strong> <strong>the</strong> population pyramid <strong>in</strong>Figure 3. The percentage of population aged 0-15 years <strong>in</strong>1990 to <strong>the</strong> total population was about 47 per cent; thatproportion decl<strong>in</strong>ed to 31 per cent <strong>in</strong> 2006.This decl<strong>in</strong>e <strong>in</strong> <strong>the</strong> percentage of <strong>the</strong> population <strong>in</strong> <strong>the</strong> 0-15-year age group <strong>in</strong>creased <strong>the</strong> percentage <strong>in</strong> <strong>the</strong> work<strong>in</strong>g-agepopulation, push<strong>in</strong>g Maldives towards a position where itcould enjoy what is popularly known as <strong>the</strong> “DemographicDividend”, a w<strong>in</strong>dow of opportunity where <strong>the</strong> dependencyratio (number of dependents per work<strong>in</strong>g-age population)tends to be lowest <strong>in</strong> its demographic transition, enabl<strong>in</strong>g <strong>the</strong>country to benefit by utiliz<strong>in</strong>g <strong>the</strong> work<strong>in</strong>g-age populationfor economic development. The period is expected to lastfor about 30 years or so. If <strong>the</strong> country fails to benefit fromthis w<strong>in</strong>dow of opportunity, once aga<strong>in</strong> <strong>the</strong> dependencyratio is likely to become imbalanced <strong>and</strong> <strong>the</strong> work<strong>in</strong>g-agepopulation will decl<strong>in</strong>e, result<strong>in</strong>g <strong>in</strong> a higher dependencyratio. Maldives has achieved this “dividend” because ofits success <strong>in</strong> promot<strong>in</strong>g socio-economic development,<strong>and</strong> by <strong>in</strong>vest<strong>in</strong>g more <strong>in</strong> improv<strong>in</strong>g people’s access toFigure1Selected <strong>in</strong>dicators of fertility <strong>and</strong> family plann<strong>in</strong>g: modern methods40353025201510501985 1990 2000 2006 2009Source: Country Contraceptive Report, Maldives: prevalence ICPD+15 <strong>and</strong> rate Beyond: (%) Progress Achievements Total Fertility <strong>and</strong> Rate Challenges, 1994-2009. Government ofMaldives <strong>and</strong> UNFPA, 2009.156

FigureFigureTableTable2FigureTrends <strong>in</strong> mortality <strong>in</strong> Maldives, various <strong>in</strong>dicators, 1990-2009Year/periodInfant mortality(per 1,000)Under-five mortality(per 1,000)Maternal mortality(per 100,000)Life expectancy(years)1990 35 48 500 58 both sexes1995-2000 35 44 143 (2001) 70.7/72.2(M/F)2000-2004 32 38 69 (2006) 71.7/72.7 (M/F)2004-2009 14 17 43 (2008)Source: Country Report, Maldives: ICPD+15 <strong>and</strong> Beyond: Progress Achievements <strong>and</strong> Challenges, 1994-2009. Government ofMaldives <strong>and</strong> UNFPA, 2009.2MPND, 2007: Population <strong>and</strong> Hous<strong>in</strong>g Census, 2006.7060504030201001990 2000 20060-1415-6465+Source: MPND, 2007: Population <strong>and</strong> Hous<strong>in</strong>g Census, 2006.Figure3Population pyramid of Maldives, 2000 <strong>and</strong> 2006Graph PP1 : Population pyramid of Maldives, 2000 & 2006Age Group75+70-4065-6960-6455-5945-4940-4435-3930-3425-2915-1910-145-90-425000 20000 15000 10000 5000 0 500 10000 15000 20000 25000PopulationFemale 2006 Female 2000 Male 2006 Male 2000Source: Source: MPND, 2007: Population <strong>and</strong> Hous<strong>in</strong>g Census, 2006.157

health care <strong>and</strong> education. In addition, a number of o<strong>the</strong>rsocio-economic <strong>and</strong> political factors have contributed toMaldives’ success.The secrets of successOf <strong>the</strong> 1,200 small isl<strong>and</strong>s that form <strong>the</strong> archipelago,<strong>the</strong> number <strong>in</strong>habited is only 198. The small size of <strong>the</strong>country’s population, <strong>the</strong> generosity of donors’ support <strong>and</strong><strong>the</strong> economic opportunities provided by <strong>the</strong> tourism sector<strong>and</strong> fisheries, all have helped <strong>the</strong> government to afford<strong>in</strong>vest<strong>in</strong>g <strong>in</strong> <strong>the</strong> people. Maldives enjoyed economic growthdur<strong>in</strong>g <strong>the</strong> 1980s <strong>and</strong> early 1990s – with <strong>the</strong> growth rateof <strong>the</strong> gross domestic product (GDP) hover<strong>in</strong>g around10 per cent per annum, hav<strong>in</strong>g reached a high of 11.4 percent <strong>in</strong> 1990 (MPND, 2003). The prolonged high rates ofGDP growth enabled <strong>the</strong> government to <strong>in</strong>vest more <strong>in</strong>social development: <strong>in</strong>vest<strong>in</strong>g <strong>in</strong> human capital, education<strong>and</strong> health, <strong>and</strong> improv<strong>in</strong>g services for <strong>the</strong> people.A notable feature of Maldives’ national development planshas been <strong>the</strong> public expenditure on health <strong>and</strong> education,which has far exceeded <strong>the</strong> population growth rate. Formany years, Maldives’ development plans cont<strong>in</strong>ued toallocate more than 24 per cent of all public expenditureto health <strong>and</strong> education, well <strong>in</strong> excess of <strong>the</strong> 20 percent recommended by <strong>the</strong> World Summit for SocialDevelopment <strong>in</strong> 1995. No gender disparity exists <strong>in</strong>primary education. Net enrolment ratios are higher forgirls at <strong>the</strong> secondary school level, whereas <strong>the</strong> gap <strong>in</strong>tertiary education is narrow<strong>in</strong>g, with more girls enter<strong>in</strong>guniversities. With <strong>the</strong> expansion of school facilities,expenditure on education has also <strong>in</strong>creased tremendously,ris<strong>in</strong>g from US$ 19 million <strong>in</strong> 1995 to US$ 169.4 million<strong>in</strong> 2009, an almost n<strong>in</strong>e-fold <strong>in</strong>crease (UNCT, 2010). In<strong>the</strong> past, <strong>the</strong> government also focused on adult educationthrough religious leaders <strong>and</strong> school teachers. Theseachievements have played an important role <strong>in</strong> expla<strong>in</strong><strong>in</strong>g<strong>the</strong> near-universal literacy rates among <strong>the</strong> 15-25-year-oldage group <strong>and</strong> gender parity <strong>in</strong> literacy.As with <strong>the</strong> case for education, <strong>the</strong>re has been rapidexpansion of health facilities. The government adopted apolicy of exp<strong>and</strong><strong>in</strong>g health facilities on all isl<strong>and</strong>s. Isl<strong>and</strong>swithout health facilities were targeted for outreachactivities conducted ei<strong>the</strong>r by <strong>the</strong> health centre or by <strong>the</strong>atoll health facilities. Maldives has achieved near-universalcoverage for diseases under <strong>the</strong> exp<strong>and</strong>ed programmeon immunization (EPI), which has contributed to childsurvival. With <strong>in</strong>creased child survival prospects, womenare bear<strong>in</strong>g fewer children, thus improv<strong>in</strong>g <strong>the</strong>ir health.The expansion of health facilities, especially <strong>the</strong> availabilityof specialist medical practitioners, such as gynaecologistsfor provid<strong>in</strong>g obstetric care <strong>and</strong> services <strong>and</strong> nurses atregional hospitals <strong>and</strong> atoll hospitals, significantly reduced<strong>the</strong> time people have to travel to seek medical care, <strong>and</strong> moreimportantly, <strong>the</strong> expenses <strong>the</strong>y have to pay for commut<strong>in</strong>gto health-care facilities.Likewise, effectiveness <strong>in</strong> promot<strong>in</strong>g <strong>the</strong> primary healthcare (PHC) approach advocated by <strong>the</strong> 1978 <strong>International</strong>Conference on Primary Health Care <strong>in</strong> Alma Ata has beenidentified as one of <strong>the</strong> critical elements of success. Thereasons for <strong>the</strong>se successes were primarily <strong>the</strong> adoptionof practices which were designed accord<strong>in</strong>g to exemplaryPHC pr<strong>in</strong>ciples <strong>and</strong> strategies: provision of accessibleservices, with special emphasis on atoll populations;awareness creation on high-risk pregnancies; cont<strong>in</strong>uityof antenatal <strong>and</strong> post-natal care, ensur<strong>in</strong>g four antenatalvisits for each pregnancy; <strong>and</strong> deliveries attended by skilledpersonnel. For example, 2006 statistics <strong>in</strong>dicated that 54per cent of deliveries were conducted by doctors, 39 percent by staff nurses, 8 per cent by nurses <strong>and</strong> only about3 per cent by traditional birth attendants, many of whomwere formally tra<strong>in</strong>ed (DPH <strong>and</strong> WHO, 2008).O<strong>the</strong>r elements of success were <strong>the</strong> implementation ofperiodic development plans well supported by sectoralpolicies <strong>and</strong> strategies, such as Health Master Plans,National Reproductive Health Strategies, <strong>and</strong> Youth Policy,which streng<strong>the</strong>ned Maldives’ <strong>in</strong>stitutional capability todeliver services <strong>in</strong> planned <strong>and</strong> <strong>in</strong>cremental ways. As earlyas 1999, Maldives had developed a national populationpolicy which was formalized <strong>in</strong> 2004 (MPND, 2005).Current issues <strong>in</strong> <strong>the</strong> nationalfamily plann<strong>in</strong>g programmeIn order to better underst<strong>and</strong> <strong>the</strong> issues, it is pert<strong>in</strong>entto know how health services <strong>in</strong> general <strong>and</strong> FP services<strong>in</strong> particular are planned, organized <strong>and</strong> delivered <strong>in</strong>Maldives. The country’s health plan of 1980 is consideredas <strong>the</strong> foundation of health plann<strong>in</strong>g <strong>and</strong> development <strong>in</strong><strong>the</strong> country. The second stage of <strong>the</strong> long-term plann<strong>in</strong>gwas <strong>the</strong> formulation of <strong>the</strong> perspective plan for <strong>the</strong>country, which ended <strong>in</strong> 2005. The M<strong>in</strong>istry of Health <strong>and</strong><strong>Family</strong> (formerly M<strong>in</strong>istry of Health) formulates annualdevelopment plans <strong>and</strong> programmes.Delivery of health services <strong>in</strong>MaldivesMaldives’ health services are organized as a four-tierhierarchical structure. Operat<strong>in</strong>g at <strong>the</strong> lowest level ofservice delivery are isl<strong>and</strong>-level health facilities known ashealth centres (HC). At this level <strong>the</strong>re are at least twogrades of facility depend<strong>in</strong>g upon <strong>the</strong> size of <strong>the</strong> populationbe<strong>in</strong>g served. Some of <strong>the</strong> facilities have had a medicaldoctor s<strong>in</strong>ce 2007, as well as community health workers158

(CHWs) <strong>and</strong> nurses <strong>in</strong> addition to o<strong>the</strong>r adm<strong>in</strong>istrativestaff. Isl<strong>and</strong>s with a smaller population base have onlyCHWs <strong>and</strong> Foolhumaas (traditional birth attendants, orTBAs). Operat<strong>in</strong>g at <strong>the</strong> atoll level, which usually consistsof more than two isl<strong>and</strong>s, are health centres that havebeen upgraded to atoll-level hospitals. There are 19 atolllevelhospitals <strong>in</strong> <strong>the</strong> country. S<strong>in</strong>ce 1993, <strong>the</strong>se have beenstaffed with medical doctors <strong>and</strong> CHWs. Accord<strong>in</strong>g to <strong>the</strong>government’s policy, which was articulated <strong>in</strong> <strong>the</strong> MasterHealth Plan (1996-2005), <strong>the</strong>se facilities provide <strong>in</strong>patienttreatment <strong>and</strong> labour-room facilities for deliveries.These facilities have now been staffed with o<strong>the</strong>r medicalservice providers, such as pediatricians, gynaecologists <strong>and</strong>nurse-cum-midwives. Some also provide comprehensiveemergency obstetrics care services.At <strong>the</strong> third level, <strong>the</strong>re are regional hospitals that cater forthree to five atolls. There are six regional hospitals <strong>in</strong> total<strong>and</strong> <strong>the</strong>y provide patients with secondary-level curativecare, <strong>in</strong>clud<strong>in</strong>g surgical <strong>and</strong> outreach services to all atolls.They are also equipped to provide ear, nose <strong>and</strong> throatservices <strong>and</strong> have programmes for deal<strong>in</strong>g with vectorbornediseases. The Hulhumale Hospital is ano<strong>the</strong>r majorhealth facility; it caters to <strong>the</strong> population of <strong>the</strong> capital,Malé, <strong>and</strong> functions as a regional hospital.At <strong>the</strong> national level, Indira G<strong>and</strong>hi Memorial Hospital <strong>in</strong>Malé serves as a tertiary-care facility. The referral systemworks with a hierarchy ascend<strong>in</strong>g from family healthworkers (FHWs) <strong>in</strong> isl<strong>and</strong>s to specialists at <strong>the</strong> Hospital.The establishment of public health units with<strong>in</strong> <strong>the</strong> healthfacility is characteristic of Maldives’ effort to comb<strong>in</strong>e bothpreventive <strong>and</strong> curative services to promote preventiveaspects of health. Abdul Rahman Dhon Kaleyfan Hospital<strong>in</strong> Malé, a private sector facility, also serves as a referral <strong>and</strong>tertiary facility.The M<strong>in</strong>istry of Health <strong>and</strong> <strong>Family</strong> formulates nationalpolicy on health matters. Follow<strong>in</strong>g <strong>the</strong> recent democraticchanges, <strong>the</strong> former Department of Public Health(DPH) was renamed <strong>the</strong> Center for Community Health<strong>and</strong> Disease Control; it looks after <strong>the</strong> programmaticside of primary health care <strong>in</strong> <strong>the</strong> country. The NationalThalassaemia Center, Maldives Water <strong>and</strong> SanitationAuthority <strong>and</strong> Institute of Health Sciences are o<strong>the</strong>rparastatal organizations <strong>in</strong>volved <strong>in</strong> one way or ano<strong>the</strong>r <strong>in</strong>health service delivery.With<strong>in</strong> <strong>the</strong> Center for Community Health <strong>and</strong> DiseaseControl, <strong>the</strong> Population Health Section is responsiblefor <strong>the</strong> plann<strong>in</strong>g, distribution <strong>and</strong> management of FPservices <strong>in</strong> <strong>the</strong> country. The Supply Unit with<strong>in</strong> thissection is responsible for <strong>the</strong> logistics management of RHcommodities, mostly FP methods. There is a policy ofma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g stock for six months at regional <strong>and</strong> atoll-levelfacilities, <strong>and</strong> three months at health facilities at <strong>the</strong> isl<strong>and</strong>level. The health centre <strong>in</strong> charge at <strong>the</strong> isl<strong>and</strong> level <strong>and</strong> <strong>the</strong>primary health unit <strong>in</strong> charge <strong>in</strong> <strong>the</strong> atoll <strong>and</strong> regional healthfacilities submit regular requisitions for contraceptives to<strong>the</strong> Population Health Section. These are <strong>the</strong>n forwardedto <strong>the</strong> Supply Unit for distribution. Over <strong>the</strong> years, <strong>the</strong>United Nations Population Fund (UNFPA) has assisted<strong>in</strong> streng<strong>the</strong>n<strong>in</strong>g <strong>the</strong> logistics management <strong>in</strong>formationsystem by provid<strong>in</strong>g management staff with tra<strong>in</strong><strong>in</strong>g toensure <strong>the</strong> un<strong>in</strong>terrupted supply of commodities at eachlevel of service delivery. The government undertakes fullresponsibility for fund<strong>in</strong>g contraceptives.Evolution of family plann<strong>in</strong>g services<strong>in</strong> MaldivesMaldives did not have an official FP programme until1984. Some headway was made <strong>in</strong> planned efforts toreduce <strong>in</strong>fant, child <strong>and</strong> maternal mortality between1984 <strong>and</strong> 1989 (Government of Maldives, 1994). Dur<strong>in</strong>gthat period, <strong>the</strong> government entered <strong>in</strong>to contract withUNFPA, United Nations Development Programme(UNDP) <strong>and</strong> World Health Organization (WHO) topromote child-spac<strong>in</strong>g programmes <strong>in</strong> order to <strong>in</strong>crease<strong>the</strong> <strong>in</strong>tervals between successive births, with <strong>the</strong> aim ofimprov<strong>in</strong>g maternal <strong>and</strong> child health. In <strong>the</strong> early days ofprogramme implementation, distribution of contraceptiveswas limited <strong>and</strong> <strong>the</strong>re were no policies or proceduresfor <strong>the</strong>ir promotion <strong>and</strong> distribution. However, <strong>in</strong> 1987Maldives formulated a policy <strong>and</strong> established proceduresfor <strong>the</strong> procurement <strong>and</strong> distribution of contraceptives,provision of contraceptive services, counsell<strong>in</strong>g of potentialacceptors <strong>and</strong> monitor<strong>in</strong>g of both supplies <strong>and</strong> services.The methods selected by <strong>the</strong> government for child-spac<strong>in</strong>g<strong>in</strong>cluded natural methods, hormonal <strong>and</strong> barriers methods<strong>and</strong> <strong>the</strong> use of pills <strong>and</strong> IUDs. Male <strong>and</strong> female sterilizationwas permitted only on medical grounds <strong>and</strong> at <strong>the</strong> requestof couples. Given that all isl<strong>and</strong>-level health posts werenot equipped with tra<strong>in</strong>ed medical personnel, it was alsodecided that contraceptive methods be distributed only atatoll-level health facilities. The protocol required that <strong>the</strong>contraceptives be given to couples only by medical doctorsor CHWs. However, <strong>in</strong> 1990, <strong>in</strong> realiz<strong>in</strong>g that limit<strong>in</strong>g<strong>the</strong> availability of contraceptives at atoll-level facilitiesh<strong>in</strong>dered <strong>the</strong> access of <strong>the</strong> majority of isl<strong>and</strong> populationsto contraceptives, it was decided that contraceptives bemade available at <strong>the</strong> isl<strong>and</strong> level as well. For that purpose,57 FHWs were upgraded by provid<strong>in</strong>g <strong>the</strong>m with tra<strong>in</strong><strong>in</strong>gon contraceptive methods <strong>and</strong> assign<strong>in</strong>g <strong>the</strong>m to <strong>the</strong> morepopulated isl<strong>and</strong>s of <strong>the</strong> country (Didi, 1991; Governmentof Maldives, 1994; Thongthai <strong>and</strong> Didi, 1996) so that <strong>the</strong>ycould furnish contraceptive services. This helped to raiseawareness <strong>and</strong> brought about a gradual <strong>in</strong>crease <strong>in</strong> CPR.The first ever knowledge, attitude <strong>and</strong> practice (KAP)survey on FP, carried out <strong>in</strong> December 1990 with f<strong>in</strong>ancial159

assistance from UNFPA <strong>and</strong> WHO, helped to evaluate <strong>the</strong>success of FP <strong>in</strong>terventions, improve service delivery <strong>and</strong>launch specific <strong>in</strong>formation, education <strong>and</strong> communication(IEC) programmes for promot<strong>in</strong>g <strong>the</strong> use of FP. Thesurvey also provided important policy- <strong>and</strong> programmerelevant<strong>in</strong>formation to improve <strong>the</strong> quality of <strong>and</strong> accessto primary health care/RH services <strong>in</strong> <strong>the</strong> country.In 1990, <strong>in</strong> recogniz<strong>in</strong>g <strong>the</strong> limited capacity of <strong>the</strong>government to exp<strong>and</strong> FP <strong>and</strong> child-spac<strong>in</strong>g services,UNFPA supported <strong>the</strong> non-governmental organizationSociety for Health Education under <strong>the</strong> project entitled“Development of Effective Child-spac<strong>in</strong>g Mechanisms<strong>in</strong> Selected Regions <strong>and</strong> Atolls”. That project helped <strong>in</strong>rais<strong>in</strong>g public awareness about population growth, <strong>the</strong>importance of FP, small family size <strong>and</strong> use of FP servicesfor child spac<strong>in</strong>g (UNFPA, 1997). The project ensuredcommunity participation <strong>in</strong> <strong>the</strong> health care of mo<strong>the</strong>rs <strong>and</strong>children <strong>and</strong> promoted <strong>the</strong> concept of volunteerism <strong>in</strong> <strong>the</strong>country. It also helped to streng<strong>the</strong>n national capacity <strong>in</strong><strong>the</strong> field of IEC, <strong>the</strong> backbone for <strong>the</strong> success of any publichealth <strong>in</strong>tervention. UNFPA’s support of <strong>the</strong> Society was<strong>in</strong> recognition of <strong>the</strong> fact that <strong>the</strong> government alone couldnot shoulder <strong>the</strong> entire burden of development <strong>and</strong> thatNGOs <strong>and</strong> civil societies should collaborate <strong>in</strong> reach<strong>in</strong>gout where <strong>the</strong> government is not able to do so (Didi, 1991;<strong>and</strong> Thongthai <strong>and</strong> Didi, 1996).Tra<strong>in</strong><strong>in</strong>g of service providers (Foolhamaas, FHWs <strong>and</strong>CHWs) toge<strong>the</strong>r with isl<strong>and</strong> leaders, through mobilehealth tra<strong>in</strong><strong>in</strong>gs at <strong>the</strong> atoll level, contributed significantly<strong>in</strong> streng<strong>the</strong>n<strong>in</strong>g <strong>the</strong> PHC services of <strong>the</strong> government.Modules covered <strong>the</strong> importance of family health, prevention<strong>and</strong> promotion of reproduction (fertility/<strong>in</strong>fertility),motivation <strong>and</strong> counsell<strong>in</strong>g of couples <strong>and</strong> contribution oflocal elites (isl<strong>and</strong>, atoll leaders) <strong>in</strong> promot<strong>in</strong>g <strong>the</strong> health ofwomen <strong>and</strong> children. Although <strong>the</strong> focus was on FHWs<strong>and</strong> CHWs, <strong>the</strong> project also streng<strong>the</strong>ned <strong>the</strong> capacity<strong>and</strong> skills of medical officers <strong>and</strong> medical supervisors.Provision of <strong>in</strong>ternational consultants, health personnelsuch as nurse-cum-midwives <strong>and</strong> several o<strong>the</strong>r forms oftechnical backstopp<strong>in</strong>g support, <strong>in</strong>clud<strong>in</strong>g United NationsVolunteers, filled <strong>the</strong> human resources gap <strong>in</strong> <strong>the</strong> deliveryof health services. Similarly, <strong>the</strong> provision of equipment,boats <strong>and</strong> supplies (contraceptives) streng<strong>the</strong>ned nationalcapacity to attend to emerg<strong>in</strong>g needs. The boats were notonly utilized for UNFPA-supported activities but alsohelped to <strong>in</strong>crease <strong>the</strong> mobility of health-care providerswith<strong>in</strong> isl<strong>and</strong>s <strong>and</strong> atolls (Thongthai <strong>and</strong> Didi, 1996).Khaleel (2001) argued that <strong>the</strong> ma<strong>in</strong> aim of <strong>in</strong>troduc<strong>in</strong>g<strong>and</strong> <strong>in</strong>tegrat<strong>in</strong>g <strong>the</strong> FP programme with<strong>in</strong> <strong>the</strong> MCHservices was among <strong>the</strong> top priority areas necessary toprovide better services for pre- <strong>and</strong> post-natal care as wellas child health. He fur<strong>the</strong>r identified that IEC activitieson population issues, <strong>in</strong>clud<strong>in</strong>g <strong>the</strong> benefits of childspac<strong>in</strong>g, were critical elements <strong>in</strong> Maldives’ FP successes.He noted that <strong>the</strong> IEC strategies played a pivotal role <strong>in</strong>motivat<strong>in</strong>g couples to accept FP as a means to limit <strong>the</strong>irfamily size. For <strong>in</strong>stance, radio, television <strong>and</strong> o<strong>the</strong>r massmedia, such as local newspapers <strong>and</strong> pr<strong>in</strong>ted materials, <strong>and</strong><strong>in</strong>terpersonal communication networks among communityleaders were used to dissem<strong>in</strong>ate <strong>in</strong>formation on FP issues.Tra<strong>in</strong><strong>in</strong>g/orientation regard<strong>in</strong>g RH/FP programmes was<strong>in</strong>troduced for atoll chiefs, department heads <strong>and</strong> religiousleaders. O<strong>the</strong>r relevant activities <strong>in</strong>cluded <strong>the</strong> tra<strong>in</strong><strong>in</strong>g ofcommunity volunteers, such as teachers, women’s groups,isl<strong>and</strong> development committee members <strong>and</strong> youths asmotivators <strong>and</strong> agents of change.Trends <strong>in</strong> method mixDespite <strong>the</strong> remarkable success of <strong>the</strong> FP programme<strong>in</strong> Maldives, not all modern contraceptive methodsare promoted <strong>and</strong> available to <strong>the</strong> population. Table 3provides a breakdown of <strong>the</strong> methods available <strong>and</strong> used,as determ<strong>in</strong>ed by comparative national surveys. WhenCPR was highest at 42 per cent <strong>in</strong> 1999, <strong>the</strong> contributionof traditional methods was also <strong>the</strong> highest (about 9%).The use of modern methods improved only slightly<strong>the</strong>reafter, from 33 per cent <strong>in</strong> 1999 to 34 per cent <strong>in</strong> 2004.Dur<strong>in</strong>g <strong>the</strong> 2004 period, <strong>the</strong> contribution of traditionalmethods decl<strong>in</strong>ed to 5 per cent, while total CPR (<strong>in</strong>clusiveof traditional methods) stood at 39 per cent. Users oftraditional methods were divided almost equally betweentwo methods: periodic abst<strong>in</strong>ence (3%) <strong>and</strong> withdrawal(4%).TableTable3Trends <strong>in</strong> contraceptive method mix, 1999-2009Methods 1999(%) 2004 2009 (%)Modern 33.0 34.0 27.0Traditional 9.0 5.0 7.8Total users 42.0 39.0 34.7Source: M<strong>in</strong>istry of Health, Republic of Maldives, UNFPA, CIET <strong>International</strong>, Reproductive Health Survey 2004, Malé, Maldives,2004, Decision Support Division, M<strong>in</strong>istry of Health <strong>and</strong> <strong>Family</strong>, Demographic Health Survey, 2009, Prelim<strong>in</strong>ary Results.160

FigurePills <strong>and</strong> female sterilization have rema<strong>in</strong>ed <strong>the</strong> backboneof <strong>the</strong> modern methods used <strong>in</strong> <strong>the</strong> country. Oral pillsare one of <strong>the</strong> most popular methods of contraception <strong>in</strong>Maldives. Dur<strong>in</strong>g <strong>the</strong> period 1999-2004, pills accountedfor 13 per cent of CPR, as <strong>in</strong>dicated <strong>in</strong> <strong>the</strong> surveys of 1999<strong>and</strong> 2004. The o<strong>the</strong>r modern contraceptive methods whichhave rema<strong>in</strong>ed constant dur<strong>in</strong>g <strong>the</strong> period 1999-2004 were<strong>in</strong>jectables (3%) <strong>and</strong> male sterilization (1%). However,dur<strong>in</strong>g <strong>the</strong> period 2004-2009, <strong>the</strong>re was a significant shift<strong>in</strong> method mix, with <strong>the</strong> use of pills, <strong>in</strong>jectables <strong>and</strong> malesterilization all show<strong>in</strong>g significant percentage decl<strong>in</strong>es. In1999, female sterilization contributed about 10 per cent toCPR. Its contribution decl<strong>in</strong>ed to 7 per cent <strong>in</strong> 2004 but<strong>in</strong>creased to 10.1 per cent <strong>in</strong> 2009. Male condoms are <strong>the</strong>only contraceptive method to show some consistency <strong>in</strong><strong>in</strong>crease across <strong>the</strong> successive survey periods – <strong>in</strong>creas<strong>in</strong>gfrom about 6 per cent <strong>in</strong> 1999 to 9.3 per cent <strong>in</strong> 2009. Theuse of IUDs <strong>in</strong> 1999 doubled to 2 per cent <strong>in</strong> 2004 butdecl<strong>in</strong>ed to 0.8 per cent <strong>in</strong> 2009.Historically, <strong>the</strong> Maldives FP programme has offeredlimited choice of methods because <strong>the</strong> government wasalways sensitive to societal norms. However, despite <strong>the</strong>limited choices of methods on offer, <strong>the</strong> rapid decl<strong>in</strong>e<strong>in</strong> fertility <strong>and</strong> mortality proved that <strong>the</strong> Maldives FPprogramme was successful. None<strong>the</strong>less, <strong>the</strong> governmentcould not ma<strong>in</strong>ta<strong>in</strong> <strong>the</strong> momentum of <strong>the</strong> FP programme.Political reform processes <strong>in</strong>itiated <strong>in</strong> <strong>the</strong> country s<strong>in</strong>cemid-2005 as well as <strong>the</strong> rehabilitation <strong>and</strong> reconstructionprocesses follow<strong>in</strong>g <strong>the</strong> 2004 tsunami were given priority<strong>in</strong> expenditures.Abortion is illegal <strong>in</strong> Maldives <strong>and</strong> is not considered anFP method. Although data on abortions are difficult toobta<strong>in</strong>, partly because people are not will<strong>in</strong>g to discuss thisissue openly ow<strong>in</strong>g to religious reasons, data from <strong>the</strong> RHsurvey of 2004 <strong>and</strong> <strong>the</strong> Biological <strong>and</strong> Behavioural Surveyof 2008 made available by <strong>the</strong> <strong>Family</strong> Protection Unitof <strong>the</strong> Indira G<strong>and</strong>hi Memorial Hospital revealed thatunwanted pregnancies <strong>and</strong> voluntary abortions do happen<strong>in</strong> Malé <strong>and</strong> <strong>in</strong> <strong>the</strong> outer isl<strong>and</strong>s.There are social <strong>and</strong> cultural barriers to <strong>the</strong> promotion<strong>and</strong> acceptance of contraceptives <strong>in</strong> <strong>the</strong> country. As withmany o<strong>the</strong>r countries <strong>in</strong> <strong>the</strong> region, Maldives adopted <strong>the</strong>“cafeteria approach” to <strong>the</strong> promotion of contraceptives;however, it has had limited impact due to sociocultural <strong>and</strong>geographical barriers. Ajmal (2003) considered that somecontraceptive methods such as condoms have been putunder schedule 3 of <strong>the</strong> drugs listed by <strong>the</strong> government,which means that <strong>the</strong>y can be sold only by a pharmacistwhen fill<strong>in</strong>g a prescription. Classification of condoms underschedule 3 of <strong>the</strong> drug list poses a barrier for sexually activepeople to access it as <strong>and</strong> when <strong>the</strong>y need it.Ow<strong>in</strong>g to <strong>the</strong> lack of services providers, <strong>the</strong> governmentwas not able to push methods, such as IUDs <strong>and</strong> implants(Implanon), on a massive scale. In summary, <strong>the</strong> methodmix has rema<strong>in</strong>ed very weak <strong>in</strong> Maldives <strong>and</strong> much needsto be improved <strong>in</strong> that regard.Unlike <strong>in</strong> o<strong>the</strong>r countries <strong>in</strong> <strong>the</strong> region, <strong>the</strong> demographictransition <strong>in</strong> Maldives is unique. The country has achieveda rapid fertility decl<strong>in</strong>e without a commensurate <strong>in</strong>creaseFigure144Population pyramid of Maldives, 2000 <strong>and</strong> 200612108642PillInjectablesCondomFemaleSterilizationMaleSterilizationIUCDImplanon01990 2004 2009Source: Source: MPND, 2007: Population <strong>and</strong> Hous<strong>in</strong>g Census, 2006.161

<strong>in</strong> CPR. Likewise, contraceptive use behaviour <strong>in</strong> Maldivesis quite different from <strong>the</strong> patterns commonly observedelsewhere. For example, contraceptive prevalence <strong>in</strong>Maldives decreased while education was <strong>in</strong>creas<strong>in</strong>g: useof modern methods was recorded at 36 per cent amongwomen with no education; among women who had receivededucation beyond secondary school, <strong>the</strong> figure stood at21 per cent. Much of <strong>the</strong> differential is attributed to <strong>the</strong>higher reliance on female sterilization among women withno education. Interest<strong>in</strong>gly, while use of <strong>the</strong> pill decl<strong>in</strong>edwith <strong>in</strong>creas<strong>in</strong>g education, condom use <strong>in</strong>creased with<strong>in</strong>creas<strong>in</strong>g education. Unlike many o<strong>the</strong>r countries, <strong>the</strong>differences <strong>in</strong> contraceptive prevalence by wealth statusor urban-rural residence are not substantial (MOHF-MDHS, 2009).Adolescent sexual <strong>and</strong> reproductivehealth <strong>and</strong> access to contraceptivesMaldives does not have an explicit policy on access tocontraceptives among adolescents, youth <strong>and</strong> unmarriedcouples/<strong>in</strong>dividuals. As a result, a large number ofadolescents do not have access to FP services despiteevidence show<strong>in</strong>g this group’s <strong>in</strong>creased sexual activity <strong>and</strong>risky behaviour.Several surveys <strong>and</strong> reports have shown <strong>in</strong>creasedvulnerability of Maldivian adolescents <strong>and</strong> youth to riskybehaviours (Narcotics Control Board, 2003; M<strong>in</strong>istry ofYouth <strong>and</strong> Sports, 2005; UNDP <strong>and</strong> MOH, 2008; <strong>and</strong>President’s Office, 2009). A rapid situation assessment ofdrug abuse <strong>in</strong> Maldives (Narcotics Control Board, 2003)reported that, by age 21, 75 per cent of youth have had atleast one sexual experience. Many of <strong>the</strong>se sexual encounterswere unprotected, mak<strong>in</strong>g <strong>the</strong>m <strong>the</strong> most at-risk group forrapid transmission of HIV/AIDS. A situational analysisof adolescents (M<strong>in</strong>istry of Youth <strong>and</strong> Sports, 2005)showed that only about 40 per cent of adolescents livedwith <strong>the</strong>ir parents. Approximately 27 per cent of youthaged 10-14 are not liv<strong>in</strong>g with <strong>the</strong>ir biological parents. Thepossible impacts of this situation are limited opportunities<strong>and</strong> stunted life skills development. The same study notedthat 14 per cent of males <strong>and</strong> 5 per cent of females under<strong>the</strong> age of 18 admitted to be<strong>in</strong>g sexually active. With accessto condoms for unmarried adolescents rema<strong>in</strong><strong>in</strong>g a barrier,many of <strong>the</strong>se young people did not use condoms.A fur<strong>the</strong>r study noted that, even though <strong>the</strong> Indira G<strong>and</strong>hiMemorial Hospital distributes condoms free of cost, manypotential users do not obta<strong>in</strong> <strong>the</strong>m from <strong>the</strong> hospital,preferr<strong>in</strong>g <strong>in</strong>stead to buy <strong>the</strong>ir supplies from pharmaciesfor <strong>the</strong> sake of confidentiality <strong>and</strong> br<strong>and</strong> availability (Ajmal,2003). The same study noted that, of <strong>the</strong> total buyers, only6 per cent were adolescents, a figure which pharmacistsacknowledge is below <strong>the</strong> actual number of users.Maldives conducted <strong>the</strong> first ever Demographic <strong>and</strong>Health Survey (DHS) <strong>in</strong> 2008/09. Prelim<strong>in</strong>ary resultsof <strong>the</strong> survey <strong>in</strong>dicated that knowledge (heard) of HIV/AIDS is almost universal among <strong>the</strong> Maldivian population(MOHF, 2009). More significantly, after receipt of <strong>the</strong> firstever <strong>in</strong>put for HIV/AIDS received from <strong>the</strong> Global Fund,<strong>the</strong> country’s first biological <strong>and</strong> behavioural survey wasconducted among <strong>the</strong> five most at-risk groups (seafarers,men hav<strong>in</strong>g sex with men (MSM), adolescent youth,commercial sex workers (CSWs) <strong>and</strong> <strong>in</strong>ject<strong>in</strong>g drug users,which showed that Maldivian youths are vulnerable toHIV/AIDS.The survey report noted that unprotected sex withmultiple partners is prevalent among <strong>the</strong> high-risk groups<strong>and</strong> that <strong>the</strong> shar<strong>in</strong>g of unsterilized needles <strong>and</strong> syr<strong>in</strong>gesis common among <strong>in</strong>ject<strong>in</strong>g drug users. The study alsofound risky behaviours among <strong>the</strong> 15-17-year-old <strong>and</strong>older age groups: buy<strong>in</strong>g <strong>and</strong> sell<strong>in</strong>g of sex; sex with nonregularpartners; premarital sex; group sex; <strong>and</strong> <strong>in</strong>ject<strong>in</strong>gdrugs. However, <strong>the</strong>se behaviours are not consistent with<strong>the</strong> self-perception of risk. The majority of respondentsbelieved <strong>the</strong>y would not get HIV from such behaviours.Some 3-6 per cent believed that <strong>the</strong>ir religion alone wouldprotect <strong>the</strong>m from HIV (UNDP <strong>and</strong> MOH, 2008). Youthseek<strong>in</strong>g counsell<strong>in</strong>g services are <strong>in</strong>creas<strong>in</strong>g 1 but <strong>the</strong> servicesare limited ma<strong>in</strong>ly to Malé. In 2009, Maldives participated<strong>in</strong> <strong>the</strong> Global School-based Student Health Survey, whichsubstantiated some of <strong>the</strong> f<strong>in</strong>d<strong>in</strong>gs of <strong>the</strong> above-mentionedsurveys <strong>and</strong> studies. The Survey found that <strong>the</strong> prevalenceof alcohol use among school students was 6.7 per cent.Alcohol use among boys was 9.1, whereas for girl students,it was 4.2 per cent. Among those who used alcohol, 66 percent of <strong>the</strong>m had used it prior to turn<strong>in</strong>g 14 years of age(Education Development Center <strong>and</strong> WHO, 2009).To address <strong>the</strong> sexual <strong>and</strong> reproductive health (SRH) careneeds of adolescents, UNFPA has been support<strong>in</strong>g <strong>the</strong><strong>in</strong>tegration of population <strong>and</strong> life skills education activities<strong>in</strong>to school curricula. However, <strong>the</strong> <strong>in</strong>troduction of thoseactivities has rema<strong>in</strong>ed modest <strong>and</strong> conf<strong>in</strong>ed mostly to <strong>the</strong>Malé area. The modules <strong>and</strong> tra<strong>in</strong><strong>in</strong>g have been very muchappreciated but ow<strong>in</strong>g to lack of support it has not beenpossible to reach out to <strong>the</strong> most vulnerable populationgroups – out-of-school adolescents <strong>and</strong> youth.To fill <strong>in</strong> <strong>the</strong> gaps <strong>in</strong> SRH services for adolescents <strong>and</strong>youth, particularly out-of-school youth, UNFPA <strong>and</strong>WHO jo<strong>in</strong>ed h<strong>and</strong>s to establish <strong>the</strong> Youth Health Café<strong>in</strong> Malé, which was a step forward <strong>in</strong> creat<strong>in</strong>g a conduciveenvironment for improv<strong>in</strong>g adolescents’ access to SRHservices. However, <strong>the</strong> <strong>in</strong>itiative did not produce <strong>the</strong>required momentum for a number of reasons. “Ownership”of <strong>the</strong> programme was lack<strong>in</strong>g. Institutionally, <strong>the</strong> Café ishoused <strong>in</strong> <strong>and</strong> run by <strong>the</strong> M<strong>in</strong>istry of Youth <strong>and</strong> Sports,but <strong>the</strong> services were to be provided <strong>and</strong> coord<strong>in</strong>ated162

y <strong>the</strong> M<strong>in</strong>istry of Health <strong>and</strong> <strong>Family</strong>. Lack of sectoralcoord<strong>in</strong>ation between agencies is ano<strong>the</strong>r reason. Given<strong>the</strong> prevail<strong>in</strong>g socio-political situation, consensus <strong>and</strong>coord<strong>in</strong>ation among all parties to improve SRH amongadolescents <strong>and</strong> youth is critically important.Likewise, UNFPA also partnered with WHO <strong>and</strong> <strong>the</strong>United Nations Children’s Fund (UNICEF) to improveaccess to services for victims of gender-based violence,with <strong>the</strong> establishment of <strong>the</strong> <strong>Family</strong> Protection Unitwith<strong>in</strong> <strong>the</strong> Indira G<strong>and</strong>hi Memorial Hospital under <strong>the</strong>supervision of a gynaecologist. Despite <strong>the</strong> potential of <strong>the</strong>unit to serve as <strong>the</strong> nodal agency to h<strong>and</strong>le cases of sexualabuse of children, teenage pregnancy <strong>and</strong> gender-basedviolence – a third of women <strong>in</strong> Maldives are reported tobe victims of gender-based violence (M<strong>in</strong>istry of Gender<strong>and</strong> <strong>Family</strong>, 2007) – lack of coord<strong>in</strong>ation among severalagencies, namely <strong>the</strong> M<strong>in</strong>istry of Health <strong>and</strong> <strong>Family</strong>, childprotection section with<strong>in</strong> <strong>the</strong> M<strong>in</strong>istry of Gender <strong>and</strong><strong>Family</strong> Welfare, police <strong>and</strong> o<strong>the</strong>r welfare agencies, hashampered <strong>the</strong> smooth function<strong>in</strong>g of <strong>the</strong> unit.Promotion of condoms as a means fordual protectionDespite critical evidence demonstrat<strong>in</strong>g <strong>the</strong> value ofpromot<strong>in</strong>g condoms as a means for “dual protection”, <strong>the</strong>government’s response has been lukewarm. A policy ondual protection <strong>and</strong> <strong>in</strong>tegration <strong>in</strong>to <strong>the</strong> RH commoditylist has yet to be formulated. Maldives’ successiveattempts to secure support from <strong>the</strong> Global Fund toFight AIDS, Tuberculosis <strong>and</strong> Malaria culm<strong>in</strong>ated <strong>in</strong>support for its HIV/AIDS programme, with UNDP as<strong>the</strong> pr<strong>in</strong>cipal recipient <strong>in</strong> 2006. Under <strong>the</strong> programme, aseries of exploratory <strong>and</strong> behavioural research activitieshave been carried out target<strong>in</strong>g <strong>the</strong> most at-risk groups.The programme has also been support<strong>in</strong>g syndromatictreatment of reproductive tract <strong>in</strong>fections <strong>and</strong> STIs <strong>in</strong><strong>the</strong> country. Table 4 shows <strong>the</strong> types of STI servicesprovided under <strong>the</strong> Global Fund-supported HIV/AIDSprogramme. STIs are a major <strong>and</strong> hidden RH problem <strong>in</strong>Maldives.The NGO sectorThe NGO sector <strong>in</strong> Maldives has been historically weak.Before <strong>the</strong> advent of multiparty democracy <strong>in</strong> 2008,only two to three national NGOs of importance were<strong>in</strong> existence. The Society for Health <strong>and</strong> Education hasrema<strong>in</strong>ed at <strong>the</strong> forefront of population activities <strong>in</strong> <strong>the</strong>country. UNFPA has provided <strong>the</strong> Society with support<strong>in</strong> order to assist <strong>the</strong> government <strong>in</strong> reach<strong>in</strong>g out tomarg<strong>in</strong>alized communities. The Society runs counsell<strong>in</strong>gcentres for adolescents, ma<strong>in</strong>ly premarital youth, offer<strong>in</strong>g<strong>the</strong>m counsell<strong>in</strong>g <strong>and</strong> referral services but not free access tocontraceptives. The Society also runs some youth-relatedactivities under <strong>the</strong> Global Fund-supported HIV/AIDSprogramme. Apart from furnish<strong>in</strong>g counsell<strong>in</strong>g support,<strong>the</strong> Society also runs an FP cl<strong>in</strong>ic, but it does not provideunmarried adolescents with free access to contraceptives;<strong>in</strong>stead it provides emergency contraceptives to victimsof sexual violence <strong>in</strong> consultation with guardians of <strong>the</strong>victims.There are a few o<strong>the</strong>r NGOs which are becom<strong>in</strong>g popular<strong>in</strong> <strong>the</strong> country, such as Journey, Maanfa-centre for <strong>the</strong>elderly population, <strong>and</strong> Mo<strong>the</strong>rs aga<strong>in</strong>st Drugs. Journeywas formed by a group of recover<strong>in</strong>g addicts for <strong>the</strong>purpose of help<strong>in</strong>g o<strong>the</strong>r addicts ma<strong>in</strong>ta<strong>in</strong> <strong>the</strong>ir recovery<strong>and</strong> to raise public awareness about drug addiction <strong>and</strong>related issues; it has played a critical role <strong>in</strong> <strong>the</strong> activitiesof <strong>the</strong> Global Fund.NGO Capacity <strong>and</strong> Needs Assessment, which waspublished <strong>in</strong> 2009 by <strong>the</strong> Raajje Foundation, <strong>the</strong> AustralianGovernment <strong>and</strong> UNDP, found that among somegovernment <strong>in</strong>stitutions <strong>the</strong>re is little underst<strong>and</strong><strong>in</strong>g of<strong>and</strong> support for mean<strong>in</strong>gfully <strong>in</strong>volv<strong>in</strong>g <strong>and</strong> collaborat<strong>in</strong>gwith NGOs <strong>and</strong> civil society. The exist<strong>in</strong>g AssociationsAct <strong>and</strong> its regulations need to be revised <strong>in</strong> order toimprove participation by <strong>in</strong>dependent <strong>and</strong> diverse civilsociety actors. The report fur<strong>the</strong>r noted that <strong>the</strong> capacityof NGOs is low ow<strong>in</strong>g to <strong>the</strong> low level of fund<strong>in</strong>g <strong>the</strong>yreceive <strong>and</strong> <strong>the</strong> <strong>in</strong>adequate human resources that run <strong>the</strong>m,as <strong>the</strong>y are managed mostly by volunteers.TableTable2DescriptionPatients with sexually transmitted <strong>in</strong>fections provided services through Global Fund-supported HIV/AIDS projects <strong>and</strong> programmeNumber of health-care providers tra<strong>in</strong>ed <strong>in</strong>diagnosis <strong>and</strong> cl<strong>in</strong>ical management of STIsNumber of STI cases treated at health-carefacilitiesBy August 2009 By June 2010Target Achieved Target Achieved248 253 261 316200 1619 1,702 2,587Source: UNDP/Global Fund to Fight AIDS, Tuberculosis <strong>and</strong> Malaria, 2010. Data furnished by UNDP/Global Fund ProgrammeManager.163

<strong>International</strong> supportMaldives has received generous support from <strong>in</strong>ternationaldevelopment partners <strong>and</strong> agencies, such as WHO,UNICEF <strong>and</strong> UNFPA, <strong>in</strong> promot<strong>in</strong>g health-care services<strong>in</strong> <strong>the</strong> country. While WHO has been actively engageds<strong>in</strong>ce <strong>the</strong> early 1960s, UNFPA came relatively late to <strong>the</strong>scene, although it contributed significantly <strong>in</strong> promot<strong>in</strong>gFP <strong>and</strong> RH services. UNFPA has been <strong>the</strong> only agencysupport<strong>in</strong>g Maldives <strong>in</strong> RH commodities, <strong>in</strong>clud<strong>in</strong>g FPservices, <strong>and</strong> with its logistics management system. Underan exit strategy agreed with <strong>the</strong> government, UNFPAhas gradually reduced its share <strong>in</strong> <strong>the</strong> procurement ofRH commodities, while <strong>the</strong> government’s share has been<strong>in</strong>creas<strong>in</strong>g. As a result, by 2010 <strong>the</strong> Government of Maldiveshad taken ownership of contraceptive procurement throughits own <strong>in</strong>ternal resources. UNFPA no longer <strong>in</strong>vests <strong>in</strong>FP procurement, although it still assists <strong>the</strong> government <strong>in</strong><strong>in</strong>ternational procurement <strong>and</strong> quality control.Maldives drafted <strong>the</strong> first National HIV/AIDS Policy<strong>in</strong> 1996 with WHO support. This policy was fur<strong>the</strong>rrevised <strong>and</strong> updated <strong>in</strong> 2004 to address emerg<strong>in</strong>g issues,<strong>in</strong>clud<strong>in</strong>g f<strong>in</strong>d<strong>in</strong>gs from youth <strong>and</strong> drug surveys (M<strong>in</strong>istryof Health, 2006a). The HIV/AIDS policy is aimed atcontroll<strong>in</strong>g <strong>and</strong> limit<strong>in</strong>g <strong>the</strong> transmission of HIV <strong>in</strong>fectionthrough IEC activities, while tak<strong>in</strong>g measures to ma<strong>in</strong>ta<strong>in</strong>confidentiality <strong>and</strong> elim<strong>in</strong>ate discrim<strong>in</strong>ation. Maldivesalso started receiv<strong>in</strong>g support from <strong>the</strong> Global Fund. The2008 Biological <strong>and</strong> Behavioral Survey conducted under<strong>the</strong> Global Fund helped to establish a scientific databaseon some of <strong>the</strong> most at-risk groups, such as FSWs, MSM,youth, <strong>in</strong>ject<strong>in</strong>g drug users <strong>and</strong> seafarers.Underst<strong>and</strong><strong>in</strong>g <strong>the</strong> currentsituationMaldives’ demographics are unique <strong>in</strong> many ways. With<strong>in</strong> ashort period of time, Maldives experienced a rapid decl<strong>in</strong>e<strong>in</strong> birth <strong>and</strong> death rates <strong>and</strong> an <strong>in</strong>creased expectation of lifeat birth. These improvements were felt across all regions<strong>and</strong> adm<strong>in</strong>istrative units <strong>and</strong> had important implicationsfor reduc<strong>in</strong>g TFR, IMR <strong>and</strong> child mortality, <strong>and</strong> MMR.As a result, Maldives has already achieved some of <strong>the</strong>ICPD goals <strong>and</strong> most of <strong>the</strong> MDGs. However, Maldivesfaces challenges <strong>in</strong> susta<strong>in</strong><strong>in</strong>g <strong>and</strong> consolidat<strong>in</strong>g <strong>the</strong> ga<strong>in</strong>sit has made.Among <strong>the</strong> implications of <strong>the</strong> demographic transition arechanges <strong>in</strong> <strong>the</strong> age <strong>and</strong> sex structures of <strong>the</strong> population.Maldives’ population is youthful <strong>and</strong> <strong>the</strong> country is alreadypositioned to take advantage of <strong>the</strong> previously mentioned“Demographic Dividend” – a w<strong>in</strong>dow of opportunitywhere <strong>the</strong> work<strong>in</strong>g-age population exceeds <strong>the</strong> number<strong>in</strong> dependent age groups, mak<strong>in</strong>g it potentially <strong>the</strong> mostproductive period <strong>in</strong> <strong>the</strong> country’s history. However, thishas also meant that <strong>the</strong>re is a high level of unemploymentamong educated youth. Because of early sexual activity<strong>and</strong> lack of safe sexual behaviour, coupled with <strong>in</strong>creas<strong>in</strong>gdrug <strong>and</strong> substance abuse, Maldives is vulnerable torapid transmission of HIV <strong>in</strong>fection if fur<strong>the</strong>r preventivemeasures are not <strong>in</strong>troduced. For example, a situationanalysis <strong>in</strong> an HIV/AIDS study estimated that, by 2015,without <strong>in</strong>tervention, Maldives would have as many 5,780HIV cases. However with <strong>in</strong>tervention, <strong>the</strong> number ofsuch cases could be reduced to 292 cases (NAC et al.,2006).There are some disturb<strong>in</strong>g signs as well. After a steepdecl<strong>in</strong>e <strong>in</strong> TFR <strong>in</strong> 2006, <strong>the</strong> latest DHS conducted <strong>in</strong> 2009showed that fertility had actually <strong>in</strong>creased dur<strong>in</strong>g <strong>the</strong>period 2006-2009 from 2.1 children per woman <strong>in</strong> 2006to 2.5 <strong>in</strong> 2009. This <strong>in</strong>crease <strong>in</strong> TFR was accompaniedby a decrease <strong>in</strong> CPR, especially for modern methods.Factors which are contribut<strong>in</strong>g to such reversed trends <strong>in</strong><strong>the</strong> country are a matter of serious concern <strong>and</strong> need to bewatched <strong>and</strong> addressed carefully.One of <strong>the</strong> ma<strong>in</strong> reasons for this reversal has been a shift <strong>in</strong>government priorities <strong>in</strong> terms of policies <strong>and</strong> programmes.Maldives is one of <strong>the</strong> few countries that conduct a censusevery five years, which enables <strong>the</strong> government to review itspolicies <strong>and</strong> programmes based on new socio-demographic<strong>in</strong>dicators. Once <strong>the</strong> government realized that <strong>the</strong>population was undergo<strong>in</strong>g rapid demographic change,especially after <strong>the</strong> 2000 census, it shifted <strong>the</strong> focus of itsdevelopment programmes to areas o<strong>the</strong>r than FP, <strong>and</strong> at alllevels. Public health workers <strong>in</strong> government departmentsacknowledged this shift <strong>and</strong> agreed that <strong>the</strong> governmentwas not aggressively pursu<strong>in</strong>g <strong>and</strong> implement<strong>in</strong>g <strong>the</strong> FPagenda as it had <strong>in</strong> <strong>the</strong> past. Government allocation ofresources is based on population figures. With <strong>the</strong> decl<strong>in</strong>e<strong>in</strong> <strong>the</strong> number of school-go<strong>in</strong>g children, isl<strong>and</strong> communitiesbelieve that <strong>the</strong> government might close schools or mergeexist<strong>in</strong>g ones with those on neighbour<strong>in</strong>g isl<strong>and</strong>s. Theythought similar action was also likely to happen to healthfacilities. Hence, isl<strong>and</strong> communities were <strong>in</strong>cl<strong>in</strong>ed towardspronatalism <strong>and</strong> shunned <strong>the</strong> use of FP services.In view of <strong>the</strong> constra<strong>in</strong>ts on national development posedby <strong>the</strong> country’s geography, <strong>the</strong> government <strong>in</strong>troduceda population consolidation policy aimed at reduc<strong>in</strong>g <strong>the</strong>sparsely populated isl<strong>and</strong>s by merg<strong>in</strong>g <strong>the</strong>m with nearbyisl<strong>and</strong>s <strong>and</strong> establish<strong>in</strong>g regional centres. However, <strong>the</strong> lackof clarity on what consolidation entails <strong>and</strong> <strong>the</strong> way it hasbeen h<strong>and</strong>led created a negative impact on FP programmes.Isl<strong>and</strong> communities, especially <strong>the</strong> elite <strong>and</strong> leaders,viewed <strong>the</strong> government as target<strong>in</strong>g <strong>the</strong>ir community forconsolidation. They surmised that if FP cont<strong>in</strong>ues to be164

practised <strong>the</strong> community would be targeted for be<strong>in</strong>gmoved to ano<strong>the</strong>r isl<strong>and</strong> for consolidation, <strong>and</strong> would haveto face more difficulties than it had <strong>in</strong> <strong>the</strong> past.The United Nations Country Team, <strong>in</strong> its countrysituation analysis drafted <strong>in</strong> preparation for <strong>the</strong> next cycleof support, recognized that <strong>the</strong>re had been an <strong>in</strong>crease <strong>in</strong>Islamic fundamentalism <strong>and</strong> this critical factor would havean important bear<strong>in</strong>g on Maldives’ future development(UNCT, 2010). Such fundamentalists were us<strong>in</strong>g FP <strong>in</strong><strong>the</strong>ir propag<strong>and</strong>a <strong>and</strong> were claim<strong>in</strong>g that <strong>the</strong> use of FP wasaga<strong>in</strong>st Islamic pr<strong>in</strong>cipals, so <strong>the</strong>y discouraged people frompractis<strong>in</strong>g FP. Their l<strong>in</strong>e of propag<strong>and</strong>a also <strong>in</strong>fluenced <strong>the</strong>attitudes <strong>and</strong> behaviour of service providers who wereencouraged to not promote FP.Despite Maldives’ relatively good socio-economic<strong>in</strong>dicators, violence aga<strong>in</strong>st women is widespread: one <strong>in</strong>every three women has experienced violence <strong>in</strong> her lifetime(M<strong>in</strong>istry of Gender <strong>and</strong> <strong>Family</strong>, 2007). Maldives also hasone of <strong>the</strong> highest percentages of women who are headsof household. This situation puts an added burden onwomen who have to take on <strong>the</strong> role of head of <strong>the</strong> family<strong>in</strong> addition to <strong>the</strong>ir o<strong>the</strong>r responsibilities.Of critical importance are <strong>the</strong> new government policies<strong>and</strong> programmes. The Strategic Action Plan 2009-2013,<strong>the</strong> National Framework for Development, will serve as<strong>the</strong> pr<strong>in</strong>cipal plann<strong>in</strong>g document of <strong>the</strong> government <strong>in</strong> <strong>the</strong>delivery of <strong>the</strong> pledges <strong>and</strong> programmes outl<strong>in</strong>ed <strong>in</strong> <strong>the</strong>alliance manifesto of <strong>the</strong> Maldives Democratic Party. Thefive pledges <strong>in</strong>volve: (a) develop<strong>in</strong>g a nationwide transportnetwork that would allow people <strong>and</strong> commerce to movewithout h<strong>in</strong>drance throughout <strong>the</strong> whole country; (b)provid<strong>in</strong>g all citizens with affordable hous<strong>in</strong>g; (c) ensur<strong>in</strong>greasonable <strong>and</strong> affordable health care for all citizens;(d) br<strong>in</strong>g<strong>in</strong>g down <strong>the</strong> cost of <strong>the</strong> most basic goods <strong>and</strong>services; <strong>and</strong> (e) elim<strong>in</strong>at<strong>in</strong>g <strong>the</strong> rampant traffick<strong>in</strong>g <strong>in</strong> <strong>and</strong>abuse of narcotic drugs currently prevalent <strong>in</strong> <strong>the</strong> country.The Strategic Action Plan is to date <strong>the</strong> government’s mostcomprehensive plann<strong>in</strong>g document. A number of policyframeworks are proposed under each sector. Under <strong>the</strong>health sector, <strong>the</strong> follow<strong>in</strong>g policy statements have beenarticulated:Streng<strong>the</strong>n health promotion, protection <strong>and</strong> advocacyfor healthy public policiesProvide access to affordable, equitable <strong>and</strong> good-qualityhealth services for all Maldivians, <strong>in</strong>clud<strong>in</strong>g provision ofuniversal health <strong>in</strong>suranceBuild a competent, professional health-serviceworkforceBuild a culture of evidence-based decision-mak<strong>in</strong>gwith<strong>in</strong> <strong>the</strong> health systemEstablish <strong>and</strong> enforce appropriate quality assurance <strong>and</strong>regulatory framework for patientsEnhance <strong>the</strong> response of health systems <strong>in</strong> emergenciesIn its mission statement <strong>the</strong> M<strong>in</strong>istry of Health <strong>and</strong> <strong>Family</strong>mentioned that it <strong>in</strong>tends to establish systems for <strong>the</strong> health,well-be<strong>in</strong>g <strong>and</strong> social protection of <strong>the</strong> people; provideaffordable, accessible <strong>and</strong> good-quality health-care services<strong>and</strong> drug rehabilitation services; streng<strong>the</strong>n mechanismsfor protect<strong>in</strong>g <strong>the</strong> rights of its children, women, personswith disabilities <strong>and</strong> <strong>the</strong> elderly; <strong>and</strong> susta<strong>in</strong> <strong>the</strong> qualityof health care <strong>and</strong> social protection services. One of <strong>the</strong>pillars of <strong>the</strong> Plan is “affordable <strong>and</strong> (good-)quality healthcare for all”. Among o<strong>the</strong>r th<strong>in</strong>gs, its strategies <strong>in</strong>cludestreng<strong>the</strong>n<strong>in</strong>g <strong>the</strong> mo<strong>the</strong>rhood <strong>and</strong> RH programmes that<strong>in</strong>clude age-appropriate adolescent sexual <strong>and</strong> reproductivehealth care, treatment of cancers, address<strong>in</strong>g genderbasedviolence, provid<strong>in</strong>g RH commodities <strong>and</strong> assur<strong>in</strong>guniversal health <strong>in</strong>surance for all.The government has formulated a new health masterplan (MOH, 2006b); it has also put <strong>in</strong>to operation anew RH strategy for <strong>the</strong> period 2008-2010. Accord<strong>in</strong>gto <strong>the</strong> Strategic Action Plan, <strong>the</strong> government <strong>in</strong>tendsto streng<strong>the</strong>n public-private partnerships <strong>and</strong> entrust<strong>the</strong> operation of health facilities to corporations. Thegovernment also <strong>in</strong>tends to promote decentralization <strong>and</strong>give greater control to <strong>the</strong> people. Accord<strong>in</strong>gly, it has alreadyformed two corporations for <strong>the</strong> Indira G<strong>and</strong>hi MemorialHospital <strong>and</strong> Addu City Regional Hospital. However,<strong>the</strong>re is no clear policy on how <strong>the</strong> corporatization of healthfacilities will help to achieve <strong>the</strong> pledges made under <strong>the</strong>Strategic Action Plan. Likewise, <strong>the</strong> government has alsodeveloped an ambitious health <strong>in</strong>surance plan known as <strong>the</strong>Madhana Scheme to cover all Maldivians. Except for <strong>the</strong>voluntary health <strong>in</strong>surance scheme, which is patronized bysemi-government entities, Madhana is <strong>the</strong> only <strong>in</strong>surancescheme that promises to cover all Maldivians. In 2011,“Madhana Plus” is likely to be <strong>in</strong>troduced to providesubsidies for treatment <strong>in</strong>ternationally. The governmentalso plans to subsidize <strong>in</strong>surance premiums for thosewho earn less than Rufiyaa (rf ) 21 per day (US$ 1 = 15.3Rufiyaa); about 100,000 persons are estimated to earn lessthan 21 rf per day. This would entail a recurr<strong>in</strong>g f<strong>in</strong>ancialburden of US$ 200 million at a time when <strong>the</strong> world isundergo<strong>in</strong>g <strong>the</strong> effects of a serious f<strong>in</strong>ancial crisis (M<strong>in</strong>istryof Health <strong>and</strong> WHO, 2009). Ano<strong>the</strong>r study (Chamaraet al., 2009) on <strong>in</strong>equality <strong>in</strong> health services <strong>in</strong> Maldivesrecognized <strong>the</strong> ga<strong>in</strong>s made by <strong>the</strong> country <strong>and</strong> noted that,even though health services outside Malé are pro-poor,<strong>in</strong>equality prevails <strong>in</strong> <strong>the</strong> provision of special services <strong>and</strong>care. The cost of travel to seek a higher level of healthservices is very high, <strong>and</strong> significant <strong>in</strong>equality is <strong>in</strong>volved<strong>in</strong> obta<strong>in</strong><strong>in</strong>g medic<strong>in</strong>e when needed. Government policies,such as <strong>the</strong> ones mentioned above, have wider implicationsfor <strong>the</strong> delivery of health services. Maldives’ current success165

<strong>in</strong> development has been through <strong>in</strong>vestments <strong>in</strong> build<strong>in</strong>gsocial capital <strong>and</strong> <strong>in</strong> provid<strong>in</strong>g <strong>the</strong> people with healthservices <strong>and</strong> education. Public expenditure on health <strong>and</strong>education is <strong>the</strong> highest of all: <strong>the</strong> public sector f<strong>in</strong>ances 90per cent of <strong>the</strong> health expenditure <strong>in</strong> <strong>the</strong> country. However,this may not be <strong>the</strong> case <strong>in</strong> <strong>the</strong> future. Vulnerable groups,such as women, adolescents <strong>and</strong> youths, <strong>and</strong> people liv<strong>in</strong>g<strong>in</strong> <strong>the</strong> outer isl<strong>and</strong>s would <strong>the</strong>n be deprived of muchneeded health services.RecommendationsRepackag<strong>in</strong>g of population <strong>and</strong> development issues.Although Maldives has made significant ga<strong>in</strong>s <strong>in</strong> achiev<strong>in</strong>gMDGs relat<strong>in</strong>g to MMR <strong>and</strong> IMR, it has yet to achieve <strong>the</strong>ICPD goal on improv<strong>in</strong>g universal access to RH services,especially among adolescents <strong>and</strong> youth. Likewise, a CPRof 27 per cent for modern methods <strong>and</strong> a seem<strong>in</strong>gly highunmet need estimated to be about 33 per cent (new DHSdata have yet to be analysed) clearly demonstrate <strong>the</strong> needfor promot<strong>in</strong>g SRH rights <strong>and</strong> services <strong>in</strong> <strong>the</strong> country,hence <strong>the</strong> refocus on FP services. UNFPA <strong>and</strong> RHadvocates must repackage <strong>the</strong> programme <strong>and</strong> its messages,capitaliz<strong>in</strong>g on <strong>the</strong> recognition of reproductive rights by<strong>the</strong> government. Emerg<strong>in</strong>g data must be analysed to createevidence to advocate for cont<strong>in</strong>ued relevancy of promot<strong>in</strong>gRH for improv<strong>in</strong>g <strong>the</strong> quality of life for Maldivian men,women <strong>and</strong> adolescents. Innovative approaches must beidentified <strong>and</strong> worked out to suit <strong>the</strong> chang<strong>in</strong>g preferencesof people.Conduct qualitative <strong>and</strong> sociocultural research. There arecritical gaps <strong>in</strong> underst<strong>and</strong><strong>in</strong>g <strong>the</strong> factors underp<strong>in</strong>n<strong>in</strong>g <strong>the</strong>demographic transition <strong>and</strong> Maldives’ success <strong>in</strong> improv<strong>in</strong>gits socio-economic condition. The relatively low CPRof 39 per cent <strong>and</strong> a decl<strong>in</strong>e <strong>in</strong> TFR to 2.1 children perwoman <strong>in</strong> 2006 dem<strong>and</strong> that much more be learned about<strong>the</strong> society’s RH behaviour. What is contribut<strong>in</strong>g to <strong>the</strong>sephenomena? Is it abortion, or <strong>the</strong> high mobility of men, orsecondary sterility, or a high prevalence of RTI/STIs, or acomb<strong>in</strong>ation of <strong>the</strong>se factors? There are several unansweredquestions. Abortion is illegal <strong>in</strong> <strong>the</strong> country, but abortionis believed to be carried out both with<strong>in</strong> <strong>the</strong> country <strong>and</strong>outside. An <strong>in</strong>-depth, sociocultural perspective to helpunderst<strong>and</strong> <strong>the</strong> situation is clearly needed.Improv<strong>in</strong>g <strong>the</strong> contraceptive method mix. Thecontraceptive method mix has rema<strong>in</strong>ed weak <strong>in</strong> Maldives.Future programme efforts must be directed at improv<strong>in</strong>g<strong>the</strong> method mix. For this purpose, tra<strong>in</strong><strong>in</strong>g of serviceproviders on <strong>the</strong> use of methods <strong>and</strong> counsell<strong>in</strong>g is criticallyimportant. Given <strong>the</strong> rise of Islamic fundamentalistelements <strong>in</strong> <strong>the</strong> country, it is likely that <strong>the</strong>re will be strongeropposition to some FP methods than o<strong>the</strong>rs, for example,male sterilization. RH <strong>and</strong> population programmes mustbe developed <strong>and</strong> designed to reflect sensitivity to <strong>the</strong>seissues, <strong>the</strong> chang<strong>in</strong>g priorities of <strong>the</strong> community at large<strong>and</strong> of service providers. FP efforts of Maldives <strong>in</strong> <strong>the</strong>past had been successful, stress<strong>in</strong>g <strong>the</strong> importance of birthspac<strong>in</strong>g for <strong>the</strong> desired number of children. In learn<strong>in</strong>gfrom past experiences, similar programmatic efforts shouldbe directed at utiliz<strong>in</strong>g <strong>the</strong> changed context to promoteSRH <strong>and</strong> <strong>the</strong> reproductive rights of <strong>in</strong>dividuals, <strong>in</strong>form<strong>in</strong>g<strong>the</strong>m about <strong>the</strong> choices of methods <strong>and</strong> <strong>the</strong>ir efficacy. Male<strong>in</strong>volvement <strong>in</strong> FP should be promoted more effectively.Such efforts should also target <strong>the</strong> capacity-build<strong>in</strong>g ofFP service providers by develop<strong>in</strong>g <strong>the</strong>ir skills <strong>in</strong> serviceprovision, of which client counsell<strong>in</strong>g is an <strong>in</strong>tegral part.Advocacy <strong>and</strong> lobby<strong>in</strong>g. There are new actors <strong>in</strong> population<strong>and</strong> development <strong>in</strong> <strong>the</strong> country. There is a new parliament(People’s Majlis), <strong>and</strong> many parliamentarians are young<strong>and</strong> restless. The Islamic party is a coalition partner <strong>and</strong><strong>the</strong> Supreme <strong>Council</strong> for Islamic Affairs has a major roleto play <strong>in</strong> shap<strong>in</strong>g <strong>the</strong> op<strong>in</strong>ions, values <strong>and</strong> behaviour of<strong>the</strong> people. To best utilize <strong>the</strong> opportunities providedby <strong>the</strong> Strategic Action Plan <strong>and</strong> Maldives’ <strong>in</strong>ternationalcommitments, new advocacy materials need to be preparedfor specific target groups at all levels. Tailored exposurevisits of ykey actors from relevant countries (Bangladesh,Indonesia, Iran, Malaysia <strong>and</strong> Pakistan) should be targetedto promote <strong>the</strong> importance of SRH.The Global Fund has successfully utilized <strong>the</strong> Supreme<strong>Council</strong> for Islamic Affairs <strong>in</strong> respect of mak<strong>in</strong>g known<strong>the</strong> benefits of <strong>the</strong> country’s HIV/AIDS programme.Population <strong>and</strong> RH programmes can also benefit fromsuch <strong>in</strong>terventions. Advocacy materials for such purposesmust be grounded <strong>and</strong> evidence-based, <strong>and</strong> <strong>the</strong> evidenceshould come from <strong>the</strong> socio-economic research proposedabove, while DHS <strong>and</strong> BBS could provide fur<strong>the</strong>r evidenceon some of <strong>the</strong> issues. Advocacy tools <strong>and</strong> materials basedon <strong>the</strong>se should be developed <strong>and</strong> used to <strong>in</strong>form <strong>and</strong> lobbyfor relevant policy <strong>and</strong> programmatic changes.Address<strong>in</strong>g <strong>the</strong> sexual <strong>and</strong> reproductive health needs ofadolescents <strong>and</strong> youth. Maldives’ adolescent <strong>and</strong> youthpopulation is sexually active <strong>and</strong> restless. A number ofsociocultural factors – high divorce rate, high unemployment<strong>and</strong> lack of access to RH services <strong>and</strong> <strong>in</strong>formation –have fur<strong>the</strong>r compounded <strong>the</strong> situation. Youth-relatedproblems have worsened <strong>in</strong> densely populated places suchas Malé <strong>and</strong> Addu. Lack of space <strong>and</strong> opportunities forplay<strong>in</strong>g sports <strong>and</strong> enjoy<strong>in</strong>g o<strong>the</strong>r forms of recreationdrives adolescents to seek o<strong>the</strong>r avenues for spend<strong>in</strong>g <strong>the</strong>irfree time. Youth reportedly are be<strong>in</strong>g used by all politicalparties for various purposes. Schools <strong>and</strong> educationalcurricula should be developed that value labour, teach lifeskillseducation <strong>and</strong> are employment-oriented, along withprovid<strong>in</strong>g students with SRH <strong>in</strong>formation <strong>and</strong> services.A multisectoral response to address adolescent RH <strong>and</strong>166

development needs should be prioritized. Evaluation of<strong>the</strong> <strong>Family</strong> Protection Unit <strong>and</strong> <strong>the</strong> Youth Health Café<strong>and</strong> related recommendations should be used to create anew model of service provision for improv<strong>in</strong>g <strong>the</strong> accessof adolescents <strong>and</strong> youth. The private sector, civil society<strong>and</strong> NGOs should be streng<strong>the</strong>ned <strong>and</strong> encouraged topromote sexual <strong>and</strong> reproductive health <strong>in</strong>formation <strong>and</strong>services for adolescents <strong>in</strong> order to protect <strong>the</strong>m from riskysexual behaviour.Communication <strong>and</strong> behavioural change. Despite universalknowledge of FP devices <strong>and</strong> HIV/AIDS <strong>in</strong> Maldives, useof recommended methods is nom<strong>in</strong>al both for meet<strong>in</strong>g <strong>the</strong>unmet need <strong>and</strong> protection from risky sexual behaviour.The focus of future RH <strong>and</strong> population programmesshould be to identify <strong>the</strong> communication messages neededto change <strong>the</strong> behaviour of people, most importantlyadolescents <strong>and</strong> youth. Peer education <strong>and</strong> role modelscould be used to <strong>in</strong>fluence <strong>the</strong> outcome. Build<strong>in</strong>g upon<strong>the</strong> <strong>in</strong>creas<strong>in</strong>g evidence from various surveys <strong>and</strong> studies,multiple media sources, both electronic <strong>and</strong> pr<strong>in</strong>t, shouldbe engaged <strong>and</strong> encouraged to dissem<strong>in</strong>ate such messagesto reach out to a wider spectrum of adolescents, youth <strong>and</strong><strong>the</strong>ir families.Address<strong>in</strong>g gender disparities <strong>and</strong> gender-based violence.Maldives is less likely to achieve MDGs <strong>in</strong> terms of reduc<strong>in</strong>ggender disparity <strong>and</strong> reduc<strong>in</strong>g violence aga<strong>in</strong>st women. As aliberal Muslim state <strong>in</strong> <strong>the</strong> past, Maldives provided womenwith relative freedom <strong>and</strong> improved <strong>the</strong>ir socio-economicstatus. However, women <strong>in</strong> Maldives suffer from genderbasedviolence. Address<strong>in</strong>g gender-based violence requiresa multi-pronged approach at all levels. The new StrategicAction Plan has some good elements for promot<strong>in</strong>g genderequality <strong>and</strong> empower<strong>in</strong>g women. Development partnersmust cont<strong>in</strong>ue to build on past achievements; while notlos<strong>in</strong>g sight of <strong>the</strong> progress that had been made, <strong>the</strong>y needto focus on what still needs to be done.End Note1 Personal communication with Dr. Mausooma Kamaludd<strong>in</strong>,Director of Sexual <strong>and</strong> Reproductive Health of <strong>the</strong> Society forHealth Education.ReferencesAjmal, Mohamed (2003). Market Research on CondomPrevalence <strong>and</strong> Promotion, 2003. UNFPA, Maldives.Chamara, Anurana et al. (2009). y, f<strong>in</strong>al draft report forWHO <strong>and</strong> Government of Maldives, Colombo:Institute of Health Policy.Chaudhury, Rafiqul H, 1996. A socio-demographicprofile of <strong>the</strong> population of Maldives, <strong>Asia</strong>-<strong>Pacific</strong>Population Journal, vol. 11(4), pp: 3-26.Department of Public Health (DPH)(2008).Reproductive Health Strategy, 2008-2010. M<strong>in</strong>istryof Health.Department of Public Health (DPH) <strong>and</strong> World HealthOrganization (WHO), 2008. Streng<strong>the</strong>n<strong>in</strong>g healthservices through primary health care <strong>in</strong> Maldives.Draft.Didi, Am<strong>in</strong>ath Mohamed (1991). Determ<strong>in</strong>ants ofcontraceptive use patterns <strong>in</strong> Addu Atoll, Maldives.Thesis submitted <strong>in</strong> partial fulfilment of <strong>the</strong>requirements for <strong>the</strong> degree of Master of Arts <strong>in</strong>Population <strong>and</strong> Social Research, Faculty of GraduateStudies, Mahidol University, Salaya, Nakhon Pathom,Thail<strong>and</strong>.Education Development Center <strong>and</strong> World HealthOrganization (WHO) (2009)., Malé: EducationDevelopment Center, M<strong>in</strong>istry of Education <strong>and</strong>WHO, Maldives.Government of Maldives (1994). National Reportfor <strong>the</strong> <strong>International</strong> Conference on Population <strong>and</strong>Development, Malé: Government of <strong>the</strong> Republic ofMaldives.__________ <strong>and</strong> UNFPA (2009). 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Health Master Plan, 2006-2015: Quality Health Care, Bridg<strong>in</strong>g <strong>the</strong> Gaps, Malé:M<strong>in</strong>istry of Health.__________ <strong>and</strong> WHO (2009). Health F<strong>in</strong>anc<strong>in</strong>g <strong>and</strong>Expenditure Review, a report prepared by Dr. SomilNagpal.M<strong>in</strong>istry of Health <strong>and</strong> <strong>Family</strong> (2009a). MaldivesDemographic <strong>and</strong> Health Survey, Prelim<strong>in</strong>ary Report,Malé: M<strong>in</strong>istry of Health <strong>and</strong> <strong>Family</strong> <strong>and</strong> ICF Macro.__________ (2009b). Maldives Health Statistics, 2009,Malé: M<strong>in</strong>istry of Health <strong>and</strong> <strong>Family</strong>.M<strong>in</strong>istry of <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> National Development(MPND) (2002). 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__________ (2007). Population <strong>and</strong> Hous<strong>in</strong>g Census,2006, Malé: MPND.M<strong>in</strong>istry of Youth <strong>and</strong> Sports (2005). Youth Voices:Facts, Op<strong>in</strong>ion <strong>and</strong> Solutions, Malé: M<strong>in</strong>istry of Youth<strong>and</strong> Sports, M<strong>in</strong>istry of <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> NationalDevelopment <strong>and</strong> United Nations Taskforce onAdolescents <strong>and</strong> Health.Narcotics Control Board (2003). Rapid SituationAssessment of Drug Abuse <strong>in</strong> Maldives, Malé: NCB.Naseem, Ibrahim, Bhakta Gubhaju <strong>and</strong> Hussa<strong>in</strong> Niyaaz(2004). Rapid fertility decl<strong>in</strong>e <strong>in</strong> <strong>the</strong> Maldives: anassessment, <strong>Asia</strong>-<strong>Pacific</strong> Population Journal, 19(3):57-74.National HIV/AIDS <strong>Council</strong> (NAC), M<strong>in</strong>istry ofHealth <strong>and</strong> <strong>the</strong> United Nations Theme Group onHIV/AIDS (2006). The HIV/AIDS Situation <strong>in</strong> <strong>the</strong>Republic of Maldives <strong>in</strong> 2006 (prepared by Mr. JanW de L<strong>in</strong>d van Wijngaarden, UNICEF consultant),Malé: M<strong>in</strong>istry of Health.Niyaaz, Hussa<strong>in</strong> (2002). Independent assessment of <strong>the</strong>level of fertility <strong>in</strong> <strong>the</strong> Maldives: results of a survey,M<strong>in</strong>istry of <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> National development.President’s Office, Government of Maldives (2009). TheStrategic Action Plan 2009-2013. Malé: President’sOffice.Thongthai, Varachai <strong>and</strong> Am<strong>in</strong>ath M. Didi (1996).Report on Knowledge, Attitude <strong>and</strong> Practice of ChildSpac<strong>in</strong>g Methods of Maldivian Women, Salaya,Nakhon Pathom, Thail<strong>and</strong>: Mahidol University.United Nations Country Team (UNCT)(2010).Situation analysis of emerg<strong>in</strong>g developmentchallenges <strong>and</strong> opportunities <strong>in</strong> Maldives, draft,March.United Nations Development Programme (UNDP) <strong>and</strong>M<strong>in</strong>istry of Health (MOH)(2008). First Biological<strong>and</strong> Behavioral Survey on HIV/AIDS <strong>in</strong> <strong>the</strong> Maldives– 2008, Malé: Global Fund Supported Programme <strong>in</strong>Maldives.United Nations Population Fund (UNFPA) (1997).Country Population Assessment UNFPA Maldives.168

NepalNepalThe Status of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong>Reproductive Health <strong>in</strong> NepalAn<strong>and</strong> Tamang*, Gov<strong>in</strong>d Subedi # <strong>and</strong> Ca<strong>the</strong>r<strong>in</strong>e Packer ¤* An<strong>and</strong> Tamang, Director, Center for Research on Environment Health <strong>and</strong> Population Activities (CREHPA),Kathm<strong>and</strong>u#Gov<strong>in</strong>d Subedi, Reader, Central Department of Population Studies, Tribhuvan University, Kathm<strong>and</strong>u.¤Ca<strong>the</strong>r<strong>in</strong>e Packer, Research Assistant, CREHPA, <strong>and</strong> c<strong>and</strong>idate for <strong>the</strong> degree Master of Science <strong>in</strong> Public Health,Johns Hopk<strong>in</strong>s University Bloomberg School of Public Health, Maryl<strong>and</strong>, United States.169

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IntroductionNepal’s population is estimated to be 28.6 million <strong>in</strong> 2011.The annual population growth rate was high over <strong>the</strong>last four <strong>in</strong>ter -census periods (1971-2011). The highestannual growth rate occurred between 1971 <strong>and</strong> 2001. Thetotal fertility rate (TFR) decreased from 6.3 children perwoman <strong>in</strong> 1976 to 3.1 <strong>in</strong> 2006 (MoH, 1976; <strong>and</strong> MoHP,2007). In <strong>the</strong> same period, <strong>the</strong> contraceptive prevalence rate(CPR) <strong>in</strong>creased from 2.9 per cent <strong>in</strong> 1976 to 48 per cent<strong>in</strong> 2006 (MoH, 1976; <strong>and</strong> MoHP, 2007). The maternalmortality ratio decl<strong>in</strong>ed from 539 deaths per 100,000live births <strong>in</strong> 1996 to 281 <strong>in</strong> 2006 (NDHS 2006); <strong>and</strong>MoHP, 2006). Much of this decl<strong>in</strong>e can be attributed to<strong>the</strong> <strong>in</strong>creased use of family plann<strong>in</strong>g.The number of females aged 15-49 years also <strong>in</strong>creasedsubstantially over <strong>the</strong> years: from 2.8 million <strong>in</strong> 1971 to3.5 <strong>in</strong> 1981, to 4.4 million <strong>in</strong> 1991 <strong>and</strong> to 5.6 million <strong>in</strong>2001. Thus, <strong>the</strong> share of females aged 15-49 <strong>in</strong> <strong>the</strong> totalpopulation rema<strong>in</strong>ed about 24 per cent over <strong>the</strong> censusyears. At <strong>the</strong> same time, <strong>the</strong> female population aged 15-24 years more than doubled dur<strong>in</strong>g 30 years – from 1.0million <strong>in</strong> 1971 to reach 2.3 million <strong>in</strong> 2011. The share ofyoung females <strong>in</strong> <strong>the</strong> total population was around 9 percent while this figure <strong>in</strong>creased to about 10 per cent <strong>in</strong> <strong>the</strong>census years of 1991 <strong>and</strong> 2001 (see Table 1). The need forfamily plann<strong>in</strong>g <strong>and</strong> reproductive health services cont<strong>in</strong>uesto be important <strong>in</strong> Nepal given its high populationgrowth rate, large number <strong>and</strong> proportion of femalesof reproductive age, <strong>and</strong> o<strong>the</strong>r poor demographic <strong>and</strong>reproductive outcome <strong>in</strong>dicators. In addition, <strong>in</strong>creas<strong>in</strong>gfocus on family plann<strong>in</strong>g will help Nepal achieve Targets5a <strong>and</strong> 5b of <strong>the</strong> Millennium Development Goals byfur<strong>the</strong>r reduc<strong>in</strong>g maternal mortality, <strong>in</strong>creas<strong>in</strong>g CPR <strong>and</strong>reduc<strong>in</strong>g unmet need.Table 2 summarizes some selected demographic <strong>and</strong>reproductive health <strong>in</strong>dicators of Nepal from 1996 to2006, draw<strong>in</strong>g on data from <strong>the</strong> Nepal <strong>Family</strong> HealthSurvey (NFHS) <strong>and</strong> <strong>the</strong> Nepal Demographic <strong>and</strong> HealthTableSurveys (NDHS). Data <strong>in</strong>dicate that <strong>the</strong> median age ofmarriage of females is still low: <strong>in</strong> 2006, <strong>the</strong> median ageof marriage was 17.2 years. Dur<strong>in</strong>g <strong>the</strong> 10-year period,<strong>the</strong> median age at marriage <strong>in</strong>creased only by 5 per cent.The median age at first birth rema<strong>in</strong>ed almost 20 yearsover <strong>the</strong> last decade. Data also show that nearly one-fifthof adolescent girls (15-19 years) became mo<strong>the</strong>rs or gotpregnant while adolescents.Indicators of fertility preference, such as desire for children<strong>and</strong> ideal family size, show <strong>the</strong> potential dem<strong>and</strong> for familyplann<strong>in</strong>g services. The proportion of currently marriedwomen who want no more children <strong>in</strong>creased from 59 percent <strong>in</strong> 1996 to 71 per cent <strong>in</strong> 2006 – an <strong>in</strong>crease of 20 percent dur<strong>in</strong>g <strong>the</strong> period. Similarly, <strong>the</strong>re was a noticeabledecl<strong>in</strong>e <strong>in</strong> <strong>the</strong> average ideal number of children desiredby women – a decl<strong>in</strong>e from 2.9 children <strong>in</strong> 1996 to 2.6<strong>in</strong> 2001 <strong>and</strong> to 2.3 <strong>in</strong> 2006. The ideal number of childrendesired by women <strong>in</strong> 2006 is close to replacement-levelfertility: 2.1 children.Indicators of maternal care, such as antenatal care <strong>and</strong>tetanus toxoid <strong>in</strong>jections, have been improv<strong>in</strong>g verysubstantially <strong>and</strong> <strong>the</strong>ir pace of improvement is also veryhigh. On <strong>the</strong> o<strong>the</strong>r h<strong>and</strong>, <strong>in</strong>dicators of delivery <strong>and</strong> bodymass <strong>in</strong>dex suggest that women are still at greater risk ofdy<strong>in</strong>g before, dur<strong>in</strong>g <strong>and</strong> immediately after delivery. This isbecause only 18 per cent of births were reported to occur <strong>in</strong>health facilities. Conversely, nearly 82 per cent of deliveriesstill occur at home without support of health workers ortra<strong>in</strong>ed birth attendants.Aims of <strong>the</strong> studyGiven this context of <strong>the</strong> position of <strong>the</strong> family plann<strong>in</strong>gprogramme, <strong>the</strong> present paper is aimed at answer<strong>in</strong>g <strong>the</strong>follow<strong>in</strong>g research questions:What are <strong>the</strong> levels <strong>and</strong> trends of contraceptive use <strong>in</strong>Nepal?Table1171

TableTable2What has <strong>the</strong> programme achieved <strong>in</strong> <strong>the</strong> last 40 years?What are <strong>the</strong> causes of success?What are <strong>the</strong> current issues <strong>in</strong> family plann<strong>in</strong>gprogrammes? Unmet need? Method mix? Qualityof services? Reach<strong>in</strong>g poor <strong>and</strong> vulnerable groups?Coord<strong>in</strong>ation <strong>and</strong> partnership? Contraceptive security?Is <strong>the</strong> family plann<strong>in</strong>g programme <strong>in</strong>tegrated witho<strong>the</strong>r reproductive health issues, such as HIV <strong>and</strong>sexually transmitted diseases (STIs), safe mo<strong>the</strong>rhood,adolescent health, male <strong>in</strong>volvement? How? Is this <strong>in</strong>l<strong>in</strong>e with <strong>the</strong> pr<strong>in</strong>ciples of <strong>the</strong> <strong>International</strong> Conferenceon Population <strong>and</strong> Development (ICPD)?What is <strong>the</strong> political <strong>and</strong> governmental commitment toprovide contraceptive services for all or <strong>the</strong> vulnerablegroups?What are <strong>the</strong> changes tak<strong>in</strong>g places <strong>in</strong> fund<strong>in</strong>g streamsboth at <strong>the</strong> domestic <strong>and</strong> <strong>in</strong>ternational levels?How has political <strong>and</strong> public support for <strong>the</strong> programmeshifted?What are <strong>the</strong> emerg<strong>in</strong>g areas <strong>in</strong> which <strong>the</strong> familyplann<strong>in</strong>g programme should concentrate <strong>in</strong> Nepal?To answer <strong>the</strong>se questions, Nepal’s demographic <strong>and</strong>health surveys were reviewed, extensive onl<strong>in</strong>e researchwas conducted, <strong>and</strong> reports <strong>and</strong> government policies <strong>and</strong>strategies were assessed. To supplement <strong>the</strong> secondaryresearch <strong>and</strong> ascerta<strong>in</strong> current perspectives on <strong>the</strong> statusof family plann<strong>in</strong>g <strong>in</strong> Nepal, 17 key stakeholders were<strong>in</strong>terviewed.Timel<strong>in</strong>e of family plann<strong>in</strong>gprogramme activities <strong>in</strong> NepalThe family plann<strong>in</strong>g programme <strong>in</strong> Nepal was <strong>in</strong>itiated <strong>in</strong>1959 by <strong>the</strong> non-governmental sector, <strong>the</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Association of Nepal (FPAN), <strong>and</strong> government-supportedfamily plann<strong>in</strong>g service delivery began <strong>in</strong> 1968. Over <strong>the</strong>years, <strong>the</strong> programme has exp<strong>and</strong>ed its coverage, <strong>and</strong> <strong>the</strong>services have been provided through different channels <strong>and</strong>agencies. Nepal began <strong>in</strong>itiat<strong>in</strong>g Health <strong>and</strong> DevelopmentPlans <strong>in</strong> <strong>the</strong> late 1950s <strong>and</strong> has already completed 10 five-172

year development plans <strong>and</strong> one three-year developmentplan. The Third Five-year Development Plan (1965-1970)was <strong>the</strong> first to clearly state <strong>the</strong> need for a populationpolicy <strong>in</strong> Nepal. <strong>Family</strong> plann<strong>in</strong>g was considered a crucial<strong>in</strong>strument <strong>in</strong> address<strong>in</strong>g high fertility. At this time, familyplann<strong>in</strong>g was <strong>in</strong>tegrated with maternal <strong>and</strong> child health(MCH). <strong>Family</strong> plann<strong>in</strong>g has always been a part of Nepal’sdevelopment plans <strong>and</strong> has had specific fertility reductionobjectives. (See Box 1 below.)Past achievements <strong>in</strong> familyplann<strong>in</strong>g <strong>and</strong> reproductivehealthThis section conta<strong>in</strong>s a review of key past achievements<strong>and</strong> lessons learned from Nepal’s national family plann<strong>in</strong>g(FP)/reproductive health (RH) programme.The follow<strong>in</strong>g are <strong>the</strong> major achievements s<strong>in</strong>ce 1970:TFR dropped from 6.3 <strong>in</strong> 1976 to 3.1 <strong>in</strong> 2006CPR rose from 2.9 per cent <strong>in</strong> 1976 to 48 per cent<strong>in</strong> 2006, with consistent <strong>in</strong>creases <strong>in</strong> every five-yearperiodMaternal mortality ratio dramatically decreased<strong>and</strong> much of this is attributed to FP, as well as safemo<strong>the</strong>rhood <strong>in</strong>itiativesNeonatal <strong>and</strong> <strong>in</strong>fant mortality decreasedEffective IEC programme encouraged smaller familysize <strong>and</strong> normalized FPKnowledge of FP methods has become nearlyuniversalSecrets of success/lessons learned are as follows:Governmental policies <strong>and</strong> programmes had specificfertility objectivesGovernment was able to establish health delivery<strong>in</strong>frastructure, <strong>in</strong>clud<strong>in</strong>g human resources, but <strong>the</strong>re isa lack of strong management <strong>and</strong> support to supervise<strong>and</strong> fur<strong>the</strong>r <strong>the</strong> programmesIntegration of services at facilities is more efficientCommunity-based distribution programmes, <strong>in</strong>clud<strong>in</strong>gFemale Community Health Volunteers, reachhouseholds <strong>in</strong> rural areasMobile camps for sterilization reach rural areasWide-reach<strong>in</strong>g public IEC campaigns on radio <strong>and</strong>television, as well as posters <strong>and</strong> billboardsSocial market<strong>in</strong>g of contraceptionEfforts to <strong>in</strong>crease education <strong>and</strong> literacy rates forwomen have led to more use of FP; importance given to<strong>in</strong>vest<strong>in</strong>g <strong>in</strong> social <strong>and</strong> economic development, as well asFP/RHCurrent issues <strong>in</strong> <strong>the</strong> nationalprogrammeService delivery<strong>Family</strong> plann<strong>in</strong>g <strong>in</strong>formation <strong>and</strong> services are providedby both <strong>the</strong> public <strong>and</strong> private sectors. The public sectordelivers family plann<strong>in</strong>g through different layers of healthfacilities <strong>in</strong> <strong>the</strong> country. At <strong>the</strong> community level, <strong>the</strong>reare 48,549 Female Community Health Volunteers <strong>in</strong> all75 districts of <strong>the</strong> country. They act as a bridge betweengovernment health services <strong>and</strong> <strong>the</strong> community, <strong>and</strong> <strong>the</strong>yare <strong>the</strong> frontl<strong>in</strong>e local health resource persons who providefamily plann<strong>in</strong>g <strong>and</strong> maternal health <strong>in</strong>formation <strong>and</strong>services. At <strong>the</strong> Village Development Committee level,<strong>the</strong>re are sub-health posts <strong>and</strong> health posts; at <strong>the</strong> area level,<strong>the</strong>re are primary health care centres <strong>and</strong> ilaka (roughlyequivalent to a sub-district) health posts; at <strong>the</strong> districtlevel, <strong>the</strong>re are district public health offices <strong>and</strong> at <strong>the</strong>central level, <strong>the</strong>re is <strong>the</strong> Department of Health Services <strong>in</strong>Kathm<strong>and</strong>u. In addition to public health services, <strong>the</strong>re arehospitals at <strong>the</strong> district, zonal, regional <strong>and</strong> central levels.Long-term methods are available only at hospitals <strong>and</strong> alimited number of health centres <strong>and</strong> selected health postswhere tra<strong>in</strong>ed personnel are available. Sterilization servicesare provided at hospitals, public health-care facilities <strong>and</strong>static sites through scheduled seasonal or mobile outreachservices. In 2005, <strong>the</strong> share of MoHP <strong>in</strong> <strong>the</strong> provisionof contraceptives was 59 per cent, while <strong>the</strong> comparablefigures for social market<strong>in</strong>g <strong>and</strong> FPAN were 25 <strong>and</strong> 16 percent, respectively (see Box 2 below for details).In addition to <strong>the</strong> public sector, several NGOs providefamily plann<strong>in</strong>g services. The largest <strong>and</strong> oldest NGOprovid<strong>in</strong>g family plann<strong>in</strong>g <strong>in</strong> Nepal is FPAN. A majorNGO provid<strong>in</strong>g family plann<strong>in</strong>g services is Marie Stopes<strong>International</strong> (MSI). In addition, <strong>the</strong> Nepal ContraceptiveRetail Store Company, supported by <strong>the</strong> United StatesAgency for <strong>International</strong> Development (USAID), <strong>and</strong>Population Services <strong>International</strong> (PSI) do social mark<strong>in</strong>g<strong>and</strong> distribute contraceptive commodities to <strong>the</strong> public <strong>and</strong>private sectors. Ow<strong>in</strong>g to social market<strong>in</strong>g services, oralcontraceptive pills, condoms <strong>and</strong> <strong>in</strong>jectables are availablefor purchase over <strong>the</strong> counter <strong>in</strong> pharmacy shops.The follow<strong>in</strong>g <strong>in</strong>ternational organizations are <strong>in</strong>volvedwith family plann<strong>in</strong>g <strong>in</strong> Nepal:Adventist Development Relief Agency NepalSave <strong>the</strong> ChildrenUSAID173

174

eproductivehealth; designs <strong>and</strong> conducts research activities on reproductive health; <strong>in</strong>itiates <strong>and</strong> upgradesservice delivery <strong>and</strong> tra<strong>in</strong><strong>in</strong>g facilities at various levels; develops adolescent reproductive health programmes;<strong>and</strong> promotes coord<strong>in</strong>ation <strong>and</strong> collaboration.1998, Safe Mo<strong>the</strong>rhood Policy: family plann<strong>in</strong>g services needed as a key component of maternal care.2000, National Adolescent Health <strong>and</strong> Development Strategy: emphasizes <strong>in</strong>creased access to <strong>and</strong> utilizationof adolescent-friendly services to reduce unwanted pregnancies, sexually transmitted <strong>in</strong>fections<strong>and</strong> HIV/AIDS.Second Long-term Plan: family plann<strong>in</strong>g is considered an essential health-care service.Kreditanstalt fur Weideraufbau (KfW)Department for <strong>International</strong> Development (DFID)Nepal <strong>Family</strong> Health Programme (NFHP)UNFPAWorld BankStatus of contraceptive use, non-use<strong>and</strong> preferred method <strong>in</strong> <strong>the</strong> futureLevels <strong>and</strong> trends <strong>in</strong> contraceptiveprevalence ratesContraceptive use has <strong>in</strong>creased dramatically <strong>in</strong> <strong>the</strong> past30 years (see Table 3). CPR us<strong>in</strong>g any method <strong>in</strong>creasedfrom 3 per cent <strong>in</strong> 1976 to 48 per cent <strong>in</strong> 2006 – a sixteenfold<strong>in</strong>crease dur<strong>in</strong>g <strong>the</strong> last 30 years. Similarly, <strong>the</strong> use ofmodern methods has also <strong>in</strong>creased considerably, from 2.9per cent <strong>in</strong> 1976 to 44.2 per cent <strong>in</strong> 2006.TableLevels <strong>and</strong> trends <strong>in</strong> method mixThe contraceptive method mix has changed over <strong>the</strong> years<strong>in</strong> Nepal (see Figure 1 <strong>and</strong> Table 4). However, femalesterilization has dom<strong>in</strong>ated <strong>the</strong> method mix s<strong>in</strong>ce <strong>the</strong>early 1980s. Its share <strong>in</strong> CPR <strong>in</strong>creased from 34 per cent<strong>in</strong> 1981 to 50 per cent <strong>in</strong> 1991 <strong>and</strong> decl<strong>in</strong>ed to 41 percent <strong>in</strong> 2006. Thus, major efforts of <strong>the</strong> family plann<strong>in</strong>gprogramme appeared to have been spent on target<strong>in</strong>gwomen for sterilization. The total share of female methods<strong>in</strong> <strong>the</strong> method mix was only one fourth of CPR <strong>in</strong> 1976but reached 81.7 per cent <strong>in</strong> 2006. Interest<strong>in</strong>gly, <strong>the</strong>percentage us<strong>in</strong>g male sterilization <strong>in</strong>creased steadilyfrom 1.9 per cent <strong>in</strong> 1976 to 7.5 per cent <strong>in</strong> 1991, <strong>the</strong>ndecreased slightly from 1991 to 1996 <strong>and</strong> <strong>the</strong>n rema<strong>in</strong>edaround 6 per cent until 2006. This is <strong>the</strong> only methodwhose use has decreased. Use of <strong>the</strong> pill rema<strong>in</strong>s very low,with only 3.5 per cent us<strong>in</strong>g this method <strong>in</strong> 2006. IUDhas been available s<strong>in</strong>ce 1976 but its use rema<strong>in</strong>s very low(only 0.7% <strong>in</strong> 2006). The use of <strong>in</strong>jectables has <strong>in</strong>creasedsubstantially (from 0.1% <strong>in</strong> 1981 to 10.1% <strong>in</strong> 2006). Theuse of condoms has also <strong>in</strong>creased, but by 2006 only 4.8Table3175

per cent of women reported us<strong>in</strong>g condoms. F<strong>in</strong>ally, <strong>the</strong>use of implants <strong>in</strong>creased from 0.4 per cent <strong>in</strong> 1996 to 0.8per cent <strong>in</strong> 2006.Reasons for non-use of contraceptionAccord<strong>in</strong>g to recent NDHS data, nearly two-thirdsof women who were not us<strong>in</strong>g or did not <strong>in</strong>tend to usecontraception gave fertility-related reasons: <strong>in</strong>frequentsex, menopause, sub-fecundity/<strong>in</strong>-fecundity <strong>and</strong> desirefor more children. Additionally, <strong>the</strong> proportion of nonusersreport<strong>in</strong>g fertility-related reasons <strong>in</strong>creased from2001 to 2006. The second major reason for not us<strong>in</strong>gcontraception was method-related reasons (17%): healthconcerns, fear of side effects, lack of access <strong>and</strong> <strong>in</strong>convenientto use. The third major reason related to non-use wasopposition to use: respondent opposed, husb<strong>and</strong> opposed,religious prohibition <strong>and</strong> fatalistic view (see Table 5). Keystakeholder <strong>in</strong>terviews reflected <strong>the</strong>se reasons for nonuse.O<strong>the</strong>r reasons for not us<strong>in</strong>g contraception given bykey stakeholders <strong>in</strong>cluded <strong>the</strong> cultural value of conceiv<strong>in</strong>gsoon after marriage, shortage of human resources, lack ofadequate family plann<strong>in</strong>g counsell<strong>in</strong>g, shortage of suppliesof certa<strong>in</strong> methods <strong>in</strong> certa<strong>in</strong> areas <strong>and</strong> lack of <strong>in</strong>tegrationof family plann<strong>in</strong>g <strong>in</strong>to every aspect of health care. In termsof reasons for not us<strong>in</strong>g short-term methods, such as pills<strong>and</strong> condoms, key stakeholders suggested that tak<strong>in</strong>g pillsevery day is cumbersome or tedious, <strong>and</strong> women may nothave <strong>the</strong> time or transportation to keep gett<strong>in</strong>g refills, plus176

FigureFigure1Percentage of married women currently us<strong>in</strong>g modern contraception, by method, Nepal, 1976-20065045ImplantsPercent of currently married woman( age 15 -49 )40353025201510501976 1981 1986 1991 1996 2001 2006Male steril.Female steril.CondomIUDInjectionsPillYearSource: MoH, 2002 <strong>and</strong> MoHP, 2007.TableTable4TableTable5storage <strong>and</strong> disposal of condoms can be an issue. Ano<strong>the</strong>rreason mentioned was <strong>in</strong>adequate counsell<strong>in</strong>g, such as on<strong>the</strong> advantages <strong>and</strong> disadvantages of each method <strong>and</strong> <strong>the</strong>benefits of us<strong>in</strong>g family plann<strong>in</strong>g.Accord<strong>in</strong>g to <strong>the</strong> report entitled Reposition<strong>in</strong>g <strong>Family</strong><strong>Plann<strong>in</strong>g</strong>: Strategic Review of <strong>the</strong> Nepal National <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Program (MoHP et al., 2006), one barrier to<strong>the</strong> use of long-act<strong>in</strong>g reversible contraception (LARC)177

is provider bias that such methods take more time toprovide than short-term methods, such as <strong>in</strong>jectables <strong>and</strong>pills. In addition, <strong>the</strong> report stated that <strong>the</strong> availabilityof female service providers, husb<strong>and</strong>'s support <strong>and</strong> goodcounsell<strong>in</strong>g with complete <strong>in</strong>formation on <strong>the</strong> advantages<strong>and</strong> disadvantages of LARC methods are o<strong>the</strong>r potentialbarriers to <strong>the</strong> use of such methods. Ano<strong>the</strong>r barrier to<strong>the</strong> use of LARC methods is that Female CommunityHealth Volunteers promote male <strong>and</strong> female sterilizationover short- <strong>and</strong> long-term methods used for spac<strong>in</strong>g birthsbecause <strong>the</strong>y get <strong>in</strong>centives from <strong>the</strong> mobile camps to doso. Insertion of LARC methods are restricted to tra<strong>in</strong>edphysicians, nurses <strong>and</strong> health assistants. Many of <strong>the</strong>sereasons were also stated by key stakeholders.Preferred method of contraception <strong>in</strong><strong>the</strong> futureTable 6 presents <strong>the</strong> preferred method of contraceptionamong Nepali women who were not us<strong>in</strong>g a contraceptivemethod but <strong>in</strong>tend to use one <strong>in</strong> <strong>the</strong> future, from recentDHS data. This is <strong>the</strong> key <strong>in</strong>dicator to underst<strong>and</strong> <strong>the</strong>future dem<strong>and</strong> for specific methods of family plann<strong>in</strong>g.Data suggest two key clues for <strong>the</strong> Nepali family plann<strong>in</strong>gprogramme. First, <strong>in</strong>jectables <strong>and</strong> female sterilization haverema<strong>in</strong>ed important preferred methods over <strong>the</strong> years <strong>in</strong>Nepal <strong>and</strong> would rema<strong>in</strong> so <strong>in</strong>to <strong>the</strong> future as well. Thisholds true for younger (< 30 years) as well as older (30-49years) women. Second, from <strong>the</strong> po<strong>in</strong>t of view of women,condoms have not ga<strong>in</strong>ed popularity as only 3 per cent ofnon-users preferred it <strong>in</strong> 2006.Levels <strong>and</strong> trends <strong>in</strong> unmet needfor family plann<strong>in</strong>gAt 25 per cent <strong>in</strong> 2006, unmet need for family plann<strong>in</strong>g<strong>in</strong> Nepal cont<strong>in</strong>ues to be high1 (see Figure 2). However,unmet need decl<strong>in</strong>ed from 31.4 per cent <strong>in</strong> 1996 to 27.8per cent <strong>in</strong> 2001 to 25 per cent <strong>in</strong> 2006 (DHS). As ofTable2006, unmet need for limit<strong>in</strong>g births was 15 per cent <strong>and</strong>for spac<strong>in</strong>g births, 9 per cent. Therefore, <strong>the</strong> contraceptiveneeds of women for limit<strong>in</strong>g births are less likely to befulfilled compared with <strong>the</strong> need of women for spac<strong>in</strong>gmethods. At <strong>the</strong> same time, <strong>the</strong> decl<strong>in</strong><strong>in</strong>g trends of unmetneed for family plann<strong>in</strong>g for both limit<strong>in</strong>g <strong>and</strong> spac<strong>in</strong>gpurposes mean that <strong>the</strong> family plann<strong>in</strong>g programme is<strong>in</strong>creas<strong>in</strong>gly reach<strong>in</strong>g women who do not want any morechildren. It should be noted that <strong>the</strong> pace of decl<strong>in</strong>e <strong>in</strong>unmet need for spac<strong>in</strong>g was three times as high as <strong>the</strong>limit<strong>in</strong>g method between 1996 <strong>and</strong> 2006. This suggeststhat ei<strong>the</strong>r <strong>the</strong> family plann<strong>in</strong>g programme is <strong>in</strong>creas<strong>in</strong>glyprovid<strong>in</strong>g spac<strong>in</strong>g methods, or couples do not wantpermanent sterilization despite hav<strong>in</strong>g <strong>the</strong> desired numberof children <strong>and</strong> <strong>the</strong>refore choose spac<strong>in</strong>g methods.Unmet need for family plann<strong>in</strong>g varies largely by place ofresidence. Rural women have relatively higher unmet needcompared with urban women. Interest<strong>in</strong>gly, unmet need<strong>in</strong> urban areas actually <strong>in</strong>creased between 2001 <strong>and</strong> 2006.This may reflect two th<strong>in</strong>gs. First, many women who haverecently migrated may be out of reach of family plann<strong>in</strong>gservices <strong>in</strong> urban areas. Second, <strong>the</strong> <strong>in</strong>crease <strong>in</strong> unmet needmay also reflect <strong>in</strong>creas<strong>in</strong>g awareness among women liv<strong>in</strong>g<strong>in</strong> urban areas of limit<strong>in</strong>g or spac<strong>in</strong>g births.Accord<strong>in</strong>g to key stakeholder <strong>in</strong>terviews, reasons for <strong>the</strong>cont<strong>in</strong>ued level of unmet need for family plann<strong>in</strong>g <strong>in</strong> Nepal<strong>in</strong>clude <strong>the</strong> follow<strong>in</strong>g factors: government programmes arenot effectively reach<strong>in</strong>g youth <strong>and</strong> marg<strong>in</strong>alized groups;<strong>the</strong> government is promot<strong>in</strong>g <strong>and</strong> prioritiz<strong>in</strong>g sterilizationra<strong>the</strong>r than long-term or spac<strong>in</strong>g methods; <strong>the</strong>re is a lackof skilled providers <strong>in</strong> rural areas to furnish long-termmethods; <strong>the</strong>re is a lack of high-quality accurate familyplann<strong>in</strong>g counsel<strong>in</strong>g; IEC campaigns have limited reach<strong>in</strong> very remote areas where people do not have access tomedia; <strong>and</strong> <strong>the</strong>re is a lack of knowledge about where toobta<strong>in</strong> certa<strong>in</strong> methods. Ano<strong>the</strong>r reason mentioned is <strong>the</strong>fact that many organizations are work<strong>in</strong>g on <strong>in</strong>creas<strong>in</strong>gTable6178

FigureFigureFigure2Population pyramid of Maldives, 2000 <strong>and</strong> 200635Percent of currently marriedwoman with unment need30252015105RuralUrbanLimit<strong>in</strong>gSpac<strong>in</strong>g01991 1996 2001 2006YearSource: Source: MPND, 2007: Population <strong>and</strong> Hous<strong>in</strong>g Census, 2006.Figure3Contraceptive prevalence rate <strong>and</strong> unmet need for contraception, Nepal, 1991-20066050Percent of currently marriedwoman with unment need40302010CPRUnmetneed01991 1996 2001 2006YearSource: MoH, 1993; ; 2002; <strong>and</strong> MoHP, 2007.awareness, but only <strong>the</strong> government, FPAN <strong>and</strong> a fewNGOs are work<strong>in</strong>g on service delivery.Quality of careThe current status of <strong>the</strong> quality of care with<strong>in</strong> <strong>the</strong> Nepalfamily plann<strong>in</strong>g programme is discussed <strong>in</strong> terms of accessto services <strong>and</strong> choice of method. O<strong>the</strong>r elements of qualityof care, such as <strong>in</strong>formed choice, <strong>in</strong>terpersonal relations,technical quality of care, client follow-up, appropriateconstellation of services <strong>and</strong> client satisfaction, cannot begeneralized <strong>in</strong> <strong>the</strong> overall context of Nepal.Access to servicesIn consider<strong>in</strong>g <strong>the</strong> regions of <strong>the</strong> country, <strong>the</strong>re is widely179

TableTable7skewed distribution of health-care professionals <strong>in</strong> Nepal(see Table 7). Almost 70 per cent of doctors, 40 per centof nurses <strong>and</strong> auxiliary nurse midwives <strong>and</strong> 64 per cent ofretail pharmacies are located <strong>in</strong> <strong>the</strong> central developmentregion, especially <strong>in</strong> <strong>the</strong> Kathm<strong>and</strong>u Valley, even thoughthis development region accounts for only 35 per cent of<strong>the</strong> total population of Nepal. Next to <strong>the</strong> central region,<strong>the</strong> eastern region has 14 per cent of doctors, 23 per centof nurses <strong>and</strong> auxiliary nurse midwives <strong>and</strong> 17 per cent ofretail pharmacies; it accounts for 23 per cent of Nepal’spopulation. The third largest share of health professionalsis <strong>in</strong> <strong>the</strong> western region: 11 per cent of doctors, 26 per centof nurses <strong>and</strong> auxiliary nurse midwives <strong>and</strong> 13 per cent ofretail pharmacies are located <strong>in</strong> this region, which accountsfor 20 per cent of <strong>the</strong> country’s population. It is <strong>the</strong> midwestern<strong>and</strong> far-western regions that share <strong>the</strong> lowestnumber of health professionals. While <strong>the</strong> mid-westernregion accounts for 12 per cent of Nepal’s population, itsshares <strong>in</strong> doctors, nurses <strong>and</strong> auxiliary nurse midwives <strong>and</strong>retail pharmacies are 3, 8 <strong>and</strong> 4 per cent, respectively. Thefar-western region has <strong>the</strong> lowest proportion of doctors(2%), nurses <strong>and</strong> auxiliary nurse midwives (3%) <strong>and</strong> retailpharmacies (3%), even though it accounts for 10 per centof <strong>the</strong> country’s total population.A shortage of female doctors <strong>and</strong> health workers, especially<strong>in</strong> <strong>the</strong> rural <strong>and</strong> most <strong>in</strong>accessible areas, is a major barrier to<strong>the</strong> use of high-quality family plann<strong>in</strong>g services. In Nepal,women <strong>and</strong> girls are often shy to make dem<strong>and</strong>s on, orshare <strong>the</strong>ir reproductive health problems with, male healthworkers. As stated above, this is a particularly importantbarrier to <strong>the</strong> use of IUDs.One of <strong>the</strong> <strong>in</strong>dicators to assess services reach<strong>in</strong>g people is<strong>the</strong> time taken to reach a source of contraception for thosewho were us<strong>in</strong>g a contraceptive method. Data reveal that<strong>the</strong> time taken to reach a source for contraceptives may notbe a major concern <strong>in</strong> terms of quality of care. The mediantime to reach a source for a contraceptive method (for pills,<strong>in</strong>jectables <strong>and</strong> condoms) is 30 m<strong>in</strong>utes (2001 NDHS).Method choice“The current method mix is a reflection of currentavailability, not about client choice”, accord<strong>in</strong>g to VictorLara of PSI Nepal.Clients have limited contraceptive choices <strong>in</strong> rural <strong>and</strong>remote areas, as reflected <strong>in</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> ProgrammeEffort Index scores. This is measured by <strong>the</strong> percentageof <strong>the</strong> population hav<strong>in</strong>g ready <strong>and</strong> easy access to eachmethod, namely male sterilization, female sterilization,pills, <strong>in</strong>jectables, condoms, diaphragm <strong>and</strong> spermicide,<strong>in</strong>trauter<strong>in</strong>e device <strong>and</strong> safe abortion. The methodavailability score <strong>in</strong> Nepal <strong>in</strong>creased from 50 <strong>in</strong> 2004 to 62<strong>in</strong> 2006, which shows that choice of method has <strong>in</strong>creasedbut still rema<strong>in</strong>s a challenge. A full range of contraceptiveshas yet to be available <strong>in</strong> rural <strong>and</strong> remote areas, amongpoor <strong>and</strong> disadvantaged groups, <strong>and</strong> adolescents <strong>and</strong>young women. Currently, private sector agencies providehigh-quality family plann<strong>in</strong>g services; however, <strong>the</strong>irservice outlets are limited to urban areas <strong>and</strong> district-levelfacilities.There are a number of issues <strong>in</strong> remote areas, for example,many rural outreach health facilities do not provide IUDsor implants because of <strong>the</strong> shortage of tra<strong>in</strong>ed healthpersonnel, but voluntary surgical contraceptive services areprovided <strong>in</strong> mobile camps, so sterilization is very accessiblefor people <strong>in</strong> <strong>the</strong>se regions. A recent study <strong>in</strong> 40 ruraldistricts by <strong>the</strong> Nepal family health programme foundthat 68 per cent of Female Community Health Volunteershad pills on h<strong>and</strong> <strong>in</strong> <strong>the</strong> previous month <strong>and</strong> 80 per centhad condoms on h<strong>and</strong> Nepal <strong>Family</strong> Health Program II<strong>and</strong> New ERA , 2010) This <strong>in</strong>dicates that those volunteersdo not always have <strong>the</strong>se two methods on h<strong>and</strong>, <strong>the</strong>rebylimit<strong>in</strong>g <strong>the</strong> access of <strong>the</strong>ir clients to contraception. Thisrestricted choice of contraceptive methods has constra<strong>in</strong>ed<strong>the</strong> opportunity of <strong>in</strong>dividual couples to obta<strong>in</strong> a method180

that suits <strong>the</strong>ir needs, result<strong>in</strong>g <strong>in</strong> a low level of contraceptiveprevalence, especially among <strong>the</strong> poor, disadvantaged <strong>and</strong>remote rural areas <strong>in</strong> Nepal (for district-level CPR, seeTable 8 below).Accord<strong>in</strong>g to key stakeholder <strong>in</strong>terviews, method choice islimited by availability, especially <strong>in</strong> rural areas, counsellorsare not adequately tra<strong>in</strong>ed or <strong>in</strong>formed of all options, <strong>and</strong>clients are not adequately <strong>in</strong>formed so <strong>the</strong>y are not able todem<strong>and</strong> what method is best for <strong>the</strong>m.O<strong>the</strong>r challenges of <strong>the</strong> nationalfamily plann<strong>in</strong>g programmeO<strong>the</strong>r challenges fac<strong>in</strong>g <strong>the</strong> national family plann<strong>in</strong>gprogramme <strong>in</strong>clude: political <strong>in</strong>stability; difficulttopography; coord<strong>in</strong>ation issues between <strong>the</strong> government,NGOs <strong>and</strong> donors; <strong>and</strong> socio-cultural practices.Political <strong>in</strong>stabilityVarious sources reported that, due to <strong>the</strong> political <strong>in</strong>stability<strong>and</strong> conflict <strong>in</strong> <strong>the</strong> late 1990s <strong>and</strong> early 2000s, it was difficultto focus on family plann<strong>in</strong>g when even basic health needswere not be<strong>in</strong>g met. Resources have been directed towardsrestor<strong>in</strong>g peace <strong>and</strong> security <strong>and</strong> rebuild<strong>in</strong>g <strong>in</strong>frastructurefollow<strong>in</strong>g <strong>the</strong> conflict, leav<strong>in</strong>g little for health programmes(FPAN, 2010). Political transformation from a monarchialsystem to a democracy (begun <strong>in</strong> 2008) is tak<strong>in</strong>g longerthan expected as a new constitution still has not yet beencompleted (<strong>the</strong> deadl<strong>in</strong>e had been set for May 2010). Thissituation has caused delays <strong>in</strong> budget allocation. Ano<strong>the</strong>rexample of how political <strong>in</strong>stability has adversely affectedfamily plann<strong>in</strong>g is that, <strong>in</strong> FY 2001/2002, voluntarysurgical contraception camps could not be conducted <strong>in</strong>32 districts for security reasons (MoHP et al., 2006). Inaddition, <strong>the</strong> conflict could have reduced <strong>the</strong> number ofacceptors of contraception, such as young males who weredisplaced <strong>and</strong> young women felt threatened <strong>in</strong> try<strong>in</strong>g to181

TableTable8TableTable9182

each a source of family plann<strong>in</strong>g services.Accord<strong>in</strong>g to key stakeholder <strong>in</strong>terviews, monitor<strong>in</strong>g offamily plann<strong>in</strong>g programmes could not be carried outeffectively due to frequent b<strong>and</strong>hs (strikes) <strong>and</strong> threatsto personal safety dur<strong>in</strong>g <strong>the</strong> Maoist conflict (1996-2006). In addition, <strong>the</strong> b<strong>and</strong>hs also affected <strong>the</strong> transportof contraceptive commodities to health facilities <strong>and</strong>clients’ access to health facilities. This also affected <strong>the</strong>geographical distribution of health personnel. For example,health personnel from different ethnic backgrounds werereluctant to serve <strong>in</strong> conflict-affected regions.Difficult topographyNepal is divided <strong>in</strong>to three ecological zones: mounta<strong>in</strong>s,hills <strong>and</strong> pla<strong>in</strong>s (Terai). The impact of topography oncontraceptive use is shown <strong>in</strong> Table 8 below. About 45per cent of <strong>the</strong> population lives <strong>in</strong> <strong>the</strong> Terai <strong>and</strong> generallyhas better access to health-care services than people liv<strong>in</strong>g<strong>in</strong> o<strong>the</strong>r zones. <strong>Family</strong> plann<strong>in</strong>g <strong>and</strong> reproductive healthservices are more limited <strong>in</strong> <strong>the</strong> hill <strong>and</strong> mounta<strong>in</strong> areasbecause few people want to work <strong>the</strong>re, <strong>the</strong> transportationis poor <strong>and</strong> supplies are limited. In addition, <strong>the</strong> high levelof out-migration of youth could contribute to <strong>the</strong> lowerCPR <strong>in</strong> those regions. Ow<strong>in</strong>g to those regions’ topography,it is also difficult to provide consistent tra<strong>in</strong><strong>in</strong>g. Tra<strong>in</strong>edhuman resources are concentrated <strong>in</strong> urban areas <strong>and</strong> someaccessible regions <strong>in</strong> <strong>the</strong> Terai (MoHP et al., 2006).Topography <strong>and</strong> physical <strong>in</strong>accessibility are associated withCPR <strong>in</strong> Nepal 2 . Among <strong>the</strong> 75 districts <strong>in</strong> Nepal, only 5of <strong>the</strong>m have a CPR of more than 60 per cent (2 are from<strong>the</strong> hills <strong>and</strong> 3 are from <strong>the</strong> Terai region). The majorityof central Terai districts fall under <strong>the</strong> middle level ofCPR classification while four districts from <strong>the</strong> hills alsofall under this classification. None of <strong>the</strong> mounta<strong>in</strong>ousdistricts have a CPR higher than 45 per cent. The eastern<strong>and</strong> central mounta<strong>in</strong> districts fall under <strong>the</strong> low CPR level,while almost all western <strong>and</strong> far-western mounta<strong>in</strong> districts(except Jumla <strong>and</strong> Mustang) fall under <strong>the</strong> very low CPRlevel. There are also a number of hill districts with very lowCPR, while <strong>the</strong>re is only one district <strong>in</strong> <strong>the</strong> Terai <strong>in</strong> thiscategory. Yet caution must be taken that some of <strong>the</strong> hillsdistricts with relatively good physical <strong>in</strong>frastructure, suchas Kaski <strong>and</strong> even Kathm<strong>and</strong>u, fall under <strong>the</strong> low CPRlevel, <strong>in</strong>dicat<strong>in</strong>g that physical access is not <strong>the</strong> only factordeterm<strong>in</strong><strong>in</strong>g CPR. In <strong>the</strong> Terai, where CPR is low or verylow, cultural <strong>and</strong> programmatic factors may be importantdeterm<strong>in</strong>ants (Table 8).In addition, data show that TFR is much higher <strong>in</strong> ruralareas, <strong>in</strong> mounta<strong>in</strong>, mid- <strong>and</strong> far-western developmentregions. On <strong>the</strong> o<strong>the</strong>r h<strong>and</strong>, CPR is much lower <strong>in</strong> <strong>the</strong>seareas <strong>and</strong> unmet need for family plann<strong>in</strong>g is substantiallyhigh <strong>in</strong> <strong>the</strong>se areas. Thus, <strong>the</strong>se places must be targetedby <strong>the</strong> programme <strong>in</strong> order to fur<strong>the</strong>r achieve fertilitydecl<strong>in</strong>e.Socio-cultural barriers tocontraceptive usePower relationsUnderly<strong>in</strong>g factors for low use of family plann<strong>in</strong>g <strong>in</strong> Nepalcould be associated with asymmetrical power relationsbetween husb<strong>and</strong>s <strong>and</strong> wives. For example, femalesterilization is more popular <strong>in</strong> <strong>the</strong> Terai where <strong>the</strong> statusof women is lower <strong>and</strong> <strong>the</strong>y have less decision-mak<strong>in</strong>gpower. Thus, female autonomy is an important factorfor expla<strong>in</strong><strong>in</strong>g unmet need <strong>and</strong> low utilization of familyplann<strong>in</strong>g services.Son preferenceLeone et al. (2003) exam<strong>in</strong>ed <strong>the</strong> impact of son preference<strong>in</strong> Nepal on contraceptive use <strong>and</strong> fertility decl<strong>in</strong>e,draw<strong>in</strong>g data from NFHS 1996. Their results <strong>in</strong>dicatedthat sex preference decreases contraceptive use by 24 percent <strong>and</strong> <strong>in</strong>creases TFR by more than 6 per cent. Thus,<strong>the</strong>y concluded that <strong>the</strong> level of sex preference <strong>in</strong> Nepalis substantial. Sex preference is an important barrier to<strong>in</strong>creas<strong>in</strong>g contraceptive use <strong>and</strong> fertility decl<strong>in</strong>e <strong>in</strong> <strong>the</strong>country, <strong>and</strong> its impact will be greater as desired family sizedecl<strong>in</strong>es. A UNFPA study carried out <strong>in</strong> four districts ofNepal <strong>in</strong> 2007 found that Nepalese women are pressuredto give birth to a son. Those women who have givenbirth to two or more daughters consecutively were underparticularly high pressure, often <strong>in</strong> <strong>the</strong> form of threats from<strong>the</strong>ir mo<strong>the</strong>rs-<strong>in</strong>-law <strong>and</strong> husb<strong>and</strong>s. Such women have nochoice but to become pregnant repeatedly until a son is born.Statistically, <strong>the</strong> practices of prenatal sex determ<strong>in</strong>ation<strong>and</strong> sex-selective abortion were found to be very low <strong>in</strong><strong>the</strong> study population: only 3 per cent (74 women) of <strong>the</strong>ever-pregnant women, women who had been pregnantirrespective of <strong>the</strong> outcome of <strong>the</strong> pregnancy; women whohad ever sought prenatal sex-determ<strong>in</strong>ation tests; <strong>and</strong> only14 per cent of <strong>the</strong> women who had ever had an <strong>in</strong>ducedabortion had done so after prenatal sex determ<strong>in</strong>ation. Thestudy subsequently po<strong>in</strong>ted to prenatal sex selection ascurrently be<strong>in</strong>g at a prelim<strong>in</strong>ary stage <strong>in</strong> Nepal, <strong>in</strong> contrastto Ch<strong>in</strong>a <strong>and</strong> India, where it is a widespread phenomenon(UNFPA, 2007).Disadvantaged social groupsCPR, TFR <strong>and</strong> unmet need for family plann<strong>in</strong>g widely varyacross <strong>the</strong> social groups <strong>in</strong> Nepal (see Table 9). This justifies<strong>the</strong> cont<strong>in</strong>ued need of <strong>the</strong> family plann<strong>in</strong>g programme forsome social groups to ensure <strong>the</strong>ir reproductive goals.Among <strong>the</strong> social groups, Muslims have <strong>the</strong> highest TFR(4.6), lowest CPR (19%) <strong>and</strong> highest unmet need for familyplann<strong>in</strong>g (37%). CPR among <strong>the</strong>m is 0.4 times lower than183

that of <strong>the</strong> national average, while unmet need for familyplann<strong>in</strong>g <strong>and</strong> TFR each is 1.5 times higher than that of<strong>the</strong> national average figures. Hill Dalit 3 have <strong>the</strong> secondhighest TFR (4.0) <strong>and</strong> have a CPR of only 37 per cent<strong>and</strong> unmet need for family plann<strong>in</strong>g of 34 per cent. Forthis group, CRP is still 0.8 times <strong>the</strong> national average <strong>and</strong>unmet need for family plann<strong>in</strong>g is 1.4 times higher than <strong>the</strong>national average. The Tarai Dalit have a TFR of 3.8, withCPR be<strong>in</strong>g 50 per cent <strong>and</strong> a much lower unmet need forfamily plann<strong>in</strong>g (18%). Hill Chhetri 4 have almost <strong>the</strong> samelevel of TFR, CPR <strong>and</strong> unmet need for family plann<strong>in</strong>gas <strong>the</strong> national averages. Hill Brahman 5 have TFR below<strong>the</strong> national average, with slightly higher unmet need forfamily plann<strong>in</strong>g <strong>and</strong> CPR. Hill/Mounta<strong>in</strong> Janajati 6 stillhave a TFR of 3.1 while <strong>the</strong>ir CPR <strong>and</strong> unmet need forfamily plann<strong>in</strong>g are 41 <strong>and</strong> 31 per cent, respectively.PovertyHousehold wealth is clearly associated with CPR <strong>and</strong> TFR.As household wealth <strong>in</strong>creases, CPR also <strong>in</strong>creases <strong>and</strong>vice versa. There is a wide gap <strong>in</strong> CPR between <strong>the</strong> top <strong>and</strong>bottom household wealth qu<strong>in</strong>tiles. A similar relationshipis observed between <strong>the</strong> wealth qu<strong>in</strong>tile <strong>and</strong> total fertilityrate. TFR of <strong>the</strong> bottom wealth qu<strong>in</strong>tile is 4.7; that of <strong>the</strong>second wealth qu<strong>in</strong>tile is 3.6. TFR is below replacementlevelfertility <strong>in</strong> <strong>the</strong> top wealth qu<strong>in</strong>tile. The overall unmetneed for family plann<strong>in</strong>g is also <strong>in</strong>versely associated with<strong>the</strong> wealth qu<strong>in</strong>tile of <strong>the</strong> households, suggest<strong>in</strong>g that <strong>the</strong>poorer is <strong>the</strong> household, <strong>the</strong> higher is <strong>the</strong> unmet need forfamily plann<strong>in</strong>g <strong>and</strong> vice versa.Adolescents <strong>and</strong> young womenEarly marriage <strong>and</strong> childbear<strong>in</strong>g rema<strong>in</strong> prevalent <strong>in</strong> Nepal.Although <strong>the</strong> legal age at marriage <strong>in</strong> Nepal is 18 years withparental consent <strong>and</strong> 20 years without such consent, <strong>the</strong>nationwide median age at marriage for women is just over17 years (2006 NDHS). Women’s median age at marriage<strong>in</strong> Nepal <strong>in</strong>creased from 16.4 years <strong>in</strong> 1991 to 17.2 years <strong>in</strong>2006. Median age at first birth <strong>in</strong>creased slightly from 19.8years to 19.9 years between 1996 (<strong>the</strong> earliest year withdata) <strong>and</strong> 2006. As of 2006, 18.5 per cent of women aged15-19 had begun childbear<strong>in</strong>g. These ages differ <strong>in</strong> rural<strong>and</strong> urban areas. The median age at marriage for women<strong>in</strong> urban areas tends to be about a year later than thosewomen <strong>in</strong> rural areas. Median age at childbirth is alsoslightly higher <strong>in</strong> urban areas than rural areas but only byabout half a year.Table 10 shows age-adjusted fertility rates, CPR <strong>and</strong>unmet need for adolescents <strong>and</strong> young women. The highestneed for family plann<strong>in</strong>g services are for adolescents <strong>and</strong>young women. Among <strong>the</strong> late adolescents (15-19 years),<strong>the</strong> age-specific fertility rate (ASFR) is very high (98 per1,000 women), while <strong>the</strong>ir use of contraception is just16 per cent <strong>and</strong> unmet need for family plann<strong>in</strong>g is veryhigh (38%). For this age group, unmet need for spac<strong>in</strong>gis very high. In <strong>the</strong> case of young women (20-24 years),ASFR is very high (234 per 1,000 women). On <strong>the</strong> o<strong>the</strong>rh<strong>and</strong>, <strong>the</strong>ir CPR is 31 per cent <strong>and</strong> unmet need for familyplann<strong>in</strong>g services 33 per cent.Accord<strong>in</strong>g to key stakeholder <strong>in</strong>terviews, reproductivehealth programmes <strong>in</strong>corporat<strong>in</strong>g adolescents arenot adequate. Although <strong>the</strong> government has removedpolicies that restrict adolescents from access<strong>in</strong>g familyplann<strong>in</strong>g services, o<strong>the</strong>r barriers to <strong>the</strong>ir use exist, such as<strong>in</strong>adequate sex education <strong>in</strong> schools, shame <strong>and</strong> negativeperceptions of unmarried women us<strong>in</strong>g contraception,lack of youth-friendly family plann<strong>in</strong>g services <strong>and</strong> lack oftarget<strong>in</strong>g adolescents <strong>in</strong> family plann<strong>in</strong>g efforts. Currentgovernmental efforts are aimed at improv<strong>in</strong>g sexual <strong>and</strong>reproductive health education <strong>in</strong> schools; at <strong>the</strong> NGOlevel, programmes are target<strong>in</strong>g adolescents <strong>in</strong> terms of<strong>in</strong>formation <strong>and</strong> services.Negative connotation of term “familyplann<strong>in</strong>g”Accord<strong>in</strong>g to MoHP et al. (2006) <strong>and</strong> key stakeholders,<strong>the</strong> term “family plann<strong>in</strong>g” (pariwar niyojan <strong>in</strong> <strong>the</strong> Nepalilanguage) has negative connotations so <strong>the</strong> government iswork<strong>in</strong>g on emphasiz<strong>in</strong>g a more positive term "byawasthitpariwar" (well-planned family) <strong>in</strong>stead.Underst<strong>and</strong><strong>in</strong>g <strong>the</strong> currentsituationGovernance of family plann<strong>in</strong>g/reproductive healthMoHP formulates, plans, monitors, supervises <strong>and</strong>evaluates basic health <strong>and</strong> family plann<strong>in</strong>g policies <strong>and</strong>programmes <strong>in</strong> <strong>the</strong> country. Under <strong>the</strong> M<strong>in</strong>istry, <strong>the</strong>Department of Health Services works as an implement<strong>in</strong>gagency. Under that department, <strong>the</strong>re are seven divisions.Among <strong>the</strong>m, <strong>the</strong> <strong>Family</strong> Health Division is responsiblefor implement<strong>in</strong>g reproductive health strategies <strong>and</strong>programmes, <strong>and</strong> <strong>the</strong> Logistics Management Divisionis responsible for <strong>the</strong> procurement, warehous<strong>in</strong>g <strong>and</strong>distribution of reproductive health commodities, <strong>in</strong>clud<strong>in</strong>gsupplies <strong>and</strong> equipment.Coord<strong>in</strong>ation mechanisms exist at <strong>the</strong> national (National<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Sub-committee) <strong>and</strong> district (ReproductiveCoord<strong>in</strong>ation Committee) levels for <strong>the</strong> purpose of revis<strong>in</strong>gfamily plann<strong>in</strong>g programmes <strong>and</strong> activities. Members of <strong>the</strong>national sub-committee <strong>in</strong>clude <strong>in</strong>ternational developmentagencies <strong>and</strong> service delivery partners, <strong>and</strong> members of <strong>the</strong>district committee <strong>in</strong>clude civil society organizations <strong>and</strong>184

TableTable10<strong>in</strong>ternational NGOs. Accord<strong>in</strong>g to <strong>the</strong> director-generalof FPAN, district committees are located <strong>in</strong> only 45districts. Although committees at <strong>the</strong> national <strong>and</strong> districtlevels have been established, <strong>the</strong>re reportedly is overlap <strong>in</strong><strong>the</strong> work between government agencies <strong>and</strong> NGOs, <strong>and</strong><strong>the</strong>re is no effective mechanism to follow-up whe<strong>the</strong>r <strong>the</strong>recommendations forwarded by such committees are met.In addition, one key stakeholder stated that, ow<strong>in</strong>g to <strong>the</strong>low priority of family plann<strong>in</strong>g <strong>in</strong> Nepal, <strong>the</strong> committeesare not effective because, at <strong>the</strong> district level, <strong>the</strong> committeefocuses on o<strong>the</strong>r reproductive health issues – not on familyplann<strong>in</strong>g. Issues related to restructur<strong>in</strong>g or reprioritiz<strong>in</strong>g<strong>the</strong> national family plann<strong>in</strong>g programme are discussed at<strong>the</strong> national sub-committee meet<strong>in</strong>gs.The <strong>International</strong> Conference onPopulation <strong>and</strong> Development,Millennium Development Goals <strong>and</strong>NepalCommon goals of <strong>the</strong> ICPD Programme of Action <strong>and</strong> <strong>the</strong>Millennium Development Goals <strong>in</strong>clude <strong>in</strong>creas<strong>in</strong>g genderequality, reduc<strong>in</strong>g poverty, improv<strong>in</strong>g maternal health<strong>and</strong> afford<strong>in</strong>g universal access to reproductive health. IfNepal still has a high unmet need for family plann<strong>in</strong>g,low maternal health-care usage, cont<strong>in</strong>ued disparities <strong>in</strong>education <strong>and</strong> <strong>in</strong> age at marriage between men <strong>and</strong> women,<strong>the</strong>n <strong>the</strong> country is at risk of not meet<strong>in</strong>g <strong>the</strong>se goals.Target 5b of <strong>the</strong> MDGs is “Achieve universal access toreproductive health by 2015”. Table 11 below shows <strong>the</strong>four <strong>in</strong>dicators used to measure progress towards achiev<strong>in</strong>gTablethis goal, along with Nepal’s targets for 2015.Political commitment to familyplann<strong>in</strong>g programme<strong>Family</strong> plann<strong>in</strong>g is currently a “Priority One” programmefor <strong>the</strong> government. However key stakeholder <strong>in</strong>terviewssuggested that o<strong>the</strong>r reproductive health programmes, suchas <strong>the</strong> Safe Mo<strong>the</strong>rhood <strong>and</strong> Safe Abortion programmes,are gett<strong>in</strong>g more attention than family plann<strong>in</strong>g. Accord<strong>in</strong>gto representatives from <strong>the</strong> <strong>Family</strong> Health Division, <strong>the</strong>family plann<strong>in</strong>g programme is be<strong>in</strong>g revamped <strong>and</strong> <strong>the</strong>rewere plans to create a specific family plann<strong>in</strong>g policy <strong>in</strong> 2011<strong>in</strong> order to accelerate progress towards reach<strong>in</strong>g <strong>the</strong> targetof 67 per cent CPR by 2015. The <strong>Family</strong> Health Division<strong>and</strong> <strong>the</strong> Department of Health Services are currentlyrevis<strong>in</strong>g <strong>the</strong> National Reproductive Health Strategy. O<strong>the</strong>rkey stakeholders reported that political commitment tofamily plann<strong>in</strong>g is high, but <strong>the</strong>re is difficulty <strong>in</strong> translat<strong>in</strong>g<strong>the</strong> policies <strong>in</strong>to <strong>the</strong> programme <strong>and</strong> practice levels on<strong>the</strong> ground. Accord<strong>in</strong>g to key stakeholders, <strong>the</strong>re is nopolitical or public opposition to family plann<strong>in</strong>g <strong>in</strong> Nepal.For example, an NGO representative stated: “The politicalcommitment is sufficient but <strong>the</strong> context <strong>and</strong> <strong>the</strong> practiceon <strong>the</strong> ground is <strong>the</strong> problem”.Political commitment related tovulnerable groupsTable 13 shows Nepal’s recent policies that relate to familyplann<strong>in</strong>g for marg<strong>in</strong>alized groups.Accord<strong>in</strong>g to key stakeholders, <strong>the</strong> commitment tovulnerable groups is not adequate even though <strong>the</strong>re areTable11185

TableTable12 7some policies that explicitly state that vulnerable groupsshould have access to family plann<strong>in</strong>g. Many of <strong>the</strong>segovernmental policies <strong>and</strong> efforts are not shared with<strong>the</strong> general population, lead<strong>in</strong>g to reduced awareness.Government representatives also spoke of current effortsto reach people <strong>in</strong> districts with low CPR <strong>and</strong> o<strong>the</strong>r specificpolicies related to this.<strong>Family</strong> plann<strong>in</strong>g <strong>in</strong>tegrationwith o<strong>the</strong>r reproductive healthprogrammes<strong>Family</strong> plann<strong>in</strong>g has been <strong>in</strong>tegrated with maternal <strong>and</strong>child health s<strong>in</strong>ce <strong>the</strong> Third Five-year Plan (1965-1970).After ICPD <strong>in</strong> 1994, <strong>the</strong> government fur<strong>the</strong>r <strong>in</strong>tegratedfamily plann<strong>in</strong>g <strong>in</strong>to <strong>the</strong> national reproductive healthprogramme.Currently, <strong>the</strong>re are almost 50,000 Female CommunityHealth Volunteers <strong>in</strong> 97 per cent of rural wards; <strong>the</strong>yprovide primary health care <strong>and</strong> referrals for FP <strong>and</strong>MCH, <strong>in</strong>clud<strong>in</strong>g immunization <strong>and</strong> de-worm<strong>in</strong>g servicesat <strong>the</strong> community level. The goal is to reduce fertility <strong>and</strong>maternal, <strong>in</strong>fant <strong>and</strong> child mortality (WHO, 2008).Although <strong>in</strong>tegration of FP <strong>in</strong>to o<strong>the</strong>r services has beenemphasized <strong>in</strong> Nepal, <strong>the</strong> regularity of family plann<strong>in</strong>gservice, particularly surgical contraception services <strong>in</strong>several service sites, is still questioned (MoHP et al.,2006).186

TableTable13Accord<strong>in</strong>g to key stakeholder <strong>in</strong>terviews, <strong>in</strong>tegration hasbeen effective to a certa<strong>in</strong> extent especially with FemaleCommunity Health Volunteers, but FP rema<strong>in</strong>s neglected<strong>in</strong> o<strong>the</strong>r crucial areas, such as safe mo<strong>the</strong>rhood, postpartum,post-abortion <strong>and</strong> safe abortion care. Many alsostated that <strong>in</strong>tegration has overburdened service providers<strong>in</strong> hospitals, primary health centres <strong>and</strong> Female CommunityHealth Volunteers, which has lessened <strong>the</strong> emphasis <strong>and</strong>quality of FP services. A few key stakeholders said that<strong>in</strong>tegration has been more successful at <strong>the</strong> NGO levelthan <strong>in</strong> <strong>the</strong> public sector. Most stakeholders agreed that,besides <strong>in</strong>creased condom promotion, HIV/AIDS has notbeen effectively <strong>in</strong>tegrated <strong>in</strong>to o<strong>the</strong>r areas of health care.However, government representatives said that <strong>in</strong>creased<strong>in</strong>tegration of HIV/AIDS is planned for <strong>the</strong> public sector<strong>in</strong> <strong>the</strong> near future.Current status of contraceptivecommodity securityContraceptive security is achieved when four essentialconditions are met <strong>in</strong> a family plann<strong>in</strong>g/reproductivehealth programme (OUTLOOK 2003; Gribble, J 2010Population Reference Bureau)(a) Forecast<strong>in</strong>g – accurate estimates are made of <strong>the</strong>requirements for contraceptives;(b) F<strong>in</strong>anc<strong>in</strong>g – <strong>the</strong> f<strong>in</strong>ancial resources exist to obta<strong>in</strong>contraceptives;(c) Procurement – <strong>the</strong> technical resources exist to procurecontraceptives on a timely basis;(d) Delivery – reliable delivery <strong>and</strong> availability ofcontraceptives to <strong>the</strong> end user is assured for <strong>the</strong>medium to long term (at least 10 years).Forecast<strong>in</strong>gNepal has set up <strong>the</strong> follow<strong>in</strong>g mechanisms to accuratelyestimate its requirements for contraceptives on a cont<strong>in</strong>uousbasis:(a) Existence of Contraceptive Security Work<strong>in</strong>g Groupunder <strong>the</strong> leadership of <strong>the</strong> <strong>Family</strong> Health Division;(b) Existence of Logistics Management InformationSystem under <strong>the</strong> Logistic Management Division,which current <strong>in</strong>formation on quantities ofcontraceptives dispensed to users;(c) Availability of NDHS surveys for forecast<strong>in</strong>g;(d) Priority placed on adequate supplies.Contraceptive Security Work<strong>in</strong>g GroupThe <strong>Family</strong> Health Division <strong>and</strong> Logistic ManagementDivision of <strong>the</strong> M<strong>in</strong>istry of Population <strong>and</strong> Health<strong>in</strong>itiated a contraceptive security process <strong>in</strong> 1997. In 1998,<strong>the</strong> Contraceptive Security Work<strong>in</strong>g Group was formedunder <strong>the</strong> leadership of <strong>the</strong> <strong>Family</strong> Health Division. Thecore group consists of representatives from <strong>the</strong> LogisticsManagement Division, UNFPA, Nepal <strong>Family</strong> HealthProgramme <strong>and</strong> USAID. The larger group consists ofrepresentatives from <strong>the</strong> core group, <strong>in</strong>clud<strong>in</strong>g FPAN,Social Market<strong>in</strong>g <strong>and</strong> <strong>the</strong> National Centre for AIDS<strong>and</strong> STD Control. The Contraceptive Security Work<strong>in</strong>gGroup meets every year <strong>in</strong> May <strong>and</strong> November. Thework<strong>in</strong>g group reviews <strong>and</strong> discusses contraceptiveforecasts, shipment schedules <strong>and</strong> o<strong>the</strong>r important issues.In August 2010, <strong>the</strong> Logistics Management Division <strong>and</strong>NFHP-II/DELIVER-II, with USAID/Nepal, held <strong>the</strong>“National Level Bi-annual Review of Consensus Forecast<strong>and</strong> Quantification of RH/FP, MCH Commodities,Essential Drugs <strong>and</strong> Vacc<strong>in</strong>es for <strong>the</strong> next five years”.Logistics Management InformationSystemS<strong>in</strong>ce 1997, USAID <strong>and</strong> John Snow <strong>International</strong> havebeen support<strong>in</strong>g Nepal <strong>in</strong> conduct<strong>in</strong>g nationwide reportsof <strong>the</strong> Logistics Management Information System (LMIS).187

The system guides <strong>the</strong> operations of <strong>the</strong> MoHP logisticmanagement system by forecast<strong>in</strong>g, provid<strong>in</strong>g <strong>in</strong>ventorymanagement, pipel<strong>in</strong>e monitor<strong>in</strong>g, <strong>and</strong> prevent<strong>in</strong>g “stockouts”(events that cause <strong>in</strong>ventories to become exhausted).By 2006, 94 per cent of health facilities (4,000) weresubmitt<strong>in</strong>g LMIS forms. This system has improved storagepractices <strong>and</strong> <strong>the</strong>refore has reduced waste <strong>and</strong> expirationof contraceptives. The reports are used to <strong>in</strong>fluence <strong>the</strong>Annual Commodity Distribution Programme.The Logistic Management Division, with technicalassistance from USAID, monitors <strong>the</strong> stock status ofcontraceptives through LMIS. The contraceptives aredistributed through <strong>the</strong> Annual Commodity DistributionProgramme (ACDP), formerly supported by UNFPA, butnow run by <strong>the</strong> government. In ACDP, 14-16 months ofcontraceptive stocks are furnished to district public healthoffices, <strong>and</strong> those offices send <strong>the</strong> contraceptives to grassrootshealth facilities on a quarterly basis accord<strong>in</strong>g to <strong>the</strong>irrequest. Data from LMIS show that <strong>the</strong> stock-out rate atservice-delivery po<strong>in</strong>ts over <strong>the</strong> years has decreased from39 per cent <strong>in</strong> 1994 to zero <strong>in</strong> 2009 (USAID/DELIVERProject, 2009).TableTable14188

Availability of NDHS surveysfor forecast<strong>in</strong>g <strong>and</strong> a shift <strong>in</strong>contraceptive commoditiesdistributedNepal has conducted fertility <strong>and</strong> family plann<strong>in</strong>g surveyss<strong>in</strong>ce 1976 for each five-year <strong>in</strong>terval; s<strong>in</strong>ce 1996 it hasconducted Demographic <strong>and</strong> Health Surveys (DHS).Nepal has already undertaken three such surveys (<strong>in</strong> 1996,2001 <strong>and</strong> 2006), <strong>and</strong> it has recently conducted ano<strong>the</strong>rone for 2011. The results of DHS 2011 are expected<strong>in</strong> October this year. These surveys provide adequate<strong>in</strong>formation on <strong>the</strong> levels <strong>and</strong> trends of contraceptivemethod mix, which can be used for estimat<strong>in</strong>g futurerequirements for contraceptives.There have been some <strong>in</strong>dications that a shift <strong>in</strong>contraceptive commodities distributed by sources <strong>in</strong>Nepal has been tak<strong>in</strong>g place (see Table 14). First, although<strong>the</strong> government sector cont<strong>in</strong>uously predom<strong>in</strong>ates as asource of any modern contraceptive method, its sharehas tended to decl<strong>in</strong>e over <strong>the</strong> years. Second, <strong>the</strong> sharesof <strong>the</strong> NGO sector <strong>in</strong> dispens<strong>in</strong>g contraceptives has alsoshown a decl<strong>in</strong><strong>in</strong>g trend. This holds true for all <strong>in</strong>dividualmodern methods except IUDs. Third, <strong>the</strong> share of <strong>the</strong>private medical sector has almost doubled between 2001<strong>and</strong> 2006; reach<strong>in</strong>g 13.8 per cent <strong>in</strong> that year after it hadbeen only 7.3 per cent <strong>in</strong> 2001. The <strong>in</strong>crease is remarkablefor all methods, especially of pills, <strong>in</strong>jectables, implants <strong>and</strong>condoms. Fourth, shops, friends <strong>and</strong> relatives have alsobecome a major source for condom.F<strong>in</strong>anc<strong>in</strong>gThe major sources of fund<strong>in</strong>g for contraceptives arepresented <strong>in</strong> Table 15. USAID is <strong>the</strong> largest funder offamily plann<strong>in</strong>g-related activities <strong>in</strong> Nepal, followed byKfW <strong>and</strong> DFID. Until FY 2000/2001, contraceptiveneeds had been fully met with donor fund<strong>in</strong>g. Thegovernment started shar<strong>in</strong>g <strong>the</strong> cost of contraceptives <strong>in</strong>FY 2001/2002. The amount has <strong>in</strong>creased from US$99,000 <strong>in</strong> 2001/2002 to US$ 140,000 <strong>in</strong> 2006/7. Thegovernment committed US$ 1,877,000 for 2006/07for contraceptives us<strong>in</strong>g a pool fund (fund created byDFID <strong>and</strong> <strong>the</strong> World Bank). There was an 87 per cent<strong>in</strong>crease <strong>in</strong> <strong>the</strong> budget from 2008/09 to 2009/10 (MoHP,USAID/DELIVER Project, 2010). In FY2009/10, <strong>the</strong>government committed 100 per cent of <strong>the</strong> public sectorprocurement needs for contraceptives, allocat<strong>in</strong>g US$2,114,300 for contraceptive procurement. Accord<strong>in</strong>g to afew key stakeholders, f<strong>in</strong>anc<strong>in</strong>g contraceptive commoditiesis not currently a problem; however, problems do exist <strong>in</strong><strong>the</strong> procurement process.Figure 4 shows <strong>the</strong> total donor expenditures for populationassistance by channel: NGO, multilateral or bilateral.Social market<strong>in</strong>g of contraceptive commodities hasTableTable15189

FigureFigure4Total donor expenditures for population assistance, by channel, Nepal, 1998-20086000050000Total $US (<strong>in</strong> thous<strong>and</strong>s)40000300002000010000NGOMultilateralBilateral01998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008YearSource: UNFPA F<strong>in</strong>ancial Resource Flows for Population Activities, 2010.been carried out by lead<strong>in</strong>g private organizations<strong>and</strong> some NGOs: Nepal Contraceptive Retails SalesCompany, Population Services <strong>International</strong>, MarieStopes <strong>International</strong> <strong>and</strong> Academy for EducationalDevelopment. In addition, Lomus Pharmaceuticals hasbeen manufactur<strong>in</strong>g three br<strong>and</strong>s of oral contraceptivepills s<strong>in</strong>ce 2009. Lomus provided <strong>the</strong> funds for productdevelopment <strong>and</strong> manufactur<strong>in</strong>g, <strong>and</strong> USAID providedfunds for market<strong>in</strong>g <strong>and</strong> distribution.The cost of contraceptives is a major factor <strong>in</strong> <strong>the</strong> promotionof methods by <strong>the</strong> government <strong>and</strong> private sector. Forexample, <strong>in</strong> comparison with o<strong>the</strong>r methods, implantsare very expensive (<strong>in</strong> <strong>the</strong> public sector: $29 per implantcompared with US$ 0.63 for <strong>in</strong>jectables <strong>and</strong> US$ 0.24for IUDs). Although <strong>the</strong>re is a dem<strong>and</strong> for <strong>the</strong> implant <strong>in</strong>Nepal, <strong>the</strong> supplies of implants are be<strong>in</strong>g reduced due to<strong>the</strong>ir high cost (key stakeholders <strong>in</strong>terviews).Payment for contraceptionIn Nepal, <strong>the</strong> public sector now provides free familyplann<strong>in</strong>g services to anyone, whereas NGOs such as FPAN<strong>and</strong> Marie Stopes <strong>International</strong> charge nom<strong>in</strong>al fees forservices, <strong>and</strong> pharmacies <strong>and</strong> private providers charge <strong>the</strong>sell<strong>in</strong>g price of <strong>the</strong> commodities.Table 16 shows <strong>the</strong> percentage of couples who paid forcontraceptive commodities <strong>in</strong> Nepal, draw<strong>in</strong>g on data from<strong>the</strong> 2006 NDHS. Overall, among <strong>the</strong> contraceptive users,one fifth paid a fee for a contraceptive method. Paymentswere only for female sterilization, male sterilization, pills,<strong>in</strong>jectables <strong>and</strong> condoms. Almost half of <strong>the</strong> users from<strong>the</strong> NGO/private medical sector paid some fee, while 12per cent of those who used <strong>the</strong> public sector paid a fee.Accord<strong>in</strong>g to <strong>the</strong> 2006 NDHS, <strong>in</strong> many cases <strong>the</strong> onlycost for public sector users was a registration fee, whereasprivate sector users had to bear <strong>the</strong> cost of <strong>the</strong> consultancy<strong>and</strong> payment for <strong>the</strong> method, as well as <strong>the</strong> registrationfee. In terms of <strong>in</strong>dividual methods, pills are <strong>the</strong> mostmarketed method (52%), followed by <strong>in</strong>jectables (43%)<strong>and</strong> condoms (23%). For sterilization (both male <strong>and</strong>female), only a small proportion (less than 5%) paid somefee for us<strong>in</strong>g <strong>the</strong> method.ProcurementIn <strong>the</strong> public sector, <strong>the</strong> Logistic Management Divisionis responsible for <strong>the</strong> procurement of contraceptives <strong>and</strong>o<strong>the</strong>r reproductive health <strong>and</strong> essential drug commodities.District-level tra<strong>in</strong><strong>in</strong>g has started <strong>in</strong> some selected districtsus<strong>in</strong>g <strong>the</strong> st<strong>and</strong>ard procurement tra<strong>in</strong><strong>in</strong>g manual.The government follows <strong>the</strong> Procurement Act 2007 whichfurnishes a st<strong>and</strong>ard procedure to issue tenders, evaluatebids <strong>and</strong> monitor supplier performance. Although <strong>the</strong>process is transparent, <strong>the</strong> actual procurement gets delayed,very often due to long bureaucratic processes. Accord<strong>in</strong>g toa key stakeholder, corruption also plays a role <strong>in</strong> delay<strong>in</strong>gprocurement. For example, last year <strong>the</strong>re was a delay <strong>in</strong>procurement, so USAID gave an advance to CRS. The190

TableTable16TableTable17bidd<strong>in</strong>g procedures comply with <strong>in</strong>ternational bidd<strong>in</strong>gprocedures of fund<strong>in</strong>g agencies.Although <strong>the</strong>re are delays <strong>in</strong> procurement, <strong>the</strong> qualityassurance <strong>in</strong> procurement is ma<strong>in</strong>ta<strong>in</strong>ed by follow<strong>in</strong>gst<strong>and</strong>ards of <strong>the</strong> World Health Organization, pre- <strong>and</strong>post-shipment <strong>in</strong>spections, <strong>in</strong>clud<strong>in</strong>g follow<strong>in</strong>g laboratorytest results.A hybrid “push-pull” system for contraceptive commoditiesbegan <strong>in</strong> Nepal <strong>in</strong> 2004/2005 <strong>in</strong> order to reduce waste <strong>and</strong>contraceptive expiry, <strong>and</strong> to ensure <strong>the</strong> availability of FPcommodities at all service po<strong>in</strong>ts of <strong>the</strong> health system. Inthis system, half <strong>the</strong> annual estimated consumption of ahealth facility is dispatched directly to <strong>the</strong> facility <strong>and</strong> <strong>the</strong>rema<strong>in</strong><strong>in</strong>g half is stored at <strong>the</strong> district level for dem<strong>and</strong>basedsupply. Health facilities use LMIS to forward<strong>the</strong>ir dem<strong>and</strong>s quarterly to <strong>the</strong> appropriate district store.Meanwhile, regional medical stores ma<strong>in</strong>ta<strong>in</strong> “bufferstocks” of 20 key essential drugs to supply district stores asneeded. All health facilities ma<strong>in</strong>ta<strong>in</strong> six-month maximumstock levels, with regular quarterly resupply. As of 2008this system was operat<strong>in</strong>g <strong>in</strong> 23 of 75 districts <strong>and</strong> seemedto be successful (2008 NFHP).Evaluation of <strong>the</strong> familyplann<strong>in</strong>g programme:The <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Effort IndexThe <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Effort (FPE) Index was developed tomeasure <strong>the</strong> strengths of <strong>in</strong>puts of national family plann<strong>in</strong>gefforts. The scores have also been used by major donors <strong>and</strong>agencies to set country priorities, to gauge progress <strong>and</strong> todiagnose programme weaknesses at <strong>the</strong> national level. The<strong>in</strong>dex is based on 120 items which are coded <strong>in</strong> 30 scores<strong>in</strong> four components: (a) policy (8 items); (b) services (13items); (c) evaluation (3 items); <strong>and</strong> (d) method access (6items). Scores are converted to a percentage value, whichranges from 0 to 100. The higher is <strong>the</strong> score, <strong>the</strong> strongerare <strong>the</strong> efforts of <strong>the</strong> family plann<strong>in</strong>g programme <strong>in</strong> terms ofpolicy development, provid<strong>in</strong>g services, regular monitor<strong>in</strong>g<strong>and</strong> evaluation <strong>and</strong> access to contraceptive methods <strong>in</strong> <strong>the</strong>country <strong>in</strong> question.Draw<strong>in</strong>g on <strong>the</strong> FPE Index calculated by <strong>the</strong> FuturesGroup (Ross <strong>and</strong> Smith, 2010), it appears that Nepalmade considerable progress <strong>in</strong> family plann<strong>in</strong>g <strong>in</strong> <strong>the</strong> 1980s(see Table 17). The score reached 59 <strong>in</strong> 1989 but decl<strong>in</strong>edto 51 <strong>in</strong> 1994. Thus, <strong>the</strong> lowest effort was recorded <strong>in</strong> <strong>the</strong>early 1990s. The score aga<strong>in</strong> <strong>in</strong>creased to 57 <strong>in</strong> 1999 <strong>and</strong>191

FigureFigureaga<strong>in</strong> decl<strong>in</strong>ed to 52 <strong>in</strong> 2004. The decl<strong>in</strong>e <strong>in</strong> <strong>the</strong> FPE Indexscore between 1999 <strong>and</strong> 2004 may have been due to <strong>the</strong>adverse impact of <strong>the</strong> armed conflict <strong>in</strong> <strong>the</strong> country at thattime <strong>and</strong> its impact on <strong>the</strong> performance of family plann<strong>in</strong>gactivities, especially <strong>in</strong> relation to provid<strong>in</strong>g services <strong>and</strong>carry<strong>in</strong>g out monitor<strong>in</strong>g <strong>and</strong> evaluation. In that period, <strong>the</strong>large majority of projects <strong>and</strong> programmes were divertedfrom rural areas to urban areas or were withdrawn, <strong>and</strong>health <strong>and</strong> family plann<strong>in</strong>g workers left <strong>the</strong> villages becauseof fear or threats aris<strong>in</strong>g from <strong>the</strong> conflict. The resurgenceof family plann<strong>in</strong>g activities subsequently appeared to be<strong>in</strong>creas<strong>in</strong>g, especially after <strong>the</strong> country entered <strong>the</strong> peaceprocess <strong>in</strong> 2006.The scores for policy, services, monitor<strong>in</strong>g <strong>and</strong> evaluation,<strong>and</strong> method availability differed. The policy score stayed<strong>the</strong> same from 1999 to 2004, but <strong>the</strong>n decl<strong>in</strong>ed from 61to 58 <strong>in</strong> 2009. The score for services decl<strong>in</strong>ed from 56 to46 from 1999 to 2004 <strong>and</strong> <strong>the</strong>n <strong>in</strong>creased to 55 <strong>in</strong> 2009.There was a steady decl<strong>in</strong>e <strong>in</strong> <strong>the</strong> score for monitor<strong>in</strong>g <strong>and</strong>evaluation from 1999 to 2009 (it decl<strong>in</strong>ed from 67 to 54<strong>and</strong> <strong>the</strong>n to 48). The only score to <strong>in</strong>crease over this periodwas method availability: from 1999 to 2004 that score<strong>in</strong>creased from 49 to 50 <strong>and</strong> <strong>in</strong> 2009 reached 62.Figure5Scores on <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Effort Index, Nepal, 1972-20097060Total Score ( percentage ofmaximum score )504030201001970 1980 1990 2000 2010YearFigure6Total fertility rate <strong>and</strong> contraceptive prevalence rate, Nepal, 1976-2006607Percent of currently marriedwoman (age 15-49) us<strong>in</strong>g contraception504030201006543210Total ferility rateCPRTFR1970 1980 1990 2000 2010Year192

TableTable18TableTable19TableTable20193

Impact of family plann<strong>in</strong>g <strong>and</strong> futureprojectionsTFR <strong>in</strong> Nepal decl<strong>in</strong>ed from 6.3 <strong>in</strong> 1976 to 3.1 <strong>in</strong> <strong>the</strong>period 2003-2005. The average annual l<strong>in</strong>ear decl<strong>in</strong>e frommid-1999 to mid-2004 was 0.2 children per woman, while<strong>the</strong> comparable figures <strong>in</strong> <strong>the</strong> earlier years were more orless 0.1 children per woman. This reveals that <strong>the</strong> pace offertility decl<strong>in</strong>e after 2000 was faster than <strong>in</strong> <strong>the</strong> decades of<strong>the</strong> 1980s <strong>and</strong> 1990s.Impact of contraception on fertilityreductionResearch conducted by Ross <strong>and</strong> Frankenberg (1993),tak<strong>in</strong>g data from 100 develop<strong>in</strong>g countries, revealed thata 15 per cent <strong>in</strong>crease <strong>in</strong> CPR is generally associated witha one-child decl<strong>in</strong>e <strong>in</strong> TFR. In Nepal, Karki <strong>and</strong> Krishna(2008) found a strong correlation between TFR <strong>and</strong> CPR(coefficient = –0.955), which was significant at <strong>the</strong> 0.01level. They also ran a l<strong>in</strong>ear regression (Y = a + b X ) ofTFRs <strong>and</strong> CPRs <strong>and</strong> found <strong>the</strong> follow<strong>in</strong>g equation:TFR = 6.648 + (– 0.068) * CPR (r2 = 0.955)Us<strong>in</strong>g this equation with Nepalese data, we have predictedTFR for each year from 1976 to 2006 (see Table 19).The predicted TFR for 2006 was 3.4 while <strong>the</strong> observedTFR was 3.1. The predicted TFR for Nepal <strong>in</strong> 2006would be 6.648 assum<strong>in</strong>g no contraceptive use (<strong>the</strong> valueof constant). Thus, <strong>the</strong> <strong>in</strong>crease <strong>in</strong> contraceptive useexpla<strong>in</strong>s roughly 96.5 per cent of <strong>the</strong> decl<strong>in</strong>e <strong>in</strong> fertility.This implies that o<strong>the</strong>r proximate determ<strong>in</strong>ants of fertility,such as post-partum amenorrhoea, abortion <strong>and</strong> marriage,have had very little effect <strong>in</strong> reduc<strong>in</strong>g fertility. Thus, us<strong>in</strong>gNepalese data, a 14.1 per cent <strong>in</strong>crease <strong>in</strong> contraceptive useis associated with a one-child decl<strong>in</strong>e <strong>in</strong> TFR. Assum<strong>in</strong>gthat o<strong>the</strong>r proximate determ<strong>in</strong>ants of fertility rema<strong>in</strong> stableat <strong>the</strong> current level, Nepal, <strong>the</strong>refore, needs to achieve 63-65 per cent CPR to reach replacement-level fertility (2.1births per woman).Future projection of contraceptiveprevalence rateCPR must <strong>in</strong>crease <strong>in</strong> <strong>the</strong> future <strong>in</strong> Nepal, but <strong>the</strong> paceof <strong>in</strong>crease will depend upon several factors, <strong>in</strong>clud<strong>in</strong>gwomen’s education, employment <strong>and</strong> <strong>the</strong> national familyplann<strong>in</strong>g programme. A fur<strong>the</strong>r expansion of dem<strong>and</strong> forfamily plann<strong>in</strong>g is likely for two reasons. First, <strong>the</strong> onsetof <strong>the</strong> fertility transition <strong>in</strong> rural areas, especially among<strong>the</strong> most vulnerable, poorest, Muslims <strong>and</strong> Dalits, has notbeen actually <strong>in</strong>itiated, while for o<strong>the</strong>r social groups <strong>the</strong>transition has not yet been completed. Second, Nepal’shigh population growth rate <strong>in</strong> <strong>the</strong> past means that <strong>the</strong>number of women enter<strong>in</strong>g <strong>the</strong> reproductive age groupwill rise for a few decades.Methodology:Global, regional <strong>and</strong> country projections <strong>and</strong> figures forCPR <strong>and</strong> <strong>the</strong> proportion of women <strong>in</strong> union are availablefrom robust sources, such as <strong>the</strong> United Nations (1999)<strong>and</strong> <strong>the</strong> Futures Group (Morel<strong>and</strong> et al., 2010). TheFutures Group projection was carried out by employ<strong>in</strong>gSPECTRUM software, i.e., DEMPROJ for populationprojections, <strong>and</strong> FAMPLN for projection of familyplann<strong>in</strong>g, <strong>in</strong>clud<strong>in</strong>g o<strong>the</strong>r proximate determ<strong>in</strong>ants offertility. The authors used <strong>the</strong> basel<strong>in</strong>e <strong>in</strong>formation from<strong>the</strong> recent Demographic <strong>and</strong> Health Survey of <strong>the</strong> country<strong>in</strong> question. In <strong>the</strong> case of Nepal, <strong>the</strong> authors used datafrom NDHS 2001. CPR was estimated for all women ofreproductive age us<strong>in</strong>g any methods, <strong>in</strong>clud<strong>in</strong>g traditionalmethods, not only for married women or women <strong>in</strong> union.For projection of <strong>the</strong> percentage of women <strong>in</strong> union, <strong>the</strong>authors assumed that marriage <strong>and</strong> union patterns wouldbe <strong>in</strong>fluenced by level of education <strong>and</strong> be taken <strong>in</strong>toaccount.The projection of CPR shows that CPR of Nepal would be54 per cent by 2015, 70 per cent by 2025 <strong>and</strong> 80 per centby 2035. It is projected that CPR will rema<strong>in</strong> at 80 percent from 2035 to 2050. It should be noted that <strong>the</strong> annuall<strong>in</strong>ear <strong>in</strong>crease <strong>in</strong> CPR is 0.60 per cent between 2001 <strong>and</strong>2005; 1.7 per cent between 2005 <strong>and</strong> 2010; <strong>and</strong> that it willbe 1.64 per cent from 2010 to 2030. Therefore, accord<strong>in</strong>gto <strong>the</strong>se projections, Nepal will not reach its target of 67per cent CPR by 2015, which is needed to achieve Target5b of <strong>the</strong> Millennium Development Goals.On <strong>the</strong> o<strong>the</strong>r h<strong>and</strong>, <strong>the</strong> proportion of women <strong>in</strong> union isprojected to decl<strong>in</strong>e l<strong>in</strong>early <strong>in</strong> each of <strong>the</strong> successive years.The proportion of women <strong>in</strong> union was projected to be 77per cent <strong>in</strong> 2005, which would decl<strong>in</strong>e to 71 per cent by2020, to 66 per cent by 2035 <strong>and</strong> to 63 per cent by 2050.RecommendationsThe follow<strong>in</strong>g recommendations have emerged from <strong>the</strong>present assessment:1. Improve <strong>the</strong> quality of familyplann<strong>in</strong>g services:Improve <strong>the</strong> quality of family plann<strong>in</strong>g counsell<strong>in</strong>g bytra<strong>in</strong><strong>in</strong>g health-care providers <strong>and</strong> volunteers to addressmisconceptions <strong>and</strong> mis<strong>in</strong>formation of providers <strong>and</strong>clients. Monitor counsell<strong>in</strong>g practices periodically.2. Increase access to family plann<strong>in</strong>gservices:194

Exp<strong>and</strong> utilization of satellite services for a broaderrange of family plann<strong>in</strong>g services, such as implants <strong>and</strong>IUD, added to voluntary surgical contraception services.Increase <strong>the</strong> number of service delivery po<strong>in</strong>ts, <strong>in</strong>clud<strong>in</strong>gimprov<strong>in</strong>g physical facilities at <strong>the</strong> sub-health post level.Create family plann<strong>in</strong>g counsellor positions at all levels <strong>in</strong><strong>the</strong> government health system to improve access to familyplann<strong>in</strong>g.3. Increase <strong>in</strong>tegration of familyplann<strong>in</strong>g services <strong>in</strong>to o<strong>the</strong>r areas:Increase <strong>in</strong>tegration of FP counsell<strong>in</strong>g <strong>in</strong>to post-partum,safe abortion, safe mo<strong>the</strong>rhood, HIV, STI, child heal<strong>the</strong>tc., services. Increase <strong>in</strong>tegration of FP <strong>in</strong>formation <strong>in</strong>tosocial <strong>and</strong> economic development <strong>in</strong>itiatives.4. Streng<strong>the</strong>n coord<strong>in</strong>ation:Female Community Health Volunteers should be <strong>in</strong>cluded<strong>in</strong> district-level coord<strong>in</strong>ation committees. Refocus familyplann<strong>in</strong>g <strong>in</strong> <strong>the</strong> district-level coord<strong>in</strong>ation committeeagenda. Increase coord<strong>in</strong>ation of large NGOs <strong>and</strong>MoHP to make service delivery more efficient. Increasecommunication of new policies with <strong>the</strong> general population<strong>and</strong> key stakeholders.5. Improve monitor<strong>in</strong>g <strong>and</strong> evaluation:Improve <strong>and</strong> <strong>in</strong>crease rout<strong>in</strong>e monitor<strong>in</strong>g, evaluation <strong>and</strong>supervision of <strong>in</strong>tegration of FP with o<strong>the</strong>r RH services(post-partum, safe mo<strong>the</strong>rhood, safe abortion, HIV etc.)<strong>and</strong> basic health-care services, availability of methods, <strong>and</strong>service providers at health delivery sites <strong>and</strong> <strong>the</strong> VillageDevelopment Committee level.6. Increase/improve human resources:Mobilize health workers, especially doctors <strong>in</strong> rural<strong>and</strong> remote areas. Review current <strong>in</strong>centives for tra<strong>in</strong>edhealth personnel <strong>in</strong> remote areas to <strong>in</strong>crease retention<strong>and</strong> motivate <strong>the</strong>m to serve <strong>the</strong> people <strong>in</strong> those areas.Increase education <strong>and</strong> tra<strong>in</strong><strong>in</strong>g at medical schools <strong>and</strong>among health providers on all FP methods, especially forlong-act<strong>in</strong>g reversible contraceptive methods. M<strong>in</strong>imizedisruption <strong>and</strong> discont<strong>in</strong>uation of services associatedwith staff transfers, through periodic tra<strong>in</strong><strong>in</strong>g of newlyappo<strong>in</strong>ted staff. Increase refresher <strong>and</strong> retra<strong>in</strong><strong>in</strong>g courses.Increase advocacy to motivate health providers to givefamily plann<strong>in</strong>g services.7. Greater impact of Female CommunityHealth Volunteers:Cont<strong>in</strong>ue to tra<strong>in</strong> <strong>and</strong> motivate (through <strong>in</strong>centives <strong>and</strong>awards) Female Community Health Volunteers on accuratecounsell<strong>in</strong>g <strong>and</strong> <strong>in</strong>sure that <strong>the</strong>y have adequate amountsof FP supplies. Improve referral l<strong>in</strong>kages to facilities thatoffer long-act<strong>in</strong>g reversible contraceptive method services.Reorient <strong>the</strong> Volunteers to engage <strong>in</strong> promot<strong>in</strong>g spac<strong>in</strong>gmethods. Increase refresher <strong>and</strong> referral tra<strong>in</strong><strong>in</strong>g. Include<strong>the</strong> Volunteers <strong>in</strong> <strong>the</strong> formulation of family plann<strong>in</strong>gprogrammes. Establish or exp<strong>and</strong> exist<strong>in</strong>g FemaleCommunity Health Volunteer funds <strong>in</strong> every VillageDevelopment Committee <strong>and</strong> properly mobilize <strong>the</strong>m toimprove <strong>the</strong> liv<strong>in</strong>g st<strong>and</strong>ards of <strong>the</strong> Volunteers. Modify <strong>the</strong>Volunteer recruitment methods to meet <strong>the</strong> dem<strong>and</strong> for<strong>the</strong>ir services <strong>in</strong> order to reduce <strong>the</strong>ir burden of work.8. Reach marg<strong>in</strong>alized populations:Prioritize equitable access to family plann<strong>in</strong>g services by<strong>the</strong> donors, government <strong>and</strong> NGOs <strong>in</strong> order to reachmarg<strong>in</strong>alized groups, such as Muslims, Dalits, <strong>the</strong> verypoor <strong>and</strong> undereducated rural people. Community healthworkers <strong>and</strong> volunteers with<strong>in</strong> <strong>the</strong>se groups should betra<strong>in</strong>ed <strong>and</strong> mobilized to exp<strong>and</strong> family plann<strong>in</strong>g education<strong>and</strong> access. Integrate family plann<strong>in</strong>g with socio-economicdevelopment programmes, as well as all health servicesthrough local participation. For example, FP should be<strong>in</strong>corporated with microcredit <strong>and</strong> women’s cooperativeprogrammes, s<strong>in</strong>ce <strong>the</strong>re are more than 1 million womenwho are organized <strong>in</strong> such programmes. Fur<strong>the</strong>r promote<strong>in</strong>formed choice <strong>and</strong> comprehensive FP services below <strong>the</strong>district level.9. Reach migrants:Increase access to <strong>in</strong>formation <strong>and</strong> <strong>in</strong>crease provision ofemergency contraception, easy access to condoms <strong>and</strong>pills for <strong>the</strong> migrant population <strong>and</strong> develop quick referralsystems to enable migrant populations to easily accesscontraception.10. Reach adolescents <strong>and</strong> youth:Increase youth-friendly services at health facilities. Increaseemphasis on sexual <strong>and</strong> reproductive health education,<strong>in</strong>clud<strong>in</strong>g <strong>the</strong> advantages of contraceptive use, <strong>in</strong> schools<strong>and</strong> <strong>in</strong> public communication campaigns, to sensitizeyoung people to <strong>the</strong>se issues.11. Contraceptive commodities:Streaml<strong>in</strong>e <strong>the</strong> procurement procedures <strong>and</strong> developnational capacity <strong>in</strong> <strong>the</strong> area of procurement plann<strong>in</strong>g.Improve warehous<strong>in</strong>g, distribution <strong>and</strong> transportationsystems <strong>in</strong> l<strong>in</strong>e with <strong>the</strong> <strong>in</strong>creas<strong>in</strong>g dem<strong>and</strong> for moresupplies. Explore cost recovery schemes, <strong>and</strong> <strong>in</strong>creaseprivate sector outreach <strong>in</strong> rural areas.12. Increase private sector<strong>in</strong>volvement:Increase role of <strong>the</strong> private sector <strong>in</strong> sell<strong>in</strong>g <strong>and</strong> social195

market<strong>in</strong>g of contraceptives to reduce <strong>the</strong> burden on <strong>the</strong>public sector, <strong>and</strong> use private networks to exp<strong>and</strong> facilities<strong>and</strong> services. Exp<strong>and</strong> <strong>the</strong> role of <strong>the</strong> commercial sectorto reduce donor dependency <strong>and</strong> recover some costs ofcontraceptives.13. Exp<strong>and</strong> <strong>in</strong>formation, education <strong>and</strong>communication campaigns:Address misconceptions about family plann<strong>in</strong>g throughlocal electronic media. Discuss advantages of familyplann<strong>in</strong>g <strong>and</strong> give <strong>in</strong>formation on where to obta<strong>in</strong> suchservices. Form male <strong>in</strong>volvement groups to dispel mythsabout family plann<strong>in</strong>g <strong>and</strong> <strong>in</strong>crease male participation.Promote long-act<strong>in</strong>g reversible contraceptive methods<strong>and</strong> o<strong>the</strong>r spac<strong>in</strong>g methods. Promote <strong>the</strong> "Well-Planned<strong>Family</strong>" (byawasthit pariwar) concept to create a positiveimage of family plann<strong>in</strong>g <strong>in</strong>stead of "pariwar niyojan"(family control). Cont<strong>in</strong>ue to promote <strong>the</strong> small familynorm <strong>and</strong> delayed marriage. Increase momentum throughadvocacy, with renewed emphasis on exist<strong>in</strong>g <strong>and</strong> newapproaches.ConclusionS<strong>in</strong>ce its <strong>in</strong>ception, considerable achievements have beenmade by <strong>the</strong> national family plann<strong>in</strong>g programme over<strong>the</strong> past 40 years <strong>in</strong> terms of reduc<strong>in</strong>g TFR <strong>and</strong> <strong>in</strong>creas<strong>in</strong>gCPR. Still a large portion of society, especially marg<strong>in</strong>alizedgroups, is underserved. In addition, <strong>the</strong>re is a fear that o<strong>the</strong>rreproductive health programmes have been prioritizedat <strong>the</strong> cost of <strong>the</strong> family plann<strong>in</strong>g programme. In orderto overcome <strong>the</strong>se challenges <strong>and</strong> achieve <strong>the</strong> ICPD <strong>and</strong>MDG goals, <strong>the</strong> government, NGOs, <strong>the</strong> private sector<strong>and</strong> civil society must mobilize resources <strong>and</strong> renew <strong>the</strong>ircommitment to reposition family plann<strong>in</strong>g <strong>in</strong> Nepal.End Notes1 In <strong>the</strong>ir analysis of World Population Prospects <strong>and</strong>Unmeet Need for <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>, Morel<strong>and</strong> et al. (2010)categorized high unmet need for countries as be<strong>in</strong>g 25 percent or higher.2 As CPR by district is not available from NDHS 2001<strong>and</strong> 2006, service statistics were used to obta<strong>in</strong> <strong>the</strong>sedata. Caution must be taken that service statistics may beoverestimated as report<strong>in</strong>g of large number of users wouldbe of advantageous to <strong>the</strong> service providers. Low CPR<strong>in</strong> Kathm<strong>and</strong>u appears to be underestimated given <strong>the</strong>high access to health/family plann<strong>in</strong>g services <strong>and</strong> almostreplacement-level fertility.3 Dalit is a term used to describe groups of people fromvarious castes who are socially marg<strong>in</strong>alized <strong>and</strong> termed as“outcastes”. Euphemisms such as untouchables, occupationalcastes, backward classes, marg<strong>in</strong>alized groups <strong>and</strong>disadvantaged groups are used to refer dalits.4 Nepal’s largest caste group; <strong>the</strong>y account for more than 15per cent of <strong>the</strong> population.5 This caste comprises ano<strong>the</strong>r ethnic group account<strong>in</strong>g forover 12 per cent of <strong>the</strong> country’s population.6 Yet ano<strong>the</strong>r major ethnic group.7 Levels of compliance have been assigned as low, low-tomoderate,moderate, moderate-to-high <strong>and</strong> high. Lowcompliance implies that <strong>the</strong> provisions embodied <strong>in</strong> <strong>the</strong>ICPD Programme of Action have not been implementedat all, or implementation is highly unsatisfactory. Lowto-moderatelevel of compliance refers to <strong>the</strong> movementtowards a satisfactory condition. Moderate compliancemeans that <strong>the</strong> provisions have not been fully realized,but <strong>the</strong>y are at a satisfactory level. Moderate-to-highlevel of compliance refers to <strong>the</strong> movement towards ahighly satisfactory state both <strong>in</strong> terms of <strong>the</strong> number ofimplementation mechanisms <strong>and</strong> <strong>the</strong>ir enforcement status.The high level of compliance means that <strong>the</strong> provisions <strong>in</strong><strong>the</strong> ICPD Programme of Action have been implementedfully <strong>and</strong> <strong>the</strong>ir enforcement is also highly satisfactory.ReferencesBennett, Lynn, Dilli Ram Dahal <strong>and</strong> Pav Gov<strong>in</strong>dasamy(2008). 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The <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Effort Index: 1999, 2004, <strong>and</strong> 2009, Wash<strong>in</strong>gton,D.C.: Futures Group, Health Policy Initiative, TaskOrder 1.Ross A <strong>and</strong> Frankenberg E (1993), F<strong>in</strong>d<strong>in</strong>gs from <strong>the</strong>Two Decades of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Research, New York,Population <strong>Council</strong>, 1993Stephenson, Rob, Michael A. Koen<strong>in</strong>g <strong>and</strong> Saifudd<strong>in</strong>Ahmed (2006). “Domestic violence <strong>and</strong> contraceptiveadoption <strong>in</strong> Uttar Pradesh, India”, Studies <strong>in</strong> <strong>Family</strong><strong>Plann<strong>in</strong>g</strong>, 37(2):75-86.Tuladhar, J.M. (2007). “Emergence <strong>and</strong> development ofNepal’s family plann<strong>in</strong>g program”, In: W.C. Rob<strong>in</strong>son<strong>and</strong> J.A. Ross, eds., The Global <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Revolution: Three Decades of Population Policies <strong>and</strong>Programs, Wash<strong>in</strong>gton, D.C.: World Bank, pp. 363-376.UNFPA (2007). A Study on Pre-natal Sex Selection <strong>in</strong>Nepal, study conducted by Center for Research onEnvironment Health <strong>and</strong> Population Activities forUNFPA.__________ (2010). F<strong>in</strong>ancial Resource Flows forPopulation Activities, 2010, New York: UNFPA.197

United States Agency for <strong>International</strong> Development(USAID)(2009). News Brief: First NepaliManufacturer of Oral Contraceptive Pills. Last accessedon 15 November 2010 at http://nepal.usaid.gov/newsroom/tell<strong>in</strong>g-our-story/health-<strong>and</strong>-familyplann<strong>in</strong>g/159-first-nepali-manufacturer-of-oralcontraceptive-pills-.html.__________ (2010). Contraceptive Security Indicators2010, Wash<strong>in</strong>gton, D.C.: USAID. Last accessed on15 November 2010 at http://deliver.jsi.com/dhome/topics/monitor<strong>in</strong>g/ monitor<strong>in</strong>gpubs/meresources.USAID <strong>and</strong> UNFPA (2006). Reposition<strong>in</strong>g <strong>Family</strong><strong>Plann<strong>in</strong>g</strong>: Strategic Review of <strong>the</strong> Nepal National<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Program, Kathm<strong>and</strong>u: USAID<strong>and</strong> UNFPA. Last accessed on 16 November 2010at http://www.jsi.com/Managed/Docs/Projects/NFHP/Docs/<strong>Family</strong><strong>Plann<strong>in</strong>g</strong>/strategic_review_of_<strong>the</strong>_fp_program_<strong>in</strong>_nepal.pdfWorld Health Organization (2007). Policy Paper onHealth Nepal, Kathm<strong>and</strong>u: WHO Country Officefor Nepal. Last accessed on 15 November 2010 athttp://www.nep.searo.who.<strong>in</strong>t/L<strong>in</strong>kFiles/Health_Information_PPH.pdfWorld Health Organization (WHO)(2008). FemaleCommunity Health Workers, Kathm<strong>and</strong>u: WorldHealth Organization. Last accessed on 15 November2010 at www.nep.searo.who.<strong>in</strong>t/L<strong>in</strong>kFiles/Home_Female_Community_Health_Volunteer1.pdf.Websiteswww.phishare.org/files/9277_FP_Effort_Index.pdfwww.un.org/esa/population198

PakistanPakistanStatus of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>in</strong> PakistanZeba Sathar* <strong>and</strong> Batool Zaidi #* Zeba Sathar is <strong>the</strong> Country Director of Population <strong>Council</strong>, Islamabad#Batool Zaidi is a Senior Program Officier at Population <strong>Council</strong>, Islamabad199

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IntroductionThis assessment is be<strong>in</strong>g carried out at a critical time <strong>in</strong>Pakistan’s history. The recently enacted 18th amendment to<strong>the</strong> constitution called for all programmes, <strong>in</strong>clud<strong>in</strong>g health<strong>and</strong> population programmes, to be <strong>the</strong> sole responsibilityof prov<strong>in</strong>ces. Therefore, <strong>the</strong> M<strong>in</strong>istry of PopulationWelfare (MoPW) ceased to exist after 1 December 2010.While MoPW had taken <strong>the</strong> responsibility of provid<strong>in</strong>gfamily plann<strong>in</strong>g services for over four decades, <strong>the</strong> mostdrastic aspect of this change is that <strong>the</strong> sole responsibilityfor provid<strong>in</strong>g such services from now on will rest with<strong>the</strong> prov<strong>in</strong>cial departments of health. There will be hugechallenges as this transformation takes place because <strong>the</strong>prov<strong>in</strong>ces currently are strapped for cash <strong>and</strong> have notmade provision for so suddenly hav<strong>in</strong>g to provide familyplann<strong>in</strong>g services. Those services are likely to be fur<strong>the</strong>rdisrupted as <strong>the</strong> responsibilities of <strong>the</strong> federal M<strong>in</strong>istry ofHealth (MoH) are also be<strong>in</strong>g shifted to <strong>the</strong> prov<strong>in</strong>cial level<strong>in</strong> 2011.This paper is ma<strong>in</strong>ly a review of <strong>the</strong> status of familyplann<strong>in</strong>g <strong>and</strong> <strong>the</strong> efforts to promote contraceptive usethrough <strong>the</strong> population programme, <strong>and</strong> <strong>the</strong> support<strong>in</strong>groles of o<strong>the</strong>r sectors <strong>and</strong> players. Both analysis ofsecondary data, primarily taken from fertility surveysconducted over <strong>the</strong> last two decades, as well as primarydata collection, through <strong>in</strong>terviews with key stakeholders,<strong>in</strong>form <strong>the</strong> discussion <strong>in</strong> this paper. While discuss<strong>in</strong>g <strong>the</strong>past <strong>and</strong> present, we po<strong>in</strong>t out areas that need correctiveaction or need to be abolished, as well as o<strong>the</strong>rs that havebeen overlooked <strong>and</strong> need to be urgently brought <strong>in</strong>to <strong>the</strong>programme’s fold.Programme evolutionHistory of <strong>the</strong> programmeMak<strong>in</strong>g <strong>the</strong> connection between <strong>the</strong> well-be<strong>in</strong>g of <strong>the</strong>population, <strong>the</strong> country’s resources <strong>and</strong> its size, FieldMarshal Ayub Khan, second President of Pakistanfrom 1958 to 1969, was <strong>the</strong> first leader to announceemphatically <strong>in</strong> 1965 that <strong>the</strong> country had a populationissue that needed attention. He <strong>the</strong>n assigned an important<strong>in</strong>dividual to take <strong>the</strong> helm of <strong>the</strong> population programme.This was ironic given that <strong>the</strong> first Pakistan census <strong>in</strong> 1961yielded a total population size of only 30 million, whichpreceded <strong>the</strong> real spurt <strong>in</strong> growth that occurred between1972 <strong>and</strong> 1981. Civil society was more advanced <strong>in</strong> <strong>the</strong>irth<strong>in</strong>k<strong>in</strong>g, recogniz<strong>in</strong>g even earlier, <strong>in</strong> 1958, that an activefamily plann<strong>in</strong>g programme was <strong>the</strong> need of <strong>the</strong> moment.The <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Association of Pakistan (FPAP)started its own voluntary non-governmental programmeat that time <strong>and</strong> has probably made a huge impr<strong>in</strong>t on<strong>the</strong> government programme operat<strong>in</strong>g by its side formany years. Pakistan’s First Five-year Plan (1955-1960)<strong>in</strong>troduced family plann<strong>in</strong>g activities through FPAP <strong>and</strong>o<strong>the</strong>r voluntary organizations.In <strong>the</strong> Third Five-year Plan (1965-1970), an <strong>in</strong>dependentfamily plann<strong>in</strong>g set-up was created; mass-scale <strong>in</strong>formation,education <strong>and</strong> communication (IEC) activities werelaunched at that time, <strong>and</strong> a service delivery networkwas established. The next five-year plan <strong>in</strong>troduced <strong>the</strong>“cont<strong>in</strong>uous motivation approach” by employ<strong>in</strong>g male<strong>and</strong> female teams of workers at <strong>the</strong> union council level.Over <strong>the</strong> next decade, <strong>the</strong> programme operated at a lowkey due to reorganization, political unrest <strong>and</strong> suspensionof IEC activities. Major achievements dur<strong>in</strong>g that time<strong>in</strong>cluded devolution to <strong>the</strong> prov<strong>in</strong>ces of field activities,<strong>in</strong>stitutionalization of <strong>the</strong> role of non-governmentalorganizations (NGOs) through <strong>the</strong> NGO Coord<strong>in</strong>ation<strong>Council</strong> (NGOCC) <strong>and</strong> <strong>the</strong> establishment of <strong>the</strong> NationalInstitute of Population Studies (NIPS). With <strong>the</strong> end of<strong>the</strong> regime of General Muhammad Zia-ul-Haq <strong>in</strong> 1989, <strong>the</strong>population programme saw strong political support from<strong>the</strong> highest levels. However, as <strong>the</strong> Eighth Five-year Plan(1993-1998) had been f<strong>in</strong>alized before <strong>the</strong> <strong>International</strong>Conference on Population <strong>and</strong> Development (ICPD) <strong>in</strong>1994, <strong>the</strong> reproductive health (RH) framework was notreflected <strong>in</strong> it.Impact of <strong>the</strong> <strong>International</strong>Conference on Population <strong>and</strong>DevelopmentPopulation was almost wholly left to <strong>the</strong> purview ofMoPW <strong>and</strong> a few organizations do<strong>in</strong>g social market<strong>in</strong>g<strong>and</strong> research formulation for at least a few decades, but<strong>the</strong>n <strong>the</strong> ICPD period as well as <strong>the</strong> earlier preparationsfor it seemed to cause some stir with<strong>in</strong> <strong>the</strong> populationarena. The 1994 Conference was attended by <strong>the</strong> <strong>the</strong>nPrime M<strong>in</strong>ister Benazir Bhutto. Her important statement,“I dream of Pakistan, of an <strong>Asia</strong>, of a world, where everypregnancy is planned <strong>and</strong> every child is nurtured, loved,educated <strong>and</strong> supported”, led to <strong>the</strong> establishment of <strong>the</strong>Lady Health Workers (LHW) programme. The launch<strong>in</strong>gof that programme, a huge public sector undertak<strong>in</strong>gm<strong>and</strong>ated to provide family plann<strong>in</strong>g <strong>and</strong> primary healthcare <strong>in</strong> remote rural areas <strong>and</strong> <strong>in</strong> urban slums, was one of<strong>the</strong> two major <strong>in</strong>novations of <strong>the</strong> early 1990s. The secondmajor <strong>in</strong>novation was <strong>the</strong> establishment of <strong>the</strong> NationalTrust for Volunteer Organizations, a successor to <strong>the</strong>similar NGOCC.The ICPD gave you ways of reach<strong>in</strong>gmen <strong>and</strong> women <strong>in</strong> a broader, moredevelopment- oriented way, <strong>and</strong>,<strong>the</strong>refore, made family plann<strong>in</strong>g more201

acceptable. From an NGO perspective,women’s rights activists started look<strong>in</strong>g atcontraception as a right. ICPD providedways of look<strong>in</strong>g at <strong>the</strong> availability ofcontraception with<strong>in</strong> <strong>the</strong> larger issues ofwomen’s space <strong>and</strong> mobility.Shirkat Gah (Advisor, Women’sRights Organization)Post-conference periodIn <strong>the</strong> N<strong>in</strong>th Five-year Plan (1998-2003), <strong>the</strong> populationprogramme <strong>in</strong>corporated a post-ICPD Plan of Action.In March 2000, <strong>the</strong> Government <strong>in</strong>itiated restructur<strong>in</strong>g<strong>and</strong> “right-siz<strong>in</strong>g” of <strong>the</strong> public sector; an assessment of<strong>the</strong> Population Welfare Programme was also undertaken,where<strong>in</strong> it was noted that <strong>the</strong> programme was mov<strong>in</strong>g <strong>in</strong><strong>the</strong> right direction <strong>and</strong> that fertility transition had set <strong>in</strong><strong>and</strong> had to be susta<strong>in</strong>ed. The process led to formulation of<strong>the</strong> Population Policy 2002, sett<strong>in</strong>g <strong>the</strong> long-term visionfor <strong>the</strong> population sector.The post-ICPD period was marked by even greater active<strong>in</strong>terest <strong>in</strong> population policies <strong>and</strong> issues of reproductivehealth. While reduc<strong>in</strong>g population growth rates rema<strong>in</strong>ed<strong>the</strong> primary concern of <strong>the</strong> Government of Pakistan <strong>and</strong>part of <strong>the</strong> Population Policy 2002, <strong>the</strong>re was greateremphasis on provid<strong>in</strong>g accessible <strong>and</strong> better-qualityservices to meet <strong>the</strong> needs of <strong>in</strong>dividuals. Fur<strong>the</strong>rmore, <strong>the</strong>need to collaborate with o<strong>the</strong>r public <strong>in</strong>stitutions on <strong>the</strong>part of MoPW, <strong>and</strong> with <strong>the</strong> private sector <strong>and</strong> NGOs,<strong>the</strong>n appeared <strong>in</strong> all government documents <strong>and</strong> plans.O<strong>the</strong>r achievements dur<strong>in</strong>g this period <strong>in</strong>cluded <strong>the</strong>establishment of <strong>the</strong> National Population Commission<strong>and</strong> <strong>the</strong> organization of <strong>the</strong> Population Summit <strong>in</strong> 2005.S<strong>in</strong>ce 2000, health outlets were also m<strong>and</strong>ated to providefamily plann<strong>in</strong>g services. However, a major obstacle hasbeen <strong>the</strong> limited delivery of family plann<strong>in</strong>g services by <strong>the</strong>health sector <strong>in</strong> general, <strong>and</strong> <strong>the</strong> departments of health <strong>in</strong>particular. In 2001, <strong>the</strong> Lady Health Workers (currentlyemploy<strong>in</strong>g close to 100,000 women who have a basiceducation) were found to be very effective <strong>in</strong> deliver<strong>in</strong>gfamily plann<strong>in</strong>g services (Oxford Policy Management,2002), but <strong>in</strong> a third-party evaluation <strong>in</strong> 2010 were foundto be falter<strong>in</strong>g <strong>in</strong> provid<strong>in</strong>g <strong>the</strong>se services because <strong>the</strong>y wereoverloaded with o<strong>the</strong>r tasks, such as hav<strong>in</strong>g to adm<strong>in</strong>isterpolio vacc<strong>in</strong>e (Oxford Policy Management, forthcom<strong>in</strong>g).Even though <strong>the</strong> provision of familyplann<strong>in</strong>g is first <strong>in</strong> <strong>the</strong>ir m<strong>and</strong>ate, <strong>the</strong>LHWs are busier provid<strong>in</strong>g primaryhealth care (polio drops). That is why<strong>the</strong> latest third party evaluation showsthat <strong>the</strong> LHWs have not succeeded <strong>in</strong>br<strong>in</strong>g<strong>in</strong>g up CPR. The programme isf<strong>in</strong>e – noth<strong>in</strong>g is better than door-to-doorservice; implementation, <strong>and</strong> monitor<strong>in</strong>g<strong>and</strong> evaluation (which should belong toMoPW) are <strong>the</strong> problem.Director-General Technical, M<strong>in</strong>istryof Population WelfareNational population policiesThe Population Policy 2002 had several notable targets ofbroaden<strong>in</strong>g responsibility for service delivery, for amass<strong>in</strong>gresources, for provid<strong>in</strong>g universal access to FP services by2010 <strong>and</strong> for reduc<strong>in</strong>g <strong>the</strong> fertility rate to <strong>the</strong> replacementlevel of 2.2 children per woman by 2020. However, <strong>the</strong>seare under serious review precisely because <strong>the</strong>se targets areglar<strong>in</strong>gly unachievable <strong>in</strong> <strong>the</strong> planned time. In fact, currenttrends <strong>in</strong> fertility, if extrapolated, <strong>in</strong>dicate that <strong>the</strong>se targetscould not be achieved even by 2030.By <strong>the</strong> end of 2009, <strong>the</strong>re was a strong move towards<strong>the</strong> formulation of a new population policy, which at<strong>the</strong> time of writ<strong>in</strong>g is <strong>in</strong> <strong>the</strong> process of ga<strong>in</strong><strong>in</strong>g Cab<strong>in</strong>etapproval; it comprises <strong>the</strong> latest projections <strong>in</strong>corporatedby <strong>the</strong> <strong>Plann<strong>in</strong>g</strong> Commission. This was <strong>in</strong>stigated byseveral shifts on <strong>the</strong> ground, such as <strong>the</strong> new NationalF<strong>in</strong>ance Commission Award, <strong>the</strong> 18th amendment to <strong>the</strong>constitution <strong>and</strong>, most of all, <strong>the</strong> slow recognition thatPakistan was off course <strong>in</strong> meet<strong>in</strong>g <strong>the</strong> objectives of <strong>the</strong>2002 policy. There is some awareness that Pakistan hasstrayed from prioritiz<strong>in</strong>g family plann<strong>in</strong>g, <strong>and</strong> that <strong>the</strong>high levels of unmet need for family plann<strong>in</strong>g <strong>and</strong> <strong>the</strong>irgeneral stagnation are a primary responsibility of <strong>the</strong> state.Resources are pressed for <strong>the</strong> social sectors generally, onceaga<strong>in</strong>, given <strong>the</strong> huge amounts be<strong>in</strong>g spent by Pakistan on<strong>the</strong> war on terror <strong>and</strong> <strong>the</strong> o<strong>the</strong>r priorities at this po<strong>in</strong>t <strong>in</strong> itshistory. Some corrective actions are under way: <strong>the</strong> mostrecent developments are renewed realization about familyplann<strong>in</strong>g <strong>and</strong> a renewed commitment to provide familyplann<strong>in</strong>g services through LHWs <strong>and</strong> <strong>the</strong> prov<strong>in</strong>cialdepartments of health, which is bound to make a significantdifference to service delivery <strong>in</strong> <strong>the</strong> next few years.202

Contraceptive commoditysecurityContraceptive procurement <strong>and</strong> distribution have beencharacterized by uncerta<strong>in</strong>ty over <strong>the</strong> years, s<strong>in</strong>ce Pakistanimports <strong>the</strong> bulk of its contraceptive supplies. MoPW hasbeen procur<strong>in</strong>g contraceptives for more than three decades.For this purpose, <strong>the</strong>re is a full-fledged Directorate ofProcurement Material <strong>and</strong> Equipment. There is a centralwarehouse <strong>in</strong> Karachi, from which contraceptives aredistributed throughout <strong>the</strong> country, ma<strong>in</strong>ly throughgovernment channels. Unfortunately, adequate purposebuiltstorage facilities do not exist at <strong>the</strong> prov<strong>in</strong>cial <strong>and</strong>district levels.Pakistan is dependent on donor funds to procurecontraceptives; <strong>in</strong> fact, <strong>the</strong> major share of its donorfund<strong>in</strong>g has been go<strong>in</strong>g towards procur<strong>in</strong>g contraceptives.The ma<strong>in</strong> bulk of <strong>the</strong> overall outlay of US$ 14 million <strong>in</strong>2007/08 (ris<strong>in</strong>g substantially from previous years) wentto social market<strong>in</strong>g ($6.7 million), <strong>the</strong>n to health ($4.6million) <strong>and</strong> lastly to MoPW ($2.7 million). Variousdonors have contributed funds to obta<strong>in</strong> contraceptivesthat are purchased <strong>in</strong> a s<strong>in</strong>gle order by <strong>the</strong> United NationsPopulation Fund (UNFPA) for <strong>the</strong> Government ofPakistan. Currently, <strong>the</strong> contraceptives are be<strong>in</strong>g procuredby UNFPA (on a payment basis) through <strong>in</strong>ternationalbidd<strong>in</strong>g; UNFPA receives 5 per cent <strong>in</strong> service chargesfrom MoPW.At <strong>the</strong> moment, <strong>the</strong> government is fac<strong>in</strong>g a crisis, as it isunable to come up with <strong>the</strong> fund<strong>in</strong>g necessary to meet <strong>the</strong>huge dem<strong>and</strong> for contraceptives. Contraceptive commodityforecast<strong>in</strong>g is based on <strong>the</strong> expectation of rais<strong>in</strong>g <strong>the</strong> level ofcurrent contraceptive practice from 30 per cent (2008/09)to 37.5 per cent by 2015. Users of contraceptives areexpected to <strong>in</strong>crease from 8.4 million <strong>in</strong> 2008/09 to 10.8million <strong>in</strong> 2014/15.The status quo with regard to how contraceptives areprocured <strong>and</strong> distributed is most likely go<strong>in</strong>g to change.Discussions are currently under way: first, for <strong>the</strong>government to procure contraceptives directly; second,for <strong>in</strong>creased local manufactur<strong>in</strong>g <strong>and</strong> self-reliance;<strong>and</strong> third, for changes <strong>in</strong> <strong>the</strong> l<strong>in</strong>es of distribution. Localmanufactur<strong>in</strong>g of pills <strong>and</strong> <strong>in</strong>jectables is already under way.Feasibility studies are under consideration for establish<strong>in</strong>gunits to manufacture <strong>the</strong> Copper-T IUD <strong>in</strong> Pakistan.Pharmaceutical firms could be encouraged, facilitated <strong>and</strong>given <strong>in</strong>centives to manufacture contraceptives.With <strong>the</strong> drastic changes anticipated follow<strong>in</strong>g dissolutionof <strong>the</strong> federal functions of MoPW, resource mobilization,forecast<strong>in</strong>g national contraceptive requirements <strong>and</strong>procurement of <strong>the</strong> national requirement will have to betaken up at <strong>the</strong> national <strong>and</strong> subnational levels by oneof <strong>the</strong> arms of <strong>the</strong> government, such as <strong>the</strong> <strong>Plann<strong>in</strong>g</strong>Commission. Warehous<strong>in</strong>g is likely to cont<strong>in</strong>ue <strong>in</strong> Karachi,but distribution is likely to be through three or four dist<strong>in</strong>ctchannels. Most likely, <strong>the</strong>re will be different streams for<strong>the</strong> LHW programme, <strong>the</strong> departments of health, socialmarket<strong>in</strong>g, NGOs <strong>and</strong> o<strong>the</strong>rs <strong>in</strong> <strong>the</strong> private sector, such ashakim (Muslim doctors) <strong>and</strong> homeopaths.On <strong>the</strong> effects of <strong>the</strong> 18 th amendment: Themoney for family plann<strong>in</strong>g was com<strong>in</strong>gfrom <strong>the</strong> federal budget <strong>and</strong> now that<strong>the</strong> m<strong>in</strong>istry is be<strong>in</strong>g dissolved it needs tocome from <strong>the</strong> NFC (National F<strong>in</strong>anceCommission) award, which has alreadybeen allocated for this year (none wasgiven to family plann<strong>in</strong>g because that wascom<strong>in</strong>g from <strong>the</strong> federal government).Now for next year, <strong>the</strong> prov<strong>in</strong>ces willactually have to reallocate funds fromano<strong>the</strong>r department to family plann<strong>in</strong>g,which will be very difficult <strong>and</strong> will bemet with resistance from <strong>the</strong> heads ofo<strong>the</strong>r departments. There is a need forhuge advocacy at this moment target<strong>in</strong>gprov<strong>in</strong>cial governments <strong>and</strong> legislators toconv<strong>in</strong>ce <strong>the</strong>m of <strong>the</strong> importance of FP toensure reallocation to <strong>the</strong> department.CEO, <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> AssociationPakistanFund<strong>in</strong>g streamsIn an atmosphere where major donors, such as USAID,were not operat<strong>in</strong>g <strong>in</strong> Pakistan for several years, <strong>the</strong>government committed its own scarce resources to familyplann<strong>in</strong>g <strong>and</strong> reproductive health. Funds for populationwelfare are released at <strong>the</strong> federal level <strong>and</strong> <strong>the</strong>n disbursedto <strong>the</strong> prov<strong>in</strong>ces, Azad Jammu <strong>and</strong> Kashmir <strong>and</strong> FederallyAdm<strong>in</strong>istered Tribal Areas. The total outlay has risen fromRs. 3.1 billion <strong>in</strong> 2003/04 to 4.2 billion <strong>in</strong> 2005/06 <strong>and</strong>rema<strong>in</strong>ed fairly stagnant until 2008/09 at Rs. 4.3 billion(roughly US$ 50 million, as US$ 1 currently equals about87 rupees). The request for 2009/10 was much higher atRs. 5.2 billion, but <strong>the</strong> releases were much lower than that,with <strong>the</strong>ir value rema<strong>in</strong><strong>in</strong>g at Rs. 3.4 billion.203

FigureThis trend of limited donor funds, used largely to purchasecontraceptives, became even more exacerbated with<strong>in</strong>ternational donor funds shift<strong>in</strong>g very much towardsreproductive health <strong>in</strong> general <strong>and</strong> HIV/AIDS <strong>in</strong>particular, <strong>and</strong> away from family plann<strong>in</strong>g.S<strong>in</strong>ce 2003, <strong>the</strong> fund<strong>in</strong>g flows from USAID, KfWDevelopment Bank of Germany <strong>and</strong> UNFPA havebegun to <strong>in</strong>crease, with <strong>the</strong> Department for <strong>International</strong>Development of <strong>the</strong> United K<strong>in</strong>gdom provid<strong>in</strong>g budgetarysupport through <strong>the</strong> M<strong>in</strong>istry of F<strong>in</strong>ance. The chart below(Figure 1) shows a major spike <strong>in</strong> donor fund<strong>in</strong>g for RH,but it is quite evident that this addition was for maternalhealth <strong>and</strong> not for family plann<strong>in</strong>g, which rema<strong>in</strong>ed flatuntil <strong>the</strong> recent past.Public/private partnershipsSocial market<strong>in</strong>gSocial market<strong>in</strong>g, start<strong>in</strong>g <strong>in</strong> <strong>the</strong> mid-1980s, wasconcentrated <strong>in</strong> urban areas <strong>and</strong> those efforts were expectedto be <strong>in</strong>tensified <strong>in</strong> <strong>the</strong> peri-urban areas <strong>and</strong> its outreachextended to rural areas. It was also expected that <strong>the</strong> scopeof services would be broadened through new <strong>in</strong>terventions<strong>in</strong> order to enhance <strong>the</strong> contribution of social market<strong>in</strong>g<strong>in</strong> rais<strong>in</strong>g contraceptive prevalence <strong>and</strong> exp<strong>and</strong><strong>in</strong>g markets.Increas<strong>in</strong>gly, <strong>the</strong> private sector, through social market<strong>in</strong>g,has taken greater responsibility for dispens<strong>in</strong>g, advertis<strong>in</strong>g<strong>and</strong> tra<strong>in</strong><strong>in</strong>g <strong>in</strong> family plann<strong>in</strong>g, <strong>and</strong> also broaden<strong>in</strong>g itsreach to o<strong>the</strong>r areas of reproductive health, <strong>in</strong>clud<strong>in</strong>gmaternal health <strong>and</strong> <strong>the</strong> prevention of HIV <strong>and</strong> o<strong>the</strong>rFiguresexually transmitted <strong>in</strong>fections (STIs). Although <strong>the</strong>private sector is play<strong>in</strong>g a vital role <strong>in</strong> provid<strong>in</strong>g FP/RHservices <strong>in</strong> <strong>the</strong> country, social market<strong>in</strong>g still cont<strong>in</strong>ues tobe concentrated <strong>in</strong> urban areas.NGOs <strong>and</strong> community-basedorganizationsHistorically, NGOs played a pioneer<strong>in</strong>g role <strong>in</strong> establish<strong>in</strong>gfamily plann<strong>in</strong>g <strong>in</strong> Pakistan <strong>and</strong> <strong>in</strong> sett<strong>in</strong>g <strong>the</strong> reproductivehealth agenda. NGOs have provided important cl<strong>in</strong>icalservices, <strong>in</strong>clud<strong>in</strong>g contraceptive surgery. Apart fromservice delivery, <strong>the</strong>re has been a considerable role forNGOs <strong>and</strong> community-based organizations (CBOs)<strong>in</strong> advocacy, behavioural change communication <strong>and</strong>community mobilization, where <strong>the</strong>y have advantages. Itis surpris<strong>in</strong>g that <strong>the</strong> contribution <strong>and</strong> <strong>the</strong> performance ofNGOs are nei<strong>the</strong>r fully reflected nor acknowledged <strong>in</strong> <strong>the</strong>reports compiled by <strong>the</strong> programme.Unfortunately, <strong>the</strong> NGO sector <strong>in</strong> Pakistan is probably <strong>the</strong>one most adversely affected by <strong>the</strong> shortages <strong>in</strong> fund<strong>in</strong>gfor FP, <strong>and</strong> NGOs have moved <strong>in</strong>to newer reproductivehealth research areas, such as HIV/AIDS, where fund<strong>in</strong>ghas been available. As a result, fund<strong>in</strong>g channels forNGOs work<strong>in</strong>g on FP <strong>and</strong> RH have been limited, exceptby <strong>the</strong> very large NGOs, such as FPAP <strong>and</strong> Marie Stopes<strong>International</strong>.NGOCC, which was active <strong>in</strong> <strong>the</strong> 1980s, was transformed<strong>in</strong>to <strong>the</strong> National Trust for Population Welfare(NATPOW), which had been fairly dormant from 19941Donor support for population assistance to Pakistan, 1996-200570MILLIONS US$6050403020Total PopulationAssistanceReproductivehealth<strong>Family</strong><strong>Plann<strong>in</strong>g</strong>HIV/AIDS1001996 1997 1998 1999 2000 2001 2002 2003 2004 2005* Fund<strong>in</strong>f for basic reseacrch, which comprises a small portion of <strong>the</strong> total population assistance, is not graphedseparately but is <strong>in</strong>cluded <strong>in</strong> <strong>the</strong> total population assistance estimates.Source: Hardee <strong>and</strong> Leahy (2008).204

Figureto 2008. NATPOW was established under <strong>the</strong> CharitableEndowment Act <strong>in</strong> 1994 as a statutory “apex body”. It createsan effective partnership between <strong>the</strong> government, donors,NGOs <strong>and</strong> private sector organizations for promot<strong>in</strong>gsmall family norms, <strong>and</strong> arranges funds <strong>and</strong> providestechnical assistance for <strong>the</strong> smaller NGOs work<strong>in</strong>g <strong>in</strong> <strong>the</strong>fields of reproductive health, <strong>in</strong>clud<strong>in</strong>g FP <strong>and</strong> maternal<strong>and</strong> child health (MCH). The organization rema<strong>in</strong>ed<strong>in</strong>effective for almost two decades until 2009; now a fulltimechief executive officer <strong>and</strong> new board of directors havebeen appo<strong>in</strong>ted who have operationalized <strong>the</strong> organizationso that it can fulfill its functions <strong>and</strong> m<strong>and</strong>ate, especiallycoord<strong>in</strong>ation with its affiliated NGOs <strong>and</strong> make grants to<strong>the</strong>m. This open<strong>in</strong>g up of a grants-mak<strong>in</strong>g channel shouldrevitalize <strong>the</strong> role of NGOs <strong>in</strong> service delivery. Even morecurrent is <strong>the</strong> move to transform NATPOW from a trustto a not-for-profit company under <strong>the</strong> Companies Act1984. Presumably this would make <strong>the</strong> organization more<strong>in</strong>dependent <strong>and</strong> a better conduit of funds for <strong>the</strong> greater<strong>in</strong>volvement of NGOs <strong>and</strong> civil society organizations,<strong>in</strong>clud<strong>in</strong>g social market<strong>in</strong>g projects.Public-private sector organizations/target group <strong>in</strong>stitutionsSelected target group <strong>in</strong>stitutions have been a part of <strong>the</strong>federal population welfare programme. These <strong>in</strong>stitutions<strong>in</strong>clude Pakistan Water <strong>and</strong> Power DevelopmentAuthority (WAPDA); <strong>the</strong> Pakistan Army, Navy <strong>and</strong> AirForce; Pakistan Ord<strong>in</strong>ance Factories (POF); PakistanRailways; Karachi Port Trust (KPT); Pakistan Steel;Pakistan Tobacco Company (PTC); Postal ServiceGroups; Pakistan <strong>International</strong> Airways (PIA); ZaraiTaraqiati Bank Ltd.; <strong>and</strong> Fauji Foundation. The targetgroup <strong>in</strong>stitutions were renamed as public-private sectorFigureorganizations <strong>in</strong> 2005, with <strong>the</strong> aim of <strong>in</strong>volv<strong>in</strong>g all public,private <strong>and</strong> corporate sector actors for <strong>the</strong> provisionof family plann<strong>in</strong>g/reproductive health through <strong>the</strong>irhealth outlets <strong>and</strong> <strong>in</strong>volv<strong>in</strong>g <strong>the</strong>m <strong>in</strong> <strong>the</strong> propagation of<strong>the</strong> Population Welfare Programme. Until 2009, 439memor<strong>and</strong>ums of underst<strong>and</strong><strong>in</strong>g (MoUs) had been signedwith <strong>the</strong>m but with virtually little implementation.Some efforts were made, through <strong>the</strong> federal, prov<strong>in</strong>cial <strong>and</strong>district chambers of commerce, to <strong>in</strong>volve <strong>the</strong> maximumnumber of service outlets of public-private sectororganizations to provide FP <strong>and</strong> RH services <strong>and</strong> establishRHS “B” centres. They were to be provided with technicalsupport, contraceptives <strong>and</strong> tra<strong>in</strong>ed staff. The respectiveprov<strong>in</strong>cial population welfare programmes were to pay <strong>the</strong>salary of <strong>the</strong> staff. Generally, this is a greatly overlookedarea, <strong>and</strong> <strong>the</strong>re is untapped potential of organizations, suchas Comb<strong>in</strong>ed Military Hospitals; <strong>Family</strong> Welfare Centresof Pakistan Army; health outlets of <strong>the</strong> Pakistan Navy<strong>and</strong> Air Force <strong>and</strong> Pakistan Ord<strong>in</strong>ance Factories, FaujiFoundation, Pakistan Railways, PTC, PIA, WAPDA,KPT, Pakistan Steel, Oil <strong>and</strong> Gas Development CompanyLtd.; <strong>the</strong> Pakistan Atomic Energy Commission hospitals;<strong>and</strong> <strong>the</strong> outlets be<strong>in</strong>g run by NGOs, CBOs <strong>and</strong> <strong>the</strong> privatesector, to become <strong>in</strong>volved <strong>in</strong> <strong>the</strong> provision of FP/RHservices.TrendsFertility decl<strong>in</strong>eThe weak population programme is reflected <strong>in</strong> Pakistan’sfertility decl<strong>in</strong>e trajectory: Pakistan was <strong>the</strong> last among allits neighbours to experience fertility decl<strong>in</strong>e <strong>and</strong> cont<strong>in</strong>ues28Total fertility rate, by country over time7654IndiaPakistanBangladeshIran32101950-19551955-19601960-19651965-19701970-19751975-19801980-19851985-19901990-19951995-20002000-20052005-2010205

Figureto have <strong>the</strong> highest total fertility rates. At <strong>the</strong> time ofits <strong>in</strong>ception, Pakistan’s TFR of 6.6 births per womanfell between India’s TFR of 5.9 <strong>and</strong> that of <strong>the</strong> IslamicRepublic of Iran’s TFR of 7 births per woman, <strong>and</strong> was <strong>the</strong>same as Bangladesh’s TFR (see Figure 2). All countries <strong>in</strong><strong>the</strong> region experienced high fertility until <strong>the</strong> late 1960s,at which po<strong>in</strong>t India’s fertility levels started to decl<strong>in</strong>egradually but consistently. Bangladesh, which was mak<strong>in</strong>gheavy <strong>in</strong>vestments <strong>in</strong> family plann<strong>in</strong>g programmes, was <strong>the</strong>next to follow, with its TFR beg<strong>in</strong>n<strong>in</strong>g to decl<strong>in</strong>e rapidly by<strong>the</strong> early 1980s. Even Iran stepped up its family plann<strong>in</strong>gefforts by <strong>the</strong> late 1980s <strong>and</strong> started experienc<strong>in</strong>g a veryrapid decl<strong>in</strong>e <strong>in</strong> its TFR.Estimates of Pakistan’s fertility rates have been <strong>the</strong>source of much disagreement <strong>and</strong> debate, with reportedTFRs diverg<strong>in</strong>g by almost one birth per woman for agiven period (Sathar <strong>and</strong> Zaidi, 2009). Despite issuesregard<strong>in</strong>g exact levels of fertility, it is now widely acceptedby demographers <strong>and</strong> government officials alike thatPakistan’s fertility decl<strong>in</strong>e began as late as <strong>the</strong> beg<strong>in</strong>n<strong>in</strong>gof <strong>the</strong> 1990s. Currently, Pakistan’s TFR rema<strong>in</strong>s morethan one birth higher than that of India <strong>and</strong> Bangladesh,<strong>and</strong> about two births higher than that of Iran, which hasreached replacement-level fertility despite hav<strong>in</strong>g startedits programme just as late. Previous projections – <strong>the</strong>Population Policy 2002 – estimated that Pakistan wouldreach replacement around 2020; however, given currenttrends, that estimate has been revised, <strong>and</strong> fertility isprojected to reach replacement some 10 years later thanexpected, accord<strong>in</strong>g to <strong>the</strong> proposed Population Plan2010.Fertility regulationFigureContraceptive prevalenceNot surpris<strong>in</strong>gly, <strong>the</strong>re was hardly any fertility controlwith<strong>in</strong> marriage before <strong>the</strong> late 1980s <strong>and</strong> marital fertility<strong>in</strong> Pakistan did not experience a significant decl<strong>in</strong>e. CPRrema<strong>in</strong>ed below 10 per cent throughout most of <strong>the</strong> 1970s<strong>and</strong> 1980s, <strong>and</strong> reached 12 per cent only <strong>in</strong> 1991 when <strong>the</strong>fertility transition began (Sathar <strong>and</strong> Zaidi, 2009).The 1990s saw a dist<strong>in</strong>ct departure from this trend, withCPR doubl<strong>in</strong>g to 24 per cent <strong>in</strong> a six-year period (PFFPS,1996-1997) <strong>and</strong> reach<strong>in</strong>g 28 per cent by <strong>the</strong> end of <strong>the</strong>decade (National Institute of Population Studies, 2001).An important report showed an <strong>in</strong>crease to 32 per cent<strong>in</strong> contraceptive use among currently married women <strong>in</strong>2003 (National Institute of Population Studies, 2007).However, <strong>the</strong> latest DHS (2006/07) <strong>in</strong>dicates stagnation<strong>in</strong> contraceptive use, with CPR fall<strong>in</strong>g slightly to 30 percent (see Figure 3) (National Institute of PopulationStudies <strong>and</strong> Macro <strong>International</strong> Inc., 2008). In <strong>the</strong> early1990s contraceptive use rose at <strong>the</strong> rate of 2 per cent perannum; however, this rate fell by half to about 1 per cent ayear <strong>and</strong> has recently gone even lower.It is important to note that, unlike current use ofcontraception, ever use of contraception has <strong>in</strong>creasedsteadily over <strong>the</strong> last two decades (see Table 1). Ever use<strong>in</strong>creased from 21 per cent at <strong>the</strong> start of <strong>the</strong> transition <strong>in</strong>1991 to 34 per cent <strong>in</strong> 2001 <strong>and</strong> f<strong>in</strong>ally to 49 per cent <strong>in</strong>2007, <strong>in</strong>dicat<strong>in</strong>g a higher per annum <strong>in</strong>crease s<strong>in</strong>ce <strong>the</strong> turnof <strong>the</strong> century (2.5% vs. 1.3% per annum <strong>in</strong> <strong>the</strong> 1990s).The stagnation <strong>in</strong> CPR is more apparent <strong>in</strong> urban areass<strong>in</strong>ce <strong>the</strong> differential between urban <strong>and</strong> rural CPR hasgone from 1:5 <strong>in</strong> 1991 to 1:2 <strong>in</strong> 2007. Dur<strong>in</strong>g <strong>the</strong> 1990s,3Current <strong>and</strong> ever use of contraception, 1991-2007%3640434921282428323012181991 1994 1997 2001 2003 2007206

Figurecontraceptive use <strong>in</strong> urban areas <strong>in</strong>creased more rapidlythan <strong>in</strong> rural areas, but this trend subsequently reversed,<strong>and</strong> s<strong>in</strong>ce 2001 <strong>the</strong> rate of <strong>in</strong>crease <strong>in</strong> rural contraceptive usehas surpassed that <strong>in</strong> urban areas. Despite <strong>the</strong> consistent<strong>in</strong>crease <strong>in</strong> rural CPR, absolute levels of contraceptiveuse <strong>in</strong> rural areas rema<strong>in</strong> extremely low; <strong>the</strong> levels mustbe almost doubled <strong>in</strong> order to reach <strong>the</strong> current levels <strong>in</strong>urban areas, from 24 to 42 per cent (see Figure 4).Contraceptive mixAt <strong>the</strong> beg<strong>in</strong>n<strong>in</strong>g of <strong>the</strong> fertility transition, among <strong>the</strong>small percentage of contraceptive users at that time, <strong>the</strong>most common type of family plann<strong>in</strong>g method was femalesterilization (30% of users), followed by condoms (23%of users). Of <strong>the</strong> o<strong>the</strong>r half of current users, a quarterreported practis<strong>in</strong>g a traditional method of contraception(National Institute of Population Studies <strong>and</strong> Macro<strong>International</strong> Inc., 1992). The rema<strong>in</strong><strong>in</strong>g quarter of womencurrently practis<strong>in</strong>g fertility control were us<strong>in</strong>g IUDs, pillsor <strong>in</strong>jectables. Over <strong>the</strong> subsequent 16 years, Pakistaniwomen’s choice of contraceptive methods did not changeTablesubstantially (see Figure 5). Female sterilization cont<strong>in</strong>uedto be <strong>the</strong> most popular method among current users, withonly a 2 percentage drop <strong>in</strong> its share of method choice.The proportion of current users choos<strong>in</strong>g condoms alsosaw no change over this period. While <strong>the</strong> share of IUDs<strong>in</strong> method choice fell from 11 to 8 per cent, <strong>the</strong> rest of<strong>the</strong> modern methods saw slight <strong>in</strong>creases <strong>in</strong> uptake. Thepractice of traditional methods of contraception also sawa small <strong>in</strong>crease; withdrawal was <strong>the</strong> more preferred of <strong>the</strong>two traditional methods, with 14 per cent of current userschoos<strong>in</strong>g this method of birth control.Trends <strong>in</strong> methods ever used are slightly different; whilecondoms, rhythm (ovulation method) <strong>and</strong> pills (<strong>in</strong> thatorder) were <strong>the</strong> top three methods to have ever been triedby women <strong>in</strong> 1990, condoms, withdrawal <strong>and</strong> rhythm arenow <strong>the</strong> three most popular methods to have been everused by women. Over <strong>the</strong> years, <strong>the</strong> ever use of withdrawalsaw <strong>the</strong> largest <strong>in</strong>crease, from 20 per cent of ever users<strong>in</strong> 1990/91 to 35 per cent <strong>in</strong> 2006/07 (data not shown).The proportion of women try<strong>in</strong>g <strong>in</strong>jectables also <strong>in</strong>creasedsubstantially.Table1Percentage of contraceptive use among currently married women 15-49 over time, by residenceVariable 1991 1994 1997 2001 2003 2007OverallEver use 20.7 28 35.7 40.2 42.8 48.7Current use 11.9 17.8 23.9 27.6 32.0 29.6Current use by residenceRural 5.8 11.0 -- 21.7 26.5 23.9Urban 25.7 31.9 -- 39.7 43.5 41.1Note: Two hyphens (--) means that no <strong>in</strong>formation is available.Figure4Trends <strong>in</strong> current <strong>and</strong> ever use of contraception, by residence10090807060% 50402007302001201019910Ever Current Ever Current Ever CurrentRural Urban Total207

FigureFigure5Percentage change <strong>in</strong> contraceptive method mix over time1991610 3 11117PillIUDInjectionCondom121420071788PillIUDInjectionCondom2330Female sterilizationRhythmWithdrawal2823Female sterilizationRhythmWithdrawalO<strong>the</strong>rO<strong>the</strong>rOverall, <strong>the</strong> trends <strong>in</strong> choice of method <strong>in</strong>dicate thata quarter of women use traditional methods of familyplann<strong>in</strong>g <strong>and</strong> ano<strong>the</strong>r quarter use condoms, mean<strong>in</strong>g thathalf are us<strong>in</strong>g couple-methods of family plann<strong>in</strong>g. Theo<strong>the</strong>r half use female methods, with about a quarter of<strong>the</strong>se choos<strong>in</strong>g permanent methods <strong>and</strong> <strong>the</strong> rema<strong>in</strong><strong>in</strong>gquarter us<strong>in</strong>g o<strong>the</strong>r modern female methods.Source of methodsIn 1991, when fertility decl<strong>in</strong>e had just come <strong>in</strong>to play<strong>and</strong> contraceptive prevalence was at a low 11 per cent, <strong>the</strong>government was <strong>the</strong> major supplier of modern contraceptivemethods: 56 per cent of users received <strong>the</strong>ir method froma government supplier (<strong>in</strong>clud<strong>in</strong>g government hospitals,doctors, cl<strong>in</strong>ics, family welfare centres etc.), while only30 per cent received methods from <strong>the</strong> private sector (seeTable 2). By 2007, while <strong>the</strong> government rema<strong>in</strong>ed <strong>the</strong>supplier for almost half of all contraceptive users, at 48 percent, <strong>the</strong> share of <strong>the</strong> private sector <strong>in</strong>creased by more than10 percentage po<strong>in</strong>ts to 41 per cent, <strong>in</strong>dicat<strong>in</strong>g that more<strong>and</strong> more users were pay<strong>in</strong>g for contraception.In look<strong>in</strong>g at source of method by specific method type, twotrends st<strong>and</strong> out. Over <strong>the</strong> 16-year period, <strong>the</strong> government’sshare <strong>in</strong> <strong>the</strong> supply of <strong>the</strong> pill <strong>in</strong>creased <strong>and</strong> it replaced <strong>the</strong>private sector to become <strong>the</strong> biggest supplier. On <strong>the</strong> o<strong>the</strong>rh<strong>and</strong>, IUDs, which <strong>in</strong> 1991 were supplied primarily by<strong>the</strong> government (81%), were now be<strong>in</strong>g provided equallyby <strong>the</strong> private sector as well. Among <strong>the</strong> o<strong>the</strong>r methods,<strong>the</strong> private sector saw slight <strong>in</strong>creases (correspond<strong>in</strong>g to aslight decrease <strong>in</strong> <strong>the</strong> government’s share) <strong>in</strong> <strong>the</strong> share of<strong>in</strong>jectables <strong>and</strong> female sterilization, while both <strong>the</strong> public<strong>and</strong> private sectors saw <strong>in</strong>creases <strong>in</strong> <strong>the</strong> market share ofcondoms. With<strong>in</strong> <strong>the</strong> private sector, <strong>the</strong> supply of condomsby non-medical stores was responsible for <strong>the</strong> <strong>in</strong>crease <strong>in</strong>market share.Induced abortionsDespite <strong>the</strong> fact that <strong>in</strong>duced abortions are illegal <strong>in</strong>Pakistan, except when performed to save women's lives,a study carried out by <strong>the</strong> Population <strong>Council</strong> estimatedthat 890,000 <strong>in</strong>duced abortions were performed <strong>in</strong> 2002,<strong>and</strong> <strong>the</strong> abortion rate was 29 per 1,000 women aged15-49 (Population <strong>Council</strong>, 2004). This was a mediumestimate; <strong>the</strong> low <strong>and</strong> high estimates were 25 <strong>and</strong> 31 per1,000, respectively. The abortion rate of 29 is most likelyan underestimate of <strong>the</strong> true abortion rate despite be<strong>in</strong>gmoderately high by global st<strong>and</strong>ards. The majority ofsuch abortions are tak<strong>in</strong>g place among married womenwith more than three children. Studies based on <strong>the</strong>sedata also found that a considerable proportion of womenwho <strong>in</strong>duced abortions had tried some method ofcontraception <strong>and</strong> some even reported that <strong>the</strong>y had beenus<strong>in</strong>g contraceptives, albeit <strong>in</strong>effectively, when <strong>the</strong>y becamepregnant (Arif <strong>and</strong> Kamran, 2007).Sathar et al. (2007) estimated measures of total pregnancy<strong>and</strong> unwanted pregnancy to portray <strong>the</strong> broader contextwith<strong>in</strong> which <strong>in</strong>duced abortion was occurr<strong>in</strong>g <strong>and</strong> tomeasure both <strong>the</strong> absolute level of unwanted pregnancy<strong>and</strong> <strong>the</strong> probability that women who experienced anunwanted pregnancy would seek an abortion. Resultsyielded an unwanted pregnancy rate of 77 per 1,000women, which accounted for almost two fifths of allpregnancies. Abortions accounted for almost two fifths of<strong>the</strong>se unwanted pregnancies.Unmet needDespite <strong>the</strong> low use of fertility regulation, more <strong>and</strong> morewomen <strong>in</strong> Pakistan are express<strong>in</strong>g <strong>the</strong> desire to limit orpostpone childbear<strong>in</strong>g. In 1991, 40 per cent of <strong>the</strong> women208

TableTable1Source of modern method over timeSourcePill IUD Injection CondomFemalesterilizationAll modernmethods1991 2007 1991 2007 1991 2007 1991 2007 1991 2007 1991 2007Government 34.9 46.1 81.1 52.4 53.0 51.2 11.7 16.9 85.1 72.4 55.7 48.2Private 56.2 39.6 15.8 47.6 42.0 44.6 47.6 58.0 13.7 25.8 30.0 41.4Medical 49.7 31.2 11.3 41.0 42.0 41.7 33.2 27.3 13.7 25.8 25.5 30.1O<strong>the</strong>r shop 6.5 7.2 0.0 0.0 0.0 1.6 13.1 30.5 na na 4.4 10.3Tra<strong>in</strong>ed birthattendant0.0 1.2 4.5 6.6 0.0 1.3 1.3 0.2 na na 1.0 1.0O<strong>the</strong>r 5.2 5.3 0.0 0.0 4.7 1.3 11.5 0.8 na na 4.3 0.9Note: na = not applicable.surveyed wanted no more children; this figure <strong>in</strong>creased to52 per cent <strong>in</strong> 2007. Regional differences <strong>in</strong> <strong>the</strong> desire tolimit childbear<strong>in</strong>g have been decreas<strong>in</strong>g steadily over times<strong>in</strong>ce more <strong>and</strong> more rural women want to have no morechildren. These trends <strong>in</strong>dicate that <strong>the</strong>re is <strong>in</strong>creas<strong>in</strong>gdem<strong>and</strong> for family plann<strong>in</strong>g among Pakistani women,particularly <strong>in</strong> rural areas. However, although more than50 per cent of women wish to limit childbear<strong>in</strong>g <strong>and</strong> about20 per cent wish to space <strong>the</strong>ir next birth, only 30 per centare us<strong>in</strong>g contraception (National Institute of PopulationStudies <strong>and</strong> Macro <strong>International</strong> Inc., 2008), support<strong>in</strong>g ahigh rate of unmet need for Pakistani women.Unmet need – <strong>the</strong> percentage of currently married womenwho are fecund <strong>and</strong> do not want to be pregnant yet arenot us<strong>in</strong>g contraception – <strong>in</strong>creased from 33 per cent(National Institute of Population Studies, 2001) to 37per cent <strong>in</strong> <strong>the</strong> 2006/07 DHS. Unmet need <strong>in</strong> rural areas,which was <strong>in</strong>itially lower, now exceeds urban unmet need,suggest<strong>in</strong>g that <strong>the</strong> availability <strong>and</strong> affordability of familyplann<strong>in</strong>g services is an obstacle <strong>and</strong> limitation to fertilitychange, a situation which applies more so <strong>in</strong> rural Pakistan.In l<strong>in</strong>e with <strong>the</strong>se f<strong>in</strong>d<strong>in</strong>gs is <strong>the</strong> trend <strong>in</strong> unplannedchildbear<strong>in</strong>g (<strong>the</strong> comb<strong>in</strong>ation of unwanted births <strong>and</strong>mistimed births): <strong>the</strong> proportion of recent births thatare unplanned rose from 21 per cent <strong>in</strong> 1990/91 to 24per cent <strong>in</strong> 2006/07. Unmet need for contraception <strong>and</strong><strong>the</strong> proportion of births that are unplanned <strong>and</strong> <strong>the</strong> highrate of abortion suggest that a large fraction of currentlymarried women <strong>in</strong> Pakistan are at risk of an unwantedpregnancy <strong>and</strong> potentially an unsafe abortion.Vulnerable group – poor womenFertility rates <strong>in</strong> Pakistan vary by women’s education <strong>and</strong>household wealth status. These <strong>in</strong>equalities can also beseen <strong>in</strong> <strong>the</strong> unmet need for family plann<strong>in</strong>g. However,unlike total fertility, <strong>the</strong> relationship of unmet need with<strong>the</strong>se background characteristics has changed over time. In1991, women from <strong>the</strong> poorest households had <strong>the</strong> lowestunmet need; over time unmet need among <strong>the</strong>se womenrose substantially, <strong>and</strong> <strong>the</strong>y now have <strong>the</strong> highest unmetneed (World Bank, 2009). The change <strong>in</strong> <strong>the</strong> relationshipbetween unmet need <strong>and</strong> wealth can be understoodby look<strong>in</strong>g at <strong>the</strong> changes <strong>in</strong> <strong>the</strong> relationship betweenpreferences <strong>and</strong> contraception <strong>and</strong> wealth (see Figure 7).The <strong>in</strong>dividual graphs <strong>in</strong> Figure 7 show that <strong>the</strong> dem<strong>and</strong>for family plann<strong>in</strong>g, as represented by <strong>the</strong> percentage ofwomen want<strong>in</strong>g no more children, rose more dramaticallyfor women from <strong>the</strong> poorest qu<strong>in</strong>tile. In fact, <strong>the</strong> figure thatshows <strong>the</strong> proportion want<strong>in</strong>g to limit childbear<strong>in</strong>g hasalmost converged at a level of about 50 per cent or morefor all wealth qu<strong>in</strong>tiles unlike <strong>the</strong> earlier period where itshowed a sharp positive association with wealth. This is<strong>in</strong> stark contrast to differentials <strong>in</strong> contraceptive use thatappear to be almost as sharp across rich <strong>and</strong> poor womenas <strong>the</strong>y were <strong>in</strong> <strong>the</strong> earlier period. Current use differentials(<strong>in</strong> absolute terms) between <strong>the</strong> poorest <strong>and</strong> richest womenwere 34 per cent <strong>in</strong> <strong>the</strong> earlier period <strong>and</strong> 32 per cent <strong>in</strong>2007, <strong>in</strong>dicat<strong>in</strong>g a negligible levell<strong>in</strong>g of contraceptive use,unlike <strong>the</strong> dramatic levell<strong>in</strong>g seen <strong>in</strong> fertility preferences.Ultimately, this expla<strong>in</strong>s <strong>the</strong> sharp <strong>in</strong>crease <strong>in</strong> unmet need,a comb<strong>in</strong>ed outcome of preferences <strong>and</strong> use, experiencedby poor women who <strong>in</strong>creased <strong>the</strong>ir dem<strong>and</strong> to limitchildbear<strong>in</strong>g without much change <strong>in</strong> contraception use.This is <strong>in</strong> contrast to <strong>the</strong> sharp fall <strong>in</strong> unmet need of <strong>the</strong>rich women who <strong>in</strong>creased <strong>the</strong>ir contraceptive use <strong>in</strong>conjunction with <strong>the</strong>ir dem<strong>and</strong> for it. The situation ofrelatively richer <strong>and</strong> poorer women has changed <strong>in</strong> <strong>the</strong>selast two decades: <strong>the</strong> differential of unmet need by wealthis significant – practically non-existent for <strong>the</strong> rich <strong>and</strong>over 30 per cent for poor women (World Bank, 2009).209

FigureFigure6Desire to limit childbear<strong>in</strong>g, current use <strong>and</strong> unmet need, by wealth status, 1991-200770605040%3020100PoorestDesire to limit20071991PoorerMiddleRicherRichest70605040%3020100PoorestCurrent use20071991PoorerMiddleRicherRichest504030%20100PoorestUnmet need19912007PoorerMiddleRicherRichestLack of accessWhile access costs are not currently <strong>the</strong> primarydeterm<strong>in</strong>ant of contraceptive use, studies have shownthat <strong>in</strong>creas<strong>in</strong>g service outlets <strong>and</strong> outreach programmescan lead to a reduction <strong>in</strong> unmet need, i.e., <strong>in</strong>creasecontraceptive prevalence (Fikree et al., 2001; Shelton etal., 1999). Data from various national surveys show thataccess to a health or FP facility varies greatly between rural<strong>and</strong> urban areas of Pakistan. Accord<strong>in</strong>g to <strong>the</strong> 1991 DHS,gett<strong>in</strong>g to a reproductive health facility took an average of40 m<strong>in</strong>utes <strong>in</strong> urban areas, while <strong>in</strong> rural areas it took morethan twice that time (96 m<strong>in</strong>utes). By 2001, urban-ruraldisparities <strong>in</strong> <strong>the</strong> availability of RH facilities still rema<strong>in</strong>edsignificant; distance to facilities was 3.4 km <strong>and</strong> 12.6 km<strong>in</strong> urban <strong>and</strong> rural areas, respectively (World Bank, 2009).The 2003 data also show that <strong>the</strong> <strong>in</strong>equality <strong>in</strong> accessrema<strong>in</strong>s strong. S<strong>in</strong>ce rural areas tend to have more poorpeople, it is not surpris<strong>in</strong>g <strong>the</strong>n that <strong>the</strong> figure above showsa negative relationship between wealth <strong>and</strong> distance tonearest FP facility.Quality of servicesThe role of <strong>the</strong> quality of family plann<strong>in</strong>g services <strong>and</strong>methods <strong>in</strong> <strong>the</strong> uptake of contraceptive use demonstratesyet ano<strong>the</strong>r fail<strong>in</strong>g <strong>in</strong> <strong>the</strong> supply of family plann<strong>in</strong>g. Inanalysis of DHS data, Zaidi (2009) found that over time<strong>in</strong>creas<strong>in</strong>g numbers of women had reported fear of sideeffects <strong>and</strong> health concerns as <strong>the</strong>ir primary reason for not<strong>in</strong>tend<strong>in</strong>g to use contraception <strong>in</strong> <strong>the</strong> future (see Figure8). In urban areas, health-related issues have replacedreligious prohibition as <strong>the</strong> most commonly reported nonfertilityreason for not <strong>in</strong>tend<strong>in</strong>g to use a method <strong>in</strong> <strong>the</strong>future. Even <strong>in</strong> rural areas, health-related issues are <strong>the</strong>second most common non-fertility-related reason for not<strong>in</strong>tend<strong>in</strong>g to use contraception. The fear of side effects<strong>and</strong> health concerns are known to be hugely related to <strong>the</strong>quality of services <strong>and</strong> choice of methods available. The<strong>in</strong>crease <strong>in</strong> <strong>the</strong> number of women try<strong>in</strong>g contraception butnot us<strong>in</strong>g it – as demonstrated by <strong>the</strong> difference <strong>in</strong> current<strong>and</strong> ever use – also suggests that health concerns <strong>and</strong>,<strong>the</strong>refore, quality of services are likely to be a significantfactor <strong>in</strong> deterr<strong>in</strong>g contraceptive use.Underst<strong>and</strong><strong>in</strong>g <strong>the</strong> currentsituationSocio-economic factorsEconomic growth but low educationWhile Pakistan has experienced economic growthconsistently s<strong>in</strong>ce its <strong>in</strong>ception, <strong>the</strong> prevalence of smallerfamily norms has yet to fully take place. A possiblereason beh<strong>in</strong>d <strong>the</strong> divergent trends <strong>in</strong> fertility decl<strong>in</strong>e <strong>and</strong>economic growth is that social development has not beencommensurate with economic progress; <strong>in</strong> Pakistan’s case,<strong>the</strong> two are not necessarily related. First, despite persistenteconomic growth <strong>and</strong> a rapid <strong>in</strong>crease <strong>in</strong> urbanization,<strong>the</strong> majority of Pakistan rema<strong>in</strong>s an agrarian society.Agriculture cont<strong>in</strong>ues to provide more than 40 per centof employment; its proportion has only decreased slightlyfrom 48 to 44 per cent. There has been little change <strong>in</strong> <strong>the</strong>proportion of employment provided by <strong>the</strong> o<strong>the</strong>r sectors,with marg<strong>in</strong>al <strong>in</strong>creases <strong>in</strong> wholesale <strong>and</strong> retail, <strong>and</strong> servicessectors.Second, <strong>the</strong> periods that saw a rise <strong>in</strong> economic growth ratesdid not see substantial progress <strong>in</strong> <strong>the</strong> social sectors <strong>and</strong>vice versa. Educational atta<strong>in</strong>ment saw little improvementover <strong>the</strong> period of <strong>the</strong> fertility transition, with gender<strong>in</strong>equalities <strong>in</strong> education rema<strong>in</strong><strong>in</strong>g high throughout. Itis only very recently that children’s enrolment rates haverisen at <strong>the</strong> primary level from about 49 per cent for boys210

FigureFigure7Non-fertility-related reasons for not <strong>in</strong>tend<strong>in</strong>g to use contraception <strong>in</strong> <strong>the</strong> future, 1991-200714Urban14Rural1212101086420199120078642019912007Husb<strong>and</strong>opposedReligiousprohibitionLack ofknowledgeHealthconcernsHusb<strong>and</strong>opposedReligious Lack ofprohibition knowledgeHealthconcerns<strong>and</strong> 38 per cent for girls <strong>in</strong> <strong>the</strong> 1990s to 59 per cent forboys <strong>and</strong> 52 per cent for girls <strong>in</strong> <strong>the</strong> recent decade. Thereare wide urban-rural disparities: enrolments are 70 percent <strong>in</strong> urban areas, but <strong>the</strong>y still lag far beh<strong>in</strong>d <strong>in</strong> <strong>the</strong> ruralareas. Secondary school enrolments are even lower, notris<strong>in</strong>g beyond 33 per cent even for 10-14-year-old boys.Less than half <strong>the</strong> population (about 47%) cont<strong>in</strong>ue to beilliterate <strong>and</strong> reside <strong>in</strong> rural areas where illiteracy is evenmore severe. Education has been a largely neglected sector<strong>in</strong> past decades <strong>and</strong> few resources have been allocated to ituntil recently.Low participation of women <strong>in</strong> societyMoreover, women’s low mobility <strong>and</strong> autonomy rema<strong>in</strong>obstacles to participation <strong>in</strong> politics, economic life <strong>and</strong>basic access to services. Accord<strong>in</strong>g to <strong>the</strong> Status of Women,Reproductive Health <strong>and</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Survey 2003,one <strong>in</strong> three women was not allowed to leave her homealone <strong>and</strong> 42 per cent of women who were able to go tohealth centres on <strong>the</strong>ir own were us<strong>in</strong>g contraceptioncompared with half that proportion, 21 per cent, who werenot allowed to go to <strong>the</strong>se facilities at all. Similarly, <strong>the</strong>proportion of women with high decision-mak<strong>in</strong>g powerwith<strong>in</strong> <strong>the</strong> households us<strong>in</strong>g contraception was twice <strong>the</strong>proportion of women with low decision-mak<strong>in</strong>g powerpractis<strong>in</strong>g family plann<strong>in</strong>g.Women have become more visible <strong>in</strong> Pakistani society; <strong>the</strong>yare certa<strong>in</strong>ly participat<strong>in</strong>g more <strong>in</strong> politics, public life <strong>and</strong>education than ever before, <strong>and</strong> an <strong>in</strong>creas<strong>in</strong>g proportionof women are enter<strong>in</strong>g <strong>the</strong> labour force, especially <strong>in</strong> urbanareas. Yet, it is still questionable whe<strong>the</strong>r this has led to an<strong>in</strong>crease <strong>in</strong> <strong>the</strong>ir status with<strong>in</strong> <strong>the</strong> household <strong>and</strong> with<strong>in</strong>society. Despite <strong>the</strong> recent <strong>in</strong>crease <strong>in</strong> female labour forceparticipation from 13 to 19 per cent over <strong>the</strong> last 18 years,female participation rema<strong>in</strong>s low compared with malelabour force participation, which has rema<strong>in</strong>ed at about71 per cent dur<strong>in</strong>g this period. Pakistan has <strong>the</strong> highestgender gap <strong>in</strong> labour force participation rates among <strong>the</strong>South, East <strong>and</strong> South-East <strong>Asia</strong>n countries (Arif <strong>and</strong>Arooj, 2009).Even <strong>the</strong> m<strong>in</strong>or <strong>in</strong>crease <strong>in</strong> female labour force participationis offset by <strong>the</strong> trends <strong>in</strong> <strong>the</strong> types of work women aretak<strong>in</strong>g up. Trends <strong>in</strong> employment status show that womenare replac<strong>in</strong>g men <strong>in</strong> unpaid <strong>and</strong> agricultural work; <strong>the</strong>proportion of women engaged <strong>in</strong> unpaid family work has<strong>in</strong>creased from 57 to 65 per cent. The proportion of womenwork<strong>in</strong>g <strong>in</strong> <strong>the</strong> agricultural sector is double <strong>the</strong> proportionof men, 75 <strong>and</strong> 37 per cent, respectively. However, <strong>the</strong>small but notable proportions of women who are educated<strong>and</strong> engaged <strong>in</strong> economic activity are likely to comprisean important <strong>in</strong>fluence on women’s empowerment <strong>and</strong>on fertility change. Recent expansion <strong>in</strong> wage work foreducated women <strong>in</strong> rural areas, such as <strong>the</strong> Lady HealthWorker scheme <strong>and</strong> <strong>the</strong> hir<strong>in</strong>g of female teachers <strong>and</strong>paramedics on a contract basis, may be pivotal to fur<strong>the</strong>rchange (Sathar et al., 2007).Explanations for programmeshortcom<strong>in</strong>gsThe Population Policy, <strong>in</strong>itiated <strong>in</strong> 1998 <strong>and</strong> passed <strong>in</strong> 2002by <strong>the</strong> Cab<strong>in</strong>et, may be considered a statement support<strong>in</strong>ga commitment to population issues. The pr<strong>in</strong>ciples werestrong but implementation details were weak. Essentially,elements of <strong>the</strong> policy underscored <strong>the</strong> need for anexpeditious completion of <strong>the</strong> fertility transition, good<strong>in</strong>ter-sectoral l<strong>in</strong>ks <strong>and</strong> <strong>in</strong>tertw<strong>in</strong>ement with developmentprogrammes. Unfortunately, while tackl<strong>in</strong>g <strong>the</strong> fertilitydecl<strong>in</strong>e, not much attention was devoted to how exactlythis would happen <strong>and</strong> <strong>the</strong> resources it would require;once more, much was left to do<strong>in</strong>g th<strong>in</strong>gs <strong>the</strong> way <strong>the</strong>y hadbeen done, with some expansion <strong>in</strong> <strong>the</strong> numbers of outlets<strong>and</strong> workers. Very little attention was given to details of211

coord<strong>in</strong>ation between <strong>the</strong> two ma<strong>in</strong>l<strong>in</strong>e m<strong>in</strong>istries of health<strong>and</strong> population welfare, with <strong>the</strong>ir respective prov<strong>in</strong>cialdepartments that are m<strong>and</strong>ated to deliver services, orwith <strong>the</strong> overall health system <strong>and</strong> LHWs. There has alsobeen <strong>in</strong>sufficient heed <strong>and</strong> concern about <strong>the</strong> supply ofcontraceptive commodities <strong>and</strong> on <strong>the</strong> role of <strong>the</strong> privatesector through social market<strong>in</strong>g, which was expected toexp<strong>and</strong> to rural areas but rema<strong>in</strong>ed restricted to urbanareas, through organizations such as Key <strong>and</strong> GreenstarSocial Market<strong>in</strong>g.S<strong>in</strong>ce <strong>the</strong>n, <strong>the</strong>re have been spurts of activity, such as<strong>the</strong> Population Summit 2005 <strong>and</strong> <strong>the</strong> formulation of<strong>the</strong> National Population Commission <strong>in</strong> one stroke,which meant that <strong>the</strong> k<strong>in</strong>d of debate that preceded <strong>the</strong>formulation of such commissions <strong>in</strong> Indonesia <strong>and</strong> Brazildid not happen.Lack of underst<strong>and</strong><strong>in</strong>g of populationissuesWhile demographic issues are brought out periodically asa topic of deliberation when doomsday scenario forecastsare recognized, <strong>the</strong>se issues are sidel<strong>in</strong>ed when times areeconomically good or when o<strong>the</strong>r more press<strong>in</strong>g issues areat h<strong>and</strong>. Population issues are not generally understood<strong>in</strong> bureaucratic or political circles, much less amongwider sections of society. This is because at no po<strong>in</strong>t hasserious attention been devoted to study<strong>in</strong>g Pakistan’slarge population numbers, <strong>the</strong>ir distribution <strong>and</strong> <strong>the</strong>implications <strong>the</strong>y hold for <strong>the</strong> country’s development,politics <strong>and</strong> ultimate stability. In fact, <strong>the</strong> demographyof Pakistan <strong>and</strong> population policy have largely been <strong>the</strong>responsibility of only a particular m<strong>in</strong>istry <strong>and</strong> a h<strong>and</strong>fulof professionals <strong>and</strong> organizations, with virtual statedenial, apart from occasional statements from state leaderson World Population Day or o<strong>the</strong>r similar occasions. Noserious debate has taken place ei<strong>the</strong>r <strong>in</strong> <strong>the</strong> parliament, <strong>the</strong>senate or, for that matter, <strong>in</strong> any of <strong>the</strong> th<strong>in</strong>k tanks <strong>and</strong>universities, or by <strong>the</strong> media, which is quite vibrant <strong>and</strong>free <strong>and</strong> usually responsive to issues close to <strong>the</strong> public’shearts <strong>and</strong> m<strong>in</strong>ds.While politicians may f<strong>in</strong>d population issues contentious<strong>and</strong> sensitive for religious reasons or for reasons hav<strong>in</strong>gto do with national award for resources, it is curiousthat economists <strong>and</strong> planners are guilty of neglect of thisimportant parameter that is here to haunt <strong>the</strong>m now, <strong>and</strong>certa<strong>in</strong>ly will haunt <strong>the</strong>m even more a few decades down <strong>the</strong>l<strong>in</strong>e. Undoubtedly, from <strong>the</strong> Third Five-year Plan onwards<strong>the</strong>re was a mention of population growth imp<strong>in</strong>g<strong>in</strong>g onresources, but <strong>the</strong> <strong>in</strong>ter-l<strong>in</strong>kages <strong>and</strong> <strong>the</strong> reasons whyPakistan’s population cont<strong>in</strong>ued to multiply were not seenas central to development plann<strong>in</strong>g (Sathar, 2011).Even now, FP is not seen as a nationalpriority. With <strong>the</strong> 18th amendmentMoPW will be one of <strong>the</strong> first federalprogrammes to be slashed, even thoughall high population countries have anational/federal level m<strong>in</strong>istry.Director-General Technical, M<strong>in</strong>istryof Population WelfareRole of <strong>in</strong>ternational politics<strong>International</strong> population movements <strong>and</strong> politics havedef<strong>in</strong>itely affected <strong>the</strong> twists <strong>and</strong> turns of Pakistan’s policies.The World Population Conference held <strong>in</strong> Belgrade <strong>in</strong>1965 was a confirmation of <strong>the</strong> role of family plann<strong>in</strong>g,but its outcome was to be upturned by <strong>the</strong> th<strong>in</strong>k<strong>in</strong>g at <strong>the</strong>World Population Conference held <strong>in</strong> Bucharest <strong>in</strong> 1974regard<strong>in</strong>g development as <strong>the</strong> best contraceptive. Thatth<strong>in</strong>k<strong>in</strong>g stalled <strong>the</strong> focus on family plann<strong>in</strong>g programmes,only to be reversed at <strong>the</strong> <strong>International</strong> Conference onPopulation, which was held <strong>in</strong> Mexico City <strong>in</strong> 1984. Thereal l<strong>and</strong>mark was ICPD held <strong>in</strong> Cairo <strong>in</strong> 1994, when<strong>the</strong> best possible balance was sought between population<strong>and</strong> development, lay<strong>in</strong>g out all its possible dimensions.Ironically, this took <strong>the</strong> biggest toll on family plann<strong>in</strong>gprogrammes, <strong>in</strong>stead of FP penetrat<strong>in</strong>g <strong>and</strong> permeat<strong>in</strong>gto all aspects of development, rang<strong>in</strong>g from education<strong>and</strong> women’s development to environment <strong>and</strong> health tomention a few.The ma<strong>in</strong> message of <strong>the</strong> 1994 ICPD Programme ofAction was <strong>the</strong> evolution of <strong>the</strong> term reproductive health,which was a holistic concept encompass<strong>in</strong>g many aspectsof family plann<strong>in</strong>g, safe mo<strong>the</strong>rhood <strong>and</strong> gender-basedviolence etc. The diffuse <strong>and</strong> large set of programmes tobe implemented, comb<strong>in</strong>ed with <strong>the</strong> dip <strong>in</strong> United Statessupport for family plann<strong>in</strong>g, led to a dramatic reduction <strong>in</strong><strong>in</strong>ternational resources for both reproductive health <strong>and</strong>– especially – family plann<strong>in</strong>g. Fur<strong>the</strong>rmore, <strong>the</strong> AIDSepidemic caught <strong>the</strong> world’s attention, <strong>and</strong> <strong>in</strong>ternationalfund<strong>in</strong>g for HIV/AIDS <strong>in</strong>creased several-fold as a result,whereas funds for RH, especially family plann<strong>in</strong>g, dippedradically, fall<strong>in</strong>g to <strong>the</strong>ir lowest levels <strong>in</strong> <strong>the</strong> early years ofthis decade.Due to ICPD, <strong>the</strong> development agendawas broadened. Even though o<strong>the</strong>rrelevant elements, such as rights, male212

<strong>in</strong>volvement <strong>and</strong> poverty, entered<strong>the</strong> agenda, FP lost some of <strong>the</strong> focus.Even <strong>the</strong> MDGs ignored FP until <strong>the</strong><strong>in</strong>troduction of (Target) 5b, which isstill universal access to reproductivehealth broadly, <strong>and</strong> not FP specifically.In 2005, <strong>the</strong>re was a shift <strong>in</strong> <strong>the</strong> IPPFframework to five As with<strong>in</strong> <strong>the</strong> area ofsexual <strong>and</strong> reproductive health (SRH)– Access, Adolescents, AIDS, Advocacy<strong>and</strong> Abortion. S<strong>in</strong>ce Rahnuma/FPAPis a member association of IPPF, it hadto address all <strong>the</strong> As <strong>and</strong>, <strong>the</strong>refore, <strong>in</strong>our performance FP was also a little “defocused”.CEO, <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Association ofPakistanNaturally, Pakistan, a country largely dependent on<strong>in</strong>ternational funds for social spend<strong>in</strong>g, <strong>in</strong> particular,suffered f<strong>in</strong>ancially. To <strong>the</strong> credit of <strong>the</strong> Pakistangovernment, however, it did not allow fund<strong>in</strong>g for <strong>the</strong>population programme to suffer; <strong>in</strong> fact, <strong>the</strong> entire amountof funds necessary has come from <strong>the</strong> public exchequerfor <strong>the</strong> last 10 years. None<strong>the</strong>less, <strong>in</strong> <strong>the</strong> very recent past,development funds have been more scarce <strong>and</strong> populationissues somewhat lagg<strong>in</strong>g <strong>in</strong> <strong>the</strong> country’s long list ofpriorities.L<strong>in</strong>kages <strong>and</strong> <strong>in</strong>tegration withhealth <strong>and</strong> o<strong>the</strong>r sectorsOne of <strong>the</strong> ma<strong>in</strong> constra<strong>in</strong>ts faced by <strong>the</strong> populationprogramme <strong>in</strong> Pakistan has been <strong>the</strong> lack of l<strong>in</strong>kageswith o<strong>the</strong>r sectors. <strong>Family</strong> plann<strong>in</strong>g has been as a st<strong>and</strong>aloneresponsibility of MoPW <strong>and</strong> not of <strong>the</strong> M<strong>in</strong>istriesof Health, Education or Social Development. The lack of<strong>in</strong>tegration <strong>and</strong> cooperation has meant limited outreach,limited consensus, lack of <strong>in</strong>novation <strong>and</strong>, <strong>the</strong>refore,extremely m<strong>in</strong>imal impact.MoPW has tried to rope <strong>in</strong> o<strong>the</strong>r socialsector m<strong>in</strong>istries. However, <strong>the</strong> frequentchange of government <strong>and</strong> secretariesmeans efforts need to be repeated over <strong>and</strong>over aga<strong>in</strong>.Director-General Technical, M<strong>in</strong>istryof Population WelfareIt is be<strong>in</strong>g seriously felt that <strong>the</strong> actual partners whowere <strong>the</strong> ma<strong>in</strong> players expected to contribute towardsfull coverage have failed. MoPW cont<strong>in</strong>ued with its ownservice delivery system, <strong>in</strong>clud<strong>in</strong>g 3,853 <strong>Family</strong> WelfareCentres, which are community based, 182 ReproductiveHealth Services A-Centres located <strong>in</strong> district/tehsil(subdistrict) headquarters hospitals, 104 ReproductiveHealth Services B-Centres located <strong>in</strong> private hospitals,292 Mobile Service Units for extension camps <strong>and</strong> 4,835social mobilizers at <strong>the</strong> union council level, all parts ofwhich have been operat<strong>in</strong>g ma<strong>in</strong>ly as st<strong>and</strong>-alone units,<strong>and</strong> <strong>the</strong>y are now expected to be <strong>in</strong>tegrated <strong>in</strong>to prov<strong>in</strong>cialhealth departments.The strong <strong>in</strong>terl<strong>in</strong>kages <strong>and</strong> re<strong>in</strong>forc<strong>in</strong>g relationshipsbetween education <strong>and</strong> population have not beencapitalized upon, with <strong>the</strong> exception of some small effortsat <strong>in</strong>troduc<strong>in</strong>g population education <strong>in</strong>to schools <strong>and</strong>colleges. Several opportunities for jo<strong>in</strong>t programmeshave been overlooked, <strong>and</strong> this has impeded ga<strong>in</strong>s <strong>in</strong>both sectors. In short, if education problems were to beimproved, family plann<strong>in</strong>g programmes would get a bigboost, <strong>and</strong>, conversely, with lower fertility <strong>the</strong> school-agepopulation would shr<strong>in</strong>k, thus reduc<strong>in</strong>g challenges fac<strong>in</strong>g<strong>the</strong> education sector.There is a need to l<strong>in</strong>k education<strong>and</strong> population behaviour. School<strong>in</strong>gcan delay age at marriage. L<strong>in</strong>kagesbetween fertility, education <strong>and</strong> femaleemployment need to <strong>the</strong> promotedtoge<strong>the</strong>r. “Healthy educated girls can doproductive work”.Shirkat Gah (Advisor, Women’s RightsOrganization)Ano<strong>the</strong>r major loss is <strong>the</strong> l<strong>in</strong>k with <strong>the</strong> environment. As<strong>the</strong> recent floods <strong>in</strong> Pakistan have clearly demonstrated,<strong>the</strong> most unsusta<strong>in</strong>able settlements, particularly thoseon riverbanks, were <strong>the</strong> ones to be most adverselyaffected. Scant attention has been paid to environmentalissues s<strong>in</strong>ce <strong>the</strong> comprehensive efforts that were made<strong>in</strong> develop<strong>in</strong>g <strong>the</strong> National Conservation Strategy <strong>in</strong>213

<strong>the</strong> 1980s <strong>and</strong> <strong>the</strong> preparations for <strong>the</strong> United NationsConference on Environment <strong>and</strong> Development (<strong>the</strong> RioSummit) <strong>in</strong> 1992. This is barr<strong>in</strong>g some narrow approacheswhich certa<strong>in</strong>ly do not take population movement <strong>and</strong>distribution <strong>in</strong>to account. Environment <strong>and</strong> populationare both marg<strong>in</strong>alized sectors. They would certa<strong>in</strong>ly havestronger lobbies <strong>and</strong> more funds if <strong>the</strong>y were seen as be<strong>in</strong>g<strong>in</strong> partnership.Most serious is <strong>the</strong> failure of MoH <strong>and</strong> <strong>the</strong> heal<strong>the</strong>stablishment <strong>in</strong> own<strong>in</strong>g any share of responsibility foroutcomes with regard to population. The evidence isstrik<strong>in</strong>g <strong>and</strong> abundant concern<strong>in</strong>g how closely l<strong>in</strong>ked health<strong>in</strong>dicators, particularly Millennium Development Goals 4<strong>and</strong> 5, are to fertility decl<strong>in</strong>e <strong>and</strong> family plann<strong>in</strong>g use. Yet,apart from <strong>the</strong> National Programme for <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong><strong>and</strong> Primary Health Care, <strong>and</strong> <strong>the</strong> Lady Health Workerprogramme, through which 100,000 women are provid<strong>in</strong>gfamily plann<strong>in</strong>g services <strong>in</strong> <strong>the</strong>ir rural communities, <strong>the</strong>sector has largely abdicated its responsibility for familyplann<strong>in</strong>g. In particular, <strong>the</strong> vast dispersion of <strong>the</strong> healthservice delivery network (compris<strong>in</strong>g at least 15,000locations) <strong>and</strong> additional allied hospitals has not resulted<strong>in</strong> any priority be<strong>in</strong>g given to family plann<strong>in</strong>g; <strong>the</strong> sectordoes not even consider FP to be one of its essential duties.It is difficult to expla<strong>in</strong> whe<strong>the</strong>r this is because of <strong>the</strong>reliance on MoPW <strong>and</strong> its departments for family plann<strong>in</strong>gservices, or because of <strong>the</strong> lack of tra<strong>in</strong>ed providers, <strong>the</strong>erratic supply of contraceptives <strong>and</strong> now <strong>the</strong> uncerta<strong>in</strong>fund<strong>in</strong>g situation associated with population.As trends <strong>in</strong> <strong>the</strong> sources of methods show, <strong>the</strong> private sectoris <strong>in</strong>creas<strong>in</strong>gly enhanc<strong>in</strong>g its share <strong>in</strong> <strong>the</strong> health sector.While social market<strong>in</strong>g is play<strong>in</strong>g a role <strong>in</strong> family plann<strong>in</strong>g,<strong>the</strong>re is a huge private sector beyond that, compris<strong>in</strong>gprivate health-care providers, chemists, homeopaths, <strong>the</strong>commercial sector <strong>and</strong> more. It is believed that 50 to 80 percent of health-care services are now be<strong>in</strong>g sought throughprivate sector providers.Thus far, <strong>the</strong>re has been little recognition or coord<strong>in</strong>ationbetween <strong>the</strong> ma<strong>in</strong> players <strong>in</strong> <strong>the</strong> family plann<strong>in</strong>g programme<strong>and</strong> <strong>the</strong> representatives of this part of <strong>the</strong> private sector.Associations such as <strong>the</strong> Pakistan Medical Association, <strong>the</strong>Society of Gynecologists <strong>and</strong> Obstetricians, <strong>the</strong> PakistanPediatric Association <strong>and</strong> Association of Homeopaths canbe brought under <strong>the</strong> umbrella of <strong>the</strong> programme to elicit<strong>the</strong> support of <strong>the</strong>se large groups of potential providers<strong>and</strong> counselors <strong>and</strong> to benefit from <strong>the</strong>ir <strong>in</strong>fluence.RecommendationsThe year 2010 will most likely prove to be a def<strong>in</strong><strong>in</strong>gone for family plann<strong>in</strong>g programmes <strong>in</strong> Pakistan. WhileMoPW was actively work<strong>in</strong>g on <strong>the</strong> Population Policy2010 <strong>and</strong> its <strong>in</strong>puts for <strong>the</strong> Tenth Five-year Plan <strong>in</strong> <strong>the</strong> areaof population, decisions were made to take population off<strong>the</strong> concurrent list <strong>and</strong> to effectively discont<strong>in</strong>ue <strong>the</strong> roleof <strong>the</strong> M<strong>in</strong>istry altoge<strong>the</strong>r. While consideration may begiven to <strong>the</strong> reformulation of <strong>the</strong> Population Commission,it is now certa<strong>in</strong> at <strong>the</strong> time this paper is be<strong>in</strong>g writtenthat on 1 December 2010 <strong>the</strong> prov<strong>in</strong>ces will hold allresponsibility for deliver<strong>in</strong>g family plann<strong>in</strong>g services. Thefate of population welfare departments is not clear, but itis known that <strong>the</strong> tra<strong>in</strong><strong>in</strong>g functions <strong>and</strong> various <strong>in</strong>stitutesof <strong>the</strong> M<strong>in</strong>istry are to be h<strong>and</strong>ed over to <strong>the</strong> prov<strong>in</strong>ces atthat time.This change offers an opportunity as well as a challenge.Resources for family plann<strong>in</strong>g may not be available <strong>in</strong> <strong>the</strong>prov<strong>in</strong>ces, or at least <strong>the</strong> mechanism of resource flows maynot be clear for awhile. However, at <strong>the</strong> same time, serviceswill become <strong>the</strong> responsibility of <strong>the</strong> prov<strong>in</strong>ces, <strong>the</strong>reby<strong>in</strong>creas<strong>in</strong>g accountability for performance at <strong>the</strong> prov<strong>in</strong>ciallevel. The family plann<strong>in</strong>g programme is now at <strong>the</strong> stage ofa huge upheaval <strong>in</strong> its historical evolution, but it can at leastimprove its service delivery components by successfully<strong>in</strong>tegrat<strong>in</strong>g <strong>and</strong> coord<strong>in</strong>at<strong>in</strong>g with <strong>the</strong> prov<strong>in</strong>cial healthdepartments. Certa<strong>in</strong> functions, such as formulation ofpolicy, monitor<strong>in</strong>g <strong>and</strong> research, <strong>and</strong> sett<strong>in</strong>g m<strong>in</strong>imumst<strong>and</strong>ards, will have to rema<strong>in</strong> a national responsibilityfor <strong>the</strong> sake of uniformity. Much will now depend on <strong>the</strong>role of all <strong>the</strong> players o<strong>the</strong>r than MoPW, particularly <strong>the</strong>health sector, to rise to <strong>the</strong> challenge of us<strong>in</strong>g its widerservice network to <strong>in</strong>corporate family plann<strong>in</strong>g <strong>in</strong>to it asa priority.Two o<strong>the</strong>r actors that have underperformed are NGOs<strong>and</strong> <strong>the</strong> private sector. The programme could be greatlystreng<strong>the</strong>ned if <strong>the</strong> NGO sector is brought moreactively <strong>in</strong>to <strong>the</strong> fold. NATPOW offers some hope thata strong umbrella organization could make grants <strong>and</strong>streng<strong>the</strong>n <strong>the</strong> capacity of NGOs, particularly <strong>the</strong> smallerorganizations located <strong>in</strong> areas where nei<strong>the</strong>r <strong>the</strong> publicnor <strong>the</strong> private sector is will<strong>in</strong>g or able to provide services.The private sector has yet to be tapped fully, but has tobe approached with some parameters about <strong>the</strong> quality<strong>and</strong> range of services that would need to be provided bydifferent cadres. A strong regulatory mechanism may needto be <strong>in</strong> place for uniformity of st<strong>and</strong>ards of service deliveryat <strong>the</strong> national <strong>and</strong> even prov<strong>in</strong>cial levels; such a board hasbeen formulated <strong>in</strong> Punjab Prov<strong>in</strong>ce already.Streng<strong>the</strong>n<strong>in</strong>g <strong>the</strong> programmeIn sum, <strong>the</strong> programme can be streng<strong>the</strong>ned through <strong>the</strong>follow<strong>in</strong>g means:Strong monitor<strong>in</strong>g <strong>and</strong> oversight role is carried out at <strong>the</strong>centre but with <strong>the</strong> full participation of <strong>the</strong> prov<strong>in</strong>ces;<strong>Family</strong> plann<strong>in</strong>g services are delivered at all health214

outlets, with population welfare outlets play<strong>in</strong>gcomplementary <strong>and</strong> specialized roles;A strong body is <strong>in</strong> place to steer, assist <strong>and</strong> coord<strong>in</strong>ate<strong>the</strong> role of <strong>the</strong> private <strong>and</strong> not-for-profit sector;The maximum number of NGOs <strong>and</strong> CBOs areprovid<strong>in</strong>g services <strong>in</strong> areas where underprivileged, hardto-reachpopulations are located.Exp<strong>and</strong><strong>in</strong>g <strong>the</strong> role of stakeholdersThe role of stakeholders is critical. It almost goes withoutsay<strong>in</strong>g that <strong>the</strong> responsibility for population issues <strong>and</strong>family plann<strong>in</strong>g programmes has been too narrow, <strong>and</strong>this has been largely to blame for <strong>the</strong> failure to <strong>in</strong>clude ofo<strong>the</strong>r important stakeholders. There is a long list of partiesthat need to be conv<strong>in</strong>ced of <strong>the</strong> importance <strong>and</strong> absolutenecessity of provid<strong>in</strong>g family plann<strong>in</strong>g services. Amongthat list, three sets of partners are critical.First are <strong>the</strong> economic, f<strong>in</strong>ancial <strong>and</strong> development plannersat <strong>the</strong> <strong>Plann<strong>in</strong>g</strong> Commission <strong>and</strong> <strong>the</strong> M<strong>in</strong>istry of F<strong>in</strong>ancewho need to be aware of <strong>the</strong> huge impact of high fertilityon all <strong>in</strong>dicators of growth, poverty reduction <strong>and</strong>employment dem<strong>and</strong>s etc.The second is <strong>the</strong> health establishment, start<strong>in</strong>g withMoH, which really needs to give its full endorsement <strong>and</strong>support on a priority basis to family plann<strong>in</strong>g, with <strong>the</strong>full realization of how closely family plann<strong>in</strong>g is l<strong>in</strong>ked toits own priority of reduc<strong>in</strong>g child <strong>and</strong> maternal mortality.This commitment has to extend to pre-service tra<strong>in</strong><strong>in</strong>g forall medical <strong>and</strong> paramedical personnel <strong>and</strong> has to seep <strong>in</strong>toactual <strong>in</strong>-service tra<strong>in</strong><strong>in</strong>g. <strong>Family</strong> plann<strong>in</strong>g is an importan<strong>the</strong>alth <strong>in</strong>tervention that is not be<strong>in</strong>g adequately providedby ei<strong>the</strong>r <strong>the</strong> public or <strong>the</strong> private sectors – this realizationhas to be advocated.Third, donors <strong>and</strong> <strong>the</strong> <strong>in</strong>ternational community needto make up for <strong>the</strong> time lost when <strong>the</strong>y neglected familyplann<strong>in</strong>g issues as a priority for almost a decade. Theyshould provide assistance f<strong>in</strong>ancially <strong>and</strong> technically toensure that Pakistan does not miss this opportunity toimprove its family plann<strong>in</strong>g record.In order to conv<strong>in</strong>ce <strong>the</strong>se stakeholders that familyplann<strong>in</strong>g needs to be repositioned <strong>in</strong> <strong>the</strong> development <strong>and</strong>policy dialogue as a means for healthy birth spac<strong>in</strong>g, whichis so closely l<strong>in</strong>ked to maternal <strong>and</strong> child health, <strong>and</strong> asa critical tool for realiz<strong>in</strong>g <strong>the</strong> demographic dividend <strong>and</strong>reduc<strong>in</strong>g poverty.Invest<strong>in</strong>g <strong>in</strong> female educationIncreas<strong>in</strong>g access to, <strong>and</strong> improv<strong>in</strong>g <strong>the</strong> quality of, familyplann<strong>in</strong>g services will take care of <strong>the</strong> immediate need forbirth control. Even if – miraculously – unmet need canbe completely elim<strong>in</strong>ated by <strong>in</strong>vestments <strong>in</strong> supply<strong>in</strong>gfamily plann<strong>in</strong>g services, CPR <strong>in</strong> Pakistan will still beabout 55 per cent <strong>and</strong> TFR about 3 births per woman.While this would be a remarkable achievement, this levelof CPR will still be significantly lower than <strong>in</strong>ternationalst<strong>and</strong>ards <strong>and</strong> <strong>in</strong>sufficient for reach<strong>in</strong>g replacement-levelfertility. Invest<strong>in</strong>g <strong>in</strong> women’s education is imperative, notonly for <strong>in</strong>creas<strong>in</strong>g women’s participation <strong>in</strong> <strong>the</strong> labourforce <strong>and</strong> society <strong>in</strong> general, but also for br<strong>in</strong>g<strong>in</strong>g about <strong>the</strong>ideational change needed for reach<strong>in</strong>g replacement fertility.More widespread education, especially among women,women’s <strong>in</strong>creased participation <strong>in</strong> <strong>the</strong> economy, greaterprosperity <strong>in</strong> general, <strong>and</strong> a more profound transformationfrom Pakistan’s current primarily agrarian structure to<strong>in</strong>dustrialized society will be necessary to transform valuesabout ideal family size from <strong>the</strong> current level of fourchildren to just two (World Bank, 2009).BibliographyArif, G.M. <strong>and</strong> Amena Arooj (2009). “Absorption ofgrow<strong>in</strong>g labour force <strong>in</strong> Pakistan: actualiz<strong>in</strong>g <strong>the</strong>full potential of demographic dividend”, In: Pakistan’sDemographic Transition <strong>in</strong> <strong>the</strong> Development Context,Islamabad: Population <strong>Council</strong>.Arif, Shafique <strong>and</strong> Iram Kamran (2007). Explor<strong>in</strong>g <strong>the</strong>Choices of Contraception <strong>and</strong> Abortion among MarriedCouples <strong>in</strong> Tret, Rural Punjab, Pakistan, Islamabad:Population <strong>Council</strong>.Fikree, Fariyal, A. Khan et al. (2001). “What <strong>in</strong>fluencescontraceptive use among young women <strong>in</strong> urbansquatter settlements of Karachi, Pakistan?”<strong>International</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Perspectives, 27(3): 130-136.Hardee, Karen <strong>and</strong> Elizabeth Leahy (2008). “Population,fertility <strong>and</strong> family plann<strong>in</strong>g <strong>in</strong> Pakistan: a program <strong>in</strong>stagnation”, Population Action <strong>International</strong>, ResearchCommentary, 3(3):1-12.National Institute of Population Studies (2001). PakistanReproductive Health <strong>and</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Survey 2000-2001, Islamabad: NIPS.__________ (2007). Status of Women,Reproductive Health <strong>and</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Survey(SWRHFPS-2003), Islamabad: NIPS.__________ <strong>and</strong> Macro <strong>International</strong> Inc. (1992).Pakistan Demographic <strong>and</strong> Health Survey 1990/1991,Islamabad <strong>and</strong> Columbia, Maryl<strong>and</strong>: NIPS <strong>and</strong>IRD/Macro <strong>International</strong> Inc.__________ (2008). Pakistan Demographic <strong>and</strong>Health Survey 2006-07: F<strong>in</strong>al Report, Islamabad<strong>and</strong> Columbia, Maryl<strong>and</strong>: NIPS <strong>and</strong> IRD/Macro<strong>International</strong> Inc.Oxford Policy Management (2002). External Evaluationof <strong>the</strong> National Programme for <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong>Primary Health Care: F<strong>in</strong>al Report, Islamabad: Oxford215

Policy Management.__________ (n.d., forthcom<strong>in</strong>g). Report on Third PartyEvaluation, Islamabad: Oxford Policy Management.Population <strong>Council</strong> (2004). Unwanted Pregnancy <strong>and</strong>Post-abortion Complications <strong>in</strong> Pakistan: F<strong>in</strong>d<strong>in</strong>gs froma National Study, Islamabad: Population <strong>Council</strong>.Sathar, Zeba (2011). “Demographic doom ordemographic dreams: Pakistan at <strong>the</strong> crossroads”,In: Reap<strong>in</strong>g <strong>the</strong> Dividend: Overcom<strong>in</strong>g Pakistan’sDemographic Challenges, Wash<strong>in</strong>gton, D.C. <strong>and</strong>Islamabad: Woodrow Wilson <strong>International</strong> Centerfor Scholars’ <strong>Asia</strong> Program <strong>and</strong> <strong>the</strong> Fellowship Fundfor Pakistan.__________ <strong>and</strong> John Casterl<strong>in</strong>e (1998). “The onsetof fertility transition <strong>in</strong> Pakistan”, Population <strong>and</strong>Development Review, 24(4):773-796.Sathar, Zeba, Susheela S<strong>in</strong>gh <strong>and</strong> Fariyal Fikree (2007).“Estimat<strong>in</strong>g abortions <strong>in</strong> an illegal sett<strong>in</strong>g: <strong>the</strong> case ofPakistan”, Studies <strong>in</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>, 38(1):11-32.Sathar, Zeba <strong>and</strong> Batool Zaidi (2009). Fertility Prospects<strong>in</strong> Pakistan. Paper submitted to United NationsExpert Group Meet<strong>in</strong>g on Recent <strong>and</strong> Future Trends<strong>in</strong> Fertility, New York: Population Division UnitedNations Department of Economic <strong>and</strong> Social Affairs.Shelton, J.D., Lois Bradshaw et al. (1999). “Putt<strong>in</strong>g unmetneed to <strong>the</strong> test: community-based distribution offamily plann<strong>in</strong>g <strong>in</strong> Pakistan”, <strong>International</strong> <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Perspectives, 25(4):191-195.World Bank (2009). Exam<strong>in</strong><strong>in</strong>g fertility change <strong>and</strong>its impact on household poverty <strong>and</strong> welfare.Background paper for Pakistan Poverty Assessmentreport, Islamabad: World Bank.Zaidi, Batool (2009). “Ensur<strong>in</strong>g fertility decl<strong>in</strong>e <strong>in</strong>Pakistan”, In: Pakistan’s Demographic Transition <strong>in</strong> <strong>the</strong>Development Context, Islamabad: Population <strong>Council</strong>,pp. 9-17.216

Sri LankaSri LankaReproductive Health <strong>and</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Programme<strong>in</strong> Sri Lanka:Achievements <strong>and</strong> ChallengesA.T.P.L. Abeykoon** Senior Fellow, Institute for Health Policy <strong>and</strong> former Director, Population Division, M<strong>in</strong>istry of Health, Government ofSri Lanka.217

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Historical overviewIn <strong>the</strong> <strong>Asia</strong>n context Sri Lanka is unique <strong>in</strong> that it has a longhistory with regard to maternal care <strong>and</strong> data collection.The first organized effort towards provid<strong>in</strong>g childbear<strong>in</strong>gwomen <strong>in</strong> Sri Lanka with such care commenced <strong>in</strong> 1879with <strong>the</strong> establishment of <strong>the</strong> De Soysa Hospital forWomen <strong>in</strong> Colombo. The registration of traditionalmidwives began <strong>in</strong> 1887, <strong>and</strong> from 1902 maternalmortality statistics were reported <strong>in</strong> <strong>the</strong> Annual Reportof <strong>the</strong> Registrar General. The first antenatal cl<strong>in</strong>ic washeld <strong>in</strong> 1921, <strong>and</strong> <strong>the</strong> first health unit was established <strong>in</strong>1926. By 1950, 91 health units had been established. Thehealth units provided domiciliary as well as cl<strong>in</strong>ic servicesdur<strong>in</strong>g pregnancy; tra<strong>in</strong>ed assistance at delivery through<strong>in</strong>stitutions or at home; <strong>and</strong> care dur<strong>in</strong>g postnatal period<strong>and</strong> <strong>in</strong>fancy. The expansion of maternal <strong>and</strong> child healthservices contributed significantly to lower<strong>in</strong>g maternal<strong>and</strong> <strong>in</strong>fant mortality rates. The maternal mortality ratiodecl<strong>in</strong>ed from 2,650 per 100,000 live births <strong>in</strong> 1935 to 560per 100,000 <strong>in</strong> 1950. Similarly, <strong>the</strong> <strong>in</strong>fant mortality ratedecl<strong>in</strong>ed from 263 to 82 per 1,000 live births dur<strong>in</strong>g <strong>the</strong>same period. Dur<strong>in</strong>g <strong>the</strong> period 1950-1965, <strong>the</strong> maternal<strong>and</strong> child health <strong>in</strong>frastructure was fur<strong>the</strong>r developed; <strong>the</strong>number of midwives <strong>in</strong>creased by more than two-fold. Thematernal mortality ratio cont<strong>in</strong>ued to decl<strong>in</strong>e to 240 per100,000 live births <strong>and</strong> <strong>the</strong> <strong>in</strong>fant mortality rate to 53 per1,000 by 1965.The family plann<strong>in</strong>g activities <strong>in</strong> Sri Lanka commenced<strong>in</strong> a modest manner with <strong>the</strong> establishment of <strong>the</strong> <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Association <strong>in</strong> 1953; it was founded by agroup of enlightened women who were concerned about<strong>the</strong> high maternal <strong>and</strong> <strong>in</strong>fant mortality rates that wereprevalent among low-<strong>in</strong>come urban families due to poorbirth spac<strong>in</strong>g. Thus <strong>the</strong> <strong>in</strong>itial work of <strong>the</strong> Associationfocused on reduc<strong>in</strong>g maternal <strong>and</strong> <strong>in</strong>fant mortality <strong>and</strong>malnutrition among <strong>the</strong> poor. The government recognized<strong>the</strong> work of <strong>the</strong> Association <strong>in</strong> 1954 by provid<strong>in</strong>g it withan annual grant.In 1958, an agreement was signed between <strong>the</strong> governmentsof Sri Lanka <strong>and</strong> Sweden for cooperation <strong>in</strong> a pilot projecton family plann<strong>in</strong>g. The ma<strong>in</strong> objectives of <strong>the</strong> project wereto <strong>in</strong>vestigate attitudes towards family plann<strong>in</strong>g; assess <strong>the</strong>prospects of family plann<strong>in</strong>g activities; provide <strong>in</strong>formationon family plann<strong>in</strong>g methods; <strong>and</strong> tra<strong>in</strong> health personnel <strong>in</strong><strong>the</strong> delivery of services <strong>in</strong> selected project areas. A surveyon family plann<strong>in</strong>g attitudes revealed that <strong>the</strong>re was nomajor religious opposition to family plann<strong>in</strong>g <strong>and</strong> that alatent dem<strong>and</strong> for family plann<strong>in</strong>g existed.Dur<strong>in</strong>g <strong>the</strong> period 1958-1965, family plann<strong>in</strong>g activitiescont<strong>in</strong>ued to ga<strong>the</strong>r momentum. The number of cl<strong>in</strong>icsrun by <strong>the</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Association <strong>in</strong>creased from35 to 135. When <strong>the</strong> 10-year economic development plan(Ten Year Plan) was presented <strong>in</strong> 1959, it highlighted<strong>the</strong> implications of <strong>the</strong> rapid <strong>in</strong>crease <strong>in</strong> population <strong>in</strong>Sri Lanka after 1946 <strong>and</strong> its effect <strong>in</strong> skew<strong>in</strong>g <strong>in</strong>vestmentaway from directly productive economic activities. In1960, a labour force survey conducted with <strong>the</strong> assistanceof <strong>the</strong> <strong>International</strong> Labour Organization showed that<strong>the</strong> unemployment rate had <strong>in</strong>creased to over 10 percent. Therefore, <strong>in</strong> view of <strong>the</strong> above, it became evident topolicymakers that <strong>the</strong> population growth rate <strong>in</strong> <strong>the</strong> countryneeded to be brought under control. The governmentonce aga<strong>in</strong> emphasized <strong>in</strong> its Short Term DevelopmentProgramme presented <strong>in</strong> 1962 <strong>the</strong> importance of br<strong>in</strong>g<strong>in</strong>gdown <strong>the</strong> rate of population growth due to its adverseimplications for economic <strong>and</strong> social development.Thus <strong>in</strong> 1965, family plann<strong>in</strong>g became a nationalprogramme <strong>and</strong> was <strong>in</strong>tegrated with <strong>the</strong> maternal <strong>and</strong>child health programme of <strong>the</strong> M<strong>in</strong>istry of Health. Itwas three decades before <strong>the</strong> <strong>International</strong> Conferenceon Population <strong>and</strong> Development (ICPD), that Sri Lankarecognized <strong>the</strong> importance of <strong>in</strong>tegrat<strong>in</strong>g family plann<strong>in</strong>gwith o<strong>the</strong>r reproductive services, such as maternal <strong>and</strong>child health. The social <strong>and</strong> political environment <strong>in</strong> <strong>the</strong>country was conducive to implement<strong>in</strong>g such a programme.The primary health-care system was well developed witha network of <strong>in</strong>stitutions <strong>and</strong> tra<strong>in</strong>ed personnel. About70 per cent of women <strong>in</strong> <strong>the</strong> reproductive age groupwere literate. Meanwhile, <strong>the</strong> Swedish-Sri Lanka <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Project, which collected a good deal of data,showed that fertility control could be achieved by familyplann<strong>in</strong>g methods acceptable to <strong>the</strong> people. Thus <strong>the</strong>efforts of both <strong>the</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Association <strong>and</strong> <strong>the</strong>Swedish-Ceylon Pilot Project demonstrated <strong>the</strong> need forfur<strong>the</strong>r action.Launch<strong>in</strong>g phase, 1965-1975In 1965, <strong>the</strong> government renewed <strong>the</strong> agreement with<strong>the</strong> government of Sweden to obta<strong>in</strong> equipment <strong>and</strong>contraceptive commodities to implement <strong>the</strong> nationalfamily plann<strong>in</strong>g programme. In 1968, <strong>the</strong> <strong>Family</strong> HealthBureau was established <strong>in</strong> <strong>the</strong> M<strong>in</strong>istry of Health tocoord<strong>in</strong>ate <strong>and</strong> implement <strong>the</strong> maternal <strong>and</strong> child health<strong>and</strong> family plann<strong>in</strong>g activities. By 1971, as a result of <strong>the</strong>rapid growth of <strong>the</strong> youth population, <strong>the</strong> unemploymentrate <strong>in</strong>creased to more than 20 per cent of <strong>the</strong> labourforce, which resulted <strong>in</strong> a youth upris<strong>in</strong>g <strong>in</strong> April that year.Therefore, <strong>in</strong> 1972, when <strong>the</strong> Five Year Plan was presentedby <strong>the</strong> government it emphasized <strong>the</strong> need to slow <strong>the</strong> rateof population growth, which <strong>the</strong>n was grow<strong>in</strong>g at 2.3 percent annually. The Plan stated that, if action was not taken,Sri Lanka would have a population of 27 million people by<strong>the</strong> year 2000. Therefore, <strong>the</strong> Plan gave high priority to <strong>the</strong>diffusion of family plann<strong>in</strong>g services among <strong>the</strong> mass of <strong>the</strong>adult population. In 1973, a project agreement was signedby <strong>the</strong> government with <strong>the</strong> <strong>the</strong>n United Nations Fund for219

Population Activities (UNFPA) for assistance <strong>in</strong> order toestablish a broad base for <strong>the</strong> population programme. Thusit took two decades from 1953 to 1973 for family plann<strong>in</strong>gto take root <strong>and</strong> become an acceptable programme. Thefact that it was possible to overcome various social <strong>and</strong>organizational barriers <strong>and</strong> become an <strong>in</strong>strument ofsocial change is undoubtedly of great significance. Theimplementation strategy was essentially designed toprovide family plann<strong>in</strong>g services through <strong>the</strong> establishedmaternal <strong>and</strong> child health (MCH) cl<strong>in</strong>ic network. Thehealth centres provid<strong>in</strong>g MCH care more than doubleddur<strong>in</strong>g <strong>the</strong> period 1953-1973 <strong>and</strong> <strong>the</strong> proportion of birthsattended by tra<strong>in</strong>ed health personnel at delivery <strong>in</strong>creasedfrom 46 to 90 per cent dur<strong>in</strong>g <strong>the</strong> same period.As many population <strong>in</strong>formation, education <strong>and</strong>communication (IEC) activities were implementedby o<strong>the</strong>r government agencies outside <strong>the</strong> M<strong>in</strong>istry ofHealth, <strong>in</strong> 1974 a Steer<strong>in</strong>g Committee was establishedto coord<strong>in</strong>ate <strong>the</strong> national population programme; it waschaired by <strong>the</strong> Secretary, M<strong>in</strong>istry of Plan Implementation.i In 1975, when <strong>the</strong> first fertility survey <strong>in</strong> <strong>the</strong> countrywas carried out, <strong>the</strong> contraceptive prevalence rate (CPR)was estimated at 34 per cent <strong>and</strong> of those practis<strong>in</strong>gcontraception <strong>the</strong> prevalence of modern methods was 20per cent. The maternal mortality ratio was down to 100per 100,000 live births <strong>and</strong> <strong>the</strong> <strong>in</strong>fant mortality rate was45.1 per 1,000 live births (Table 1).Progressive phase, 1975-1985In 1977, <strong>the</strong> government policy on population was clearlystated <strong>in</strong> <strong>the</strong> so-called Throne Speech of <strong>the</strong> government. Itnoted <strong>the</strong> need to streng<strong>the</strong>n cl<strong>in</strong>ical contraceptive services<strong>and</strong> provide f<strong>in</strong>ancial <strong>in</strong>ducements to those who voluntarilyaccept sterilization as a method of contraception.TableIn May 1979, <strong>the</strong> government <strong>in</strong>troduced for <strong>the</strong> firsttime f<strong>in</strong>ancial <strong>in</strong>centives to medical teams that carried outsterilizations. This scheme was extended to new acceptorsof sterilization from January 1980. The ma<strong>in</strong> purposeof provid<strong>in</strong>g f<strong>in</strong>ancial <strong>in</strong>ducements was to meet out-ofpocketexpenditure of clients, such as loss of daily wages<strong>and</strong> transport costs. Fur<strong>the</strong>rmore, medical officers whoperformed a large number of sterilizations were awardedcertificates <strong>and</strong> some were sent on study tours abroad tostudy programmes <strong>in</strong> o<strong>the</strong>r countries.The programme received greater visibility through IECactivities organized by <strong>the</strong> government <strong>and</strong> NGOs. Thegovernment also recognized <strong>the</strong> role that NGOs could play<strong>in</strong> supplement<strong>in</strong>g <strong>the</strong> national programme <strong>and</strong> encouraged<strong>the</strong>m all.In 1979, <strong>the</strong> Population Division was created <strong>in</strong> <strong>the</strong> M<strong>in</strong>istryof Plan Implementation with a view to evaluate currentpopulation policies <strong>and</strong>, where necessary, to formulate newpolicies; establish mechanisms for <strong>in</strong>tegrat<strong>in</strong>g populationfactors <strong>in</strong>to development plann<strong>in</strong>g; coord<strong>in</strong>ate <strong>and</strong> monitor<strong>the</strong> national population programme; <strong>and</strong> undertake <strong>and</strong>subcontract policy-oriented research. At <strong>the</strong> subnationallevel, District Population Committees were established,with <strong>the</strong> District Secretary appo<strong>in</strong>ted as <strong>the</strong> chairperson, tocoord<strong>in</strong>ate population activities at <strong>the</strong> district level. In 1982,<strong>the</strong> President of Sri Lanka appo<strong>in</strong>ted <strong>the</strong> ParliamentaryAdvisory Committee on Population (PACP) to advise <strong>the</strong>government on appropriate policies <strong>in</strong> respect of population<strong>and</strong> family plann<strong>in</strong>g. In 1983, <strong>the</strong> National Coord<strong>in</strong>at<strong>in</strong>gCommittee on Population (NCCP) was established tocoord<strong>in</strong>ate <strong>the</strong> national programme, with <strong>the</strong> M<strong>in</strong>isterof Health serv<strong>in</strong>g as <strong>the</strong> chairperson, <strong>and</strong> <strong>the</strong> Secretary,M<strong>in</strong>istry of Plan Implementation, act<strong>in</strong>g as its secretary.The Population Division functioned as <strong>the</strong> secretariat forboth PACP <strong>and</strong> NCCP.Table1220

In view of <strong>the</strong> fact that an <strong>in</strong>creas<strong>in</strong>g number of coupleswere resort<strong>in</strong>g to sterilization (a cumulative sixteenfold<strong>in</strong>crease from 1979 to 1985), <strong>the</strong> government tookaction to give equal emphasis to non-term<strong>in</strong>al methodsof modern contraception. In March 1985, <strong>the</strong> M<strong>in</strong>istryof Health <strong>in</strong>troduced <strong>the</strong> use of <strong>in</strong>jectable contraceptives<strong>in</strong>to <strong>the</strong> national programme. Subsequently, Norpant wasalso <strong>in</strong>troduced. In addition, a long-act<strong>in</strong>g IUD namely,TCU 380A, was added to <strong>the</strong> programme. Thus manyTable<strong>in</strong>dicators of family plann<strong>in</strong>g <strong>and</strong> reproductive healthfur<strong>the</strong>r improved (Table 2).Maturity phase, 1985-1994Dur<strong>in</strong>g this decade, <strong>the</strong> population programme cont<strong>in</strong>uedto ga<strong>the</strong>r momentum; it was transformed from a phasecharacterized by dem<strong>and</strong>-creation to a supply-oriented one,Table2TableTable3221

where family plann<strong>in</strong>g service delivery became <strong>the</strong> focus ofattention. Thus <strong>in</strong> August 1989, <strong>the</strong> function of populationpolicy formulation <strong>and</strong> implementation was assigned to <strong>the</strong>M<strong>in</strong>istry of Health. As a result, <strong>the</strong> Population Divisionof <strong>the</strong> M<strong>in</strong>istry of Plan Implementation was moved to<strong>the</strong> M<strong>in</strong>istry of Health with <strong>the</strong> same functions <strong>and</strong>responsibilities as previously. With this move, populationpolicy formulation, IEC strategy implementation <strong>and</strong>family plann<strong>in</strong>g service delivery came under <strong>the</strong> purviewof one m<strong>in</strong>istry, namely <strong>the</strong> M<strong>in</strong>istry of Health.Thus <strong>the</strong> M<strong>in</strong>istry of Health took over <strong>the</strong> overallcoord<strong>in</strong>ation <strong>and</strong> management of <strong>the</strong> national populationprogramme. The Population Division, be<strong>in</strong>g placeddirectly under <strong>the</strong> Secretary, M<strong>in</strong>istry of Health, assumedgreater responsibility <strong>in</strong> population policy plann<strong>in</strong>g <strong>and</strong>coord<strong>in</strong>ation of <strong>the</strong> national programme.The responsibility for implement<strong>in</strong>g <strong>the</strong> family plann<strong>in</strong>gservice delivery activities cont<strong>in</strong>ued to be vested <strong>in</strong> <strong>the</strong><strong>Family</strong> Health Bureau. Unmet need for family plann<strong>in</strong>g<strong>in</strong> 1987 was 12 per cent. Thus meet<strong>in</strong>g <strong>the</strong> dem<strong>and</strong> forfamily plann<strong>in</strong>g became a key service delivery issue,which was addressed by improv<strong>in</strong>g field supervision <strong>and</strong>streng<strong>the</strong>n<strong>in</strong>g IEC activities.In 1991, for <strong>the</strong> first time <strong>the</strong> government set a target ofachiev<strong>in</strong>g replacement-level fertility by <strong>the</strong> year 2000 <strong>in</strong>its policy statement on population, which was approvedTableby <strong>the</strong> National Health <strong>Council</strong> chaired by <strong>the</strong> PrimeM<strong>in</strong>ister. Fur<strong>the</strong>r, <strong>the</strong> government streng<strong>the</strong>ned itscentral policy plann<strong>in</strong>g, monitor<strong>in</strong>g <strong>and</strong> implementationagencies, namely <strong>the</strong> National Coord<strong>in</strong>at<strong>in</strong>g <strong>Council</strong> onPopulation, chaired by <strong>the</strong> Secretary, M<strong>in</strong>istry of Health;<strong>the</strong> Population Division; <strong>and</strong> <strong>the</strong> <strong>Family</strong> Health Bureau.Thus by 1993, family plann<strong>in</strong>g <strong>and</strong> reproductive <strong>in</strong>dicatorsshowed fur<strong>the</strong>r improvement (Table 3).The Post-<strong>International</strong> Conference onPopulation <strong>and</strong> Development phaseIn 1994, Sri Lanka along with 179 o<strong>the</strong>r countries, wasa signatory to <strong>the</strong> adoption of <strong>the</strong> Programme of Actionon Population <strong>and</strong> Development at ICPD held <strong>in</strong> Cairo.It was considered one of <strong>the</strong> most significant globalconferences held <strong>in</strong> <strong>the</strong> twenty-first century. The adoptionof <strong>the</strong> broad-based concept of reproductive health atICPD by <strong>the</strong> <strong>in</strong>ternational community was a l<strong>and</strong>markachievement.Sri Lanka adopted a number of <strong>in</strong>itiatives respond<strong>in</strong>g to<strong>the</strong> ICPD Programme of Action. An important <strong>in</strong>itiativewas <strong>the</strong> formulation of <strong>the</strong> Population <strong>and</strong> ReproductiveHealth Policy <strong>in</strong> 1998 <strong>and</strong> <strong>the</strong> subsequent developmentof <strong>the</strong> Action Plan based on that Policy. In addition, <strong>the</strong>Advocacy Strategy was also developed for <strong>the</strong> promotionof population <strong>and</strong> reproductive health activities. ThePopulation Division of <strong>the</strong> M<strong>in</strong>istry of Health playedTable4222

a key role <strong>in</strong> <strong>the</strong> development of <strong>the</strong>se three policydocuments. O<strong>the</strong>r <strong>in</strong>itiatives were <strong>the</strong> paradigm shift froma focus on family plann<strong>in</strong>g to a broader holistic approachto reproductive health <strong>and</strong> <strong>the</strong> <strong>in</strong>clusion of o<strong>the</strong>r agencies,such as <strong>the</strong> National Cancer Control Programme <strong>and</strong><strong>the</strong> STD/AIDS Control Programme, <strong>in</strong>to <strong>the</strong> nationalpopulation <strong>and</strong> reproductive health programme.The structure of <strong>the</strong> national population <strong>and</strong> reproductivehealth programme took <strong>the</strong> shape of a pyramid. At <strong>the</strong> apexwas <strong>the</strong> national policy on population <strong>and</strong> reproductivehealth. At <strong>the</strong> next level was <strong>the</strong> advocacy programmeaimed at parliamentarians, women’s groups <strong>and</strong> mediapersonnel. At <strong>the</strong> next level were <strong>the</strong> IEC activitiesimplemented by relevant government agencies <strong>and</strong> NGOs<strong>and</strong> <strong>the</strong> reproductive health programme for school childrenimplemented by <strong>the</strong> M<strong>in</strong>istry of Education. What followednext at <strong>the</strong> base was <strong>the</strong> largest programme, namely <strong>the</strong>reproductive health <strong>and</strong> family plann<strong>in</strong>g services.The maternal <strong>and</strong> child health <strong>and</strong> family plann<strong>in</strong>g serviceswere broad based <strong>in</strong> order to <strong>in</strong>clude o<strong>the</strong>r elements ofreproductive health through a network of already exist<strong>in</strong>gprimary health-care facilities. A life cycle approach towomen’s reproductive health was adopted. Diagnosis <strong>and</strong>treatment for sexually transmitted diseases (STDs) amongpregnant women was <strong>in</strong>tegrated with <strong>the</strong> maternal <strong>and</strong>child health <strong>and</strong> family plann<strong>in</strong>g services.In 1996, <strong>the</strong> <strong>Family</strong> Health Bureau established WellWomen’s Cl<strong>in</strong>ics <strong>in</strong> subdivisional health areas for <strong>the</strong>screen<strong>in</strong>g of breast <strong>and</strong> cervical cancer <strong>and</strong> detection ofhypertension <strong>and</strong> diabetes among women over 35 yearsof age. There was a renewed commitment to reproductivehealth <strong>in</strong>formation, counsell<strong>in</strong>g <strong>and</strong> health-care servicesfor adolescents with <strong>the</strong> development of a health policyfor adolescents. In 2008, <strong>the</strong> <strong>Family</strong> Health Bureauformulated <strong>the</strong> National Maternal <strong>and</strong> Child HealthPolicy, provid<strong>in</strong>g strategic directions to meet some of <strong>the</strong>important challenges <strong>in</strong> <strong>the</strong> national reproductive health(RH) programme. The government also took action tofur<strong>the</strong>r streng<strong>the</strong>n <strong>the</strong> National STD/AIDS <strong>and</strong> CancerControl programmes. These <strong>in</strong>itiatives have resulted <strong>in</strong> an<strong>in</strong>crease <strong>in</strong> screen<strong>in</strong>g, diagnosis <strong>and</strong> treatment. As a result,Sri Lanka has rema<strong>in</strong>ed a low prevalence country withregard to HIV/AIDS despite <strong>the</strong> relatively large numberof cases be<strong>in</strong>g reported <strong>in</strong> neighbour<strong>in</strong>g South India.The <strong>in</strong>cidence of breast <strong>and</strong> cervical cancers has <strong>in</strong> recentyears <strong>in</strong>creased due to better screen<strong>in</strong>g through <strong>the</strong> WellWomen’s Cl<strong>in</strong>ics.The <strong>Family</strong> Health Bureau functions <strong>in</strong> close collaborationwith <strong>the</strong> National Cancer Control Programme <strong>and</strong> <strong>the</strong>National STD/AIDS Control Programme. The <strong>Family</strong>Health Bureau undertakes <strong>in</strong>-service tra<strong>in</strong><strong>in</strong>g of healthpersonnel <strong>in</strong> RH; offers technical assistance <strong>in</strong> programmemanagement <strong>and</strong> service delivery; conducts relevantresearch to streng<strong>the</strong>n service delivery; <strong>and</strong> monitors <strong>and</strong>evaluates <strong>the</strong> service delivery programme. The Bureau isalso responsible for <strong>the</strong> procurement <strong>and</strong> distribution ofcontraceptives, equipment <strong>and</strong> o<strong>the</strong>r supplies needed for<strong>the</strong> RH programme.In <strong>the</strong> delivery of RH services, <strong>the</strong> Bureau cont<strong>in</strong>ues toutilize <strong>the</strong> well-developed health <strong>in</strong>frastructure consist<strong>in</strong>gof a network of medical <strong>in</strong>stitutions <strong>and</strong> health units.The Health Units are responsible for preventive <strong>and</strong>promotional aspects of health, <strong>in</strong>clud<strong>in</strong>g domiciliary RHservices. There are more than 300 Health Unit areas withpopulations rang<strong>in</strong>g from 40,000 to 60,000. The HealthUnit areas are managed by Medical Officers of Healthalso referred to as Divisional Directors of Health Services(DDHS). Each DDHS is supported by a team of publichealth personnel compris<strong>in</strong>g one or two Public HealthNurs<strong>in</strong>g Sisters, four to six Public Health Inspectors,one or two Supervis<strong>in</strong>g Public Health Midwives <strong>and</strong> 20-25 Public Health Midwives (PHM). Each health unit issubdivided <strong>in</strong>to PHM areas, which constitute <strong>the</strong> smalles<strong>the</strong>alth area.The Public Health Midwife who is <strong>in</strong>stitutionally tra<strong>in</strong>edis<strong>the</strong> “front l<strong>in</strong>e” health worker provid<strong>in</strong>g <strong>the</strong> communitywith domiciliary RH services. Each PHM has a welldef<strong>in</strong>edarea consist<strong>in</strong>g of a population rang<strong>in</strong>g from2,000 to 4,000 people. Through systematic home visits,PHMs provide pregnant mo<strong>the</strong>rs, <strong>in</strong>fants <strong>and</strong> pre-schoolchildren with care. They also furnish family plann<strong>in</strong>g (FP)services, <strong>in</strong>clud<strong>in</strong>g counsell<strong>in</strong>g <strong>and</strong> <strong>the</strong> distribution ofcontraceptive pills <strong>and</strong> condoms to couples of reproductiveage. In addition, <strong>the</strong>y provide necessary education <strong>and</strong>advice to adolescents on reproductive health when needed<strong>and</strong> educate women on <strong>the</strong> importance of screen<strong>in</strong>g forreproductive organ malignancies, <strong>and</strong> motivate <strong>the</strong>m toattend Well Women’s Cl<strong>in</strong>ics for necessary screen<strong>in</strong>g.PHMs also assist rout<strong>in</strong>ely at <strong>the</strong> area MCH/FP cl<strong>in</strong>ics,which are conducted every two weeks, <strong>the</strong>reby l<strong>in</strong>k<strong>in</strong>g<strong>the</strong> community with <strong>the</strong> <strong>in</strong>stitutional health-care system.Their duties also <strong>in</strong>clude record-keep<strong>in</strong>g, which enables<strong>the</strong>m to plan <strong>and</strong> monitor rout<strong>in</strong>e activities.Despite a slight <strong>in</strong>crease <strong>in</strong> <strong>the</strong> country’s total fertilityrate recently, unmet need for contraception has decl<strong>in</strong>edfrom 12.3 per cent <strong>in</strong> 1987 to 7.3 per cent <strong>in</strong> 2006/07.The fertility rate for women aged 15-19 years has fur<strong>the</strong>rdecl<strong>in</strong>ed from 38 per 1,000 <strong>in</strong> <strong>the</strong> period 1982-1987 to28 <strong>in</strong> 2003-2006. Infant <strong>and</strong> maternal mortality rateshave cont<strong>in</strong>ued to decl<strong>in</strong>e. Although <strong>the</strong> contraceptiveprevalence rate has rema<strong>in</strong>ed about 70 per cent dur<strong>in</strong>g<strong>the</strong> period 2000-2006/07, <strong>the</strong> prevalence of moderntemporary methods has <strong>in</strong>creased from 26.4 to 36.0 percent dur<strong>in</strong>g this period (Table 4).223

Thus an objective assessment of <strong>the</strong> performance ofpopulation <strong>and</strong> reproductive <strong>in</strong>dicators <strong>in</strong> <strong>the</strong> post-ICPDperiod shows an impressive record. The population growthrate has cont<strong>in</strong>ued to decl<strong>in</strong>e from 1.5 per cent dur<strong>in</strong>g <strong>the</strong>early 1990s to 1.0 per cent <strong>in</strong> 2009. The prevalence ofunderweight children under 5 years of age has droppedfrom 37.7 per cent <strong>in</strong> 1993 to 21.6 per cent <strong>in</strong> 2006/07.The <strong>in</strong>fant mortality rate has decl<strong>in</strong>ed from 16.9 per 1,000live births <strong>in</strong> 1994 to 8.5 <strong>in</strong> 2007 . The maternal mortalityratio has cont<strong>in</strong>ued to decl<strong>in</strong>e from 20 per 100,000 livebirths <strong>in</strong> 1994 to 14.2 <strong>in</strong> 2006. The coverage of antenatalcare has <strong>in</strong>creased from 90 per cent <strong>in</strong> 1993 to 99 per cent<strong>in</strong> 2007. Females have lower mortality rates at all ages.The adolescent fertility rate has decl<strong>in</strong>ed from 35 per1,000 population <strong>in</strong> 1993 to 28 per 1,000 <strong>in</strong> 2007. Thecontraceptive prevalence of modern methods has <strong>in</strong>creasedfrom 42.1 per cent <strong>in</strong> 1993 to 52.8 per cent <strong>in</strong> 2007. Theunmet need for contraception has cont<strong>in</strong>ued to decl<strong>in</strong>efrom 10.8 to 7.3 per cent dur<strong>in</strong>g <strong>the</strong> same period.Future challengesThe major challenge that confronts Sri Lanka is to improve<strong>the</strong> quality of <strong>the</strong> family plann<strong>in</strong>g <strong>and</strong> reproductive healthprogramme. In order to achieve this, <strong>the</strong> follow<strong>in</strong>g strategiesare required.Identify vulnerable groups <strong>in</strong> geographic pockets forfocused attention <strong>in</strong> reproductive health activities.Give priority to <strong>the</strong> improvement of logistic management<strong>and</strong> commodity security of contraceptives <strong>and</strong> drugs<strong>and</strong> <strong>the</strong> availability of equipment.Reduce septic abortions, which account for about 12per cent of maternal deaths.Provide <strong>in</strong>formation <strong>and</strong> education on <strong>the</strong> need foradequate nutrition dur<strong>in</strong>g pregnancy <strong>and</strong> lactation <strong>and</strong><strong>the</strong> importance of birth spac<strong>in</strong>g.Develop age-appropriate behaviour changecommunication approaches to <strong>in</strong>fluence <strong>the</strong> behaviourpatterns of adolescents.Promote equal participation of men <strong>and</strong> women <strong>in</strong>parent<strong>in</strong>g <strong>and</strong> family care.Streng<strong>the</strong>n <strong>the</strong> adm<strong>in</strong>istration of justice <strong>and</strong> effectivelaw enforcement for progress on gender equality <strong>and</strong>zero tolerance for violence aga<strong>in</strong>st women <strong>in</strong> <strong>the</strong> family<strong>and</strong> <strong>the</strong> community.Streng<strong>the</strong>n <strong>the</strong> database used for population <strong>and</strong>reproductive health plann<strong>in</strong>g at national <strong>and</strong> subnationallevels by improv<strong>in</strong>g <strong>the</strong> quality of data <strong>and</strong> <strong>the</strong>ir timelyreport<strong>in</strong>g.Advocate <strong>the</strong> importance of <strong>in</strong>formed choice <strong>in</strong> <strong>the</strong> useof family plann<strong>in</strong>g services.Advocate, through government agencies <strong>and</strong> women’sorganizations, higher representation of women <strong>in</strong>governance <strong>and</strong> decision-mak<strong>in</strong>g positions.Undertake research to ascerta<strong>in</strong> <strong>the</strong> causes of <strong>the</strong>widen<strong>in</strong>g gap between male <strong>and</strong> female life expectancyat birth.Incorporate population <strong>and</strong> development concerns <strong>in</strong>tonational development plann<strong>in</strong>g with a focus on povertyalleviation.ReferencesAbeykoon, A.T.P.L. (2009). “ICPD 15 years on: SriLanka’s participation, policy <strong>and</strong> programme<strong>in</strong>itiatives”, In: <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Association of SriLanka <strong>and</strong> Bradman Weerakoon, eds., ICPD – “15Years On” Sri Lanka: A Review of Progress by 12 SriLankan Scholars <strong>and</strong> Practioners, Colombo.__________ (1996). Population Programme <strong>in</strong> Sri Lanka:The Environment, Strategies, Structure, ManagerialProcesses <strong>and</strong> Strategic Issues for <strong>the</strong> Future, PopulationDivision, M<strong>in</strong>istry of Health <strong>and</strong> Social Services,Colombo.Department of Census <strong>and</strong> Statistics (2009). Sri LankaDemographic <strong>and</strong> Health Survey, 2006-07, M<strong>in</strong>istry ofHealthcare <strong>and</strong> Nutrition, Colombo.__________ (2002). Sri Lanka Demographic <strong>and</strong> HealthSurvey 2000, M<strong>in</strong>istry of Health, Nutrition <strong>and</strong>Welfare, Colombo.__________ (1993). Sri Lanka Demographic <strong>and</strong> HealthSurvey 1993, M<strong>in</strong>istry of Health, Nutrition <strong>and</strong>Welfare, Colombo.__________ (1988). Sri Lanka Demographic <strong>and</strong> HealthSurvey 1987, M<strong>in</strong>istry of Plan Implementation,Colombo.__________ (1983). Sri Lanka Contraceptive PrevalenceSurvey 1982, Colombo.Department of National <strong>Plann<strong>in</strong>g</strong> (1962). The Short-Term Implementation Programme, Colombo.M<strong>in</strong>istry of <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> Employment (1971). The FiveYear Plan 1972-1976, Colombo.National <strong>Plann<strong>in</strong>g</strong> <strong>Council</strong> (1959). The Ten Year Plan,<strong>Plann<strong>in</strong>g</strong> Secretariat, Colombo.Population Division (2005). Population Statistics of SriLanka, M<strong>in</strong>istry Healthcare <strong>and</strong> Nutrition, Colombo.224

IndonesiaIndonesiaThe Status of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> ReproductiveHealth <strong>in</strong> Indonesia: A Story of Success <strong>and</strong> FragmentationAdrian C. Hayes** Adjunct Professor, Australia Demographic <strong>and</strong> Social Research Institute, The Australian National University225

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FigureAims of <strong>the</strong> reportIndonesia has a mature national family plann<strong>in</strong>g programmewith many successes to its credit. Now that it has realizedmany of <strong>the</strong> objectives it set out to achieve, however, manycommentators believe it lacks a central motivat<strong>in</strong>g vision<strong>and</strong> has lost its sense of direction. The aims of this report areto provide a succ<strong>in</strong>ct review of <strong>the</strong> overall status of familyplann<strong>in</strong>g (FP) <strong>and</strong> related reproductive health programmes<strong>in</strong> Indonesia today; identify key issues <strong>and</strong> obstacles whichmay be limit<strong>in</strong>g universal access to quality FP services; <strong>and</strong>make recommendations (where appropriate) regard<strong>in</strong>ghow <strong>the</strong> provision of services <strong>and</strong> practice of FP can beimproved by “reposition<strong>in</strong>g”, “revitaliz<strong>in</strong>g” or o<strong>the</strong>rwiseadjust<strong>in</strong>g <strong>the</strong> national FP programme.Past achievements <strong>in</strong> familyplann<strong>in</strong>g <strong>and</strong> reproductivehealthPresident Suharto <strong>in</strong>troduced <strong>the</strong> national family plann<strong>in</strong>gprogramme <strong>in</strong> 1968 <strong>and</strong> established <strong>the</strong> National <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Programme – well known around <strong>the</strong> world byits Indonesian acronym, BKKBN – <strong>in</strong> 1970. BKKBNwas charged with develop<strong>in</strong>g a national FP programme<strong>and</strong> manag<strong>in</strong>g foreign aid provided for this purpose. Theprogramme was a great success <strong>and</strong> fertility levels droppeddramatically (see Figure 1). Accord<strong>in</strong>g to <strong>the</strong> latest UnitedNations estimates, <strong>the</strong> total fertility rate (TFR) decl<strong>in</strong>edfrom 5.6 live births per woman <strong>in</strong> <strong>the</strong> period 1965-1970to 3.4 <strong>in</strong> <strong>the</strong> period 1985-1990 (United Nations, 2009).President Suharto was presented with <strong>the</strong> United NationsPopulation Award <strong>in</strong> 1989 <strong>in</strong> recognition of this success.The Indonesian FP programme was “widely recognized asone of <strong>the</strong> most successful <strong>in</strong> <strong>the</strong> world” (Piet, 2003: 83).The latest United Nations estimate for TFR (2005-2010)<strong>in</strong> Indonesia is 2.2 (see also Hartanto <strong>and</strong> Hull, 2009).If <strong>the</strong> current status of FP is to be assessed accurately,it is important to underst<strong>and</strong> <strong>the</strong> factors underly<strong>in</strong>g <strong>the</strong>country’s early success. Those work<strong>in</strong>g <strong>in</strong> <strong>the</strong> FP programmecommitted to solv<strong>in</strong>g <strong>the</strong> country’s “population problem”often spoke (<strong>and</strong> wrote) at <strong>the</strong> time as if success derivedexclusively from “programme effort”. It is true that <strong>the</strong>programme enjoyed <strong>in</strong>spired leadership dur<strong>in</strong>g most of itsfirst quarter century <strong>and</strong> that BKKBN was able to recruitmany of <strong>the</strong> best new entrants <strong>in</strong>to <strong>the</strong> civil service toproduce an impressive <strong>and</strong> effective “can-do” organization(Hull, 2007). On top of <strong>the</strong>se factors <strong>the</strong> programme had<strong>the</strong> strong <strong>and</strong> enthusiastic support of President Suharto,which guaranteed generous resources (<strong>in</strong>clud<strong>in</strong>g foreignassistance) <strong>and</strong> political leverage.However, <strong>the</strong>re were o<strong>the</strong>r important non-programmefactors at work too. Suharto’s authoritarian New Ordergovernment established a highly centralized state apparatuswhich reached down <strong>in</strong>to villages <strong>and</strong> tolerated no organizedopposition; had this broader political-adm<strong>in</strong>istrative systemnot been <strong>in</strong> place it is difficult to believe that BKKBNcould have exp<strong>and</strong>ed <strong>and</strong> coord<strong>in</strong>ated <strong>the</strong> FP programmeso effectively (Hull <strong>and</strong> Hull, 1997). 2 The New Ordergovernment ma<strong>in</strong>ta<strong>in</strong>ed political stability <strong>and</strong> impressiveFigure1Total fertility rate, Indonesia, 1950-2010654TFR32101950-55 1960-65 1970-75 1980-85 1990-95 2000-05Source: United Nations (2009).227

Figureeconomic growth dur<strong>in</strong>g most of <strong>the</strong> period 1970-1995,<strong>and</strong> <strong>the</strong>se factors too contributed to many people want<strong>in</strong>gsmaller families. The dramatic decl<strong>in</strong>e <strong>in</strong> fertility was <strong>in</strong>fact due to a comb<strong>in</strong>ation of many factors, although no onedenies that <strong>the</strong> programme contributed significantly to <strong>the</strong>tim<strong>in</strong>g <strong>and</strong> quick pace of <strong>the</strong> fertility decl<strong>in</strong>e <strong>and</strong> that <strong>the</strong>rapid expansion <strong>in</strong> FP services led to improved health <strong>and</strong>well-be<strong>in</strong>g for millions of Indonesians. It is important toacknowledge <strong>the</strong> role of non-programme factors <strong>in</strong> <strong>the</strong>early success of <strong>the</strong> programme because when we exam<strong>in</strong>e<strong>the</strong> change <strong>in</strong> status of <strong>the</strong> FP programme <strong>in</strong> Indonesiatoday we f<strong>in</strong>d it is has a lot to do with changes <strong>in</strong> nonprogrammecontextual factors.By <strong>the</strong> early 1990s <strong>the</strong> FP programme was at its zenith.The Indonesian Demographic <strong>and</strong> Health Survey (DHS)cover<strong>in</strong>g that period showed that <strong>the</strong> contraceptiveprevalence rate (CPR) for currently married women aged15-49 had reached 50 per cent. 3 (There were no nationalsurveys to measure CPR <strong>in</strong> <strong>the</strong> 1960s but it is estimatedthat <strong>the</strong> rate was significantly below 10 per cent <strong>in</strong> 1970.)However, by <strong>the</strong> end of <strong>the</strong> decade it was obvious to manyobservers that <strong>the</strong> programme was beg<strong>in</strong>n<strong>in</strong>g to lose steam.The apparent “plateau<strong>in</strong>g” of CPR at about 60 per centwas often taken as a clear signal of this (see Figure 2). Thesteady <strong>in</strong>crease <strong>in</strong> CPR for modern methods dur<strong>in</strong>g <strong>the</strong>1990s occurred at a slower pace at <strong>the</strong> end of <strong>the</strong> decadethan at <strong>the</strong> beg<strong>in</strong>n<strong>in</strong>g; dur<strong>in</strong>g <strong>the</strong> most recent period2002-2007, it was <strong>in</strong>creas<strong>in</strong>g at an average of only one fifthof one percentage po<strong>in</strong>t per year (see Table 1). In fact <strong>the</strong>challenges fac<strong>in</strong>g <strong>the</strong> FP programme s<strong>in</strong>ce <strong>the</strong> mid-1990swere much more complex than any s<strong>in</strong>gle <strong>in</strong>dicator couldsuggest, as we discuss <strong>in</strong> <strong>the</strong> follow<strong>in</strong>g two sections.FigureCurrent issues <strong>in</strong> <strong>the</strong> nationalprogrammeA long litany of unresolved issues <strong>and</strong> challenges face<strong>the</strong> Indonesian FP plann<strong>in</strong>g programme today. Forconvenience we discuss <strong>the</strong>m under four major head<strong>in</strong>gs:chang<strong>in</strong>g demographics, political decentralization, <strong>the</strong>chang<strong>in</strong>g <strong>in</strong>ternational agenda <strong>and</strong> <strong>the</strong> grow<strong>in</strong>g dem<strong>and</strong>for “good governance” (see Figure 3).Chang<strong>in</strong>g demographicsAs a country goes through its demographic transition <strong>the</strong>demographic profile of its population changes. This <strong>in</strong> turnresults <strong>in</strong> changes <strong>in</strong> <strong>the</strong> dem<strong>and</strong> for FP <strong>and</strong> RH services,<strong>and</strong> successful programmes need to be responsive to this.Dem<strong>and</strong> for servicesWe have already noted <strong>the</strong> apparent recent plateau<strong>in</strong>gof CPR. This does not pose a major problem for futurepopulation growth s<strong>in</strong>ce <strong>the</strong> balance of evidence suggestsTFR is already quite close to <strong>the</strong> replacement level offertility. A more urgent concern is that such plateau<strong>in</strong>garound 60 per cent is associated with cont<strong>in</strong>u<strong>in</strong>g unmetneed. Unmet need for FP is def<strong>in</strong>ed by DHS as “<strong>the</strong>percentage of currently married women who ei<strong>the</strong>r do notwant any more children or who want to wait before <strong>the</strong>irnext birth, but who are not us<strong>in</strong>g any method of familyplann<strong>in</strong>g” (BPS <strong>and</strong> ORC Macro, 2003: 85). 4Unmet need for FP (expressed as a percentage of currentlymarried women 15-49 years of age) cont<strong>in</strong>ued to decl<strong>in</strong>edur<strong>in</strong>g <strong>the</strong> 1990s even as total dem<strong>and</strong> cont<strong>in</strong>ued to rise,2Contraceptive prevalence rate, Indonesia, 1987-20077060504030201001986 1989 1992 1995 1998 2001 2004 2007all methods modern methods Poly. (all methods)Source: Indonesian Demographic <strong>and</strong> Health Surveys.228

Figurebut rema<strong>in</strong>ed about 9 per cent dur<strong>in</strong>g <strong>the</strong> period 1997-2007 (see Table 2). In absolute terms <strong>the</strong> number ofcurrently married women 15-49 years of age with unmetneed cont<strong>in</strong>ued to <strong>in</strong>crease. In short, <strong>the</strong> plateau<strong>in</strong>g ofCPR around 60 per cent was not consistent with <strong>the</strong>government’s stated policy objective of ensur<strong>in</strong>g that FPservices would be available to all married couples whoneeded <strong>the</strong>m. 5Method choiceEven if changes <strong>in</strong> CPR are currently slow this does notmean that FP is static. There are strik<strong>in</strong>g trends <strong>in</strong> methodmix, especially <strong>in</strong>creas<strong>in</strong>g reliance on <strong>in</strong>jectables <strong>and</strong> a shiftaway from IUDs (see Table 3). By 2007, 45.0 per cent of allcurrently married women were us<strong>in</strong>g short-term hormonalmethods, or more than two thirds of those practis<strong>in</strong>g FP.Sterilization meanwhile rema<strong>in</strong>ed below 5 per cent.These trends <strong>in</strong> method mix warrant attention. Although<strong>the</strong> medical evidence overwhelm<strong>in</strong>gly suggests that lowdosemodern hormonal methods pose no serious healthrisk (except for those with contra<strong>in</strong>dications), some healthpractitioners still caution whe<strong>the</strong>r it is wise for a womanto take hormones for decades, especially when o<strong>the</strong>r nonhormonallong-term methods are available. 6 Second, someFP programme experts (e.g., Ross, 2003) argue that itmay be additionally difficult to reach <strong>the</strong> high levels ofCPR needed to atta<strong>in</strong> long-term population stabilizationif a programme relies heavily on short-term “resupplymethods” because of <strong>the</strong> “churn<strong>in</strong>g effect” among <strong>the</strong>programme’s clients. A programme that depends heavilyon short-term methods requir<strong>in</strong>g constant resupply isespecially vulnerable to disruption dur<strong>in</strong>g turbulent times(e.g., dur<strong>in</strong>g a transition to decentralization). A programmewith more clients on long-term methods can focus moreattention on reach<strong>in</strong>g those couples who still have unmetneed.Adolescents <strong>and</strong> <strong>the</strong> unmarriedO<strong>the</strong>r significant trends <strong>the</strong> FP programme must respondto concern about chang<strong>in</strong>g patterns <strong>in</strong> family formation. At<strong>the</strong> time of <strong>the</strong> 2000 population census almost one thirdof all women aged 15-49 (32.9% of that age group, or 18.5million women) were not currently married. Table 4 shows<strong>the</strong> sharp rise <strong>in</strong> <strong>the</strong> percentage never married for females<strong>in</strong> age groups under age 30. For both sexes, 92 per cent ofall young people aged 15-19 were s<strong>in</strong>gle <strong>in</strong> 2000; <strong>the</strong> figurewas 58 per cent for those aged 20-24. Most (84%) youngpeople aged 10-24 have never been married.Accord<strong>in</strong>g to <strong>the</strong> 2002/03 DHS, among women currently25-29 years old <strong>the</strong> median age at first marriage was 20.2years, compared with 17.9 years reported by womencurrently 45-49. Among women currently aged 20-24,only 4 of 10 were married by age 20, while for thosecurrently aged 45-49, 7 of 10 were married by age 20.Urban women marry later than rural women, <strong>and</strong> thosewith more education marry later than those with less. Themedian age at first marriage among women currently aged25-29 who have some education above <strong>the</strong> secondary levelis 23.9 years.The long <strong>in</strong>terval common nowadays between puberty<strong>and</strong> marriage represents an <strong>in</strong>tensely challeng<strong>in</strong>g period<strong>in</strong> <strong>the</strong> development of a young person’s life, <strong>and</strong> <strong>the</strong> wayshe or he deals with that period helps to determ<strong>in</strong>e her orhis future life chances <strong>and</strong> adult personality. Young peopleneed <strong>in</strong>formation <strong>and</strong> o<strong>the</strong>r services to help <strong>the</strong>m navigatethis stretch of <strong>the</strong>ir life, <strong>and</strong> most importantly <strong>the</strong>y need<strong>in</strong>formation <strong>and</strong> services to help protect <strong>the</strong>ir reproductivehealth. The chang<strong>in</strong>g demographics of Indonesia as itcompletes its demographic transition are plac<strong>in</strong>g grow<strong>in</strong>gFigure3Challenges fac<strong>in</strong>g Indonesia’s FP programChang<strong>in</strong>gDemographicsChang<strong>in</strong>g<strong>International</strong>AgendaFP/RHPolicymakersDecentralizationGoodGovernanceSource: Indonesian Demographic <strong>and</strong> Health Surveys.229

TableTable1TableTable2For spac<strong>in</strong>gFor limit<strong>in</strong>gTotal25.437.963.328.138.366.330.037.467.430.037.467.429.541.170.6Percentage of dem<strong>and</strong> satisfied 79.9 84.0 876.4 87.6 87.2Source: Indonesian Demographic <strong>and</strong> Health Surveys.pressure on FP programme managers to provide additionalservices for <strong>the</strong> grow<strong>in</strong>g proportion of <strong>the</strong> population thatis currently unmarried. However, an FP programme thatcont<strong>in</strong>ues to restrict itself to provid<strong>in</strong>g services almostexclusively to married couples will necessarily miss a vital,<strong>and</strong> <strong>in</strong>creas<strong>in</strong>gly large, part of <strong>the</strong> action.Sources of supplyAno<strong>the</strong>r major trend is that FP clients have been shift<strong>in</strong>gto <strong>the</strong> private sector at a rapid rate <strong>in</strong> recent years (seeTable 5). The 2007 DHS reported that 69.1 per cent ofclients were us<strong>in</strong>g a “private medical” source of supply, afigure that rose to more than 75.0 per cent when “o<strong>the</strong>rprivate” sources were <strong>in</strong>cluded. Government-provided“public” sources account for only 22.2 per cent of <strong>the</strong> total.The trend towards <strong>the</strong> private sector was, if anyth<strong>in</strong>g,accelerated by <strong>the</strong> 1997/98 <strong>Asia</strong>n f<strong>in</strong>ancial crisis (Strausset al., 2004). The precise details are complicated because<strong>the</strong> public-private dist<strong>in</strong>ction is not clear-cut, with manyprivate practitioners also work<strong>in</strong>g <strong>in</strong> <strong>the</strong> public sector,<strong>and</strong> because what gets listed under each category head<strong>in</strong>gof “source” <strong>in</strong> <strong>the</strong> DHS has changed over <strong>the</strong> years (e.g.,posy<strong>and</strong>u was listed as a “Government source” <strong>in</strong> 1991, as“O<strong>the</strong>r private” <strong>in</strong> 1994 <strong>and</strong> 1997, <strong>and</strong> as “O<strong>the</strong>r source”<strong>in</strong> 2002/03: see Table 5). None<strong>the</strong>less, <strong>the</strong> overall trend<strong>in</strong> privatization is clear <strong>and</strong> corroborated by o<strong>the</strong>r datasources, such as <strong>the</strong> annual National Socio-EconomicSurvey <strong>and</strong> <strong>the</strong> Indonesia <strong>Family</strong> Life Survey.This trend <strong>in</strong> privatization is broadly consistent with <strong>the</strong>government’s objectives; <strong>the</strong> policy of KB M<strong>and</strong>iri (“selfreliantfamily plann<strong>in</strong>g”) was first <strong>in</strong>troduced <strong>in</strong> 1989.Policymakers still need to question some of <strong>the</strong> nuancesof this trend, however. One obvious question is whe<strong>the</strong>r,as <strong>the</strong> programme becomes <strong>in</strong>creas<strong>in</strong>gly privatized, thiswould lead to a rise <strong>in</strong> clients’ out-of-pocket costs so as tocause many among <strong>the</strong> poor to lose access to services. O<strong>the</strong>rquestions are whe<strong>the</strong>r <strong>the</strong> private sector is adequatelyregulated to guarantee a satisfactory m<strong>in</strong>imum st<strong>and</strong>ardof services, <strong>and</strong> whe<strong>the</strong>r adequate systems of redress are<strong>in</strong> place when needed. There are also questions regard<strong>in</strong>gwhe<strong>the</strong>r providers <strong>in</strong> <strong>the</strong> private sector are equipped <strong>and</strong>motivated to provide clients with an adequate choice ofmethods, or whe<strong>the</strong>r <strong>the</strong> method mix to some extent may230

TableTable3Source: BPS (Central Bureau of Statistics) (1992). ‘Population of Indonesia: Result of 1990 Population Census’, Jakarta: BPSTableTable4TableTable5231

eflect a provider bias (e.g., <strong>the</strong> heavy reliance on <strong>in</strong>jectablesprovided by private midwives).F<strong>in</strong>ally, <strong>the</strong>re are sensitive questions about just how selfreliant<strong>the</strong> private sector really is, <strong>and</strong> how much it relies on<strong>in</strong>direct or hidden government subsidies, for example <strong>the</strong>well-known “leakage” of subsidized FP commodities from<strong>the</strong> public sector <strong>in</strong>to <strong>the</strong> private sector, <strong>and</strong> <strong>the</strong> fact thatprivate providers still get tra<strong>in</strong>ed (<strong>and</strong> retra<strong>in</strong>ed) at publicexpense <strong>and</strong> often use publicly provided facilities <strong>and</strong>equipment (Lubis, 2003: 46-48). Most of <strong>the</strong>se “exchanges”across <strong>the</strong> public-private divide may be legitimate butsome can be shown to underm<strong>in</strong>e <strong>the</strong> government’s statedcommitment to privatization.Regional <strong>and</strong> socio-economicdifferencesAno<strong>the</strong>r area of concern for programme managers is thatconsiderable regional differences <strong>in</strong> <strong>the</strong> practice of FPstill exist <strong>in</strong> Indonesia (see Table 6). In some prov<strong>in</strong>cesCPR for modern methods is higher than 60 per cent( Jambi, 62.5%; South Sumatra, 62.6%; Bengkulu, 70.4%;Lampung, 66.0%; Bangka-Belitung, 64.7%; West Java,60.3%; Central Java, 60.0%; East Java, 62.3%; Bali, 65.4%;West Kamilantan, 61.2%; Central Kalimantan, 65.2%;South Kalimantan, 63.2%; <strong>and</strong> North Sulawesi, 66.7%);o<strong>the</strong>rs are under 45 per cent (notably North Sumatra,42.6%; East Nusa Tenggara, 30.1%; South Sulawesi,42.9%; Sou<strong>the</strong>ast Sulawesi, 44.4%; West Sulawesi, 44.5%;Maluku, 29.4%; Papua, 24.5%; <strong>and</strong> West Papua, 39.6%).It is important to focus on unmet dem<strong>and</strong> <strong>in</strong> <strong>the</strong> last eightprov<strong>in</strong>ces if universal access to FP services is to be achievedby 2015.The 2002/03 DHS also <strong>in</strong>cluded a household wealth<strong>in</strong>dex. 7 While CPR for modern methods for all currentlymarried women aged 15-49 was found to be 56.7 per cent,it was only 43.4 per cent for extremely poor women (lowestqu<strong>in</strong>tile) <strong>and</strong> 53.2 per cent for those moderately poor(second lowest decile) (Schoemaker, 2004: 8). Schoemakershowed that this is predom<strong>in</strong>antly not because <strong>the</strong> poorhave more unmet need but because <strong>the</strong>y want morechildren than <strong>the</strong> non-poor. Schoemaker’s analysis alsohighlights questions that programme managers need toaddress about <strong>the</strong> target<strong>in</strong>g of subsidized FP services <strong>and</strong>supplies: even among <strong>the</strong> extremely poor, more womenrely on <strong>the</strong> private sector than <strong>the</strong> public sector for sourceof supply, while among <strong>the</strong> non-poor just over 25 per centuse <strong>the</strong> public sector (Schoemaker, 2004: 17). The DHSwealth <strong>in</strong>dex cannot be taken as a def<strong>in</strong>itive def<strong>in</strong>ition ofpoverty, but Schoemaker’s analysis is consistent with thatof o<strong>the</strong>rs, such as Ross (2003) <strong>and</strong> Strauss et al. (2004),which suggested that <strong>the</strong> government’s subsidized FPservices are largely not benefit<strong>in</strong>g <strong>the</strong> poor <strong>in</strong> <strong>the</strong> way<strong>in</strong>tended.F<strong>in</strong>ish<strong>in</strong>g <strong>the</strong> jobThese <strong>the</strong>n are some of <strong>the</strong> challenges fac<strong>in</strong>g <strong>the</strong> FPprogramme <strong>in</strong> Indonesia today result<strong>in</strong>g from chang<strong>in</strong>gdemographics as <strong>the</strong> country goes through <strong>the</strong> advancedstages of its demographic transition. The consensus amongfriends <strong>and</strong> observers of <strong>the</strong> programme is that <strong>the</strong> FPprogramme is not tackl<strong>in</strong>g <strong>the</strong>se challenges especially well,<strong>and</strong> that BKKBN is certa<strong>in</strong>ly not formulat<strong>in</strong>g <strong>in</strong>novativesolutions <strong>and</strong> coord<strong>in</strong>at<strong>in</strong>g <strong>the</strong>ir implementation with<strong>the</strong> focus <strong>and</strong> determ<strong>in</strong>ation that <strong>the</strong> organization haddisplayed dur<strong>in</strong>g <strong>the</strong> 1970s <strong>and</strong> 1980s. Why?The overall goals of <strong>the</strong> programme – giv<strong>in</strong>g couples<strong>the</strong> <strong>in</strong>formation <strong>and</strong> means <strong>the</strong>y need to control <strong>the</strong>irown fertility, reduc<strong>in</strong>g high fertility to br<strong>in</strong>g populationgrowth more <strong>in</strong> l<strong>in</strong>e with <strong>the</strong> country’s developmentgoals, support<strong>in</strong>g <strong>the</strong> norm of <strong>the</strong> small prosperousfamily – have rema<strong>in</strong>ed remarkably stable s<strong>in</strong>ce <strong>the</strong>programme was launched <strong>in</strong> 1970. Policymakers haveTableTable6232

had to adjust <strong>the</strong> <strong>in</strong>termediate objectives periodically,however, <strong>in</strong> response to chang<strong>in</strong>g circumstances. Indeedas <strong>the</strong> programme exp<strong>and</strong>ed rapidly dur<strong>in</strong>g <strong>the</strong> 1970s <strong>and</strong>1980s new approaches were constantly be<strong>in</strong>g tested <strong>and</strong>applied to <strong>in</strong>crease coverage <strong>and</strong> <strong>in</strong>stitutionalize FP as asocial norm. By <strong>the</strong> 1990s <strong>the</strong> majority of couples werealready practis<strong>in</strong>g FP, <strong>and</strong> <strong>the</strong> depth of <strong>the</strong>ir commitmentwas demonstrated by <strong>the</strong>ir resolve to cont<strong>in</strong>ue even whensome supplies were disrupted for awhile dur<strong>in</strong>g <strong>the</strong> heightof <strong>the</strong> <strong>Asia</strong>n f<strong>in</strong>ancial crisis. The programme seemed tobe on track to deliver universal access to services by 2015<strong>and</strong> to br<strong>in</strong>g about <strong>the</strong> programme’s orig<strong>in</strong>al goal of longtermpopulation stabilization. Paradoxically it was at thisjuncture that <strong>the</strong> programme first appeared to lose itsfocus <strong>and</strong> stall.We argue <strong>in</strong> <strong>the</strong> next section that this was largely becauseof changes <strong>in</strong> <strong>the</strong> <strong>in</strong>ternational <strong>and</strong> <strong>in</strong>stitutional context<strong>in</strong> which BKKBN operates. BKKBN has not beenable to take a conv<strong>in</strong>c<strong>in</strong>g leadership role <strong>in</strong> tackl<strong>in</strong>g <strong>the</strong>challenges listed above – what many would argue shouldbe regarded as its “core bus<strong>in</strong>ess” – because o<strong>the</strong>r changes<strong>in</strong> its <strong>in</strong>stitutional context have effectively neutralizedmany of <strong>the</strong> non-programme factors which were vitalto its organizational success <strong>in</strong> <strong>the</strong> past. BKKBN hasnot been able to focus dur<strong>in</strong>g <strong>the</strong> last 15 years on howits “core bus<strong>in</strong>ess” has evolved separately from tackl<strong>in</strong>go<strong>the</strong>r formidable challenges which have arisen regard<strong>in</strong>g<strong>the</strong> <strong>in</strong>ternational agenda, political decentralization <strong>and</strong>governance reform.In <strong>the</strong> longer term <strong>the</strong> central government’s responsibilitywill likely change <strong>in</strong> o<strong>the</strong>r ways too. Governmentsponsorednational FP programmes have f<strong>in</strong>ite lifespans.“<strong>Family</strong> plann<strong>in</strong>g programs, like <strong>the</strong> fertility transition that<strong>the</strong>y have helped to drive, will be a transient phenomenon”(Caldwell et al., 2002: 1). More than a dozen countries <strong>in</strong><strong>Asia</strong> have by now a TFR at or below <strong>the</strong> replacement level,<strong>and</strong> have already disb<strong>and</strong>ed, or are consider<strong>in</strong>g disb<strong>and</strong><strong>in</strong>g,<strong>the</strong>ir FP programmes. It is only a matter of time before <strong>the</strong>Government of Indonesia will want to phase out much ofits programme support for FP services, except perhaps for<strong>the</strong> poor <strong>and</strong> o<strong>the</strong>r vulnerable groups, <strong>and</strong> for areas where<strong>the</strong>re is still a demonstrable need (cf. Jones <strong>and</strong> Leete,2002).That does not mean <strong>the</strong> government <strong>the</strong>n will have nofur<strong>the</strong>r role to play regard<strong>in</strong>g <strong>the</strong> delivery of services.The government will still need to develop national FPpolicy <strong>and</strong> guidel<strong>in</strong>es, protect people’s reproductiverights, monitor districts’ performance of essential FP/RHservices <strong>and</strong> ensure that satisfactory quality st<strong>and</strong>ards arefollowed by service providers <strong>in</strong> all parts of <strong>the</strong> countryetc. The government will also still need to monitor fertilitybehaviour <strong>and</strong> perhaps do what it can to make sure thatfertility <strong>in</strong> Indonesia does not eventually fall too far belowreplacement, as it has <strong>in</strong> some neighbour<strong>in</strong>g countries(<strong>and</strong> most of Europe). However, <strong>the</strong> publicly funded FPprogramme as we know it will likely be eventually phasedout or significantly refocused <strong>and</strong> reduced <strong>in</strong> scale. In factas we saw <strong>in</strong> Table 6, this process is already far along, withonly a m<strong>in</strong>ority of clients depend<strong>in</strong>g on <strong>the</strong> governmentfor <strong>the</strong>ir rout<strong>in</strong>e FP services.Senior BKKBN officials are, of course, aware of thissituation, whereby “success” can imply redundancy for<strong>the</strong> organization, <strong>and</strong> are carefully weigh<strong>in</strong>g alternativescenarios. (We give our own recommendation on thispo<strong>in</strong>t towards <strong>the</strong> end of <strong>the</strong> paper.)Underst<strong>and</strong><strong>in</strong>g <strong>the</strong> currentsituationChang<strong>in</strong>g <strong>in</strong>ternational agendaOne set of challenges for <strong>the</strong> FP programme arises becauseof vicissitudes <strong>in</strong> <strong>the</strong> <strong>in</strong>ternational agenda. The Programmeof Action adopted at ICPD <strong>in</strong> Cairo <strong>in</strong> 1994 is recognizedas mark<strong>in</strong>g a def<strong>in</strong>itive shift <strong>in</strong> family plann<strong>in</strong>g ideology,away from an approach oriented towards populationcontrol <strong>and</strong> demographic targets towards a client-orientedRH approach emphasiz<strong>in</strong>g good-quality services grounded<strong>in</strong> human rights. 8 S<strong>in</strong>d<strong>in</strong>g (2007: 10) characterized <strong>the</strong>situation as follows:Cairo was truly a watershed. Some havealready seen it as <strong>the</strong> end of <strong>the</strong> familyplann<strong>in</strong>g movement, an event celebratedby many fem<strong>in</strong>ists <strong>and</strong> women’s rightsactivists as a paradigm shift <strong>and</strong> equallyregretted by traditional populationadvocates, <strong>in</strong>clud<strong>in</strong>g many demographers<strong>and</strong> o<strong>the</strong>rs concerned about high fertilityrates, as ab<strong>and</strong>onment of a decades-longcommitment to population stabilization.In <strong>the</strong> years s<strong>in</strong>ce <strong>the</strong> conference, globalattention has <strong>in</strong>creas<strong>in</strong>gly shifted awayfrom population growth as a centralpolitical or development concern, while<strong>the</strong> ris<strong>in</strong>g toll of HIV <strong>in</strong>fection <strong>and</strong> AIDSdeaths has captured <strong>the</strong> attention of policymakers.233

The Indonesian delegation was very active <strong>in</strong> ICPD. 9That conference did not spell <strong>the</strong> end of <strong>the</strong> national FPprogramme <strong>in</strong> Indonesia but it did pose a difficult dilemmafor BKKBN. BKKBN had been set up as a st<strong>and</strong>-aloneagency with<strong>in</strong> <strong>the</strong> central government <strong>in</strong> order to take <strong>the</strong>lead on population control. If FP was now to be seen asessentially a health <strong>and</strong> gender issue, such a perspectivewould imply h<strong>and</strong><strong>in</strong>g over responsibility for FP policy to<strong>the</strong> M<strong>in</strong>istry of Health; after all, it was always governmen<strong>the</strong>alth personnel <strong>and</strong> public health facilities which wereactually deliver<strong>in</strong>g <strong>the</strong> public FP services. BKKBN wasclearly reluctant to do this. Without a radically new mission,BKKBN would be stuck <strong>in</strong>stitutionally <strong>in</strong> an impossibleposition: it could not move forward <strong>and</strong> wholeheartedlyembrace ICPD because that would require acknowledg<strong>in</strong>gthat FP is first <strong>and</strong> foremost a matter of RH <strong>and</strong> <strong>the</strong>reforebelonged logically to <strong>the</strong> mission of <strong>the</strong> M<strong>in</strong>istry of Health,<strong>and</strong> it could not move backwards towards <strong>the</strong> directionof population control because that would require us<strong>in</strong>glanguage no one else wanted to speak anymore <strong>and</strong> <strong>the</strong>orig<strong>in</strong>al “population problem” had mostly been resolved by<strong>the</strong>n anyway. Institutionally BKKBN was stuck between<strong>the</strong> proverbial rock <strong>and</strong> a hard place. 10In short BKKBN chose not to redef<strong>in</strong>e its central vision<strong>and</strong> mission explicitly <strong>in</strong> terms of ICPD (i.e., <strong>in</strong> terms ofpromot<strong>in</strong>g reproductive rights <strong>and</strong> reproductive health)even though it had adopted specific elements from ICPD.As a result nei<strong>the</strong>r <strong>the</strong> goals of <strong>the</strong> government’s FPprogramme nor <strong>the</strong> explicit contributions of BKKBN to<strong>the</strong> country’s development objectives are def<strong>in</strong>ed todaywith <strong>the</strong> same clarity <strong>and</strong> conviction that <strong>the</strong>y had beendur<strong>in</strong>g <strong>the</strong> 1970s <strong>and</strong> 1980s. An <strong>in</strong>creas<strong>in</strong>g number ofreproductive health advocates <strong>and</strong> fem<strong>in</strong>ists have come toregard BKKBN now as be<strong>in</strong>g “beh<strong>in</strong>d <strong>the</strong> curve” <strong>in</strong> mattersof RH <strong>and</strong> FP (for example, see Juliantoro, 2000).Millennium Development Goals <strong>and</strong>numerical targetsAt <strong>the</strong> same time, <strong>the</strong> victory of women’s RH advocatesat <strong>the</strong> Cairo conference did not translate <strong>in</strong>to all <strong>the</strong>promised results ei<strong>the</strong>r, <strong>and</strong> <strong>in</strong>ternational fund<strong>in</strong>g forimplement<strong>in</strong>g <strong>the</strong> Programme of Action subsequently fellfar short of expectations (Sch<strong>in</strong>dlmayr, 1999; PopulationAction <strong>International</strong>, 2005). When 189 member statesadopted <strong>the</strong> United Nations Millennium Declaration<strong>in</strong> September 2000 with <strong>the</strong> commitment to “mak<strong>in</strong>g<strong>the</strong> right to development a reality for everyone” <strong>and</strong>“creat[<strong>in</strong>g] an environment – at <strong>the</strong> national <strong>and</strong> globallevels alike – which is conducive to development <strong>and</strong> <strong>the</strong>elim<strong>in</strong>ation of poverty” (United Nations, 2000), <strong>the</strong>y didnot <strong>in</strong>clude RH as an one of <strong>the</strong> Millennium DevelopmentGoals or one of its targets, even though <strong>the</strong> Declarationwas be<strong>in</strong>g promoted as an explicit culm<strong>in</strong>ation of <strong>the</strong>sequence of United Nations conferences held dur<strong>in</strong>g <strong>the</strong>1990s, <strong>in</strong>clud<strong>in</strong>g ICPD. The omission was deliberate <strong>and</strong>calculated (Bernste<strong>in</strong>, 2005; Crossette, 2005).UNFPA, <strong>the</strong> United Nations Millennium Project <strong>and</strong>o<strong>the</strong>r stakeholders cont<strong>in</strong>ued to argue <strong>the</strong> case thatpopulation <strong>and</strong> RH policy are essential elements ofsuccessful strategies to eradicate <strong>in</strong>come poverty <strong>and</strong>atta<strong>in</strong> o<strong>the</strong>r MDGs. At <strong>the</strong> High-Level Plenary Meet<strong>in</strong>gof <strong>the</strong> 60th session of <strong>the</strong> General Assembly (2005 WorldSummit) <strong>in</strong> September 2005, <strong>the</strong> ICPD goal of universalaccess to RH by 2015 was reaffirmed, <strong>and</strong> it was agreedthat this goal should be <strong>in</strong>tegrated <strong>in</strong>to “strategies to atta<strong>in</strong><strong>the</strong> <strong>in</strong>ternationally agreed development goals, <strong>in</strong>clud<strong>in</strong>gthose conta<strong>in</strong>ed <strong>in</strong> <strong>the</strong> Millennium Declaration, aimed atreduc<strong>in</strong>g maternal mortality, improv<strong>in</strong>g maternal health,reduc<strong>in</strong>g child mortality, promot<strong>in</strong>g gender equality,combat<strong>in</strong>g HIV/AIDS <strong>and</strong> eradicat<strong>in</strong>g poverty” (UnitedNations, 2005: para 57(g)). There is irony <strong>in</strong> see<strong>in</strong>g FP<strong>and</strong> RH once aga<strong>in</strong> tied to development goals expressed asnumerical targets. The danger is that programme managerswill be rewarded more for meet<strong>in</strong>g <strong>the</strong> numerical targetsthan for br<strong>in</strong>g<strong>in</strong>g about <strong>the</strong> substantive changes that <strong>the</strong>numbers are meant to <strong>in</strong>dicate. 11A review of current underst<strong>and</strong><strong>in</strong>g of <strong>the</strong> l<strong>in</strong>kagesamong population, RH <strong>and</strong> poverty confirms that <strong>the</strong>sefactors are causally <strong>in</strong>terrelated <strong>in</strong> significant ways, <strong>and</strong>that population <strong>and</strong> RH can <strong>and</strong> do have impacts onpoverty status, even though our underst<strong>and</strong><strong>in</strong>g of all <strong>the</strong>specific mechanisms <strong>in</strong>volved is still far from complete(Hayes, 2005). Practical measures, <strong>the</strong>refore, to eradicatepoverty need to take population matters <strong>in</strong>to account,<strong>and</strong> improv<strong>in</strong>g RH is important if <strong>the</strong>y are to be effective.However, whe<strong>the</strong>r <strong>the</strong> target-driven approach of MDGs is<strong>the</strong> best way to accomplish this is ano<strong>the</strong>r question (Reddy<strong>and</strong> Heaty, 2008).The challenge for central <strong>and</strong> prov<strong>in</strong>cial-level FPpolicymakers is to negotiate performance targets fordistricts which fairly measure substantive improvements<strong>in</strong> FP/RH services, <strong>and</strong> which do not serve to distort<strong>the</strong> <strong>in</strong>centive structure of FP <strong>and</strong> RH workers so as toreward <strong>the</strong>m for reach<strong>in</strong>g easily measurable yet essentiallysuperficial changes ra<strong>the</strong>r than reach<strong>in</strong>g more substantialgoals.DecentralizationEffective 1 January 2004, most of BKKBN’s authority foradm<strong>in</strong>ister<strong>in</strong>g <strong>the</strong> programme was transferred to more than420 “autonomous” districts (kabupaten) <strong>and</strong> municipalities(kota), <strong>and</strong> much of its responsibility for develop<strong>in</strong>g FPpolicy is now shared with regional governments. 12 When itbecame clear <strong>in</strong> early 2002 that BKKBN would be obligedto decentralize, <strong>the</strong> agency made a concerted effort to ensure234

that <strong>the</strong> transfer of authority would go smoothly <strong>and</strong> thataccess to FP services would not suffer unduly. BKKBNadvocated with local government authorities to ensure thata suitable <strong>in</strong>stitutional home would be provided for <strong>the</strong> FPprogramme <strong>in</strong> <strong>the</strong> respective districts/municipalities afterdecentralization. It developed, <strong>in</strong> consultation with regionalgovernments <strong>and</strong> <strong>the</strong> M<strong>in</strong>istry of Home Affairs, a list of“essential” family plann<strong>in</strong>g services which districts wouldbe obligated by law to provide, toge<strong>the</strong>r with associatedperformance <strong>in</strong>dicators to be used for monitor<strong>in</strong>g. BKKBNalso managed to secure central government funds to enableit to cont<strong>in</strong>ue furnish<strong>in</strong>g subsidized contraceptives (<strong>and</strong>some o<strong>the</strong>r supports) to districts on request.BKKBN fur<strong>the</strong>r negotiated a favourable <strong>in</strong>stitutionalarrangement with <strong>the</strong> government whereby <strong>the</strong> BKKBNprov<strong>in</strong>cial offices could stay “vertical” under <strong>the</strong> directcontrol of BKKBN at <strong>the</strong> central level (at least <strong>in</strong> <strong>the</strong> shortterm) ra<strong>the</strong>r than be part of <strong>the</strong> adm<strong>in</strong>istrative apparatuscontrolled by <strong>the</strong> prov<strong>in</strong>cial governor. 13 O<strong>the</strong>r proactive<strong>in</strong>itiatives <strong>in</strong>cluded develop<strong>in</strong>g an early warn<strong>in</strong>g <strong>and</strong> rapidresponse system, so that even if (as seemed <strong>in</strong>evitable)rout<strong>in</strong>e monitor<strong>in</strong>g systems faltered <strong>in</strong> <strong>the</strong> early stagesof decentralization, BKKBN <strong>and</strong> o<strong>the</strong>r stakeholderscould still obta<strong>in</strong> some basic <strong>in</strong>formation on how <strong>the</strong>programme was perform<strong>in</strong>g from a national perspective,<strong>and</strong> could identify emerg<strong>in</strong>g problems quickly <strong>and</strong> work<strong>in</strong> partnership with districts to overcome <strong>the</strong>m. BKKBNprepared for decentralization with arguably more care <strong>and</strong>deliberation than any o<strong>the</strong>r government agency <strong>in</strong>volvedwith <strong>the</strong> delivery of public services.Follow<strong>in</strong>g decentralization FP programme officials atall government levels now face new challenges regard<strong>in</strong>g<strong>the</strong> sourc<strong>in</strong>g of resources, <strong>the</strong> plann<strong>in</strong>g of programmeactivities, recruit<strong>in</strong>g <strong>and</strong> manag<strong>in</strong>g personnel, def<strong>in</strong><strong>in</strong>g <strong>the</strong>scope of <strong>the</strong>ir authority for policy formulation, establish<strong>in</strong>g<strong>the</strong> need for advocacy, foster<strong>in</strong>g good relations with o<strong>the</strong>rgovernmental <strong>and</strong> non-governmental units, report<strong>in</strong>g onperformance <strong>and</strong> f<strong>in</strong>ances, <strong>and</strong> determ<strong>in</strong><strong>in</strong>g how <strong>the</strong>irown performance would be evaluated. It is important torecognize that decentralization <strong>in</strong> Indonesia <strong>in</strong>volves bothadm<strong>in</strong>istrative <strong>and</strong> political dimensions, so FP programmeofficials could not resolve all <strong>the</strong> adm<strong>in</strong>istrative issues<strong>in</strong>volved before politicians resolved outst<strong>and</strong><strong>in</strong>g issuesregard<strong>in</strong>g <strong>the</strong> distribution of authority across <strong>the</strong> central,prov<strong>in</strong>cial <strong>and</strong> district levels of government.Much of <strong>the</strong> technical assistance offered to BKKBN (<strong>and</strong><strong>the</strong> M<strong>in</strong>istry of Health) has tended to focus on technicalissues as if <strong>the</strong> political issues had already been resolved.Sometimes <strong>the</strong> “form follows function” adage is <strong>in</strong>cludedwith <strong>the</strong> advice offered. This assumes that <strong>the</strong> functionsare already well def<strong>in</strong>ed, but often <strong>the</strong>y are not. Even if<strong>the</strong>y were, <strong>in</strong>stitutions <strong>in</strong> <strong>the</strong> real world never adapt tofunctional requirements alone – every <strong>in</strong>stitution has itsown traditions, <strong>and</strong> those with power are able to <strong>in</strong>fluenceprocesses of change <strong>in</strong> ways more favourable to <strong>the</strong>mselves;<strong>in</strong>stitutional reform is always path-dependent. Sometimestechnical assistance has been offered to help def<strong>in</strong>e <strong>the</strong>functions; however, as should be clear by now, this is partlya political process, not a simple technical matter. In o<strong>the</strong>rwords, problems fac<strong>in</strong>g <strong>the</strong> FP programme brought aboutby decentralization that often seem to outsiders to lend<strong>the</strong>mselves to technical solutions <strong>in</strong> fact often have anirreducible political component <strong>and</strong> <strong>the</strong>refore need to beapproached as governance issues.The grow<strong>in</strong>g dem<strong>and</strong> for goodgovernanceAlthough <strong>the</strong>re is little agreement on an exact def<strong>in</strong>ition of“good governance” as promoted by <strong>in</strong>ternational agencies<strong>and</strong> donors (for example, see Jenk<strong>in</strong>s <strong>and</strong> Plowden,2006), <strong>the</strong>re is broad agreement that certa<strong>in</strong> items, suchas freedom of speech, political party organization, publicaccountability of governments, transparency <strong>in</strong> politicaldecision-mak<strong>in</strong>g <strong>and</strong> an <strong>in</strong>dependent judiciary, are all keycomponents of a “healthy” democracy. Institutionaliz<strong>in</strong>g<strong>the</strong>se items systemically can also make sectors, <strong>in</strong>clud<strong>in</strong>ghealth <strong>and</strong> FP, more responsive to local communities’ needs<strong>and</strong> aspirations.At <strong>the</strong> programme level, <strong>in</strong>troduc<strong>in</strong>g such elements asaccountability <strong>and</strong> transparency is relatively easy, <strong>and</strong> thoseelements engender local participation <strong>in</strong>, <strong>and</strong> ownershipof, <strong>the</strong> programme. Good governance <strong>in</strong> this sense is animportant part of <strong>the</strong> ICPD Programme of Action. An<strong>in</strong>itial obstacle, usually short-lived, is that <strong>in</strong> <strong>the</strong> early stagesfew officials or members of <strong>the</strong> public are familiar with <strong>the</strong>senotions, <strong>and</strong> <strong>the</strong> mechanisms <strong>in</strong>troduced tend to be weak<strong>and</strong> <strong>in</strong>nocuous: “accountability” is simply a “suggestionsbox” placed at a service delivery po<strong>in</strong>t, for example. Goodgovernance depends crucially on <strong>the</strong> development ofstrong civil society <strong>in</strong>stitutions, not just on an efficientstate apparatus, <strong>and</strong> programme managers might not see itas <strong>the</strong>ir responsibility to foster this. Indonesian NGOs are<strong>in</strong>creas<strong>in</strong>gly effective <strong>in</strong> promot<strong>in</strong>g good governance. Goodgovernance <strong>and</strong> strong civil society <strong>in</strong>stitutions are neededto check that key “pr<strong>in</strong>cipals” <strong>in</strong> <strong>the</strong> state apparatus at alllevels do <strong>in</strong>deed serve <strong>the</strong> public <strong>in</strong>terest <strong>and</strong> that servicesare responsive to <strong>the</strong> population’s needs <strong>and</strong> aspirations.BKKBN has supported some good governance <strong>in</strong>itiatives– for example, support<strong>in</strong>g local NGOs <strong>in</strong> <strong>the</strong>ir watchdogfunctions – but <strong>the</strong>y could show much more leadership <strong>in</strong>promot<strong>in</strong>g good governance <strong>in</strong> <strong>the</strong> FP programme. To dateBKKBN <strong>in</strong>vests far more energy <strong>in</strong> protect<strong>in</strong>g <strong>the</strong> legalstatus of FP <strong>in</strong> government decrees <strong>and</strong> development plans235

than <strong>in</strong> ensur<strong>in</strong>g a grow<strong>in</strong>g role for public accountability.O<strong>the</strong>r recent developments <strong>in</strong> familyplann<strong>in</strong>g <strong>and</strong> population policyThere have been a number of o<strong>the</strong>r recent developments <strong>in</strong>FP <strong>and</strong> population policy <strong>in</strong> Indonesia which are importantfor underst<strong>and</strong><strong>in</strong>g <strong>the</strong> current situation.Hull <strong>and</strong> Mosley reviewThere have been a number of reviews of <strong>the</strong> current statusof FP <strong>in</strong> Indonesia <strong>in</strong> recent years (e.g., Hayes, Lewis<strong>and</strong> Vogel, 2003; Hayes, 2006). The most importantreview was that undertaken by Hull <strong>and</strong> Mosley (2009),entitled Revitalization of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>in</strong> Indonesia.They discussed many of <strong>the</strong> same issues described <strong>in</strong> <strong>the</strong>present report. Their recommendations are reproduced <strong>in</strong>Table 7, toge<strong>the</strong>r with snippets from <strong>the</strong>ir accompany<strong>in</strong>gjustification <strong>and</strong> clarification, <strong>and</strong> some additional briefcomments of our own.Their review was followed by ano<strong>the</strong>r which suggestedoperational strategies for implement<strong>in</strong>g <strong>the</strong> Hull <strong>and</strong>Mosley recommendations (Lewis <strong>and</strong> Haripurnomo,2009). Eight strategies were outl<strong>in</strong>ed:Strategy to support <strong>the</strong> role of <strong>the</strong> private sector <strong>in</strong> RE/FPStrategy for technical support for decentralizationNational communications strategyCapacity-build<strong>in</strong>g strategy to address decentralization<strong>and</strong> priorities <strong>in</strong> RH/FPStrategy to improve <strong>the</strong> quality of RH/FPSupport strategy for ensur<strong>in</strong>g equity <strong>in</strong> access <strong>and</strong> useof RH/FP servicesStrategy for prevent<strong>in</strong>g high-risk pregnanciesStrategy for balanc<strong>in</strong>g <strong>the</strong> contraceptive method mix.BKKBN has adopted some of <strong>the</strong>se recommendations,although not necessarily <strong>in</strong> ways that o<strong>the</strong>rs would regardas engender<strong>in</strong>g a “revitalization” of <strong>the</strong> FP programme.For example, BKKBN has begun to address <strong>the</strong> issue ofmethod mix, but <strong>the</strong> lynchp<strong>in</strong> of its strategy is to provideall contraceptive methods free of charge: that is, a strategywhich secures a large procurement budget for <strong>the</strong> agencywithout requir<strong>in</strong>g any significant organizational reform.It is not clear how this strategy adds value to “work<strong>in</strong>gclosely” with <strong>the</strong> M<strong>in</strong>istry of Health (<strong>the</strong> phrase oftenused <strong>in</strong> public statements) or adds value to implement<strong>in</strong>geffective decentralization; no premium appears to havebeen placed on provid<strong>in</strong>g contraceptive methods <strong>in</strong> a costeffectiveway. The fact that BKKBN can comm<strong>and</strong> sucha large procurement budget demonstrates that <strong>the</strong> agencystill has a lot of political capital, but it is be<strong>in</strong>g spent mostlyto ma<strong>in</strong>ta<strong>in</strong> bus<strong>in</strong>ess as usual, not to <strong>in</strong>troduce <strong>in</strong>novativereform.The Hull <strong>and</strong> Mosley recommendations are em<strong>in</strong>entlysensible <strong>and</strong> well thought out. However, <strong>the</strong>se qualitiesare rarely sufficient <strong>in</strong> any democracy to ensure that <strong>the</strong>government will adopt <strong>the</strong>m. In Indonesia governmentagencies are still largely neo-patrimonial bureaucracies;promotion <strong>in</strong> <strong>the</strong> civil service is still not clearly determ<strong>in</strong>edby performance, although this situation is slowly chang<strong>in</strong>g.Key political decisions are often determ<strong>in</strong>ed by websof patronage <strong>and</strong> <strong>the</strong> capacity to capture <strong>and</strong> comm<strong>and</strong>resources. Under <strong>the</strong>se circumstances it is difficult forany agency to adopt changes on <strong>the</strong> grounds that <strong>the</strong>ywill result <strong>in</strong> everyone do<strong>in</strong>g a better job at serv<strong>in</strong>g <strong>the</strong>needs <strong>and</strong> aspirations of <strong>the</strong> public. It is difficult to<strong>in</strong>troduce evidence-based reforms designed to improve anagency’s performance without fur<strong>the</strong>r civil service reform(Synnerstrom, 2007).RecommendationsOur recommendations, which were presented as discussionquestions for <strong>the</strong> Consultation <strong>in</strong> Bangkok, 8-10 December2010, are as follows:Recommendation 1Can Indonesia’s national FPprogramme be given a central focusto meet all rema<strong>in</strong><strong>in</strong>g unmet need forservices by 2015?The FP programme does not currently have a clear focus.Its core bus<strong>in</strong>ess should be reduc<strong>in</strong>g unmet need, butlittle progress has been made on this dur<strong>in</strong>g <strong>the</strong> last 15years. Unmet need is primarily a health <strong>and</strong> reproductiverights issue <strong>and</strong> it needs to be addressed urgently for anumber of reasons. Unmet dem<strong>and</strong> for FP services meansthat millions of women <strong>in</strong> Indonesia today are at risk ofunwanted pregnancy. This is a serious health <strong>and</strong> genderissue.Focus<strong>in</strong>g <strong>the</strong> FP programme on reduc<strong>in</strong>g unmet need forFP services is <strong>the</strong> k<strong>in</strong>d of challenge which could revitalize<strong>the</strong> programme. It is a goal which has major health benefits<strong>and</strong> which promises to empower more women (<strong>and</strong>couples), toge<strong>the</strong>r with all <strong>the</strong> flow-on benefits this entails.It is also a goal which enjoys almost universal support, both236

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<strong>in</strong>-country <strong>and</strong> <strong>in</strong>ternationally, <strong>and</strong> which, if accomplished,will help <strong>the</strong> country reach its MDGs as well as achieve <strong>the</strong>ICPD target of universal access to FP by 2015.Recommendation 2Can primary responsibility for FP policybe transferred to <strong>the</strong> M<strong>in</strong>istry of Healthwith<strong>in</strong> <strong>the</strong> next few years?BKKBN was established at a time when <strong>the</strong>re was arecognized massive “population problem” <strong>in</strong> <strong>the</strong> country,which related to very high fertility levels <strong>and</strong> a highpopulation growth rate, <strong>and</strong> <strong>the</strong> <strong>in</strong>ternational communitysupported population control programmes at <strong>the</strong> time.Nei<strong>the</strong>r condition is true today.Thanks largely to <strong>the</strong> successful efforts of BKKBN <strong>the</strong>orig<strong>in</strong>al “population problem” has been brought undercontrol. <strong>Family</strong> plann<strong>in</strong>g is now <strong>the</strong> prevail<strong>in</strong>g norm <strong>in</strong>Indonesia, although responsible practice is low for somegroups <strong>and</strong> for some parts of <strong>the</strong> country. Less than aquarter of <strong>the</strong> couples practis<strong>in</strong>g FP rely on <strong>the</strong> governmentto provide <strong>the</strong>m with <strong>the</strong>ir services. The country as awhole is close to replacement-level fertility. For most of <strong>the</strong>population whe<strong>the</strong>r fertility cont<strong>in</strong>ues to fall or whe<strong>the</strong>r itedges up aga<strong>in</strong> will depend more on social <strong>and</strong> economicconditions than actions <strong>in</strong>troduced by BKKBN. Fertilitylevels need to be monitored carefully but so far <strong>the</strong>reis no compell<strong>in</strong>g evidence to suggest that <strong>the</strong>re will be amajor baby boom if BKKBN no longer manages <strong>the</strong> FPprogramme. 14 In short, <strong>the</strong>re is no conv<strong>in</strong>c<strong>in</strong>g argument forma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g <strong>in</strong>def<strong>in</strong>itely a separate agency with primaryresponsibility for family plann<strong>in</strong>g policy formulationoutside <strong>the</strong> M<strong>in</strong>istry of Health.Giv<strong>in</strong>g <strong>the</strong> M<strong>in</strong>istry responsibility for FP policy wouldfacilitate <strong>the</strong> <strong>in</strong>tegration of FP <strong>in</strong>to <strong>the</strong> broader clusterof reproductive <strong>and</strong> maternal health services <strong>in</strong> <strong>the</strong> wayenvisioned by ICPD. Without “reposition<strong>in</strong>g” <strong>the</strong> FPprogramme <strong>in</strong> this way, it is difficult to see how it couldever be revitalized.Recommendation 3Can a new vision <strong>and</strong> mission bedeveloped for BKKBN which satisfiesthree requirements: (a) it is centredon a holistic vision of populationpolicy <strong>and</strong> its role <strong>in</strong> development; (b)it is acceptable to o<strong>the</strong>r parts of <strong>the</strong>government if <strong>the</strong> mission is assumedby BKKBN; <strong>and</strong> (c) it is a vision <strong>and</strong>mission which is attractive to BKKBNitself <strong>and</strong> which gives <strong>the</strong> organizationan excit<strong>in</strong>g future?The new population law (Law 52/2009 on <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> <strong>and</strong> Population Development) gives BKKBNexplicit responsibility for population policy, <strong>and</strong> <strong>the</strong>name of BKKBN has been changed accord<strong>in</strong>gly (whilestill conveniently keep<strong>in</strong>g <strong>the</strong> same acronym). 15 BKKBNas an organization is not happy with <strong>the</strong> way <strong>the</strong> newresponsibility has been assigned to it because <strong>the</strong>mission is not associated with sufficient status with<strong>in</strong> <strong>the</strong>government structure for BKKBN to be able to fulfill thisresponsibility effectively. However, <strong>the</strong>re is <strong>the</strong> seed of apromis<strong>in</strong>g core mission here. If BKKBN embraces it <strong>and</strong>advocates with <strong>the</strong> skill <strong>and</strong> persuasion it has traditionallydisplayed for <strong>the</strong> status <strong>and</strong> resources it needs to do <strong>the</strong> jobwell, <strong>the</strong>n this could be a new <strong>and</strong> excit<strong>in</strong>g beg<strong>in</strong>n<strong>in</strong>g foran <strong>in</strong>stitution that is already a legend <strong>in</strong> population policycircles around <strong>the</strong> world.ConclusionIndonesia has a mature FP programme which appearsto have lost its way now that it has substantially realizedits orig<strong>in</strong>al objective. Nei<strong>the</strong>r BKKBN nor <strong>the</strong> M<strong>in</strong>istryof Health is happy with <strong>the</strong> present status of FP <strong>in</strong> <strong>the</strong>country. Plenty of “b<strong>and</strong>-aid” solutions have been suggested<strong>in</strong> recent years, but if <strong>the</strong> FP programme is to be revitalized<strong>and</strong> responsive to <strong>the</strong> evolv<strong>in</strong>g needs <strong>and</strong> aspirations of <strong>the</strong>238

population, this will require significant structural changes<strong>in</strong> <strong>the</strong> current <strong>in</strong>stitutional arrangements.End Notes1 (Please <strong>in</strong>sert Dr. Hayes’ position etc. here), Australian NationalUniversity, Canberra. The author would like to express hisgratitude to <strong>the</strong> many people who shared <strong>in</strong>formation <strong>and</strong> <strong>in</strong>sightswith him dur<strong>in</strong>g <strong>the</strong> preparation of this report, <strong>and</strong> to EddyHasmi, Terry Hull, Sugiri Syarief <strong>and</strong> anonymous reviewers for<strong>the</strong>ir helpful comments on an earlier draft.2 Accord<strong>in</strong>g to <strong>the</strong> Hulls (1997: 392, 384), “<strong>the</strong> most dramaticachievement of <strong>the</strong> New Order government of <strong>the</strong> period 1966-90 was <strong>the</strong> major construction of state <strong>and</strong> civil <strong>in</strong>stitutionalstructures <strong>in</strong> ways that enhanced central government control whilepromot<strong>in</strong>g decentralized responsibilities”. It was, <strong>the</strong>y argued, <strong>the</strong>government’s unique way of us<strong>in</strong>g <strong>the</strong> <strong>in</strong>struments of social controlmade available by this political-adm<strong>in</strong>istrative system which, <strong>in</strong>comb<strong>in</strong>ation with a highly patrimonial state ideology committed topolitical stability, was responsible for <strong>the</strong> success of “a wide varietyof popular government programmes <strong>in</strong>clud<strong>in</strong>g primary school<strong>in</strong>g,health service delivery, <strong>and</strong> family plann<strong>in</strong>g”. For fur<strong>the</strong>r elaborationof this po<strong>in</strong>t see also Hull (2003) <strong>and</strong> Piet (2003).3 HS data were collected <strong>in</strong> Indonesia <strong>in</strong> 1987, 1991, 1994, 1997,2002/03 <strong>and</strong> 2007. The 1987 DHS was actually a nationalcontraceptive prevalence survey; it covered 20 of <strong>the</strong> country’s 27prov<strong>in</strong>ces at <strong>the</strong> time, <strong>and</strong> thus was representative of 93.7 per centof <strong>the</strong> national population. The surveys <strong>in</strong> 1991, 1994 <strong>and</strong> 1997were “complete” DHS <strong>and</strong> were representative of <strong>the</strong> nationalpopulation as a whole. The DHS <strong>in</strong> 2002/03 covered 26 of <strong>the</strong> 33prov<strong>in</strong>ces <strong>in</strong> Indonesia at that time; Nanggroë Aceh Darussalam,Maluku, North Maluku <strong>and</strong> Papua were not <strong>in</strong>cluded for securityreasons (<strong>and</strong> East Timor was dropped because it was no longerpart of Indonesia). The last DHS, conducted <strong>in</strong> 2007, covered <strong>the</strong>whole country.4 The def<strong>in</strong>ition is specified fur<strong>the</strong>r as follows: “Women with anunmet need for ‘spac<strong>in</strong>g’ <strong>in</strong>clude pregnant women whose pregnancywas mistimed; amenorrheic women whose last birth was mistimed;<strong>and</strong> fecund women who are nei<strong>the</strong>r pregnant nor amenorrheic,who are not us<strong>in</strong>g any method of family plann<strong>in</strong>g, <strong>and</strong> who wantto wait two or more years for <strong>the</strong>ir next birth. Also <strong>in</strong>cluded <strong>in</strong>unmet need for spac<strong>in</strong>g are fecund women whoa re not us<strong>in</strong>g anymethod of family plann<strong>in</strong>g <strong>and</strong> are unsure whe<strong>the</strong>r <strong>the</strong>y wantano<strong>the</strong>r child or who want ano<strong>the</strong>r child but are unsure when tohave <strong>the</strong> birth. Unmet need for ‘limit<strong>in</strong>g’ refers to pregnant womenwhose pregnancy was unwanted; amenorrheic women whose lastchild was unwanted; <strong>and</strong> women who are nei<strong>the</strong>r pregnant noramenorrheic, who are not us<strong>in</strong>g any method of family plann<strong>in</strong>g, <strong>and</strong>who want no more children”. Ross (2003) argued that <strong>the</strong> DHSdef<strong>in</strong>ition is too conservative <strong>and</strong> that a more realistic def<strong>in</strong>itionwould mean that unmet need is actually a few percentage po<strong>in</strong>tshigher.5 For a more general account of plateau<strong>in</strong>g, <strong>in</strong>clud<strong>in</strong>g somespeculation on possible causes, see Ross, Abel <strong>and</strong> Abel (2004).6 From an evolutionary perspective on population health, see <strong>the</strong>comments on oral contraception, menstruation <strong>and</strong> <strong>in</strong>creases <strong>in</strong>cycles of cellular proliferation by McMichael (2001: 216-219).7 This <strong>in</strong>dex is not used <strong>in</strong> <strong>the</strong> chapter on use of family plann<strong>in</strong>g <strong>in</strong><strong>the</strong> published DHS report, however.8 In fact <strong>the</strong> Programme of Action is more complex than this becauseit seeks to comb<strong>in</strong>e a number of perspectives on population <strong>and</strong>development – <strong>the</strong> economic, ecological <strong>and</strong> NGO – <strong>and</strong> not justthat of human rights (Hayes, 1995).9 On <strong>the</strong> pivotal issue of targets, BKKBN was already mov<strong>in</strong>g awayfrom targets before ICPD <strong>and</strong> towards “dem<strong>and</strong> fulfilment” (seeGalway, 1996).10 Similar agencies <strong>in</strong> o<strong>the</strong>r countries that were <strong>in</strong>itially establishedwith foreign assistance to manage vertical population controlprogrammes presumably face a similar dilemma. ICPD articulatedwell an important paradigm shift <strong>and</strong> <strong>the</strong> <strong>in</strong>ternational communitypromptly shifted its support from one paradigm to <strong>the</strong> o<strong>the</strong>r,but did not offer much help when it came to <strong>the</strong> practicalitiesof effect<strong>in</strong>g such a change <strong>in</strong> <strong>the</strong> typical political context of adevelop<strong>in</strong>g country.11 For example, a recent World Bank project aimed at help<strong>in</strong>g <strong>the</strong>Government of Indonesia br<strong>in</strong>g about effective decentralizationof <strong>the</strong> health sector <strong>in</strong>cluded a component aimed at personnelreform. One element was to reduce <strong>the</strong> number of non-health staffat puskesmas (health centres – one of <strong>the</strong> ma<strong>in</strong> sites for publiclysupported FP services). This was meant to be just one element<strong>in</strong> a broader package of HR reforms (gett<strong>in</strong>g rid of unproductivestaff, establish<strong>in</strong>g clear job descriptions, bas<strong>in</strong>g promotions oncompetency, downsiz<strong>in</strong>g through early retirement etc.). However,this element was given a numerical target (reduce by 20% by acerta<strong>in</strong> date) <strong>and</strong> <strong>the</strong> o<strong>the</strong>r elements were not. Consequently somedistrict-level project managers chose to focus on reduc<strong>in</strong>g thisparticular element so that <strong>the</strong>y could claim evidence of success for<strong>the</strong> component as a whole. The method often chosen to accomplishthis – us<strong>in</strong>g project funds to tra<strong>in</strong> non-health staff so that <strong>the</strong>ycould <strong>the</strong>n be classified as health staff – was probably not costeffective<strong>and</strong> certa<strong>in</strong>ly defeated <strong>the</strong> component’s broader objectiveof a smaller more efficient workforce (Hayes et al., 2007).12 For a review, see USAID (2006). Decentralization has a long <strong>and</strong>complex history <strong>in</strong> Indonesia go<strong>in</strong>g back to colonial times.13 This k<strong>in</strong>d of <strong>in</strong>stitutional arrangement is now largely pro formaafter <strong>the</strong> passage of <strong>the</strong> decentralization laws <strong>in</strong> 2004.14 Reports <strong>in</strong> <strong>the</strong> press about <strong>the</strong> risk of a new population explosionfollow<strong>in</strong>g <strong>the</strong> release of prelim<strong>in</strong>ary results from <strong>the</strong> 2010population census are mostly ill <strong>in</strong>formed.15 The acronym BKKBN used to st<strong>and</strong> for Badan Koord<strong>in</strong>asiKeluarga Berencana Nasional (National <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Coord<strong>in</strong>ation Board); it now st<strong>and</strong>s for Badan Kependudukan danKeluarga Berencana (National <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> PopulationBoard).ReferencesBernste<strong>in</strong>, Stan (2005). “The chang<strong>in</strong>g discourse onpopulation <strong>and</strong> development: toward a new politicaldemography”, Studies <strong>in</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>, 36(2):127-132.BPS (Central Bureau of Statistics) (2001). 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McMichael, Anthony (2001). Human Frontiers,Environments <strong>and</strong> Disease, Cambridge: CambridgeUniversity Press.Niehof, Anke <strong>and</strong> Firman Lubis (eds.)(2003). Two IsEnough: <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>in</strong> Indonesia Under <strong>the</strong> New Order1968-1998. Leiden: KITLV Press.Piet, David L. (2003). “The significance of foreign assistanceto <strong>the</strong> Indonesian family plann<strong>in</strong>g program”, In: AnkeNiehof <strong>and</strong> Firman Lubis, eds., Two Is Enough: <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> <strong>in</strong> Indonesia under <strong>the</strong> New Order (1968-1998),Leiden, The Ne<strong>the</strong>rl<strong>and</strong>s: KITLV Press, pp. 83-106.Population Action <strong>International</strong> (2005). Progress <strong>and</strong>Promises: Trends <strong>in</strong> <strong>International</strong> Assistance for ReproductiveHealth <strong>and</strong> Population, Wash<strong>in</strong>gton, D.C.: PAI.Reddy, Sanjay <strong>and</strong> Anto<strong>in</strong>e Heaty (2008). “Globaldevelopment goals: <strong>the</strong> folly of technocratic pretensions”,Development Policy Review, 26(1):5-28.United Nations (1994). Report of <strong>the</strong> <strong>International</strong>Conference on Population <strong>and</strong> Development, Cairo, 5-13September 1994 (United Nations publication, Sales No.E.95.XIII.18), chap. I, resolution 1, annex.__________ (2000). United Nations MillenniumDeclaration, General Assembly resolution 55/2.__________ (2005). 2005 World Summit Outcome,General Assembly resolution 60/1 of 16 September 2005,accessed through <strong>the</strong> 2005 World Summit website.USAID Democratic Reform Support Program (DRSP)(2006). Decentralization 2006: Stock Tak<strong>in</strong>g on Indonesia’sRecent Decentralization Reforms, Jakarta: United StatesAgency for <strong>International</strong> Development, AustralianIndonesian Partnership <strong>and</strong> Democratic Reform SupportGroup.Rob<strong>in</strong>son, Warren C. <strong>and</strong> John A. Ross (eds.)(2007).The Global <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Revolution: Three Decadesof Population Policies <strong>and</strong> Programs, Wash<strong>in</strong>gton, D.C.:World Bank.Ross, John (2003). Contraceptive Security <strong>in</strong> Indonesia:What Do <strong>the</strong> Data Say? Jakarta: STARH Program.__________, Edward Abel <strong>and</strong> Ka<strong>the</strong>r<strong>in</strong>e Abel (2004).“Plateaus dur<strong>in</strong>g <strong>the</strong> rise of contraceptive prevalence”,<strong>International</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Perspectives, 30(1):39-44.Sch<strong>in</strong>dlmayr, Thomas-Markus (1999). The Nature, Trends<strong>and</strong> Determ<strong>in</strong>ants of Population Assistance, unpublishedPh.D. <strong>the</strong>sis, Canberra: Australian National UniversityDemography Program.Schoemaker, Juan (2004). Contraceptive Use among <strong>the</strong>Poor <strong>in</strong> Indonesia, Jakarta: STARH Program.S<strong>in</strong>d<strong>in</strong>g, Steven W. (2007). “Overview <strong>and</strong> perspective”, In:Warren C. Rob<strong>in</strong>son <strong>and</strong> John A. Ross, eds., The Global<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Revolution: Three Decades of PopulationPolicies <strong>and</strong> Programs, Wash<strong>in</strong>gton, D.C.: World Bank, pp.1-12.Strauss, John, Kathleen Beegle, Agus Dwiyanto, YuliaHerawati, Daan Patt<strong>in</strong>asarany, Elan Satriawan, BondanSikoki, Sukamdi <strong>and</strong> Firman Witoelar (2004). IndonesianLiv<strong>in</strong>g St<strong>and</strong>ards: Before <strong>and</strong> After <strong>the</strong> F<strong>in</strong>ancial Crisis,S<strong>in</strong>gapore: Institute of Sou<strong>the</strong>ast <strong>Asia</strong>n Studies.Synnerstrom, Staffan (2007). “The civil service: towardsefficiency, effectiveness <strong>and</strong> honesty”, In: Ross H. McLeod<strong>and</strong> Andrew MacIntyre, eds., Indonesia: Democracy <strong>and</strong><strong>the</strong> Promise of Good Governance, S<strong>in</strong>gapore: Institute ofSou<strong>the</strong>ast <strong>Asia</strong>n Studies, pp. 159-177.241

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MalaysiaMalaysiaStatus of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>in</strong> Malaysia, 2010Norliza Ahmad*, Tey Nai Peng # , Kamarul Faridah Kamarul Zaman ¤ , Noor Azl<strong>in</strong>Muhd Sapri , Majdah Mohamed <strong>and</strong> Yeoh Yeok Kim * Director of Human Reproduction, National Population & <strong>Family</strong> Development Board, Malaysia#Associate Professor Faculty of Bus<strong>in</strong>ess & Adm<strong>in</strong>istration, University Malaya¤Officer National Population & <strong>Family</strong> Development Board, MalaysiaOfficer National Population & <strong>Family</strong> Development Board, MalaysiaPr<strong>in</strong>cipal Assistant Director, National Population <strong>and</strong> <strong>Family</strong> Development Board, MalaysiaExecutive Director, Reproductive Health Association of Malaysia243

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FigureThe beg<strong>in</strong>n<strong>in</strong>g of <strong>the</strong> National<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> ProgrammePrior to 1966, family plann<strong>in</strong>g services <strong>in</strong> Malaysia wereprovided by <strong>the</strong> various state <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Associations,<strong>and</strong> <strong>the</strong> services were conf<strong>in</strong>ed largely to major urbancentres. F<strong>in</strong>d<strong>in</strong>gs from <strong>the</strong> 1966 West Malaysia <strong>Family</strong>Survey conducted <strong>in</strong> Pen<strong>in</strong>sular Malaysia reported acontraceptive prevalence rate (CPR) of merely 8.8 percent.With <strong>the</strong> launch<strong>in</strong>g of <strong>the</strong> National <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Programme <strong>in</strong> conjunction with <strong>the</strong> First Malaysia Plan<strong>in</strong> 1966, family plann<strong>in</strong>g became an official policy. Theprogramme was aimed at improv<strong>in</strong>g maternal <strong>and</strong> childhealth <strong>and</strong> decelerat<strong>in</strong>g <strong>the</strong> rate of annual populationgrowth from 3 per cent <strong>in</strong> 1966 to 2 per cent <strong>in</strong> 1985 bysett<strong>in</strong>g targets to <strong>in</strong>crease <strong>the</strong> number of family plann<strong>in</strong>gacceptors (Noor Laily et al., 1982). The National <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Board was established <strong>in</strong> order to plan, execute<strong>and</strong> coord<strong>in</strong>ate all family plann<strong>in</strong>g activities <strong>in</strong> <strong>the</strong>country. The programme began with <strong>the</strong> provision ofcl<strong>in</strong>ical contraceptive services ma<strong>in</strong>ly <strong>in</strong> <strong>the</strong> urban areas.Subsequently, <strong>the</strong> programme was exp<strong>and</strong>ed to <strong>the</strong> ruralareas of <strong>the</strong> country through <strong>the</strong> <strong>in</strong>tegration of familyplann<strong>in</strong>g with primary health-care services of <strong>the</strong> M<strong>in</strong>istryof Health <strong>in</strong> <strong>the</strong> early 1970s.CPR <strong>in</strong>creased substantially from 8 per cent <strong>in</strong> 1966 to 36per cent <strong>in</strong> 1974 <strong>and</strong> fur<strong>the</strong>r to 52 per cent <strong>in</strong> 1984, buthas levelled off s<strong>in</strong>ce <strong>the</strong>n. Despite <strong>the</strong> stagnation <strong>in</strong> CPR,fertility has cont<strong>in</strong>ued to decl<strong>in</strong>e towards <strong>the</strong> replacementlevel. Ris<strong>in</strong>g age at marriage <strong>and</strong> <strong>in</strong>creased contraceptiveuse have been <strong>the</strong> ma<strong>in</strong> contributory factors to fertilitydecl<strong>in</strong>e.FigureEvolution of family plann<strong>in</strong>gpolicyIn review<strong>in</strong>g <strong>the</strong> population policy <strong>in</strong> 1984, <strong>the</strong> governmentcalled for a major shift from “family plann<strong>in</strong>g” to “family<strong>and</strong> human resources development”, <strong>and</strong> for achiev<strong>in</strong>g anultimate population size of 70 million by 2100. Under<strong>the</strong> New Population Policy, <strong>the</strong> National <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Board was renamed <strong>the</strong> National Population <strong>and</strong><strong>Family</strong> Development Board (NPFDB), <strong>and</strong> <strong>in</strong> 1989 wasplaced under <strong>the</strong> M<strong>in</strong>istry of National Unity <strong>and</strong> SocialDevelopment. After <strong>the</strong> dissolution of that M<strong>in</strong>istryfollow<strong>in</strong>g <strong>the</strong> 2001 general election, NPFDB was placedunder <strong>the</strong> newly created M<strong>in</strong>istry of Women, <strong>Family</strong> <strong>and</strong>Community Development.In <strong>the</strong> early stages of <strong>the</strong> national programme, <strong>in</strong>formation,education <strong>and</strong> communication (IEC) activities played animportant role <strong>in</strong> <strong>in</strong>creas<strong>in</strong>g family plann<strong>in</strong>g acceptance.However, s<strong>in</strong>ce <strong>the</strong> promulgation of <strong>the</strong> new populationpolicy <strong>and</strong> <strong>the</strong> change <strong>in</strong> <strong>the</strong> programme thrust <strong>in</strong> 1984from family plann<strong>in</strong>g to family development, familyplann<strong>in</strong>g per se has been de-emphasized <strong>and</strong> IEC activitieswere discont<strong>in</strong>ued (Tey, 2007).As <strong>the</strong> fertility rate began approach<strong>in</strong>g <strong>the</strong> replacementlevel, <strong>the</strong> government’s view on fertility changed from“too high” <strong>in</strong> 1996 to “satisfactory” <strong>in</strong> 2007. The policyon fertility has s<strong>in</strong>ce been revised from one that soughtto lower fertility to a policy with no <strong>in</strong>tervention butwith emphasis on rais<strong>in</strong>g <strong>the</strong> quality of <strong>the</strong> populationthrough education <strong>and</strong> human resources development. Inrecogniz<strong>in</strong>g <strong>the</strong> importance of <strong>the</strong> family as a social <strong>and</strong>production unit, <strong>the</strong> family’s vital role <strong>in</strong> nurtur<strong>in</strong>g futuregenerations <strong>and</strong> <strong>in</strong> car<strong>in</strong>g for older people, steps were takento start develop<strong>in</strong>g a national family policy that would gobeyond <strong>the</strong> national population policy.1Contraceptive prevalence rate for any method <strong>and</strong> modern methods <strong>in</strong> Pen<strong>in</strong>sular Malaysia60.052.254.851.950.040.030.036.026.330.330.234.420.010.00.01974 1984 1994 2004Any MethodModernSource: National Population <strong>and</strong> <strong>Family</strong> Development Board (NPFDB); Malaysian Population <strong>and</strong> <strong>Family</strong> Surveys <strong>in</strong> 1974, 1984,1994 <strong>and</strong> 2004.245

FigureTrends <strong>and</strong> patterns <strong>in</strong>contraceptive useTrends <strong>in</strong> <strong>the</strong> contraceptiveprevalence rateCPR <strong>in</strong> Pen<strong>in</strong>sular Malaysia has levelled off at around 50per cent for <strong>the</strong> past three decades (see Figure 1). In termsof modern methods, CPR <strong>in</strong>creased slightly from 30.2 percent <strong>in</strong> 1994 to 34.4 per cent <strong>in</strong> 2004. As for non-modernmethods, <strong>the</strong>re was a decrease <strong>in</strong> use from 24.6 per cent <strong>in</strong>1994 to 17.5 per cent <strong>in</strong> 2004.Method mixAlthough <strong>the</strong> oral pill has always been <strong>the</strong> most popularcontraceptive method among Malaysians, <strong>the</strong>re has beena noticeable <strong>in</strong>crease <strong>in</strong> <strong>the</strong> use of IUDs <strong>and</strong> <strong>in</strong>jectablemethods s<strong>in</strong>ce 1984. The prevalence rate for femalesterilization decl<strong>in</strong>ed from 7.6 per cent <strong>in</strong> 1984 to 6.9 percent <strong>in</strong> 1994 <strong>and</strong> 6.6 per cent <strong>in</strong> 2004, but <strong>the</strong> prevalencerate for condoms has been more ra<strong>the</strong>r erratic (see Table1).Of <strong>the</strong> non-modern methods, <strong>the</strong> rhythm method has beenby far <strong>the</strong> most popular method, with a prevalence rate ofabout 9 per cent <strong>in</strong> both 1994 <strong>and</strong> 2004. The prevalencerate for o<strong>the</strong>r non-modern methods, which <strong>in</strong>clude herbalpreparations, has decl<strong>in</strong>ed substantially s<strong>in</strong>ce 1984. Thepractice of withdrawal to prevent a pregnancy had alsobecome less common between 1994 <strong>and</strong> 2004. In <strong>the</strong>same period, while <strong>the</strong>re had been slight <strong>in</strong>crease <strong>in</strong> maleparticipation <strong>in</strong> <strong>the</strong> use of modern methods (condom),<strong>the</strong> participation of men <strong>in</strong> <strong>the</strong> use of traditional methods(withdrawal) has decl<strong>in</strong>ed.Table 2 shows that a much higher proportion of <strong>the</strong> women<strong>in</strong> Sabah <strong>and</strong> Sarawak were us<strong>in</strong>g <strong>the</strong> pill <strong>and</strong> <strong>in</strong>jection ascompared with <strong>the</strong>ir counterparts <strong>in</strong> Pen<strong>in</strong>sular Malaysia,but a lower proportion were rely<strong>in</strong>g on condoms <strong>and</strong>withdrawal. There was no significant difference <strong>in</strong> <strong>the</strong>overall CPR across <strong>the</strong> three regions.Socio-economic differentials <strong>in</strong>contraceptive useTable 3 shows <strong>the</strong> differentials <strong>in</strong> CPR across states <strong>and</strong>sociodemographic variables. CPR for Malays has alwaysbeen lower than for <strong>the</strong> o<strong>the</strong>r ma<strong>in</strong> ethnic groups, especially<strong>the</strong> Ch<strong>in</strong>ese. In 2004, CPR for modern methods was 28.2per cent for Malays, 45.6 per cent for Ch<strong>in</strong>ese <strong>and</strong> 32.2 percent for Indians.Wide variations <strong>in</strong> CPR can be observed across states.The east-coast states (where Malays make up more than90% of <strong>the</strong> population) had <strong>the</strong> lowest CPR. However, itshould be noted that <strong>the</strong>se states registered a substantial<strong>in</strong>crease <strong>in</strong> CPR between 1994 <strong>and</strong> 2004. On <strong>the</strong> o<strong>the</strong>rh<strong>and</strong>, CPR for modern methods decl<strong>in</strong>ed significantly <strong>in</strong>some nor<strong>the</strong>rn states dur<strong>in</strong>g <strong>the</strong> same period.Urbanization <strong>and</strong> education have had positive effects onCPR. However, <strong>the</strong> differentials <strong>in</strong> CPR between womenFigure1Contraceptive prevalence rate <strong>in</strong> Sabah <strong>and</strong> Sarawak57.86050.150.45044.437.44030.1302053.042.310SABAHSARAWAK01989 2004 1989 2004Any MethodModernSource: National Population <strong>and</strong> <strong>Family</strong> Development Board (NPFDB); Malaysian Population <strong>and</strong> <strong>Family</strong> Surveys <strong>in</strong> 1992 <strong>and</strong> 2004.246

<strong>in</strong> urban <strong>and</strong> rural areas <strong>and</strong> across educational categoriesare much less pronounced than ethnic differentials.methods <strong>in</strong>creased among women aged 30-39 <strong>and</strong> thosewith 2-3 children.CPR for any method decl<strong>in</strong>ed for women <strong>in</strong> all age groups<strong>and</strong> parity between 1994 <strong>and</strong> 2004, but CPR for modernTableTable1TableTable2247

TableTable3Unmet need for contraceptionUnmet need for modern contraception for <strong>the</strong> purpose oflimit<strong>in</strong>g births <strong>in</strong>creased from 25 per cent <strong>in</strong> 1988 to 36 percent <strong>in</strong> 2004, <strong>and</strong> all subgroups <strong>and</strong> states registered verysignificant <strong>in</strong>creases <strong>in</strong> unmet need, except for those aged30-39 years. Paradoxically, while <strong>the</strong> Ch<strong>in</strong>ese <strong>and</strong> Indianshad a much higher CPR than Malays, <strong>the</strong>y also had higherunmet need for contraception, as shown <strong>in</strong> Table 4. Thismay be attributed to a higher proportion want<strong>in</strong>g to stopchildbear<strong>in</strong>g among Ch<strong>in</strong>ese (80%) <strong>and</strong> Indians (73%) ascompared with Malays (48%).The level of unmet need for contraception <strong>in</strong> Sabah<strong>and</strong> Sarawak was slightly lower than that of Pen<strong>in</strong>sularMalaysia. The Ch<strong>in</strong>ese <strong>in</strong> Sabah <strong>and</strong> Sarawak also hadhigher unmet need for contraception compared withMalays (Table 5).The urban-rural differential <strong>in</strong> unmet need for contraception248

TableTable4is not very pronounced. However, those with a primary levelof education or no education had much higher unmet needfor contraception as compared with more highly educatedwomen <strong>and</strong> this was true for all <strong>the</strong> three regions. Unmetneed for contraception was much higher among older <strong>and</strong>higher parity women (see Tables 4 <strong>and</strong> 5).Tables 6-8 show that <strong>in</strong> 2004 unmet need for moderncontraception for birth limitation was ra<strong>the</strong>r low amongwomen younger than 30 years of age, <strong>and</strong> among thosewith fewer than 2 children. However, women 40 years<strong>and</strong> older had a very high level of unmet need for moderncontraception for birth limitation, regardless of <strong>the</strong> number249

TableTable5TableTable6TableTable7250

of children <strong>the</strong>y had. Close to two thirds of women aged40 <strong>and</strong> older hav<strong>in</strong>g two or more children had unmet needfor modern contraception.Reasons for not us<strong>in</strong>g or forstopp<strong>in</strong>g use of contraceptivemethodTable 9 shows that more than half of non-users <strong>in</strong>Pen<strong>in</strong>sular Malaysia <strong>in</strong> <strong>the</strong> 1994 survey mentionedwant<strong>in</strong>g to have children as a reason for not us<strong>in</strong>g acontraceptive method, but this had decl<strong>in</strong>ed to 39.3 percent <strong>in</strong> <strong>the</strong> 2004 survey. There was a significant <strong>in</strong>crease <strong>in</strong><strong>the</strong> proportion who mentioned “fear of side effects” as <strong>the</strong>irreason for not us<strong>in</strong>g a method, <strong>and</strong> this became <strong>the</strong> secondmost important reason <strong>in</strong> 2004. It is noteworthy that<strong>the</strong> percentage who had mentioned husb<strong>and</strong>’s objection<strong>in</strong>creased ra<strong>the</strong>r substantially from 8 per cent <strong>in</strong> 1994 to12.6 per cent <strong>in</strong> 2004.In <strong>the</strong>se sample surveys, no respondent had specificallymentioned religion as pos<strong>in</strong>g a barrier to contraceptiveuse. However, it is possible that religious considerations,which may be limited to pockets of <strong>the</strong> population not<strong>in</strong>cluded <strong>in</strong> <strong>the</strong>se sample surveys, may expla<strong>in</strong> partly <strong>the</strong>lower contraceptive prevalence rate among Malays.Compared with <strong>the</strong>ir counterparts <strong>in</strong> Pen<strong>in</strong>sular Malaysia,women <strong>in</strong> Sabah <strong>and</strong> Sarawak were more likely to mentionwant<strong>in</strong>g more children as <strong>the</strong> reason for not us<strong>in</strong>g acontraceptive method, but were less likely to mentionedhusb<strong>and</strong>’s objection. Fear of side effects was an importantreason for not us<strong>in</strong>g a contraceptive <strong>in</strong> all <strong>the</strong> threeregions.The percentage of women stopp<strong>in</strong>g contraceptive use<strong>in</strong> order to become pregnant <strong>and</strong> have children as <strong>the</strong>irreason for stopp<strong>in</strong>g contraceptive use decreased from38.4 per cent <strong>in</strong> 1994 to 27.4 per cent <strong>in</strong> 2004. However,side effects, discomfort caused by method use, advice bya medical professional <strong>and</strong> husb<strong>and</strong>’s objection becamean important reason for stopp<strong>in</strong>g contraceptive use, asshown <strong>in</strong> Table 10. Husb<strong>and</strong>’s objection constituted arelatively less important reason for women to stop us<strong>in</strong>g amethod. A small proportion of women mentioned methodfailure as <strong>the</strong>ir reason for stopp<strong>in</strong>g contraceptive use. Thediscont<strong>in</strong>uation rate for all methods was calculated at 17.2per cent (computed data from <strong>the</strong> Malaysian Population<strong>and</strong> <strong>Family</strong> Survey, 2004).Availability of contraceptiveservices/<strong>in</strong>formation <strong>and</strong>commodity securitySources of contraceptive services <strong>and</strong><strong>in</strong>formationUnder <strong>the</strong> national programme, family plann<strong>in</strong>g services<strong>and</strong> <strong>in</strong>formation are widely available through a widenetwork of cl<strong>in</strong>ics under <strong>the</strong> M<strong>in</strong>istry of Health, NPFDB<strong>and</strong> <strong>the</strong> Federation of Reproductive Health Associationsof Malaysia (FRHAM). Private hospitals/cl<strong>in</strong>ics <strong>and</strong>commercial outlets also provide family plann<strong>in</strong>g services.NPFDB provides a “cafeteria” type of service to ensurethat clients receive <strong>the</strong> widest possible choices of safe,effective, affordable <strong>and</strong> acceptable methods at all its 55cl<strong>in</strong>ics throughout <strong>the</strong> country. At <strong>the</strong> same time, NPFDBcomplements <strong>the</strong> M<strong>in</strong>istry of Health’s family plann<strong>in</strong>gservices by conduct<strong>in</strong>g motivational talks <strong>in</strong> maternitywards. NPFDB also extends its services at <strong>the</strong> grass-rootslevel through health camps or special events as part of itscommunity service. <strong>Family</strong> plann<strong>in</strong>g services at NPFDBheadquarters was awarded ISO 9001:2008 accreditation.NPFDB launched an outreach programme called“LPPKN@komuniti” <strong>in</strong> <strong>the</strong> middle of 2010. This is aprogramme under National Key Result Areas targeted atfamilies with a low household <strong>in</strong>come. This programme,which is designed to <strong>in</strong>crease knowledge <strong>and</strong> skills tostreng<strong>the</strong>n <strong>the</strong> family <strong>in</strong>stitution, <strong>in</strong>corporates familyplann<strong>in</strong>g services <strong>and</strong> <strong>in</strong>formation <strong>in</strong> its two-dayprogramme. Targeted families <strong>in</strong> all states were identifiedwith <strong>the</strong> assistance of <strong>the</strong> Welfare Department.Marg<strong>in</strong>alized urban poor women are served by six mobileNPFDB cl<strong>in</strong>ics. Each mobile cl<strong>in</strong>ic is a renovated bus fittedwith two consultation rooms; <strong>the</strong>y are well equipped withall <strong>the</strong> necessary cl<strong>in</strong>ical equipment. It is envisaged thatthis programme will be exp<strong>and</strong>ed to all <strong>the</strong> o<strong>the</strong>r statesthroughout <strong>the</strong> country.The M<strong>in</strong>istry of Health <strong>in</strong>troduced guidel<strong>in</strong>es on WHOMedical Eligibility Criteria for Contraceptive Use <strong>and</strong> SelectedPractice Recommendations for Contraceptive Use as ameans to ma<strong>in</strong>ta<strong>in</strong> high-quality family plann<strong>in</strong>g services.Tra<strong>in</strong><strong>in</strong>g workshops were conducted at all levels of care totra<strong>in</strong> all government health care providers (<strong>in</strong>clud<strong>in</strong>g those<strong>in</strong> NPFDB) on <strong>the</strong> use of <strong>the</strong> guidel<strong>in</strong>es. The guidel<strong>in</strong>eswere translated <strong>in</strong>to <strong>the</strong> Malay language <strong>and</strong> customizedfor better underst<strong>and</strong><strong>in</strong>g <strong>and</strong> use by <strong>the</strong> providers.Tables 11-13 show that a sizable proportion of contraceptiveusers obta<strong>in</strong>ed <strong>the</strong>ir supplies from private hospitals<strong>and</strong> cl<strong>in</strong>ics as well as pharmacies <strong>in</strong> 2004. In Pen<strong>in</strong>sular251

TableTable8TableTable9Malaysia, about three quarters of women who underwentsterilization had <strong>the</strong> procedure performed at privatehospitals <strong>and</strong> cl<strong>in</strong>ics, <strong>and</strong> close to 6 of every 10 pill usersobta<strong>in</strong>ed <strong>the</strong>ir supplies from non-programme sources.Even among married couples, <strong>the</strong> majority of condom usersobta<strong>in</strong>ed <strong>the</strong>ir condom supplies from commercial sources.It should be mentioned that <strong>the</strong>re is no law or regulation<strong>in</strong> Malaysia prohibit<strong>in</strong>g <strong>the</strong> sale of condoms to unmarriedpersons.Commodity securityA partnership <strong>and</strong> collaborative system is <strong>in</strong> place <strong>in</strong>volv<strong>in</strong>gNPFDB, <strong>the</strong> M<strong>in</strong>istry of Health <strong>and</strong> FRHAM <strong>in</strong> provid<strong>in</strong>gfamily plann<strong>in</strong>g <strong>and</strong> o<strong>the</strong>r reproductive health services.The M<strong>in</strong>istry of Health <strong>in</strong>tegrates family plann<strong>in</strong>g services<strong>in</strong>to rural health services, while NPFDB, FRHAM <strong>and</strong><strong>the</strong> private sector provide for family plann<strong>in</strong>g services <strong>in</strong>urban areas.The availability of a range of contraceptive methods iscentral to <strong>the</strong> quality of services <strong>in</strong> <strong>the</strong> family plann<strong>in</strong>gprogramme. The three key agencies (M<strong>in</strong>istry of Health,NPFDB <strong>and</strong> FRHAM) are <strong>in</strong>volved <strong>in</strong> family plann<strong>in</strong>gefforts nationwide <strong>and</strong> all three have <strong>the</strong>ir own system/supply cha<strong>in</strong>s, from <strong>the</strong> procurement (<strong>in</strong>clud<strong>in</strong>g storage)of contraceptives to <strong>the</strong> distribution/dissem<strong>in</strong>ation offamily plann<strong>in</strong>g commodities/contraceptives to users.For <strong>the</strong> M<strong>in</strong>istry, logistics management of <strong>the</strong> familyplann<strong>in</strong>g programme is decentralized to all respective statehealth departments: <strong>the</strong> M<strong>in</strong>istry allocates specific budgetsto state health departments for purchas<strong>in</strong>g contraceptivesupplies. The amount depends on <strong>the</strong> state’s requirements,which vary accord<strong>in</strong>g to <strong>the</strong> forecast number of femaleclients of reproductive age. Each state programmemanager is responsible for manag<strong>in</strong>g his or her familyplann<strong>in</strong>g logistics systems, from <strong>the</strong> po<strong>in</strong>t of purchas<strong>in</strong>g<strong>and</strong> deliver<strong>in</strong>g supplies to <strong>the</strong> health cl<strong>in</strong>ics, which are <strong>the</strong>service delivery po<strong>in</strong>ts. Data are collected on <strong>the</strong> client’scontraceptive <strong>in</strong>formation <strong>and</strong> on stock-keep<strong>in</strong>g.NPFDB forecasts its contraceptive requirements based onprevious <strong>and</strong> current performance <strong>in</strong> terms of contraceptiveusage. Procurement is carried out centrally every threeyears, with staggered deliveries every six months <strong>in</strong> orderto ma<strong>in</strong>ta<strong>in</strong> a cont<strong>in</strong>uous fresh supply to all three states.Additional requests are allowable, subject to approval.Operational budgets for family plann<strong>in</strong>g services are ma<strong>in</strong>lyfrom <strong>the</strong> Board’s annual operational budget, which as252

TableTable10TableTable11TableTable12253

previously mentioned is based on forecast needs. NPFDBrarely experiences a shortage of contraceptive suppliesas purchases are made from reliable <strong>and</strong> establishedsuppliers.While <strong>the</strong> M<strong>in</strong>istry <strong>and</strong> NPFDB may not experiencea shortage <strong>in</strong> terms of supply (as <strong>the</strong>se are undergovernment allocation), FRHAM may encounterdifficulties <strong>in</strong> susta<strong>in</strong><strong>in</strong>g supplies, as <strong>the</strong> <strong>International</strong>Planned Parenthood Federation (IPPF), <strong>the</strong> ma<strong>in</strong> sourceof fund<strong>in</strong>g for contraceptives for FRHAM, <strong>in</strong> 2010 startedimpos<strong>in</strong>g a gradual decrease of 30 per cent each year <strong>in</strong> itsfund<strong>in</strong>g for <strong>the</strong> purchase of contraceptives.Special target groups <strong>and</strong>l<strong>in</strong>kages with o<strong>the</strong>r reproductivehealth programmesYouthsThe national programme does not provide contraceptiveservices to <strong>the</strong> un-married. With ris<strong>in</strong>g marriage <strong>and</strong> <strong>the</strong>out-migration of young people to cities, adolescent fertilityhas become a major concern <strong>in</strong> Malaysia ow<strong>in</strong>g to <strong>the</strong>mount<strong>in</strong>g problems of youth sexuality, teenage pregnancy<strong>and</strong> ab<strong>and</strong>oned babies. These problems arise largely as aresult of <strong>the</strong> lack of reproductive health knowledge amongyoung people.The 2004 Malaysian Population <strong>and</strong> <strong>Family</strong> Survey showsthat a little less than half <strong>the</strong> young people aged 13-24had heard of at least one family plann<strong>in</strong>g method, <strong>and</strong><strong>the</strong> response to <strong>the</strong> question about methods varied from26.9 per cent among those younger than 15 years of ageto about 60 per cent among those aged 20-24. A higherproportion of young females than males had heard offamily plann<strong>in</strong>g methods. The lowest proportion of thosewho had heard of family plann<strong>in</strong>g methods among <strong>the</strong>ethnic groups comprised young Indians. The proportionof young people who had knowledge of family plann<strong>in</strong>gmethods was significantly higher <strong>in</strong> urban areas comparedwith rural areas.The pill was <strong>the</strong> most commonly cited method, followedby condoms. Despite <strong>the</strong> availability of condoms <strong>in</strong>pharmacies <strong>and</strong> provision shops, only one <strong>in</strong> four youngpeople had heard about this method. The rhythm methodwas mentioned by a mere 2 per cent of <strong>the</strong> young people <strong>in</strong><strong>the</strong> survey (see Table 14).Between 2005 <strong>and</strong> 2007, <strong>the</strong> adolescent fertility rates forMalaysia did not change much. The age-specific fertilityrate for those aged 15-19 years decl<strong>in</strong>ed slightly from 13.8per 1,000 women <strong>in</strong> 2004, 13.5 <strong>in</strong> 2005, 13.1 <strong>in</strong> 2006 <strong>and</strong>12.8 <strong>in</strong> 2007.To address social issues among youth with regard topremarital sexual <strong>in</strong>tercourse, ab<strong>and</strong>oned babies, unwantedpregnancies <strong>and</strong> HIV/AIDS, <strong>the</strong> government developedvarious programmes for youth, such as <strong>the</strong> kafe@TEENprogramme <strong>and</strong> PROSTAR (Programme for YouthLiv<strong>in</strong>g without AIDS). In <strong>the</strong> kafe@TEEN programme,dissem<strong>in</strong>ation of reproductive health <strong>in</strong>formation,provid<strong>in</strong>g necessary assertive <strong>and</strong> protective skills, isemphasized; kafe@TEEN centres also provide cl<strong>in</strong>icalservices, counsell<strong>in</strong>g services <strong>and</strong> recreational activities.Teen educators who run <strong>the</strong> centres also visit schools,higher learn<strong>in</strong>g centres <strong>and</strong> communities for outreachprogramme. NPFDB is plann<strong>in</strong>g to exp<strong>and</strong> <strong>the</strong> kafe@TEEN programme throughout <strong>the</strong> country by build<strong>in</strong>gone kafe@TEEN youth centre <strong>in</strong> each state.IEC programmes are be<strong>in</strong>g developed for adolescentswhere education materials <strong>and</strong> modules are used forskills development <strong>and</strong> preventive measures to deal withreproductive health issues. Two modules have beendeveloped to empower adolescents with regard to <strong>the</strong>irreproductive health knowledge <strong>and</strong> “soft skills”, such asassess<strong>in</strong>g risk <strong>and</strong> h<strong>and</strong>l<strong>in</strong>g negative peer pressure. Thesemodules provide a holistic approach <strong>and</strong> are molded to suitMalaysian societal values, cultures <strong>and</strong> religious aspects.One of <strong>the</strong> modules, “I Am <strong>in</strong> Control”, was developedunder a UNFPA project with special focus on reproductiveheath. The o<strong>the</strong>r module, “Kesejahteraan Hidup” (Wellness<strong>in</strong> Life), <strong>in</strong>cludes o<strong>the</strong>r components, namely gender, family<strong>and</strong> liv<strong>in</strong>g without violence.Concurrently, youth portals were developed for provid<strong>in</strong>geasy access to reproductive health knowledge through<strong>the</strong> Internet. Two such portals are portal kafe@TEENdeveloped by NPFDB <strong>and</strong> <strong>the</strong> My Health portal developedby <strong>the</strong> M<strong>in</strong>istry of Health.FRHAM as <strong>the</strong> key NGO <strong>in</strong> <strong>the</strong> field of RH/FP hasdeveloped several tra<strong>in</strong><strong>in</strong>g modules for young people.The “Reproductive Health Adolescent Module” has beenutilized by <strong>the</strong> M<strong>in</strong>istry of Education <strong>and</strong> some schools,while <strong>the</strong> “Perjalanan Kehidupan” (Life’s Journey), which<strong>in</strong>corporates more elements on HIV, is be<strong>in</strong>g used for<strong>in</strong>terventions at juvenile homes throughout <strong>the</strong> country.There are youth-friendly centres/cl<strong>in</strong>ics <strong>in</strong> 11 FRHAMcl<strong>in</strong>ics where <strong>in</strong>formation, para-counsell<strong>in</strong>g, sexual <strong>and</strong>reproductive health <strong>and</strong> rights education <strong>and</strong> services areavailable to young people. Cl<strong>in</strong>ical <strong>and</strong> referral services arealso provided where appropriate.Women at <strong>the</strong> end of reproductionCurrently no special programme targets women aged40-49, i.e., those who are at <strong>the</strong> end of <strong>the</strong>ir reproductivelife. In view of <strong>the</strong> high unmet need for contraceptionamong <strong>the</strong>se “older women”, as shown <strong>in</strong> Tables 4 <strong>and</strong> 5,<strong>the</strong>se women need special attention to prevent unwanted254

TableTable13TableTable14Any methodsPill IUD Injection Condom SterilizationRhythmTableTable15255

TableTable16births <strong>and</strong> abortion. The reproductive health risks amongolder women are known to be higher than for youngerwomen. For <strong>in</strong>stance, while women aged 40-44 <strong>and</strong> 45-49contributed, respectively, only 5.1 <strong>and</strong> 0.4 per cent of <strong>the</strong>total births, <strong>the</strong>y accounted for 12.0 <strong>and</strong> 1.6 per cent of <strong>the</strong>maternal deaths, as shown <strong>in</strong> Table 15.L<strong>in</strong>kages of family plann<strong>in</strong>gwith o<strong>the</strong>r reproductive healthprogrammesIn <strong>the</strong> M<strong>in</strong>istry of Health, family plann<strong>in</strong>g services arealready <strong>in</strong>tegrated with o<strong>the</strong>r services, namely maternal<strong>and</strong> child care services, <strong>and</strong> outpatient care, <strong>in</strong>clud<strong>in</strong>gfor HIV <strong>and</strong> sexually transmitted <strong>in</strong>fections (STIs). For<strong>in</strong>stance, women who are be<strong>in</strong>g followed up for medicalreasons <strong>in</strong> outpatient care are also counseled on familyplann<strong>in</strong>g. HIV <strong>and</strong> STI education <strong>and</strong> counsell<strong>in</strong>g aregiven dur<strong>in</strong>g family plann<strong>in</strong>g visits. S<strong>in</strong>ce its <strong>in</strong>ception,NPFDB has <strong>in</strong>corporated STI management <strong>in</strong> its familyplann<strong>in</strong>g services; however, it is only recently that HIV<strong>in</strong>formation <strong>and</strong> counsell<strong>in</strong>g have been <strong>in</strong>troduced.FRHAM has also played a substantial role <strong>in</strong>implement<strong>in</strong>g HIV/AIDS-related programmes s<strong>in</strong>ce <strong>the</strong>launch<strong>in</strong>g of <strong>the</strong> first country report on <strong>the</strong> MillenniumDevelopment Goals (MDGs) <strong>in</strong> 2005. Although sexual<strong>and</strong> reproductive health (SRH) <strong>and</strong> family plann<strong>in</strong>g havebeen <strong>the</strong> core bus<strong>in</strong>ess of FRHAM, <strong>the</strong>re are some shared<strong>and</strong> common areas of concern with regard to both SRH/FP <strong>and</strong> HIV/AIDS; some l<strong>in</strong>kages between <strong>the</strong> two areashave been promoted <strong>and</strong> <strong>in</strong>tegrated wherever necessary<strong>and</strong> possible. FRHAM has been promot<strong>in</strong>g SRH <strong>and</strong>HIV/AIDS education at state FPAs <strong>in</strong> deliver<strong>in</strong>g <strong>the</strong>irprogrammes <strong>and</strong> services for <strong>the</strong> general public, as well asfor vulnerable population groups (sex workers, men whohave sex with men, <strong>in</strong>ject<strong>in</strong>g drug users, spouses of suchpersons, transsexuals <strong>and</strong> o<strong>the</strong>rs). Based on <strong>the</strong> UNFPA<strong>and</strong> World Health Organization study on streng<strong>the</strong>n<strong>in</strong>gHIV <strong>and</strong> SRH l<strong>in</strong>kages <strong>in</strong> Malaysia (August 2010),FRHAM is currently try<strong>in</strong>g to network with HIV/AIDSorganizations on promot<strong>in</strong>g fur<strong>the</strong>r <strong>and</strong> more mean<strong>in</strong>gfull<strong>in</strong>kages.Role of <strong>in</strong>ternational agencies<strong>and</strong> <strong>in</strong>ternational cooperationForeign assistance played an important role <strong>in</strong> <strong>the</strong> earlystages of <strong>the</strong> Malaysian family plann<strong>in</strong>g programme.<strong>International</strong> agencies <strong>and</strong> foreign foundations, suchas <strong>the</strong> Ford Foundation, Population <strong>Council</strong>, Swedish<strong>International</strong> Development Cooperation Agency <strong>and</strong>United Nations Children’s Fund, provided various typesof assistance. With <strong>the</strong> implementation of <strong>the</strong> PopulationProject (1973-1978) <strong>and</strong> <strong>the</strong> Population <strong>and</strong> <strong>Family</strong>Health Project (1979-1982), UNFPA <strong>and</strong> <strong>the</strong> WorldBank also furnished significant f<strong>in</strong>ancial <strong>and</strong> technicalassistance for <strong>the</strong> implementation of <strong>the</strong> population, familyplann<strong>in</strong>g <strong>and</strong> family health programmes (Noor Lailyet al., 1982). NPFDB has also been collaborat<strong>in</strong>g with256

o<strong>the</strong>r <strong>in</strong>ternational agencies, such IPPF, <strong>the</strong> <strong>International</strong><strong>Council</strong> on Management of Population Programmes,Japanese Organization for <strong>International</strong> Cooperation<strong>in</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>, <strong>Asia</strong>n Forum of Parliamentarianson Population <strong>and</strong> Development, <strong>Asia</strong>n Institute forDevelopment Communication, Pan-<strong>Pacific</strong> <strong>and</strong> Sou<strong>the</strong>ast<strong>Asia</strong> Women’s Association <strong>and</strong> <strong>Asia</strong>n-<strong>Pacific</strong> Resource<strong>and</strong> Research Centre for Women.Malaysia has been participat<strong>in</strong>g actively <strong>in</strong> <strong>in</strong>ternationalforums on population issues; for example, it participatesactively <strong>in</strong> <strong>the</strong> ASEAN-Australian PopulationProgramme, among o<strong>the</strong>rs. UNFPA Malaysia has playeda bridg<strong>in</strong>g role <strong>in</strong> some of <strong>the</strong> pioneer<strong>in</strong>g work done <strong>in</strong> <strong>the</strong>country on population, <strong>the</strong> reproductive health of youngpeople <strong>and</strong> gender issues. UNFPA support has enabledparticipat<strong>in</strong>g agencies to <strong>in</strong>itiate new programmes <strong>and</strong>strategies, streng<strong>the</strong>n exist<strong>in</strong>g ones, develop expertise <strong>and</strong>capability (capacity-build<strong>in</strong>g) <strong>and</strong> foster network<strong>in</strong>g <strong>and</strong>partnership <strong>in</strong> implement<strong>in</strong>g programmes to address areasthat are of grow<strong>in</strong>g concern. The assistance of UNFPA hasmade it possible for NGOs to implement projects that areconsidered sensitive, such as those <strong>in</strong>volv<strong>in</strong>g HIV <strong>in</strong>fection<strong>and</strong> sex workers.UNFPA began provid<strong>in</strong>g assistance to Malaysia <strong>in</strong> 1973for its national family plann<strong>in</strong>g programme. In addition tof<strong>in</strong>ancial assistance, UNFPA has been provid<strong>in</strong>g technicaladvisory services <strong>and</strong> support for strategic development <strong>in</strong>population-related areas, focus<strong>in</strong>g on family/reproductivehealth <strong>and</strong> gender issues. From 1973 through 1996,UNFPA supported programmes <strong>and</strong> projects for RH/FP, tra<strong>in</strong><strong>in</strong>g, research <strong>and</strong> capacity-build<strong>in</strong>g activities,as well as o<strong>the</strong>r project areas related to population <strong>and</strong>development. In view of Malaysia’s progress towardsbecom<strong>in</strong>g self-reliant <strong>and</strong> its success with populationstrategies, <strong>the</strong> assistance provided by UNFPA s<strong>in</strong>ce 1997has been directed towards selected areas of <strong>in</strong>tervention,particularly <strong>in</strong> <strong>the</strong> area of reproductive health, as prescribed<strong>in</strong> <strong>the</strong> ICPD Programme of Action. The areas covered<strong>in</strong>clude family plann<strong>in</strong>g; maternal <strong>and</strong> child health; family<strong>and</strong> reproductive health; population <strong>and</strong> development;population education; population studies <strong>and</strong> surveyresearch; tra<strong>in</strong><strong>in</strong>g of staff, women <strong>and</strong> youth; sett<strong>in</strong>g upspecialist <strong>and</strong> research centres; upgrad<strong>in</strong>g <strong>in</strong>frastructure<strong>and</strong> facilities; community participation; <strong>and</strong> South-Southcooperation.In 2004, UNFPA funded <strong>the</strong> project entitled “South-SouthCooperation <strong>in</strong> Reproductive Health <strong>in</strong> Malaysia”, whichwas aimed at <strong>in</strong>creas<strong>in</strong>g <strong>the</strong> utilization of reproductivehealth services through <strong>the</strong> shar<strong>in</strong>g of knowledge <strong>and</strong>experience with<strong>in</strong> countries that are members of <strong>the</strong>Association of Sou<strong>the</strong>ast <strong>Asia</strong>n Nations (ASEAN). It wasalso aimed at streng<strong>the</strong>n<strong>in</strong>g <strong>the</strong> capacity of <strong>the</strong> agencies<strong>in</strong>volved, particularly NPFDB, M<strong>in</strong>istry of Health <strong>and</strong>FRHAM, to organize, manage <strong>and</strong> monitor broader,<strong>in</strong>tegrated reproductive health services.A regional technical meet<strong>in</strong>g <strong>and</strong> regional tra<strong>in</strong><strong>in</strong>g workshopheld <strong>in</strong> December 2004 contributed to <strong>the</strong> shar<strong>in</strong>g ofexperience <strong>and</strong> <strong>the</strong> tra<strong>in</strong><strong>in</strong>g of programme managers/service providers from ASEAN countries <strong>and</strong> Uzbekistanon <strong>the</strong> key elements of reproductive health at <strong>the</strong> primarycarelevel. In summary, many of <strong>the</strong> participants learnednew strategies for streng<strong>the</strong>n<strong>in</strong>g <strong>the</strong>ir capacity <strong>in</strong> plann<strong>in</strong>g,manag<strong>in</strong>g <strong>and</strong> implement<strong>in</strong>g RH services at <strong>the</strong> primarycarelevel.Impact of <strong>the</strong> national familyplann<strong>in</strong>g programme on fertilitytrendsFertility <strong>in</strong> Pen<strong>in</strong>sular Malaysia decl<strong>in</strong>ed sharply from 5.7children per woman <strong>in</strong> <strong>the</strong> mid-1960s to 4.2 by <strong>the</strong> mid-1970s, follow<strong>in</strong>g <strong>the</strong> implementation of <strong>the</strong> national familyplann<strong>in</strong>g programme.The total fertility rate (TFR) cont<strong>in</strong>ued to decl<strong>in</strong>e from3.3 <strong>in</strong> 1995 to 3.0 <strong>in</strong> 2000 <strong>and</strong> 2.3 <strong>in</strong> 2006, despitestagnation <strong>in</strong> CPR. This can be expla<strong>in</strong>ed partly by <strong>the</strong>ris<strong>in</strong>g age at first marriage. Data from population censusesshow that <strong>the</strong> s<strong>in</strong>gulate mean age at marriage (SMAM)for Malaysian women has been <strong>in</strong>creas<strong>in</strong>g from 22.0 years<strong>in</strong> 1970 to 24.8 years <strong>in</strong> 1991 <strong>and</strong> 25.1 years <strong>in</strong> 2000. In2000, SMAM for women was highest at 27 years among<strong>the</strong> Ch<strong>in</strong>ese population <strong>and</strong> lowest at 24.8 years amongMalays. The proportion of women <strong>in</strong> <strong>the</strong> age group 30-34who had never been married also <strong>in</strong>creased from 6 per cent<strong>in</strong> 1970 to 13 per cent <strong>in</strong> 2000, with <strong>the</strong> Ch<strong>in</strong>ese hav<strong>in</strong>g<strong>the</strong> highest proportion at 18 per cent.Table 16 shows that fertility among women aged 40 <strong>and</strong>older has fallen to a very low level, <strong>and</strong> those <strong>in</strong> <strong>the</strong>ir thirtieshave also registered significant decl<strong>in</strong>e. Fertility decl<strong>in</strong>e hasoccurred <strong>in</strong> all age groups <strong>and</strong> among all ethnic groups.Low CPR <strong>and</strong> low TFR could <strong>in</strong>dicate <strong>the</strong> possibility of<strong>in</strong>creased abortions, but this rema<strong>in</strong>s speculative as dataon abortion are not available.The impact of contraceptive use on fertility can be assessedby compar<strong>in</strong>g <strong>the</strong> CPR <strong>and</strong> fertility levels of differentsubgroups. In Malaysia, fertility rates are much loweramong subgroups that have higher CPR (<strong>the</strong> non-Malays<strong>and</strong> <strong>the</strong> better educated population).CPR among Malays has always been lower than that ofnon-Malays, <strong>and</strong> this is reflected <strong>in</strong> <strong>the</strong> fertility differentials,as shown <strong>in</strong> Figure 3. Among <strong>the</strong> Malays <strong>and</strong> Ch<strong>in</strong>ese, <strong>the</strong>effects of <strong>in</strong>creased contraceptive use on <strong>the</strong> fertility levelover <strong>the</strong> period 1974-2004 is obvious, but TFR for Indians257

FigureFigure3TRF54.5Scatter plots of total fertility rate with contraceptive prevalence rate, by ethnic group, 1974 <strong>and</strong> 2004,Pen<strong>in</strong>sular MalaysiaMalay 1974Contraceptive prevalence rate (%)43.5India 1974Ch<strong>in</strong>ese 197432.5Malay 200421.510.5India 2004Ch<strong>in</strong>ese 2004020 30 40 50 60 70Source: National Population <strong>and</strong> <strong>Family</strong> Development Board (NPFDB); Malaysian Population <strong>and</strong> <strong>Family</strong> Surveys <strong>in</strong> 1974, 1984,1994 <strong>and</strong> 2004.also decl<strong>in</strong>ed sharply despite <strong>the</strong> ra<strong>the</strong>r modest <strong>in</strong>crease <strong>in</strong><strong>the</strong>ir CPR over <strong>the</strong> same period.A correlation analysis between CPR <strong>and</strong> TFR at <strong>the</strong> statelevel shows a correlation ratio of –.72. The more developedstates generally have a higher CPR <strong>and</strong> lower TFR. Thetwo east-coast states (Kelantan <strong>and</strong> Terengganu) have <strong>the</strong>lowest CPR (see Table 3) <strong>and</strong> highest TFR at 4.3 <strong>and</strong> 3.7respectively.Emerg<strong>in</strong>g issues <strong>and</strong>recommendationsAs part of its efforts to monitor <strong>the</strong> implementation of <strong>the</strong>national family plann<strong>in</strong>g <strong>and</strong> development programmes,NPFDB has conducted Malaysian Population <strong>and</strong> <strong>Family</strong>Surveys <strong>in</strong> 1974, 1984, 1994 <strong>and</strong> 2004. Many o<strong>the</strong>rsmaller-scale surveys on specific topics, such as adolescentsexuality, <strong>in</strong>ternational migration <strong>and</strong> <strong>in</strong>fertility, have alsobeen conducted. NPFDB recently conducted an assessmentof <strong>the</strong> implementation of ICPD+10 (NPFDB, 2005)<strong>and</strong> a second population strategic plan (unpublished). Amid-term review of <strong>the</strong> UNFPA Country Programmefor Malaysia (2008-2012) has just been completed (Tey,2010). These reviews <strong>and</strong> assessments have highlightedseveral emerg<strong>in</strong>g issues that warrant attention.The stagnation <strong>in</strong> CPR <strong>and</strong> <strong>the</strong> <strong>in</strong>crease <strong>in</strong> unmet needshow that <strong>the</strong>re is a need to revitalize family plann<strong>in</strong>g <strong>in</strong>order to prevent unplanned/unwanted births <strong>and</strong> <strong>in</strong>ducedabortion, <strong>in</strong> l<strong>in</strong>e with <strong>the</strong> targets of MDGs. The lowlevel of contraceptive use may have resulted <strong>in</strong> <strong>in</strong>creasedabortion among married as well as unmarried women.<strong>Family</strong> plann<strong>in</strong>g <strong>and</strong> reproductive health services shouldbe targeted at <strong>the</strong> underserved <strong>and</strong> <strong>the</strong> disadvantaged,<strong>in</strong>clud<strong>in</strong>g foreign migrants <strong>and</strong> those <strong>in</strong> remote areas ofSabah <strong>and</strong> Sarawak. Improved family plann<strong>in</strong>g serviceswould lead to a reduction <strong>in</strong> maternal mortality, which is<strong>the</strong> aim of Goal 5 of MDGs. In this regard, specializedservices are needed, such as treatment of <strong>in</strong>fertility,reproductive tract <strong>in</strong>fection, sexually transmitted diseases,menopause <strong>and</strong> o<strong>the</strong>r reproductive health conditions; <strong>in</strong>addition cancer screen<strong>in</strong>g needs to be made more accessible<strong>and</strong> affordable to <strong>the</strong> public. The private sector should beencouraged to play an important role <strong>in</strong> this regard, asmany are rely<strong>in</strong>g on such services.To improve reproductive health <strong>and</strong> to br<strong>in</strong>g <strong>the</strong> benefitsof planned parenthood <strong>and</strong> to a wider segment of <strong>the</strong>population, programme adm<strong>in</strong>istrators should pay specialattention to <strong>the</strong> follow<strong>in</strong>g target groups:Those with unmet need for contraception <strong>in</strong> orderto space childbear<strong>in</strong>g, <strong>and</strong> to prevent unwanted ormistimed births;Husb<strong>and</strong>s/males who are apa<strong>the</strong>tic to <strong>the</strong> benefits ofplanned parenthood;Marg<strong>in</strong>alized groups who may lack knowledge of <strong>and</strong>access to family plann<strong>in</strong>g;Users of traditional methods;258

Foreign workers.The method mix shows that male participation <strong>in</strong> familyplann<strong>in</strong>g is still very low. More concerted efforts are neededto encourage <strong>and</strong> facilitate <strong>the</strong> active participation of males,<strong>and</strong> to reduce <strong>the</strong>ir objection to <strong>the</strong> practice of familyplann<strong>in</strong>g. Male participation <strong>in</strong> shar<strong>in</strong>g <strong>the</strong> responsibilityto practise family plann<strong>in</strong>g is identified as a vital strategyfor <strong>in</strong>creas<strong>in</strong>g CPR. It is important to neutralize <strong>the</strong>stereotyp<strong>in</strong>g or “fem<strong>in</strong>ization” of <strong>the</strong> service as a whole;<strong>the</strong>refore, activities must <strong>in</strong>volve both <strong>the</strong> health-careproviders <strong>and</strong> <strong>the</strong> clients (Rosliza <strong>and</strong> Majdah, 2010).A ra<strong>the</strong>r high proportion of couples are still us<strong>in</strong>g traditionalmethods. Users of traditional methods represent a potentialtarget group for modern methods of contraception.However, religious issues <strong>and</strong> fear of <strong>the</strong> side effects ofsome modern methods need to be addressed properly.With regard to <strong>the</strong> high non-use <strong>and</strong> discont<strong>in</strong>uation rates,a wider range of contraceptives methods, such as low-doseestrogen <strong>and</strong> long-act<strong>in</strong>g formulations, need to be madewidely available with <strong>in</strong>creased coverage, as well as effortsto effectively reduce side effects.Much has been said about social <strong>and</strong> health problemsbrought about by foreign workers. With <strong>the</strong> <strong>in</strong>creas<strong>in</strong>gnumber of foreign workers <strong>in</strong> Malaysia, <strong>the</strong>ir reproductivehealth needs must be addressed. More concerted efforts arerequired to prevent <strong>the</strong> spread of STIs <strong>and</strong> HIV/AIDSamong this population group.The IEC programmes that had previously played a veryimportant role <strong>in</strong> promot<strong>in</strong>g planned parenthood shouldbe <strong>in</strong>tegrated <strong>in</strong>to <strong>the</strong> reproductive health programme.There is also a need to <strong>in</strong>troduce reproductive <strong>and</strong> sexeducation <strong>in</strong>to schools <strong>in</strong> order to prepare young peoplefor healthy <strong>and</strong> responsible liv<strong>in</strong>g. With <strong>the</strong> advent ofmodern <strong>in</strong>formation <strong>and</strong> communications technologies,IEC programmes can now be implemented more effectively<strong>in</strong> educat<strong>in</strong>g <strong>and</strong> motivat<strong>in</strong>g <strong>the</strong> public concern<strong>in</strong>g <strong>the</strong>benefits of planned parenthood <strong>and</strong> <strong>in</strong>form<strong>in</strong>g <strong>the</strong>m of <strong>the</strong>availability of reproductive health services. Appropriateprogrammes should be implemented for specific targetgroups to enable <strong>the</strong>m to decide on <strong>the</strong> number <strong>and</strong> tim<strong>in</strong>gof births <strong>and</strong> to upgrade <strong>the</strong>ir socio-economic <strong>and</strong> healthconditions. On a broader scale, IEC programmes shouldencompass promotion by <strong>the</strong> private sector <strong>in</strong> respect ofprovid<strong>in</strong>g family plann<strong>in</strong>g services <strong>in</strong> areas where CPR islow.Adolescent sexuality has emerged as one of <strong>the</strong> mostpress<strong>in</strong>g social problems <strong>in</strong> Malaysia. The ris<strong>in</strong>g problemsof youth sexuality, teenage pregnancy <strong>and</strong> ab<strong>and</strong>onedbabies have been highlighted <strong>in</strong> <strong>the</strong> media. Strategiesare be<strong>in</strong>g developed <strong>and</strong> implemented to overcome suchproblems. The <strong>in</strong>troduction of reproductive health <strong>and</strong>social education must <strong>the</strong>refore be given high priority,especially now that <strong>the</strong> government has approved <strong>the</strong> policyon reproductive health <strong>and</strong> social education. The allianceof partners needs to be streng<strong>the</strong>ned <strong>in</strong> advocat<strong>in</strong>g <strong>the</strong>desensitization of SRH education so that it can be moreeffectively implemented. The M<strong>in</strong>istry of Education hasdecided to <strong>in</strong>troduce sex education <strong>in</strong>to schools, based on<strong>the</strong> previously mentioned module “I Am <strong>in</strong> Control” under<strong>the</strong> Kafe@Teen project. The Kafe@Teen concept <strong>and</strong>strategies have proven to be acceptable to <strong>the</strong> community;hence, efforts will be made to streng<strong>the</strong>n <strong>and</strong> up-scale<strong>the</strong>m. The Reproductive Health Adolescent Moduledeveloped by FRHAM should also be updated for widerdissem<strong>in</strong>ation.The HIV/AIDS p<strong>and</strong>emic has been a major concerns<strong>in</strong>ce <strong>the</strong> 1990s. Measures implemented to combat HIV/AIDS <strong>in</strong>clude blood screen<strong>in</strong>g, <strong>in</strong>formation <strong>and</strong> educationcampaigns, antiretroviral treatment, non-discrim<strong>in</strong>atorypolicies <strong>and</strong> <strong>the</strong> distribution of condoms. FRHAM hassuccessfully implemented many projects, some with <strong>the</strong>assistance of UNFPA, to reach youth <strong>and</strong> women, especially<strong>in</strong> areas considered sensitive. FRHAM has also been animportant partner <strong>in</strong> <strong>the</strong> fight aga<strong>in</strong>st HIV/AIDS. Thevarious pilot projects should be exp<strong>and</strong>ed <strong>and</strong> up-scaledwith assistance from UNFPA <strong>and</strong> o<strong>the</strong>r agencies.Studies have shown <strong>the</strong> close l<strong>in</strong>kage between reproductivehealth <strong>and</strong> HIV/AIDS <strong>and</strong> provided evidence ofimportant synergies between reproductive health <strong>and</strong>HIV prevention, care <strong>and</strong> treatment <strong>in</strong>terventions.Forg<strong>in</strong>g closer l<strong>in</strong>kages between such programme areasshould result <strong>in</strong> significant public health benefits. WHO<strong>and</strong> UNFPA are currently conduct<strong>in</strong>g a jo<strong>in</strong>t study aimedat streng<strong>the</strong>n<strong>in</strong>g <strong>the</strong> l<strong>in</strong>kages between HIV <strong>and</strong> SRH <strong>in</strong>Malaysia. UNFPA should cont<strong>in</strong>ue to work with WHO,<strong>the</strong> M<strong>in</strong>istry of Health <strong>and</strong> o<strong>the</strong>r relevant agencies <strong>in</strong>implement<strong>in</strong>g programmes to reduce HIV <strong>in</strong>fectionthrough SRH programmes.To be effective, NPFDB must cont<strong>in</strong>ue to work closely with<strong>the</strong> relevant government agencies, such as <strong>the</strong> Economic<strong>Plann<strong>in</strong>g</strong> Unit, <strong>the</strong> M<strong>in</strong>istry of Health, <strong>the</strong> M<strong>in</strong>istry ofEducation, <strong>the</strong> M<strong>in</strong>istry of Information, <strong>the</strong> Treasury<strong>and</strong> <strong>the</strong> M<strong>in</strong>istry of Youth <strong>and</strong> Sport, all of which arerepresented on <strong>the</strong> Board. NPFDB must also engage <strong>in</strong>smart partnerships with <strong>the</strong> private sector <strong>and</strong> NGOs,as well as <strong>in</strong>stitutions of higher learn<strong>in</strong>g <strong>in</strong> implement<strong>in</strong>g<strong>the</strong>se programmes. At <strong>the</strong> same time, it is necessary towork closely with United Nations agencies, <strong>in</strong> particularUNFPA, <strong>and</strong> engage <strong>in</strong> <strong>in</strong>ternational collaboration.259

ReferencesAng, Eng Suan (2007). Study on Safe Haven for Babies,National Population <strong>and</strong> <strong>Family</strong> Development Board.Department of Statistics (2008). Vital Statistics Malaysia,2008.Division of <strong>Family</strong> Health Development, M<strong>in</strong>istry ofHealth Malaysia (2008). Report on <strong>the</strong> ConfidentialEnquiries <strong>in</strong>to Maternal Deaths <strong>in</strong> Malaysia 2001-2005.National Population <strong>and</strong> <strong>Family</strong> Development Board(NPFDB)(various years). Malaysian Population <strong>and</strong><strong>Family</strong> Surveys <strong>in</strong> 1974, 1984, 1994 <strong>and</strong> 2004.__________ (2005). Assess<strong>in</strong>g <strong>the</strong> Implementation of <strong>the</strong>ICPD PoA <strong>in</strong> Malaysia, Kuala Lumpur:Noor, Laily et al. (1982). Facts <strong>and</strong> Figures. MalaysianNational Population <strong>and</strong> <strong>Family</strong> DevelopmentProgramme.Report Malaysian <strong>Family</strong> Life Survey II (1988).Rosliza, A.M. <strong>and</strong> M. Majdah (2010). “Male participation<strong>and</strong> shar<strong>in</strong>g of responsibility <strong>in</strong> streng<strong>the</strong>n<strong>in</strong>g familyplann<strong>in</strong>g activities <strong>in</strong> Malaysia”, Malaysia Journal ofPublic Health Medic<strong>in</strong>e, 10(1):23-27.Tey, Nai Peng (2007). “The family plann<strong>in</strong>g program <strong>in</strong>Malaysia”, <strong>in</strong> Warren Rob<strong>in</strong>son <strong>and</strong> John Ross, eds.,The Emergence of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Programs <strong>in</strong> <strong>the</strong>Develop<strong>in</strong>g World, Wash<strong>in</strong>gton, D.C.: World Bank.__________ (2008). Contraceptive use <strong>and</strong> unmet(need) for contraception <strong>in</strong> Pen<strong>in</strong>sular Malaysia.Paper presented at FFPAM RRAAM Consultationon Increas<strong>in</strong>g Access to <strong>the</strong> Reproductive Right toContraceptive Information <strong>and</strong> Services; Monitor<strong>in</strong>gProgress s<strong>in</strong>ce 1994 ICPD Agreements, 21 October,Subang Jaya, Selangor, Malaysia.__________ (2010). Mid-term Review Report ofUNFPA Country Programme for Malaysia (2008-2010).260

MyanmarMyanmarThe Status of Birth Spac<strong>in</strong>g <strong>in</strong> Myanmar, 2010Hla Hla Aye* <strong>and</strong> T<strong>in</strong> T<strong>in</strong> Nyunt #* Consultant, Human Resources for Health#Consultants, UNFPA-Myanmar, 2009-2010.261

Demographic data sheet: population <strong>in</strong>dicators for Myanmar, various years/periodsIndicatorNumbers/rates/source/yearsTotal population (millions) 59.13 (2009)Population density (persons/per sq km) 87 (2009)Annual population growth rate (%) 1.29 (2009)Crude birth rate (per 1,000 live births) 17.3 (FRHS, 2006)Crude death rate (per 1,000 population) 6.0 (FRHS, 2006)Total fertility rate (births per woman) 2.03 (FRHS, 2006)Adolescent fertility rate (per 1,000 female adolescents 15-24years old)Proportion married (among female adolescents 15-24 years old)(%)16.9 (FRHS, 2006)6.8 (FRHS 2006)Maternal mortality rate (per 100,000 live births) 240 ()(WHO, UNFPA, UNICEF &WB, 2008)Neonatal mortality rate (per 1,000 live births) 33.8 (FRHS, 2006)Infant mortality rate (per 1,000 live births) 53.0 (FRHS, 2006)Child mortality rate (per 1,000 children under age-5) 56.3 (FRHS, 2006 for period 1997-2006)66.1 (Overall Cause-specific Under-five Mortality Survey(2002/03)Number of women <strong>in</strong> reproductive age group (15-49 years) 16.2 (2009)(Statistical Yearbook, 2008)Average age at first marriage (years) Male 24.1 (FRHS, 2006)Average age at first marriage (years) Female 21.0 (FRHS, 2006)Contraceptive prevalence rate (%) 40.9 (any method) (2006)Unmet need for contraception (%) 17.7 (FRHS, 2006)Antenatal coverage (%) 79.8 (FRHS, 2006),Deliveries by skilled birth attendants (doctors, nurses, midwives)(%)64 (2006)Deliveries at home (%) 76.4 (2006)Deliveries at government facilities (%) 16.6 (2006)Expectation of life at birth (both sexes) (years) 65 (FRHS, 2006)Male 63 (FRHS, 2006)Female 66 (FRHS, 2006)Note: FRHS = Fertility <strong>and</strong> Reproductive Health Survey.262

IntroductionMyanmar has undergone considerable demographic,social, economic, environmental <strong>and</strong> political changes s<strong>in</strong>ce1994, when <strong>the</strong> United Nations hosted <strong>the</strong> <strong>International</strong>Conference on Population <strong>and</strong> Development (ICPD)<strong>in</strong> Cairo <strong>and</strong> adopted <strong>the</strong> Programme of Action. As adevelop<strong>in</strong>g country <strong>in</strong> South-East <strong>Asia</strong>, Myanmar hasmade considerable progress <strong>in</strong> recent years towards meet<strong>in</strong>g<strong>the</strong> ICPD goals <strong>and</strong> <strong>the</strong> Millennium Development Goals(MDGs), through its implementation of <strong>the</strong> Five-yearNational Strategic Plan for Reproductive Health (2004-2008) <strong>and</strong> <strong>the</strong> current plan (2009-2013). Implementationof those plans has resulted <strong>in</strong> improvements <strong>in</strong> <strong>the</strong> coverage<strong>and</strong> quality of maternal <strong>and</strong> child health (MCH) care <strong>and</strong>birth-spac<strong>in</strong>g services, as well as HIV/AIDS prevention,care <strong>and</strong> support. Despite <strong>the</strong> strong political commitment<strong>and</strong> cont<strong>in</strong>uous efforts by multiple partners, reproductivehealth (RH), birth spac<strong>in</strong>g <strong>and</strong> population development <strong>in</strong>Myanmar rema<strong>in</strong> a challenge, as <strong>the</strong> country is characterizedby a high maternal mortality ratio (MMR), high <strong>in</strong>fantmortality rate (IMR) <strong>and</strong> high burden of HIV <strong>in</strong>fection,all of which <strong>in</strong>dicate that, for successful implementationof <strong>the</strong> ICPD Programme of Action, much rema<strong>in</strong>s to beaccomplished.This report on Myanmar is based on primary <strong>and</strong> secondarydata collection <strong>and</strong> a major report 1 for <strong>the</strong> situation analysisconducted <strong>in</strong> <strong>the</strong> period 2009-2010 under <strong>the</strong> auspicesof <strong>the</strong> United Nations Population Fund (UNFPA). Thesituation analysis assessed <strong>the</strong> reproductive health situationaga<strong>in</strong>st <strong>the</strong> objectives <strong>and</strong> targets of <strong>the</strong> ICPD Programmeof Action <strong>and</strong> MDGs. The present report fur<strong>the</strong>r updatesthose data <strong>and</strong> furnishes an analysis us<strong>in</strong>g <strong>in</strong>terviews <strong>and</strong>self-adm<strong>in</strong>istered questionnaires distributed to <strong>the</strong> ma<strong>in</strong>stakeholders <strong>in</strong> <strong>the</strong> Department of Health, M<strong>in</strong>istry ofHealth, M<strong>in</strong>istry of Immigration <strong>and</strong> Population, UNFPA<strong>and</strong> <strong>in</strong>ternational non-governmental organizations(NGOs) work<strong>in</strong>g <strong>in</strong> <strong>the</strong> areas of RH <strong>and</strong> birth spac<strong>in</strong>g <strong>in</strong>Myanmar. The report also encompasses recommendationsfor giv<strong>in</strong>g direction <strong>and</strong> po<strong>in</strong>t<strong>in</strong>g to <strong>the</strong> way forward forMyanmar, with emphasis on birth spac<strong>in</strong>g.The reader will notice that <strong>the</strong> term “birth spac<strong>in</strong>g” isused throughout <strong>the</strong> report, as it is <strong>the</strong> policy of <strong>the</strong>Government of <strong>the</strong> Republic of <strong>the</strong> Union of Myanmar tohave <strong>the</strong> current population grow to a larger size; thus, <strong>the</strong>term “family plann<strong>in</strong>g” is not <strong>the</strong> preferred term. There isno separate family plann<strong>in</strong>g programme <strong>in</strong> Myanmar <strong>and</strong>birth spac<strong>in</strong>g is provided as part of <strong>the</strong> MCH programmeof <strong>the</strong> Department of Health, which uses an <strong>in</strong>tegratedapproach <strong>in</strong> implement<strong>in</strong>g birth spac<strong>in</strong>g.There are limitations <strong>in</strong> <strong>the</strong> present report as <strong>the</strong> availabledata <strong>and</strong> <strong>in</strong>formation are scarce; <strong>the</strong>refore, <strong>the</strong> sourcesheavily relied upon to prepare <strong>the</strong> report were fertility <strong>and</strong>reproductive health surveys, a nationwide cause-specificmaternal mortality survey, a family <strong>and</strong> youth survey <strong>in</strong> 2004<strong>and</strong> an RH basel<strong>in</strong>e survey <strong>in</strong> 2002. The views expressedhere are extracted from <strong>the</strong> responses to self-adm<strong>in</strong>isteredquestionnaires <strong>and</strong> <strong>in</strong>terviews with actors work<strong>in</strong>g <strong>in</strong> <strong>the</strong>area of RH <strong>and</strong> birth spac<strong>in</strong>g, plus <strong>the</strong> authors’ analyticalcomments. Where divergence exists, it is hoped that thisreport will be helpful <strong>in</strong> provid<strong>in</strong>g reflections from adifferent perspective with only one concern: <strong>the</strong> well-be<strong>in</strong>g<strong>and</strong> progress of <strong>the</strong> population of Myanmar.Population <strong>and</strong> reproductivehealth situation <strong>and</strong> pastachievementsPopulationThe population of Myanmar is estimated to have been59.13 million <strong>in</strong> 2009/10, with <strong>the</strong> annual growthrate be<strong>in</strong>g 1.29 per cent <strong>and</strong> <strong>the</strong> majority (70%) of <strong>the</strong>population liv<strong>in</strong>g <strong>in</strong> rural areas 2 .The population was expected to grow to about 60 millionby <strong>the</strong> end of 2010; 62.6 million by 2015; <strong>and</strong> 66 millionby 2020, tak<strong>in</strong>g <strong>in</strong>to consideration <strong>the</strong> current decreas<strong>in</strong>gtrend <strong>in</strong> <strong>the</strong> population growth rate.The United Nations estimated that <strong>the</strong> population was49.8 million <strong>in</strong> 2007, with <strong>the</strong> rate of natural <strong>in</strong>creasebe<strong>in</strong>g 0.9 per cent annually; <strong>the</strong> Population ReferenceBureau also projected that <strong>the</strong> population would growto 61.7 million by 2025 3 . O<strong>the</strong>r United Nations 4 <strong>and</strong><strong>in</strong>ternational 5 sources have estimated <strong>the</strong> population ofMyanmar to have been 50 million <strong>in</strong> 2009, with <strong>the</strong> rateof natural <strong>in</strong>crease be<strong>in</strong>g 0.9 to 1.1 per cent annually. Thepopulation of Myanmar is <strong>in</strong> <strong>the</strong> late transitional stage, withdecl<strong>in</strong><strong>in</strong>g fertility accompanied by moderate <strong>and</strong> decl<strong>in</strong><strong>in</strong>gmortality. In study<strong>in</strong>g past population trends, it may beobserved that <strong>the</strong> population has <strong>in</strong>creased steadily from10.7 million <strong>in</strong> 1901 to 28.9 million <strong>in</strong> 1973 (<strong>the</strong> pre-warcensus populations were estimated accord<strong>in</strong>g to <strong>the</strong> 1973census area) 6 . At <strong>the</strong> last census <strong>in</strong> 1983, <strong>the</strong> populationstood at 35.3 million. There is a vast difference between<strong>the</strong> United Nations estimates of population at 50 million<strong>in</strong> 2009 <strong>and</strong> <strong>the</strong> government’s estimate of 59.13 million,a situation which reflects <strong>the</strong> dire need for a populationcensus to be conducted.Regard<strong>in</strong>g spatial distribution, <strong>the</strong> population is unevenlydistributed among <strong>the</strong> regions of <strong>the</strong> country. TheM<strong>and</strong>alay <strong>and</strong> Ayeyarwady Regions are <strong>the</strong> most populous<strong>in</strong> Myanmar, each account<strong>in</strong>g for about 13.5 <strong>and</strong> 14 percent of <strong>the</strong> country’s population respectively. Kayah Stateprovides a stark contrast; it is <strong>the</strong> smallest region <strong>in</strong>263

population size, with just 336,000 <strong>in</strong>habitants, or 0.6 percent of <strong>the</strong> total population.The sex ratio is 98.9 males per 100 females at <strong>the</strong> nationallevel; however, <strong>the</strong>re are variations among states <strong>and</strong>divisions, rang<strong>in</strong>g from over 100 <strong>in</strong> Kayah, Bago, Mon,Shan <strong>and</strong> Ayeyarwady to 95 <strong>in</strong> Ch<strong>in</strong>. Sex ratios exceed<strong>in</strong>g100 <strong>in</strong> <strong>the</strong> five above-mentioned areas <strong>in</strong>dicate that <strong>the</strong>yhave an excess of males, which is probably due to <strong>the</strong> factthat <strong>the</strong>se areas offer favourable employment opportunities<strong>and</strong> <strong>the</strong>refore attract male <strong>in</strong>ternal migrants. The sex ratiois a proxy <strong>in</strong>dicator show<strong>in</strong>g <strong>the</strong> absence of sex selectiveabortion <strong>and</strong> <strong>in</strong>fanticide. Myanmar has an impartialattitude towards sex preference, at least as reflected <strong>in</strong> <strong>the</strong>number of males vis-à-vis females. Data on <strong>the</strong> estimatedpopulation by region, density <strong>and</strong> sex ratio are given <strong>in</strong>Table 1.FertilityIn Myanmar, fertility has been decl<strong>in</strong><strong>in</strong>g. The crude birthrate (CBR) has decreased from 34.8 births per 1,000population <strong>in</strong> 1983 to 17.3 <strong>in</strong> 2006; fertility halved dur<strong>in</strong>gthose decades, with fertility decl<strong>in</strong>e between 2001 <strong>and</strong>2006 be<strong>in</strong>g about 30 per cent, accord<strong>in</strong>g to various reportsof <strong>the</strong> Fertility <strong>and</strong> Reproductive Health Survey (FRHS).The Nationwide Cause-specific Maternal Mortality Survey(2004-2005) revealed that CBR was close to <strong>the</strong> 2006rates (18.4 at <strong>the</strong> national level; 15.7 for urban <strong>and</strong> 19.5 forrural areas). The rates for <strong>the</strong> national level as <strong>in</strong>dicated by<strong>the</strong> vital registration system also showed a decl<strong>in</strong><strong>in</strong>g trend,but at somewhat higher levels. Urban, rural <strong>and</strong> regionalvariations exist; <strong>the</strong> urban-rural differential is about 2,with urban CBR be<strong>in</strong>g less than rural. The 2007 FRHSshowed <strong>the</strong> lowest CBR of 15 <strong>in</strong> M<strong>and</strong>alay Division <strong>and</strong><strong>the</strong> highest CBR of 22 <strong>in</strong> Rakh<strong>in</strong>e State (see Figures 1 <strong>and</strong>2). 7The total fertility rate (TFR) was 4.7 children per woman<strong>in</strong> 1983; it decreased to 3.5 <strong>in</strong> 1991 <strong>and</strong> 2.0 <strong>in</strong> 2006,accord<strong>in</strong>g to <strong>the</strong> 1983 census, 1991 Population Changes<strong>and</strong> Fertility Survey (PCFS) <strong>and</strong> 2007 FRHS. TFR decl<strong>in</strong>e<strong>in</strong> 1983 <strong>and</strong> 2006 was about 43 per cent, or 1.8 per centper annum. Urban <strong>and</strong> rural differences exist. Women <strong>in</strong>rural areas have two to three children on average, whereaswomen <strong>in</strong> urban areas have fewer than two children. Withregard to <strong>the</strong> regional differential, it follows <strong>the</strong> same trendas CBR, with M<strong>and</strong>alay hav<strong>in</strong>g <strong>the</strong> lowest TFR (1.7) <strong>and</strong>Rakh<strong>in</strong>e State hav<strong>in</strong>g <strong>the</strong> highest (2.9) 8 .TableTable1Population, density <strong>and</strong> sex ratio for 2009-2010SNState/ Division= StatesPopulation (<strong>in</strong> thous<strong>and</strong>s)Total Males FemalesDensity (Per sqkm)Sex RatioUnion 59130 29400 29730 87 98.91 Kach<strong>in</strong> 1560 771 789 17 97.82 Kayah 351 178 173 29 102.73 Kay<strong>in</strong> 1794 888 906 60 98.04 Ch<strong>in</strong> 545 266 279 14 95.25 Mon 3106 1560 1546 253 100.86 Rakh<strong>in</strong>e 3271 1630 1641 89 99.37 Shan 5594 2803 2791 36 100.4Divisions8 Saga<strong>in</strong>g 6479 3184 3295 69 96.69 Tan<strong>in</strong>tharyi 1691 844 847 38 99.510 Bago 5944 2988 2956 150 101.111 Magway 5564 2738 2826 124 96.912 M<strong>and</strong>alay 8333 4118 4215 178 97.713 Yangon 6944 3447 3497 683 98.614 Ayeyarwady 7952 3984 3968 227 100.4Source: Department of Population. Nay Pyi Taw, Myanmar, 2010* Calculated based on <strong>the</strong> data from Department of Population264

FigureFigureFigureFigure1Crude Birth Rate for selected years40353025201510501983 1991 2001 2007Source: 1983 Census, 1991 PCFS, 2001 FRHS, 2007 FRHSFigure2Crude Birth Rate by State/Divisions of Myanmar, 200725201510TotalUrbanRural50UnionKach<strong>in</strong>/Kayah/ShanKay<strong>in</strong>/Mon/Tan<strong>in</strong>tharyiCh<strong>in</strong>/Saga<strong>in</strong>gBagoMagwayM<strong>and</strong>alayRakh<strong>in</strong>eYangonAyeyarwadySource: Country Report, 2007 Fertility Reproductive Health Survey, Department of Population.Figure3Nuptiality trend, 1973- 20066050Percent403020100Never marriedMarriedWidowedDivorced/separated1973 Census39.65171.51983 Census42.149.46.31.41991 PCFS44.747.86.61.52001 FRHS55.737.85.41.12007 FRHS54.139.25.61Source: Population census, 1973 <strong>and</strong> 2007 FRHS.265

NuptialityIn Myanmar nuptiality is <strong>in</strong> transition, with <strong>the</strong> proportionnever married (PNM) for both sexes hav<strong>in</strong>g been 39.6 percent <strong>in</strong> 1973, <strong>in</strong>creas<strong>in</strong>g over time to peak <strong>in</strong> 2001 at 55.7per cent <strong>and</strong> decreas<strong>in</strong>g <strong>the</strong>reafter to 54.1 per cent <strong>in</strong> 2006.However, <strong>the</strong> trend for PNM from 1973 to 2006 stillshowed an <strong>in</strong>crease. The proportion married was 51 percent <strong>in</strong> 1973, decreas<strong>in</strong>g cont<strong>in</strong>uously to 37.8 per cent <strong>in</strong>2001 – its lowest value, <strong>the</strong>n <strong>in</strong>creas<strong>in</strong>g slightly to 39.2 percent <strong>in</strong> 2006. Aga<strong>in</strong>, <strong>the</strong> net trend is a decl<strong>in</strong>e, although it<strong>in</strong>creased aga<strong>in</strong> <strong>in</strong> <strong>the</strong> period 2001-2006. The gender gapalso narrowed among <strong>the</strong> population “never married” <strong>and</strong>“married over time” (see Figure 3). It can be assumed thatPNM has leveled off at about 50 per cent <strong>and</strong> has nowstarted to stabilize.Mean ideal family size decl<strong>in</strong>ed slightly from 3.3 children<strong>in</strong> 1991 to 3.2 <strong>in</strong> 2006. About half of currently marriedwomen of reproductive age have no desire to have any morechildren. Age at marriage varies with rural-urban residence<strong>and</strong> educational atta<strong>in</strong>ment: persons <strong>in</strong> urban areas <strong>and</strong> <strong>the</strong>more highly educated tend to marry later 9 . Given that <strong>the</strong>age at marriage is <strong>in</strong>creas<strong>in</strong>g <strong>and</strong> a grow<strong>in</strong>g proportion of<strong>the</strong> population never marry, effective mechanisms need tobe developed to reach unmarried persons with appropriateRH <strong>in</strong>formation <strong>and</strong> contraceptive services.Myanmar’s population is <strong>in</strong> <strong>the</strong> last stages of demographictransition where <strong>the</strong>re is a decl<strong>in</strong>e <strong>in</strong> <strong>the</strong> proportion ofthose under age 15 <strong>and</strong> an <strong>in</strong>crease <strong>in</strong> <strong>the</strong> proportion <strong>in</strong> <strong>the</strong>work<strong>in</strong>g age population (15-59 years) <strong>and</strong> <strong>in</strong> <strong>the</strong> elderlypopulation (60 years <strong>and</strong> older). This pattern of decl<strong>in</strong>e <strong>in</strong>fertility below <strong>the</strong> replacement level, low dependency ratio<strong>and</strong> <strong>in</strong>crease <strong>in</strong> <strong>the</strong> work<strong>in</strong>g age group may be considereda “demographic w<strong>in</strong>dow of opportunity” or a “demographicdividend” for <strong>the</strong> country to make effective <strong>in</strong>vestments <strong>in</strong>job creation <strong>and</strong> <strong>in</strong> health <strong>and</strong> education, which <strong>in</strong> turnwill lead to susta<strong>in</strong>able economic growth.Maternal mortality ratioData on maternal mortality are not collected <strong>in</strong> mostsurveys because it is difficult to cover <strong>the</strong> required sizeof <strong>the</strong> population for direct calculation, as estimat<strong>in</strong>gMMR requires a large sample. MMR is typically difficultto measure for both conceptual <strong>and</strong> practical reasons, asmaternal deaths are difficult to identify with precision 10 .Only three large countrywide surveys, namely <strong>the</strong> 1997<strong>and</strong> 2007 FRHS, <strong>and</strong> <strong>the</strong> 1999 National Mortality Survey,<strong>in</strong>cluded questions concern<strong>in</strong>g maternal mortality. TheNationwide Cause-specific Maternal Mortality Survey(2004-2005) was specially designed to collect <strong>in</strong>formationon maternal mortality. Myanmar’s MMR was 283 per100,000 live births for <strong>the</strong> period 1986-1990. 11 Accord<strong>in</strong>gto <strong>the</strong> 1999 National Mortality Survey, it was 255 at <strong>the</strong>national level, 178 <strong>in</strong> urban areas <strong>and</strong> 281 <strong>in</strong> rural areas. 12The values varied widely among <strong>the</strong> regions of <strong>the</strong> country.It was as high as 500 or more <strong>in</strong> most of Shan State <strong>and</strong> aslow as 136 <strong>in</strong> Saga<strong>in</strong>g Division. The cause-specific surveyestimated MMR at <strong>the</strong> national level to be 316 (rang<strong>in</strong>gfrom 177 to 451) per 100,000 live births, 140 for urbanareas <strong>and</strong> 363 for rural areas <strong>in</strong> 2004-2005 13 . The HealthManagement Information System (HMIS) reportedMMR to be 150 per 100,000 live births <strong>in</strong> 2008, vary<strong>in</strong>gamong regions from 220 <strong>in</strong> Kayah State, Ch<strong>in</strong> State <strong>and</strong>Shan State to 110 <strong>in</strong> Bago (West) <strong>and</strong> Magway, <strong>and</strong> 90 <strong>in</strong>Yangon 14 . Vital statistics <strong>in</strong>dicate that MMR was 94 forurban areas <strong>and</strong> 136 for rural areas <strong>in</strong> 2007 15 .Approximately 1.3 million women give birth each year <strong>in</strong>Myanmar. 16 MMR, referr<strong>in</strong>g to <strong>the</strong> number of pregnancyrelatedmaternal deaths per 100,000 live births, rema<strong>in</strong>edelevated at an estimated 316 maternal deaths <strong>in</strong> 2004-2005 17 . Some researchers estimated MMR <strong>in</strong> Myanmar tobe 219 <strong>in</strong> 2008 18 , whereas <strong>the</strong> World Health Organization(WHO), United Nations Children’s Fund (UNICEF),UNFPA <strong>and</strong> <strong>the</strong> World Bank estimated it to be 240 per100,000 live births.Myanmar has made progress <strong>in</strong> br<strong>in</strong>g<strong>in</strong>g down maternalmortality <strong>and</strong> <strong>in</strong> work<strong>in</strong>g towards reach<strong>in</strong>g <strong>the</strong> nationaltarget of atta<strong>in</strong><strong>in</strong>g an MMR lower than 145 per 100,000live births by <strong>the</strong> year 2015 19 , but <strong>the</strong> effort rema<strong>in</strong>s anongo<strong>in</strong>g challenge. The fact that MMR estimates werehigher <strong>in</strong> 2005 than <strong>the</strong> estimated levels <strong>in</strong> 1994 <strong>and</strong> 1999(Figure 3) is suggestive of <strong>the</strong> compounded impact thateconomic <strong>and</strong> social factors have on women's health <strong>and</strong>survival <strong>and</strong> <strong>the</strong> <strong>in</strong>tense vulnerability of <strong>the</strong> health statusof women. The higher figures could also be due to betterreport<strong>in</strong>g of maternal deaths due to <strong>in</strong>creased awareness<strong>and</strong> improved data-collection methods 20 .The Nationwide Cause-specific Maternal Mortality Survey(2004-2005) depicted a wide range of MMR values thatdiffered accord<strong>in</strong>g to geographical location, age group,urban-rural residency <strong>and</strong> place of birth 21 . The lead<strong>in</strong>gdirect obstetric causes of maternal death are postpartumhemorrhage (31%), followed by hypertensive disordersof pregnancy, <strong>in</strong>clud<strong>in</strong>g eclampsia (17%) <strong>and</strong> abortionrelatedcauses (10%) There is evidence that wide use ofcontraceptives significantly lowers MMR. Thus, birthspac<strong>in</strong>g should be advocated for women who do not wantto get pregnant <strong>in</strong> order to reduce MMR <strong>and</strong> unwantedpregnancies.Birth spac<strong>in</strong>gPopulation density for <strong>the</strong> whole country is 87 persons persquare kilometer, rang<strong>in</strong>g from 683 per sq km <strong>in</strong> YangonDivision, which encompasses <strong>the</strong> city of Yangon, to 15 per266

FigureTableTable2Comparison of 1990, 1995, 2000, 2005 <strong>and</strong> 2008 estimates of <strong>the</strong> maternal mortality ratio,by selected countriesCountryEstimated MMR1990 1995 2000 2005 2008EstimatedMMRPercentagechange<strong>in</strong> MMRbetween1990 <strong>and</strong>2008Annualpercentagechange<strong>in</strong> MMRbetween1990 <strong>and</strong>2008Myanmar 420 350 290 250 240 -43 -3.1Bangladesh 870 640 500 420 340 –61 –5.3Mak<strong>in</strong>gprogressMak<strong>in</strong>gprogressMaldives 510 240 110 52 37 –93 –14.6 On trackBhutan 940 650 420 260 200 –79 –8.6 On trackIndia 570 470 390 280 230 –59 –4.9Mak<strong>in</strong>gprogressSri Lanka 91 73 59 45 39 –58 –4.8 On trackSudan 830 780 770 760 750 –9 –0.5InsufficientprogressSource: World Health Organization, Trends <strong>in</strong> Maternal Mortality: 1990 to 2008: Estimates Developed by WHO, UNICEF, UNFPA<strong>and</strong> The World Bank, Geneva: WHO, 2010.Figure4Maternal mortality ratio (per 100,000 live births), 1994-2005450400350300250200150100500420350290250 240105199019952000200520102015MyanmarSource: Trend of MMR2008 – Source: WHO, UNCEF, UNFPA& World Bank:2010sq km <strong>in</strong> Ch<strong>in</strong> State 22 <strong>in</strong> <strong>the</strong> western part of <strong>the</strong> country,which is still much less dense than its close neighbours <strong>in</strong><strong>the</strong> region. Thus, <strong>the</strong> draft population policy documentof <strong>the</strong> government 23 calls for a pronatalist populationpolicy; to date <strong>the</strong>re is no family plann<strong>in</strong>g programmeper se <strong>in</strong> Myanmar. As mentioned previously, <strong>the</strong> term“birth spac<strong>in</strong>g” is preferred over “family plann<strong>in</strong>g” <strong>and</strong>contraceptives are used primarily to space births for betterreproductive outcomes <strong>and</strong> maternal <strong>and</strong> child health.The term birth spac<strong>in</strong>g is also preferred because it impliesgiv<strong>in</strong>g healthy adult men <strong>and</strong> women a choice on howmany children <strong>the</strong>y want <strong>and</strong> when <strong>the</strong>y want <strong>the</strong>m 24 .267

FigureIn Myanmar, birth-spac<strong>in</strong>g projects started only <strong>in</strong>1991 <strong>in</strong> 20 townships, prior to which time differentcontraceptive methods were available only <strong>in</strong> privatepharmacies; permanent family plann<strong>in</strong>g methods for men<strong>and</strong> women are not popular. Birth spac<strong>in</strong>g was exp<strong>and</strong>edto 72 townships <strong>in</strong> 1997 <strong>and</strong> gradually exp<strong>and</strong>ed fur<strong>the</strong>rby 7 townships per year dur<strong>in</strong>g <strong>the</strong> period 2002-2005,until reach<strong>in</strong>g 100 townships. In 2006, birth spac<strong>in</strong>g wasexp<strong>and</strong>ed to 12 additional townships; <strong>in</strong> 2009 <strong>and</strong> 2010,<strong>the</strong> rate of expansion was <strong>in</strong>creased to 10 additionaltownships per year. Currently <strong>the</strong>re are 132 townshipsthat receive UNFPA support out of 325 townships <strong>in</strong> <strong>the</strong>country as a whole.Birth spac<strong>in</strong>g <strong>and</strong> contraceptiveprevalenceUnder <strong>the</strong> 2009-2013 Reproductive Health StrategicPlan, a CPR (for modern methods) of 45 per cent has beenset as a target to be achieved by 2013. CPR for marriedwomen has gradually <strong>in</strong>creased from 37 per cent <strong>in</strong> 2001to 41 per cent <strong>in</strong> 2007, which is still low compared witho<strong>the</strong>r countries <strong>in</strong> <strong>the</strong> region 25 .Nationally, <strong>the</strong> unmet need for contraception has decreasedfrom 20.6 per cent <strong>in</strong> 1991 to 19.1 per cent <strong>in</strong> 1997 <strong>and</strong> 17.7per cent <strong>in</strong> 2007 among married women of reproductiveage (4.9% for spac<strong>in</strong>g <strong>and</strong> 12.8% for limit<strong>in</strong>g) 26 , a slightreduction from 19.1 per cent <strong>in</strong> 1997 (5.8% unmet needfor spac<strong>in</strong>g <strong>and</strong> 13.3% for limit<strong>in</strong>g) 27 . However, unmetneed for contraception may be underestimated <strong>and</strong> couldbe higher if unmarried women were also <strong>in</strong>cluded <strong>in</strong> <strong>the</strong>calculation. The data show that a large proportion ofwomen need or want to use contraceptives but <strong>the</strong>ir needrema<strong>in</strong>s unmet. Thus, birth-spac<strong>in</strong>g commodity provisionshould be exp<strong>and</strong>ed <strong>in</strong> order to reduce MMR <strong>and</strong> enableMyanmar to reach <strong>the</strong> MDG targets. Practical <strong>in</strong>novativemethods <strong>and</strong> youth-friendly strategies need to be applied sothat birth-spac<strong>in</strong>g services could be accessed also by youngpeople, <strong>the</strong> unmarried <strong>and</strong> hard-to-reach populations.Contraceptive methods <strong>and</strong>availabilityMethods of contraception practiced today <strong>in</strong> Myanmar<strong>in</strong>clude “modern” <strong>and</strong> “traditional” methods. The formerrefers to cl<strong>in</strong>ical <strong>and</strong> supply methods, such as voluntarysurgical sterilization, IUDs, oral contraceptives, implants,<strong>in</strong>jectables, condoms <strong>and</strong> vag<strong>in</strong>al barrier methods. The ma<strong>in</strong>traditional or non-supply methods are periodic abst<strong>in</strong>ence<strong>and</strong> withdrawal, as well as traditional folk methods (whichhave uncerta<strong>in</strong> efficacy). 28 The use of contraceptive methodsis usually <strong>in</strong>fluenced by <strong>the</strong> availability of options or <strong>the</strong>methods promoted by <strong>the</strong> family plann<strong>in</strong>g programme ofa country. Birth-spac<strong>in</strong>g services <strong>in</strong> Myanmar are providedthrough both <strong>the</strong> public <strong>and</strong> private sectors.For <strong>the</strong> present report, <strong>the</strong> mix of methods refers to <strong>the</strong>number of contraceptive methods available from whichwomen <strong>and</strong> men may choose. Knowledge of contraceptivemethods <strong>and</strong> sources are among <strong>the</strong> important determ<strong>in</strong>antsFigure5Trends <strong>in</strong> contraceptive prevalence rate <strong>and</strong> unmet need, 1991-200745404135373032,7Percent25201520,616,819,117,817,7Unmet needCPR10501991 1997 2001 2007YearSource: Fertility <strong>and</strong> Reproductive Health Survey, 2007.268

Figureof contraceptive use. There are low rates of use for longtermmethods <strong>and</strong> it is common for mixed methods tobe used. Although four methods are be<strong>in</strong>g supported<strong>in</strong> Myanmar by UNFPA through <strong>the</strong> public sector, <strong>the</strong>use of IUDs <strong>and</strong> condoms for birth spac<strong>in</strong>g is very low.Implants are not widely available. Recently, PopulationServices <strong>International</strong> (PSI) has been provid<strong>in</strong>g specialists<strong>in</strong> obstetrics <strong>and</strong> gynaecology with implant supplies, but<strong>the</strong> cost of this method is too high for most communitiesto afford 29 .Female sterilization is available through <strong>the</strong> public sector<strong>in</strong> all townships, but is subject to official approval –permission must first be granted by a state/division-levelboard. Medical sterilization can be performed if officiallyapproved <strong>and</strong> under certa<strong>in</strong> conditions, such as multiparity,health complications <strong>and</strong> medical conditions. However,ow<strong>in</strong>g to <strong>the</strong> tedious paperwork <strong>in</strong>volved for patients toobta<strong>in</strong> formal clearance for sterilization from <strong>the</strong> state/division health department (3-5 months), permanentmethods are not <strong>the</strong> most widely used methods <strong>in</strong>Myanmar 30 . Male sterilization is restricted by law to menwhose wife had been approved for female sterilization butwas unable to undergo sterilization for medical reasons 31 .Common methods usedCommonly used methods of contraception are <strong>in</strong>jectables(3-month duration) (19.3percent), followed by dailycomb<strong>in</strong>ed oral pills (10.1 percent) (see Figure 5). Thereis negligible use of IUDs <strong>and</strong> male methods such ascondoms.Accord<strong>in</strong>g to <strong>the</strong> 2007 FRHS, over 95 per cent of <strong>the</strong>population has knowledge of at least 3 methods ofcontraception; 52 per cent of <strong>the</strong> respondents mentionedprivate sources <strong>and</strong> 42 per cent mentioned governmentoutlets as sources for contraceptive supplies. Mostrespondents (84.2% of females <strong>and</strong> 77.2% of males)mentioned that government facilities are <strong>the</strong> ma<strong>in</strong> source forsterilization <strong>and</strong> IUD <strong>in</strong>sertion, while private pharmaciesare known as <strong>the</strong> major source for contraceptive pills (over70%) <strong>and</strong> condoms (61.1%). However, with <strong>the</strong> <strong>in</strong>creasedsocial market<strong>in</strong>g of contraceptives by NGOs, trends havechanged over time <strong>and</strong> private health cl<strong>in</strong>ics are cited asa major source for <strong>in</strong>jectable contraceptives, followed bypublic nurses <strong>and</strong> midwives <strong>and</strong> private pharmacies.There are considerable differentials <strong>in</strong> <strong>the</strong> use ofcontraceptives, both among urban <strong>and</strong> rural groups, <strong>and</strong>rich <strong>and</strong> poor groups. Nearly 49 per cent of currentlymarried urban women are us<strong>in</strong>g any modern contraceptivemethods compared with only 34 per cent of rural womendo<strong>in</strong>g so. Among <strong>the</strong> regions, contraceptive use is <strong>the</strong>highest <strong>in</strong> Yangon Division (57%) followed by Bago (45%)<strong>and</strong> M<strong>and</strong>alay (42%); <strong>the</strong> lowest CPRs are <strong>in</strong> Ch<strong>in</strong> <strong>and</strong>Saga<strong>in</strong>g (28% each). The quality of service is better <strong>in</strong>DOH-UNFPA project townships than <strong>in</strong> non-projecttownships as <strong>the</strong> staff concerned did not receive tra<strong>in</strong><strong>in</strong>g.In project townships, women liv<strong>in</strong>g <strong>in</strong> rural areas haveaccess to birth-spac<strong>in</strong>g services, especially where <strong>the</strong>re isa midwife. Quality <strong>and</strong> cost depend on <strong>the</strong> availability<strong>and</strong> <strong>the</strong> price is fixed by Township Medical Officer.Contraceptive commodity security needs streng<strong>the</strong>n<strong>in</strong>gas, even <strong>in</strong> project townships <strong>the</strong>re are “stock-outs” (eventsthat cause <strong>in</strong>ventory to be exhausted) due to fund<strong>in</strong>g <strong>and</strong>transportation constra<strong>in</strong>ts, <strong>and</strong> weak logistical management<strong>and</strong> plann<strong>in</strong>g.Figure6Contraceptive method mix among currently married women, 1991-20072519912019.71997Percent151050410.18.67.40.91.3 1.8 1.83.111.714.80.1 0.1 0.3 0.75.54.7 4.43.7Pill IUD Injectables Condom FemaleSterilization1.82.21.5 1MaleSterilization20012007Cont racept ive met hodsSource: Fertility <strong>and</strong> Reproductive Health Survey, 2007269

Scope of coverage <strong>and</strong>partnerships for birth-spac<strong>in</strong>gservicesHealth facilities under <strong>the</strong> M<strong>in</strong>istry ofHealth:Health centres of <strong>the</strong> Department of Health provide facilities<strong>and</strong> manpower for contraceptives provided by UNFPA atsubsidized rates <strong>in</strong> 132 of <strong>the</strong> country’s 325 townships.UNFPA also supports Marie Stopes <strong>International</strong> (MSI),Population Services <strong>International</strong> (PSI) <strong>and</strong> <strong>the</strong> MyanmarMedical Association (MMA) with contraceptives; thus,<strong>the</strong> total number of townships receiv<strong>in</strong>g birth-spac<strong>in</strong>gcommodities from UNFPA is about 225 townshipsout of <strong>the</strong> total 325 townships 32 . There is still a gap ofapproximately 100 townships, whereas <strong>in</strong> some townships<strong>the</strong>re are birth-spac<strong>in</strong>g services provided by <strong>the</strong> M<strong>in</strong>istry ofHealth, PSI, MSI, MMCWA <strong>in</strong> collaboration with IPPF<strong>and</strong> MMA. Currently, UNFPA supports <strong>the</strong> M<strong>in</strong>istrywith five contraceptive methods (oral contraceptive pills,3-monthly Depo-Provera <strong>in</strong>jections, IUDs, condoms <strong>and</strong>emergency contraceptive pills). Among <strong>the</strong>m, <strong>the</strong> IUD is<strong>the</strong> only long-term method. Use of IUDs is <strong>in</strong>creas<strong>in</strong>g butstill low at about 4 per cent of all methods, accord<strong>in</strong>g to<strong>the</strong> 2007 FRHS; however, <strong>the</strong> use of condoms for birthspac<strong>in</strong>g is even lower. UNFPA also supported <strong>the</strong> M<strong>in</strong>istryof Health with RH commodities <strong>and</strong> tra<strong>in</strong><strong>in</strong>g. <strong>in</strong> 132townships (<strong>in</strong>clud<strong>in</strong>g German-funded townships) up to2010. In 2011 <strong>and</strong> 2012, 10 more townships each year willbe exp<strong>and</strong>ed to UNFPA support with German bilateralfunds. There are low rates of use of long-term methods<strong>and</strong> it is common for mixed methods to be used 33 .Population Services <strong>International</strong>Partnerships <strong>in</strong> birth-spac<strong>in</strong>g programmes PSI/Myanmar signed a memor<strong>and</strong>um of underst<strong>and</strong><strong>in</strong>g with<strong>the</strong> government which allows PSI/Myanmar to work <strong>in</strong><strong>the</strong> field of RH. PSI/Myanmar now has <strong>the</strong> privilege ofhav<strong>in</strong>g a tax exemption <strong>and</strong> is allowed to procure highqualitycontraceptives <strong>in</strong>ternationally 34 . PSI/Myanmarconducts social market<strong>in</strong>g of contraceptives at highlysubsidized prices so that even low-<strong>in</strong>come women <strong>and</strong>men could afford <strong>the</strong>m. PSI has secured birth-spac<strong>in</strong>gcommodities until 2012 35 <strong>and</strong> operates an extensive socialmarket<strong>in</strong>g programme through franchised general practicecl<strong>in</strong>ics <strong>and</strong> primary providers (village volunteers) <strong>in</strong> 173townships. The major portion of <strong>the</strong> fund<strong>in</strong>g budget isspent on commodities. PSI conducts social market<strong>in</strong>g ofproducts at highly subsidized prices to Sun Quality HealthFranchise Cl<strong>in</strong>ics which <strong>in</strong> turn sell <strong>the</strong>m to women at anagreed price, with PSI/Myanmar mak<strong>in</strong>g a small profitwhich covers fees for services. However, <strong>the</strong> fee for IUD<strong>in</strong>sertion is 500 Kyats for <strong>the</strong> woman concerned, <strong>and</strong> PSI/Myanmar reimburses Sun providers 4,000 Kyats for <strong>the</strong>irIUD service.In 2010 UNFPA also supported PSI/Myanmar with 6contraceptive methods <strong>in</strong> 177 townships. Now PSI obta<strong>in</strong>sIUDs <strong>and</strong> implants (both long-term methods) from o<strong>the</strong>rdonor sources. Implants are available only for specialistswho are tra<strong>in</strong>ed specifically for <strong>in</strong>sert<strong>in</strong>g contraceptiveimplants which are still quite expensive compared witho<strong>the</strong>r contraceptive methods. Some clients practicemethod switch<strong>in</strong>g, chang<strong>in</strong>g from one contraceptivemethod to ano<strong>the</strong>r because of side effects, availability <strong>and</strong>affordability.In addition to UNFPA’s support, PSI/Myanmar providescontraceptives through social market<strong>in</strong>g strategies foreight contraceptive products, namely OK pills, OK onemonth<strong>in</strong>jectable, OK three-month <strong>in</strong>jectable, OK malecondoms, OK female condoms, OK IUDs, implants <strong>and</strong>emergency contraceptive pills through <strong>the</strong> Sun QualityHealth Franchise Cl<strong>in</strong>ics <strong>in</strong> 177 townships. In fact, PSI/Myanmar distributed 25 per cent of <strong>the</strong> market share ofcontraceptives <strong>in</strong> Myanmar <strong>in</strong> 2009.The target populations of PSI are <strong>the</strong> poor <strong>and</strong> o<strong>the</strong>rvulnerable groups. PSI/Myanmar procures RHcommodities directly from PSI/Wash<strong>in</strong>gton; its logisticsmanagement plan is <strong>in</strong> place to ensure that <strong>the</strong>re is noshortage of products <strong>in</strong> <strong>the</strong> programme 36 .Currently a total of 1,192 private doctors are tra<strong>in</strong>ed <strong>in</strong>RH <strong>and</strong> are conduct<strong>in</strong>g birth-spac<strong>in</strong>g services <strong>in</strong> 177townships of 13 states/divisions, <strong>and</strong> through socialmarket<strong>in</strong>g provide users with eight good-quality productsat highly subsidized prices so that women could select<strong>the</strong> birth-spac<strong>in</strong>g method of <strong>the</strong>ir own choice. Yearly RHconsultations <strong>in</strong> <strong>the</strong> Sun franchise network <strong>in</strong>creased from2,937 <strong>in</strong> 2001 to over 1 million consultations <strong>in</strong> 2009.Marie Stopes <strong>International</strong>MSI has a memor<strong>and</strong>um of underst<strong>and</strong><strong>in</strong>g with <strong>the</strong>Department of Health <strong>and</strong> is implement<strong>in</strong>g socialmarket<strong>in</strong>g of contraceptives <strong>in</strong> approximately 24 townships.MSI carries out capacity-build<strong>in</strong>g for youth through itsAdolescent <strong>and</strong> Sexual Reproductive Health (ASRH)tra<strong>in</strong><strong>in</strong>g programmes <strong>and</strong> reaches out to peri-urban youth<strong>in</strong> large cities, such as Yangon <strong>and</strong> M<strong>and</strong>alay 37 . MSI opensRH cl<strong>in</strong>ics <strong>and</strong> reaches communities us<strong>in</strong>g differentapproaches, work<strong>in</strong>g <strong>in</strong> collaboration with basic health staff<strong>and</strong> support<strong>in</strong>g tertiary hospitals with emergency obstetriccommodities. Sometimes overlapp<strong>in</strong>g of data collectionoccurs for <strong>the</strong> RH care provided <strong>and</strong> thus requires propermanagement <strong>and</strong> coord<strong>in</strong>ation between NGO <strong>and</strong> publichealth staff at <strong>the</strong> township level.270

Myanmar Medical AssociationMMA has well-established partnerships with <strong>the</strong> publicsector <strong>and</strong> private general practitioners. MMA tra<strong>in</strong>sprivate general practitioners <strong>in</strong> RH service skills, <strong>in</strong>clud<strong>in</strong>gbirth spac<strong>in</strong>g, <strong>and</strong> provides mobile health services. MMAalso focuses on work<strong>in</strong>g women <strong>in</strong> factories under <strong>the</strong>M<strong>in</strong>istry of Industry (2) provid<strong>in</strong>g factory workers withRH <strong>and</strong> birth-spac<strong>in</strong>g services <strong>and</strong> RH education, <strong>and</strong>supports pregnant women with antenatal care <strong>and</strong> birth<strong>in</strong>gkits.O<strong>the</strong>r NGOs, such as Medec<strong>in</strong>s du Monde (MDM),Adventist Multisectoral <strong>and</strong> Integrated DevelopmentServices (AMDA), Aide Médicale <strong>International</strong>e (AMI),Save <strong>the</strong> Children (SC) <strong>and</strong> Young Women’s ChristianAssociation (YWCA), provide antenatal care. Malteser<strong>International</strong> also has demonstrated <strong>the</strong> potential toimprove access to birth-spac<strong>in</strong>g commodities 38 , provid<strong>in</strong>gbirth-spac<strong>in</strong>g services through social market<strong>in</strong>g <strong>and</strong>subsidiz<strong>in</strong>g those commodities; however, only a few NGOsare provid<strong>in</strong>g services totally free of charge. With manyactors <strong>in</strong> <strong>the</strong> field of RH <strong>and</strong> Birth spac<strong>in</strong>g <strong>the</strong>re is a needfor better coord<strong>in</strong>ation leadership <strong>in</strong>itiated by M<strong>in</strong>istryof Health among <strong>the</strong> various partners so that tangibleimprovements <strong>in</strong> quality <strong>and</strong> coverage of RH <strong>and</strong> birthspac<strong>in</strong>gservices would be possible. The private commercialsector also imports contraceptives. The majority ofhouseholds <strong>and</strong> consumers have to pay for services <strong>and</strong>commodities offered by private cl<strong>in</strong>ics.As a rule, contraceptives are available <strong>in</strong> pharmacies;however, anecdotal evidence suggests that women oftenei<strong>the</strong>r get low-quality or imported counterfeit drugs or use<strong>the</strong> chosen method improperly. More evidence is neededto learn about <strong>the</strong> magnitude <strong>and</strong> consequences of <strong>the</strong> useof monthly contraceptive pills offered over <strong>the</strong> counter <strong>in</strong>private drug stores.Myanmar Maternal <strong>and</strong> Child WelfareAssociation(MMCWA) it is an NGO under <strong>the</strong> auspices of <strong>the</strong>MOH. The MMCWA was <strong>in</strong>itiated <strong>in</strong> April 1991, for<strong>the</strong> promotion of nation-wide maternal <strong>and</strong> child welfareactivities at central, township <strong>and</strong> ward/village levels. TheMMCWA is at present function<strong>in</strong>g with 324 townshipassociations, <strong>and</strong> 11,233 branch associations formed toundertake health <strong>and</strong> welfare activities nation-wide. TheMMCWA now has over 2,000,000 volunteers serv<strong>in</strong>g <strong>the</strong>community throughout Myanmar 39 . The <strong>International</strong>Planned Parenthood Federation (IPPF) has an MOUwith MMCWA <strong>and</strong> works <strong>in</strong> partnership for support ofRH <strong>and</strong> BS <strong>and</strong> counsell<strong>in</strong>g services through tra<strong>in</strong><strong>in</strong>gs <strong>and</strong>commodity support.South-South cooperationThis concept is relatively new <strong>in</strong> Myanmar as it only recentlystarted <strong>in</strong> this country; it <strong>in</strong>volves 13 develop<strong>in</strong>g countries<strong>in</strong> <strong>the</strong> sou<strong>the</strong>rn hemisphere that cooperate <strong>and</strong> supporteach o<strong>the</strong>r <strong>in</strong> RH <strong>and</strong> birth-spac<strong>in</strong>g programmes throughtechnology <strong>and</strong> <strong>in</strong>formation transfer 40 . Representativesfrom Myanmar attended <strong>the</strong> Global Consultation onSouth-South Cooperation, which was held <strong>in</strong> Bangkokfrom 27 to 29 July 2010. In <strong>the</strong> context of new aiddynamics, this emerg<strong>in</strong>g South-South paradigm exploreddifferent South-South modalities that are commonlyapplied to deliver technical cooperation <strong>and</strong> enhance <strong>the</strong>capacities of recipient partners. One of its objectives was topromote implement<strong>in</strong>g <strong>the</strong> ICPD Programme of Action<strong>and</strong> for capacity development to achieve MDGs 41 <strong>and</strong><strong>in</strong>troduce <strong>in</strong>novative ways of cooperation <strong>in</strong> addition toNorth-South cooperation strategies.The role of <strong>the</strong> South-South cooperation modalitycould be <strong>in</strong>itiated <strong>in</strong> <strong>the</strong> area of RH <strong>and</strong> birth-spac<strong>in</strong>gcommodity security through <strong>the</strong> shar<strong>in</strong>g of <strong>in</strong>ternationalbest practices, technology transfer <strong>and</strong> <strong>in</strong> plann<strong>in</strong>g for anew census (<strong>the</strong> most recent census hav<strong>in</strong>g been conducted<strong>in</strong> 1983). Gender statistics, study on <strong>in</strong>ternal migration<strong>and</strong> RH disability statistics are also doma<strong>in</strong>s that need tobe developed if Myanmar is to take forward South-Southcooperation.Contraceptive commoditysecurityUNFPA launched <strong>the</strong> Global Programme to EnhanceReproductive Health Commodity Security <strong>in</strong> Cairo <strong>in</strong>1994 as part of ICPD. The programme <strong>and</strong> all of <strong>the</strong>comb<strong>in</strong>ed efforts <strong>in</strong> <strong>the</strong> area of reproductive health supplieshave helped people to exercise <strong>the</strong>ir right to sexual <strong>and</strong>reproductive health.Promotion of family plann<strong>in</strong>g (FP) <strong>in</strong> develop<strong>in</strong>g countrieswith high birth rates has <strong>the</strong> potential to reduce poverty <strong>and</strong>hunger, <strong>and</strong> avert 25 to 35 per cent of all maternal deaths<strong>and</strong> nearly 10 per cent of childhood deaths. FP wouldalso contribute substantially to women’s empowerment,achievement of universal primary school<strong>in</strong>g <strong>and</strong> long-termenvironmental susta<strong>in</strong>ability 42 . Globally, fund<strong>in</strong>g shortagescont<strong>in</strong>ue to hamper <strong>the</strong> comb<strong>in</strong>ed efforts to ensure <strong>the</strong>adequate provision of contraceptives, condoms <strong>and</strong> o<strong>the</strong>rreproductive health supplies. However, <strong>the</strong> situation isgett<strong>in</strong>g worse 43 . In Myanmar, contraceptive commoditiesare supplied ma<strong>in</strong>ly by UNFPA, <strong>and</strong> <strong>the</strong> governmentstill needs to allot budget for purchas<strong>in</strong>g birth-spac<strong>in</strong>gcommodities. Although <strong>the</strong>re is a national-level committeefor RH commodity security, implementation actually islimited 44 .271

FigureIn Myanmar, out of six selected states <strong>and</strong> divisions visitedby <strong>the</strong> UNFPA Situational Assessment Team <strong>in</strong> 2009,five had stock-outs of contraceptives at all levels for oneor more contraceptive methods. Not all four methods ofcontraception were available at a given time, from whichwomen could choose 45 . Basic health staff are responsible forrecord<strong>in</strong>g <strong>and</strong> report<strong>in</strong>g <strong>the</strong> requirements for, <strong>and</strong> utilizationof, contraceptives through <strong>the</strong> completion on a monthlybasis of Reproductive Health Management InformationSystem (RHMIS) forms <strong>in</strong> UNFPA-supported projecttownships. These are <strong>the</strong>n compiled by <strong>the</strong> Departmentof Health <strong>Plann<strong>in</strong>g</strong> (DHP). However, distribution of RHcommodities is carried out by <strong>the</strong> Maternal <strong>and</strong> ChildHealth unit of <strong>the</strong> Department of Health, us<strong>in</strong>g a quotasystem, allotted from <strong>the</strong> national level. This system isslow to respond to stock-outs. The basic health staff arecurrently be<strong>in</strong>g tra<strong>in</strong>ed by Department of Health <strong>Plann<strong>in</strong>g</strong>(DHP) staff to fill <strong>in</strong> RHMIS forms to ensure <strong>the</strong> qualityof <strong>the</strong> data collected; however, much more is needed <strong>in</strong><strong>the</strong> way of capacity-build<strong>in</strong>g for project<strong>in</strong>g contraceptiverequirements <strong>and</strong> mak<strong>in</strong>g needs-based supply functional.There is a need for better coord<strong>in</strong>ation between <strong>the</strong>programme managers <strong>and</strong> <strong>the</strong> townships <strong>and</strong> beyond levelof <strong>the</strong> health system. Problems also exist <strong>in</strong> terms of a soundlogistical management system for forecast<strong>in</strong>g, procur<strong>in</strong>g,warehous<strong>in</strong>g, distribut<strong>in</strong>g <strong>and</strong> controll<strong>in</strong>g RH commodity<strong>in</strong>ventories. This <strong>in</strong>cludes <strong>the</strong> supply of reproductive healthcommodities <strong>and</strong> contraceptives result<strong>in</strong>g <strong>in</strong> <strong>in</strong>termittentstock-outs at <strong>the</strong> facility level, a situation which adverselyaffects <strong>the</strong> end-users.There is evidence that <strong>in</strong> My<strong>in</strong> Mu Township, under <strong>the</strong>able leadership of <strong>the</strong> Township Medical Officer, plann<strong>in</strong>gfor <strong>and</strong> projection of contraceptive requirements werespearheaded at <strong>the</strong> township level <strong>and</strong> <strong>the</strong>re were no stockoutsof commodities 46 . These closer-to-client good practicesneed to be exp<strong>and</strong>ed throughout <strong>the</strong> country toge<strong>the</strong>r with<strong>the</strong> tra<strong>in</strong><strong>in</strong>g of health personnel, <strong>the</strong> coord<strong>in</strong>ation <strong>and</strong>utilization of a computerized logistics management <strong>and</strong><strong>in</strong>formation system (LMIS), mapp<strong>in</strong>g, monitor<strong>in</strong>g <strong>and</strong>supervision, <strong>and</strong> functional LMIS is needed. Myanmar doesnot have a viable commodity security plan; however, <strong>the</strong>second National Strategic Plan for RH has an operationalplan for RH commodity security. If all partners wouldcomplement each o<strong>the</strong>r by pledg<strong>in</strong>g to adhere to <strong>the</strong> workplan, commodity security for birth spac<strong>in</strong>g <strong>and</strong> RH wouldbecome a reality.Fund<strong>in</strong>g gap for birth-spac<strong>in</strong>gcommoditiesAnalysis of past fund<strong>in</strong>g for birth-spac<strong>in</strong>g commodities <strong>in</strong>Myanmar found that, <strong>in</strong> 2009, <strong>the</strong> fund<strong>in</strong>g gap was overUS$ 5.5 million <strong>and</strong> that UNFPA is <strong>the</strong> major source forbirth-spac<strong>in</strong>g commodities. There is no budget l<strong>in</strong>e forbirth-spac<strong>in</strong>g commodities <strong>in</strong> <strong>the</strong> budget of <strong>the</strong> M<strong>in</strong>istry ofHealth. At <strong>the</strong> current CPR of 41 per cent <strong>in</strong> 2007 <strong>and</strong> 17.7per cent unmet need for contraceptives, <strong>and</strong> provided thatUNFPA cont<strong>in</strong>ues to support <strong>the</strong> supply of contraceptiveseven just at <strong>the</strong> current level, <strong>in</strong>creased f<strong>in</strong>ancial supportwould be required from <strong>the</strong> national budget as well as fromFigure7Projected costs aga<strong>in</strong>st contraceptive requirements <strong>and</strong> funds committed for supplies only, (2009-2013)Projected costs, million US$$12,00$10,00$8,00$6,00$4,00$2,00$0,00$10,74 $10,98$11,25$11,51$9,72$4,20 $4,37 $4,41 $4,46 $4,501 2 3 4 5YearProjected costs Committed fundsSource: United Nations Population Fund/Myanmar, Report on Situation Analysis of Population <strong>and</strong> Development, ReproductiveHealth <strong>and</strong> Gender <strong>in</strong> Myanmar, Yangon: UNFPA/Myanmar, 2010.272

Figuredonors to make up for a shortfall of US$ 26 million, whichwould account for about 60 per cent of contraceptiverequirements <strong>in</strong> <strong>the</strong> period 2010-2013. (Figure 7) depicts<strong>the</strong> predicted shortfall of funds aga<strong>in</strong>st <strong>the</strong> contraceptiverequirements (assumptions: method-mix does not changeover <strong>the</strong> next five years <strong>and</strong> <strong>the</strong>re is no <strong>in</strong>flation).Fund<strong>in</strong>g mechanism for birthspac<strong>in</strong>gcommoditiesWhile <strong>the</strong> government bears <strong>the</strong> costs of personnel <strong>and</strong><strong>the</strong> logistics supply cha<strong>in</strong>, as mentioned previously <strong>the</strong>re isno national budget l<strong>in</strong>e for procurement of contraceptivecommodities. The <strong>in</strong>itial fund<strong>in</strong>g for RH commodities wasfrom <strong>the</strong> David <strong>and</strong> Lucile Packard Foundation <strong>in</strong> 2001;later <strong>the</strong> project was funded by various donors, <strong>in</strong>clud<strong>in</strong>g<strong>the</strong> UNFPA donor community.Over <strong>the</strong> past decade, <strong>the</strong> supply of contraceptives to <strong>the</strong>public sector was solely supported by <strong>in</strong>ternational aid(ma<strong>in</strong>ly from UNFPA). These programmes were able tochannel contraceptives to 132 of <strong>the</strong> 325 townships <strong>in</strong><strong>the</strong> country. The ma<strong>in</strong> sources of fund<strong>in</strong>g for <strong>the</strong> birthspac<strong>in</strong>gprogramme were <strong>the</strong> UNFPA core fund <strong>and</strong><strong>the</strong>matic trust fund for <strong>the</strong> period of 2001 to 2010, , <strong>in</strong>addition to bilateral funds from donor countries such asGermany. The majority of <strong>the</strong> fund<strong>in</strong>g goes to <strong>the</strong> publicsector with DOH be<strong>in</strong>g major implement<strong>in</strong>g partner. PSI,MSI, MMA <strong>and</strong> o<strong>the</strong>r implement<strong>in</strong>g partners contributetowards RH commodities <strong>and</strong> o<strong>the</strong>r supportive measures,such as tra<strong>in</strong><strong>in</strong>g <strong>and</strong> development <strong>and</strong> production of IECmaterials 47 .NGOs such as PSI <strong>and</strong> MSI also receive funds from <strong>the</strong>irrespective headquarters <strong>and</strong> o<strong>the</strong>r donors for <strong>the</strong> birthspac<strong>in</strong>gprogramme 48 . The effective implementation of apro-poor cost-shar<strong>in</strong>g policy for contraceptive suppliesrema<strong>in</strong>s a challenge to make a reality <strong>the</strong> availability ofmodern contraceptive methods free of cost or at subsidizedrates.While contraceptives are also available <strong>in</strong> privatepharmacies <strong>and</strong> cl<strong>in</strong>ics <strong>and</strong> have been cited as <strong>the</strong> ma<strong>in</strong>source of contraceptive <strong>in</strong>jectables by <strong>the</strong> 2007 FRHS 49 ,<strong>the</strong> costs <strong>in</strong>curred may pose an obstacle for <strong>the</strong> poor <strong>and</strong>quality may not be appropriate to meet <strong>the</strong> population’sneeds.Political commitment to<strong>the</strong> birth-spac<strong>in</strong>g <strong>and</strong> RHprogrammesIn recogniz<strong>in</strong>g <strong>the</strong> urgent need to address <strong>the</strong> shortfall<strong>in</strong> contraceptives, a high-level stakeholder meet<strong>in</strong>g,chaired by <strong>the</strong> Deputy M<strong>in</strong>ister for Health, was held <strong>in</strong>Nay Pyi Taw, <strong>the</strong> capital city, <strong>in</strong> December 2008 50 . TheNational Reproductive Health Commodity Security Sub-Committee was formed to assess <strong>the</strong> current situation onRH commodities <strong>in</strong> both <strong>the</strong> private <strong>and</strong> public sectors,<strong>and</strong> identify <strong>and</strong> coord<strong>in</strong>ate efforts <strong>in</strong> secur<strong>in</strong>g supplies ofcommodities, while improv<strong>in</strong>g <strong>the</strong> RH <strong>in</strong>formation system<strong>and</strong> streng<strong>the</strong>n<strong>in</strong>g LMIS for <strong>the</strong> forecast<strong>in</strong>g, procurement,supply, storage <strong>and</strong> distribution of contraceptivecommodities. 51The second meet<strong>in</strong>g of <strong>the</strong> National RH work<strong>in</strong>gcommittee meet<strong>in</strong>g, <strong>in</strong>vited all partners – United Nations<strong>and</strong> NGOs work<strong>in</strong>g <strong>in</strong> <strong>the</strong> area of RH <strong>and</strong> birth spac<strong>in</strong>g<strong>and</strong> <strong>the</strong> Deputy M<strong>in</strong>ister provided policy direction <strong>and</strong>advocacy for resource mobilization to meet RH commodityFigure8Source of fund<strong>in</strong>g to meet contraceptive requirements over <strong>the</strong> period (2009-2013)$42 346 555(66%)$21 948 469(34%)UNFPAShortfallSource: United Nations Population Fund/Myanmar, Report on Situation Analysis of Population <strong>and</strong> Development, ReproductiveHealth <strong>and</strong> Gender <strong>in</strong> Myanmar, Yangon: UNFPA/Myanmar, 2010.273

equirements. The M<strong>in</strong>istry of Health also discussedwith UNFPA, <strong>the</strong> major provider of birth-spac<strong>in</strong>gcommodities, to exp<strong>and</strong> its coverage of project townshipsas much as possible <strong>in</strong> order to exp<strong>and</strong> <strong>the</strong> coverage <strong>and</strong> toachieve universal access, even though it has not allocatedany budget for contraceptives 52 .In <strong>the</strong> public health facilities <strong>the</strong>re is a mechanism forbirth-spac<strong>in</strong>g commodity susta<strong>in</strong>ability by provid<strong>in</strong>gbirth-spac<strong>in</strong>g services through a cost-shar<strong>in</strong>g system,whereby <strong>the</strong> client pays a m<strong>in</strong>imal amount for birthspac<strong>in</strong>gcommodities. The funds thus generated areaccumulated <strong>in</strong> <strong>the</strong> Health Facility OA head<strong>in</strong>g account(OA-O<strong>the</strong>r Accounts) as a revolv<strong>in</strong>g fund, which is to beutilized if <strong>and</strong> when UNFPA funds are not available 53 .However, this system needs policy direction as to how <strong>the</strong>funds should be managed <strong>and</strong> utilized effectively, as <strong>the</strong>substantial amount of fund<strong>in</strong>g is accumulated without<strong>in</strong>terest <strong>in</strong> township banks.Relationship of <strong>the</strong> reproductivehealth <strong>and</strong> birth-spac<strong>in</strong>gprogrammes to health,communities <strong>and</strong> women’sempowermentCommunity volunteers such as Community supportgroups (CSG) <strong>and</strong> MCH promoters <strong>and</strong> Male frontl<strong>in</strong>ehealth promoters are tra<strong>in</strong>ed <strong>in</strong> selected townships toact as a bridge between health-care providers <strong>and</strong> people<strong>in</strong> communities. This programme is a jo<strong>in</strong>t <strong>in</strong>itiative<strong>in</strong>volv<strong>in</strong>g UNFPA, <strong>the</strong> Central Health Education Bureauof Department of Health, M<strong>in</strong>istry of Health <strong>and</strong> <strong>the</strong>Japanese Organization for <strong>International</strong> Cooperation<strong>in</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> ( JOICFP) 54 . The ma<strong>in</strong> aims ofcommunity volunteers are to dissem<strong>in</strong>ate RH knowledge<strong>and</strong> birth spac<strong>in</strong>g <strong>and</strong> to support <strong>the</strong> community <strong>in</strong><strong>the</strong> behavioural change process for healthy liv<strong>in</strong>g. Theobjectives of mobiliz<strong>in</strong>g community volunteers are todissem<strong>in</strong>ate RH knowledge to <strong>the</strong> relevant population <strong>in</strong>townships <strong>and</strong> provide means of transport <strong>and</strong> referrals tohospital <strong>in</strong> times of obstetrical emergencies so that proper<strong>and</strong> timely referral could be provided.Start<strong>in</strong>g <strong>in</strong> 2002 members of CSG were selected from eachcommunity by <strong>the</strong> local midwife <strong>and</strong> <strong>the</strong> village healthcommittee, accord<strong>in</strong>g to criteria for selection: persons<strong>in</strong>terested <strong>in</strong> <strong>the</strong> health <strong>and</strong> welfare of <strong>the</strong> community,<strong>and</strong> active males <strong>and</strong> females between 18 <strong>and</strong> 50 years ofage. Each CSG member is given tra<strong>in</strong><strong>in</strong>g on reproductivehealth, is given a record booklet <strong>and</strong> is put <strong>in</strong> charge of30 households. The CSG members give health educationto <strong>the</strong>ir assigned households, provide help <strong>and</strong> supportwith transport when a person needs to be referred to adistant hospital or health-care provider, raise funds from<strong>the</strong> community if <strong>the</strong>re is a need <strong>in</strong> emergency situations,<strong>and</strong> assist midwives or health-care providers <strong>in</strong> healthactivities. CSGs work very closely with village healthcommittee members <strong>and</strong> basic health staff; <strong>the</strong>y havebeen successful <strong>in</strong> provid<strong>in</strong>g timely referral <strong>and</strong> support <strong>in</strong>obstetric emergencies.CSG was implemented as a model project <strong>in</strong> DalahTownship <strong>in</strong> Yangon Division, <strong>and</strong> Sarmalauk village <strong>in</strong>Nyaung Done Township. When <strong>the</strong> model communityRH project was assessed, it was found that CPR roseby 50 per cent over exist<strong>in</strong>g levels <strong>and</strong> that awareness ofreproductive tract <strong>in</strong>fections, sexually transmitted diseases<strong>and</strong> HIV/AIDS had <strong>in</strong>creased by about 50 per cent.CPR <strong>in</strong> Sarmalauk raised from 31 per cent <strong>in</strong> 2001 to42.6 per cent <strong>in</strong> 2003 55 , <strong>and</strong> was later exp<strong>and</strong>ed to reach64 townships by <strong>the</strong> end of 2010 56 . The Situation AnalysisTeam members also observed success stories dur<strong>in</strong>g <strong>the</strong>irvisits to rural health centres <strong>and</strong> felt that this programmehad <strong>the</strong> potential to br<strong>in</strong>g about better RH outcomes <strong>in</strong>rural areas 57 .PSI/Myanmar’s mission is to serve <strong>the</strong> poor <strong>and</strong>vulnerable groups <strong>in</strong> <strong>the</strong> country, <strong>and</strong> all programme<strong>and</strong> service deliveries are targeted towards <strong>the</strong>se groups.All Sun providers have been tra<strong>in</strong>ed <strong>in</strong> counsel<strong>in</strong>g skills.Women are empowered to select a method of <strong>the</strong>ir choice<strong>and</strong> considerable progress has been made <strong>in</strong> reach<strong>in</strong>gcommunities nationwide.Role of youth volunteers <strong>and</strong>Youth Information Centres 58UNFPA-supported youth programmes <strong>in</strong> collaborationwith <strong>the</strong> MSI, AFXB, MMA, DOH <strong>and</strong> DHP are successstories with regard to reproductive <strong>and</strong> sexual heal<strong>the</strong>ducation <strong>and</strong> services through youth programmes. YouthInformation Centres (YIC) have become a good modelfor young people to learn about ASRH; <strong>the</strong>y furnisha socially friendly environment for behavioural changecommunication <strong>and</strong> for <strong>the</strong> adoption of positive habitstowards safe sex <strong>and</strong> abst<strong>in</strong>ence from <strong>the</strong> tobacco, alcohol<strong>and</strong> betel-chew<strong>in</strong>g habits. The “Leadership development<strong>and</strong> healthy happy adolescent life programme” had muchsuccess <strong>in</strong> engag<strong>in</strong>g youth to adopt healthy behaviouralchanges. The YIC programme, which is supported byMMA, AFXB <strong>and</strong> <strong>the</strong> Central Health Education Bureau-JIOCFP, has been successful <strong>in</strong> engag<strong>in</strong>g youth but willneed fur<strong>the</strong>r expansion <strong>and</strong> quality assurance whenfranchised. It is not enough simply to furnish young peoplewith <strong>in</strong>formation on health; youth also need support for<strong>the</strong>ir personal <strong>and</strong> professional development <strong>in</strong> order toachieve holistic growth 59 .274

Most of <strong>the</strong> youth volunteers are <strong>in</strong>formed about youthprogrammes <strong>and</strong> youth centres by <strong>the</strong>ir friends <strong>and</strong>through HIV knowledge fairs. They attend youth tra<strong>in</strong><strong>in</strong>gsto <strong>in</strong>crease <strong>the</strong>ir level of knowledge about reproductive<strong>and</strong> sexual health <strong>and</strong> share it with o<strong>the</strong>r friends so that<strong>the</strong>y too could avoid risky behaviour <strong>and</strong> diseases. InYangon, MMA has a comprehensive tra<strong>in</strong><strong>in</strong>g programmefor personal <strong>and</strong> leadership development for youth. Forsuburban youth, AFXB has youth centres where practicalvocational tra<strong>in</strong><strong>in</strong>g opens young people to job opportunitieswere <strong>the</strong>y can ga<strong>the</strong>r toge<strong>the</strong>r for peer educator tra<strong>in</strong><strong>in</strong>gs.In rural areas, some youth are now peer educators for youth<strong>in</strong> <strong>the</strong>ir villages <strong>and</strong> conduct outreach activities, provid<strong>in</strong>go<strong>the</strong>r youth <strong>in</strong> <strong>the</strong> village with health education sessions.The community <strong>and</strong> <strong>the</strong> families of <strong>the</strong> youth appreciate<strong>the</strong>se activities because of <strong>the</strong> many positive changes <strong>the</strong>yhave observed <strong>in</strong> youth: <strong>in</strong>creased awareness about health,changes <strong>in</strong> lifestyle <strong>and</strong> behaviour <strong>and</strong> participation <strong>in</strong>social work with parents. Fur<strong>the</strong>rmore <strong>the</strong> youth becomegood leaders <strong>in</strong> <strong>the</strong> community <strong>and</strong> organize many o<strong>the</strong>ryouth to jo<strong>in</strong> <strong>in</strong> <strong>the</strong>se activities.The constra<strong>in</strong>ts to <strong>the</strong> outreach activities are that work<strong>in</strong>gyouth face difficulties <strong>in</strong> committ<strong>in</strong>g <strong>the</strong>ir free timeto engage <strong>in</strong> group activities <strong>in</strong> <strong>the</strong> community; alsosometimes <strong>the</strong>y cannot answers questions that peers mightask dur<strong>in</strong>g peer sessions. In Mawlamya<strong>in</strong>g <strong>and</strong> Thahtonedistricts, <strong>the</strong>re has been migration of community youthpeer educators <strong>and</strong> tra<strong>in</strong>ed volunteers, which served to<strong>in</strong>crease <strong>the</strong> attrition rate of peer educators for socioeconomicreasons. This programme needs to be exp<strong>and</strong>edto reach o<strong>the</strong>r youth <strong>in</strong> <strong>the</strong> nation.There is a need to produce IEC about sexually transmitted<strong>in</strong>fections (STIs) <strong>and</strong> to provide <strong>the</strong> peer educationprogramme <strong>and</strong> tra<strong>in</strong><strong>in</strong>g sessions at universities; alsomonitor<strong>in</strong>g guidel<strong>in</strong>es are needed for peer educators, <strong>and</strong>more volunteer peer educators are needed to substitute fordropouts. There is a need to develop books of frequentlyasked questions compiled from such sessions <strong>and</strong> distribute<strong>the</strong>m to peer educators for <strong>the</strong> purpose of <strong>the</strong> shar<strong>in</strong>gprecise, correct messages with <strong>the</strong> community.In l<strong>in</strong>e with <strong>the</strong> low economic conditions that prevail <strong>the</strong>reis a need to exp<strong>and</strong> vocational tra<strong>in</strong><strong>in</strong>g for out-of-schoolyouth who are unemployed. More advocacy is neededto exp<strong>and</strong> youth centres so that youth who are highlyvulnerable would be able to participate. For outreachactivities, peer educators need to be provided with moneyto pay for transport (bicycles or trawlagy- motorized, locallyassembled-open-top vehicle). Accord<strong>in</strong>g to <strong>the</strong> workplan forscheduled outreach activities, regular tra<strong>in</strong><strong>in</strong>g is neededfor <strong>the</strong> recruitment of new peer educators <strong>and</strong> refreshertra<strong>in</strong><strong>in</strong>g to update <strong>in</strong>formation about reproductive health<strong>and</strong> o<strong>the</strong>r health-related issues. A forum is neededto enable <strong>the</strong> shar<strong>in</strong>g of experiences among youth <strong>in</strong>different townships; <strong>in</strong> addition supplies of IEC materials<strong>and</strong> condoms are needed cont<strong>in</strong>uously <strong>and</strong> <strong>in</strong> adequatequantities 60 .These young peer educators can be resources for l<strong>in</strong>k<strong>in</strong>g <strong>the</strong>prevention of HIV/STIs to birth-spac<strong>in</strong>g services. Theycan advocate birth spac<strong>in</strong>g <strong>and</strong> emergency contraceptionto reduce un<strong>in</strong>tended pregnancies among young people.More youth-friendly spaces need to be developed whereyouth peer educators can <strong>in</strong>teract with o<strong>the</strong>r village youthsfor ARSH education.Government, religious <strong>and</strong>public support for RH <strong>and</strong> birthspac<strong>in</strong>gprogrammesThere are nei<strong>the</strong>r significant restrictions on nor oppositionto birth spac<strong>in</strong>g <strong>in</strong> Myanmar <strong>in</strong> terms of religious beliefsor cultural concepts, except <strong>the</strong> government’s propensitytowards a pronatalist population policy <strong>and</strong> caution <strong>in</strong>exp<strong>and</strong><strong>in</strong>g contraception <strong>and</strong> control over <strong>the</strong> population 61 .Politically, <strong>the</strong> government has been becom<strong>in</strong>g morepositive towards birth spac<strong>in</strong>g, especially <strong>in</strong> <strong>the</strong> later partof 2010 62 . This may be due to <strong>the</strong> publication by UNFPA<strong>in</strong> 2010 of <strong>the</strong> Report on Situation Analysis of Population<strong>and</strong> Development, Reproductive Health <strong>and</strong> Gender <strong>in</strong>Myanmar, which highlighted birth-spac<strong>in</strong>g gaps <strong>and</strong> maderecommendations for birth-spac<strong>in</strong>g commodity securityfor a better RH outcome. PSI/Myanmar has been askedby <strong>the</strong> Department of Health to support IUD tra<strong>in</strong><strong>in</strong>gs fortownship medical officers <strong>and</strong> has been requested to allowmidwives to refer IUD clients to Sun cl<strong>in</strong>ics 63 . This is seenas a major shift for <strong>the</strong> Department which <strong>in</strong> past yearspersistently discouraged PSI/Myanmar’s IUD activities<strong>and</strong> rem<strong>in</strong>ded <strong>the</strong> NGO repeatedly to work passively<strong>and</strong> for each Sun cl<strong>in</strong>ic not to carry out more than five<strong>in</strong>sertions a day 64 .About 90 per cent of <strong>the</strong> population of Myanmar isBuddhist. Buddhism welcomes large families <strong>and</strong> regards<strong>the</strong>m as a bless<strong>in</strong>g. Christians <strong>and</strong> Muslims comprise about5 <strong>and</strong> 4 per cent of <strong>the</strong> population, respectively, <strong>and</strong> o<strong>the</strong>rreligions toge<strong>the</strong>r comprise about 1 per cent 65 . The peopleof Myanmar are made up of 135 national races belong<strong>in</strong>gto eight major groups: Kach<strong>in</strong>, Kayah, Kay<strong>in</strong>, Ch<strong>in</strong>,Bamar, Mon, Rakh<strong>in</strong>e <strong>and</strong> Shan. There are more than 100languages <strong>and</strong> dialects spoken across <strong>the</strong> country.One of <strong>the</strong> m<strong>in</strong>ority religions <strong>in</strong> Myanmar is Christianity.Catholics do have reservations about <strong>the</strong> use ofcontraception, which may affect a m<strong>in</strong>or proportion of <strong>the</strong>population. All citizens of Myanmar have equality <strong>in</strong> accessto education <strong>and</strong> health, <strong>and</strong> enjoy freedom of worship275

accord<strong>in</strong>g to <strong>the</strong> Constitution of <strong>the</strong> Republic of <strong>the</strong>Union of Myanmar. The majority of people <strong>in</strong> Nor<strong>the</strong>rnRakh<strong>in</strong>e State (NRS) are Muslim; <strong>the</strong>y speak a dialectof Bengali that is spoken <strong>in</strong> sou<strong>the</strong>rn Bangladesh <strong>and</strong> isl<strong>in</strong>guistically different from <strong>the</strong> native Rakh<strong>in</strong>e. Most of<strong>the</strong>m are given temporary registration cards (TRC) issuedby <strong>the</strong> government 66 .That population group needs permission to marry <strong>and</strong> totravel. Socio-cultural concepts compounded with <strong>the</strong>selimitations have had a significant impact on <strong>the</strong> status ofwomen <strong>and</strong> adolescent females <strong>in</strong> NRS. After pubertywomen are conf<strong>in</strong>ed to <strong>the</strong> house <strong>and</strong> permitted to goout only <strong>in</strong> <strong>the</strong> company of a male family member. As aresult some Muslim girls <strong>in</strong> NRS, if <strong>the</strong>y are attend<strong>in</strong>gschool, withdraw after <strong>the</strong> fourth grade. This could be oneof <strong>the</strong> contributory factors for a low literacy rate amongfemales, lead<strong>in</strong>g to disempowerment 67 . Because of suchrestrictions, delays <strong>in</strong> <strong>the</strong> decision to seek assistance <strong>and</strong>ga<strong>in</strong> access to health care have had a major negative impacton <strong>the</strong> reproductive health of women <strong>in</strong> NRS. Currently,more attention has been given by <strong>the</strong> government to NRSensur<strong>in</strong>g better social support.Major socio-cultural <strong>and</strong>economic issues of relevancewith regard to birth spac<strong>in</strong>gConservative <strong>and</strong> religious cultural norms can sometimescause limitations on birth spac<strong>in</strong>g. Myths <strong>and</strong> beliefs,such as hav<strong>in</strong>g an IUD (a foreign body) <strong>in</strong> <strong>the</strong> uterus,are harmful. Weak public <strong>in</strong>formation, education <strong>and</strong>services related to family plann<strong>in</strong>g with little or noknowledge about <strong>the</strong> different birth-spac<strong>in</strong>g methods alsoare deleterious. Opposition by husb<strong>and</strong>s <strong>and</strong> <strong>the</strong> wrong<strong>in</strong>fluence of elderly people, especially gr<strong>and</strong>mo<strong>the</strong>rs <strong>and</strong>mo<strong>the</strong>rs-<strong>in</strong>-law who believe that knowledge about sex <strong>and</strong>FP is for married women <strong>and</strong> talk<strong>in</strong>g about <strong>the</strong>m is seenas improper conduct, also are detrimental to RH. Mostunmarried women do not seek RH services from publicsuppliers. Official permission is needed even for marriedwomen to obta<strong>in</strong> sterilization, which takes a long timefor local health authorities to process; when <strong>the</strong> womangets <strong>the</strong> official permission, she may already be pregnant 68 .Traditionally, big families are considered a bless<strong>in</strong>g <strong>in</strong>Myanmar. Although this culture is chang<strong>in</strong>g <strong>in</strong> urbanitesas a country whose economy is based on agriculture,farmers <strong>in</strong> rural areas still want to have a large family towork <strong>the</strong> l<strong>and</strong> 69 .Factors contribut<strong>in</strong>g to successThe birth-spac<strong>in</strong>g <strong>and</strong> RH programmes have ga<strong>in</strong>edmomentum despite <strong>the</strong>se challenges, as ev<strong>in</strong>ced by <strong>the</strong>decrease <strong>in</strong> TFR, <strong>the</strong> <strong>in</strong>crease <strong>in</strong> CPR <strong>and</strong> <strong>the</strong> decrease<strong>in</strong> unmet need for contraception. The ma<strong>in</strong> reasons forsuccess are as follows:(a) Strong political commitment of <strong>the</strong> M<strong>in</strong>istry ofHealth, work<strong>in</strong>g toge<strong>the</strong>r with UNFPA, WHO <strong>and</strong><strong>in</strong>ternational NGOs, with a high level of <strong>in</strong>volvement <strong>in</strong>coord<strong>in</strong>at<strong>in</strong>g commodity security. Given <strong>the</strong> significantunmet need for FP, much rema<strong>in</strong>s to be done to reachreproductive health commodity security.(b) Increased knowledge of contraceptives <strong>and</strong> accessibility<strong>and</strong> affordability of different methods both <strong>in</strong> <strong>the</strong>public <strong>and</strong> private sectors.(c) Improved access to high-quality RH services byenhanc<strong>in</strong>g <strong>the</strong> knowledge <strong>and</strong> skills of providersabout birth spac<strong>in</strong>g through tra<strong>in</strong><strong>in</strong>g <strong>in</strong> sexual <strong>and</strong>reproductive health. Access is also enhanced by giv<strong>in</strong>gwomen <strong>the</strong> chance to select <strong>the</strong> method of <strong>the</strong>ir choiceus<strong>in</strong>g social market<strong>in</strong>g of high-quality products whichare attractively packaged, <strong>and</strong> social market<strong>in</strong>g by PSIconta<strong>in</strong><strong>in</strong>g <strong>in</strong>formation for both clients <strong>and</strong> generalpractitioners. Such <strong>in</strong>formation enables <strong>the</strong>m tochoose/recommend different contraceptive methods<strong>and</strong> compare prices so that <strong>the</strong>y have freedom tochoose accord<strong>in</strong>g to <strong>in</strong>dividual affordability 70 .(d) The birth-spac<strong>in</strong>g programme is not a st<strong>and</strong>-aloneprogramme; it is supported by <strong>the</strong> national reproductivehealth behaviour change communication activitieswhich create greater dem<strong>and</strong> for birth spac<strong>in</strong>g 71 .(e) Community empowerment contributed to success <strong>in</strong>selected townships where CSGs form a l<strong>in</strong>k between<strong>the</strong> community <strong>and</strong> health-service providers at <strong>the</strong>grass-roots level.Current issues of concernAdolescent sexual <strong>and</strong> reproductivehealth <strong>and</strong> vulnerabilitiesYoung people (15-24 years) represent <strong>the</strong> future of everysociety <strong>and</strong> comprise a great resource of a nation. InMyanmar <strong>the</strong>y constitute one fifth of <strong>the</strong> total population 72 .Of <strong>the</strong> estimated population of 57.5 million 73 , <strong>the</strong>proportion of young people has decl<strong>in</strong>ed to 19.2 per centfrom 20 per cent <strong>in</strong> 2001. The trend <strong>in</strong> <strong>the</strong> age-specificfertility rate for <strong>the</strong> age group 15-19 is decl<strong>in</strong><strong>in</strong>g (see Figure276

Figure3.12). The proportion of TFR attributed to <strong>the</strong> age group15-19 years was 3.37 per cent <strong>in</strong> 2002 74 <strong>and</strong> was less than4-5 per cent <strong>in</strong> 2007 75 . Accord<strong>in</strong>g to <strong>the</strong> 2007 FRHS only1.9 per cent of females had <strong>the</strong>ir first birth before age 15,<strong>and</strong> slightly over 25 per cent had <strong>the</strong>ir first birth before age20. However, <strong>the</strong>re are regional differentials, with Rakh<strong>in</strong>eState hav<strong>in</strong>g <strong>the</strong> lowest age at first birth.Usually adolescents do not use contraception <strong>and</strong> maybe prone to unsafe abortion <strong>in</strong> <strong>the</strong> case of unwantedpregnancy. With regard to pre-marital sex, 16 per cent ofyouth approved it for boys while only 7 per cent of youthapproved of it for girls 76 . Young people perceived thatsocioculturally Myanmar youth should not be <strong>in</strong>volved <strong>in</strong>pre-marital sex; however, <strong>the</strong> majority expressed <strong>the</strong> viewthat <strong>the</strong>re are <strong>in</strong>creased numbers of young people engaged<strong>in</strong> pre-marital sex 77 .Accord<strong>in</strong>g to <strong>the</strong> 2007 FRHS, 11.4 per cent of pregnancies<strong>in</strong> women aged 15-19 ended <strong>in</strong> abortion. The 2004<strong>Family</strong> <strong>and</strong> Youth Survey conducted by <strong>the</strong> Departmentof Population, M<strong>in</strong>istry of Immigration <strong>and</strong> Population,<strong>and</strong> UNFPA 78 reported that 78 per cent of <strong>the</strong> youth<strong>in</strong>terviewed <strong>in</strong>dicated that <strong>the</strong> home of tra<strong>in</strong>ed birthassistants was <strong>the</strong> place where abortions could be done;home (40%) <strong>and</strong> private cl<strong>in</strong>ic (36%) were o<strong>the</strong>r oftencitedplaces. In addition, young people make up a segmentof <strong>the</strong> population that is particularly vulnerable to HIV<strong>in</strong>fection ow<strong>in</strong>g to several specific factors, such as lack ofknowledge about HIV/AIDS, lack of education <strong>and</strong> lifeskills, poor access to health services <strong>and</strong> commodities,early sexual debut, sexual coercion, sexual violence,traffick<strong>in</strong>g <strong>and</strong> grow<strong>in</strong>g up without parents or o<strong>the</strong>r formsof protection from exploitation <strong>and</strong> abuse. As <strong>the</strong>y are<strong>in</strong>fluenced by socio-economic factors, contemporary socialnorms <strong>and</strong> lifestyles, young adults tend to acquire riskysexual behaviours.Accord<strong>in</strong>g to Behavioural Sent<strong>in</strong>el Surveillance, 2008, forout-of-school youth 79 per cent have complete <strong>and</strong> accurateknowledge of HIV/AIDS <strong>and</strong> about half of <strong>the</strong>m did notuse condoms dur<strong>in</strong>g <strong>the</strong>ir last sexual encounter with causalpartners, although 90 per cent of <strong>the</strong>m used condoms <strong>the</strong>last time <strong>the</strong>y had sex with sex workers. Anecdotal evidencesuggests that an <strong>in</strong>crease <strong>in</strong> number of men who have sexwith men (MSM) is associated with new registrations atPSI youth drop-<strong>in</strong> centres of young men below 19 years ofage 80 . While adolescents do have a high level of awarenessabout STIs/HIV (75% for STIs <strong>and</strong> 91% for reproductivetract <strong>in</strong>fections) 81 , detailed knowledge on RH <strong>and</strong> STIsis limited. The school dropout rate is highest at grade 11(55.4%). The percentage of youth with a high school orhigher level of education is almost 60 per cent for bothsexes <strong>in</strong> urban areas, whereas it is less than 25 per cent<strong>in</strong> rural areas. Employment opportunities for out-ofschoolyouth are very limited; an estimated 90 per cent areunemployed.Traffick<strong>in</strong>g is <strong>the</strong> crim<strong>in</strong>al <strong>and</strong> illegal trad<strong>in</strong>g of humanbe<strong>in</strong>gs for <strong>the</strong> purpose of exploit<strong>in</strong>g <strong>the</strong>ir labour. Youngpeople are more likely to be <strong>the</strong> victims of traffick<strong>in</strong>g thanadults. While <strong>the</strong>re are no national-level data on traffick<strong>in</strong>g,<strong>the</strong> 2004 <strong>Family</strong> <strong>and</strong> Youth Survey, 2004, reported that 87per cent of youth had ever heard about <strong>the</strong> term traffick<strong>in</strong>g<strong>and</strong>, of <strong>the</strong>m, 71 per cent suggested that <strong>the</strong> 15-19 agegroup was <strong>the</strong> most likely target for traffick<strong>in</strong>g <strong>and</strong> ano<strong>the</strong>r20 per cent suggested that <strong>the</strong> age group 20-24 was. Girlsare especially vulnerable <strong>and</strong> are likely to be <strong>in</strong>fluenced byfalse job offers, promises of marriage <strong>and</strong> a better life.Figure9Trend <strong>in</strong> age-specific fertility rate per 1,000 among females aged 15-19 years, (1971-2001)504040ASFR3020102922.701971 1996 2001yearSource: For <strong>the</strong> years 1971 <strong>and</strong> 1996, World Fertility Report 2003 (United Nations publication, Sales No. E.04.XIII.10); for 2001:Myanmar Fertility <strong>and</strong> Reproductive Health Survey 2001, M<strong>in</strong>istry of Immigration <strong>and</strong> Population, Yangon, 2003.277

Adolescent sexual <strong>and</strong> reproductivehealth educationReproductive health services <strong>and</strong> <strong>in</strong>formation can improve<strong>the</strong> health status of adolescents <strong>and</strong> help <strong>the</strong>m atta<strong>in</strong> <strong>the</strong>level of underst<strong>and</strong><strong>in</strong>g required to make responsibledecisions. Participation of young people <strong>in</strong> plann<strong>in</strong>g,implementation <strong>and</strong> monitor<strong>in</strong>g of services could ensureadolescent-friendly health services. Adequate supportfrom <strong>the</strong> education sector <strong>and</strong> <strong>the</strong> community should beencouraged to support <strong>the</strong> <strong>in</strong>itiative.PSI/Myanmar <strong>and</strong> its Sun network members are tra<strong>in</strong>ed<strong>in</strong> adolescent reproductive health (ARH) <strong>and</strong> specialcommunication materials have been developed for <strong>the</strong>m.One million copies of an ARH booklet were distributedto young people dur<strong>in</strong>g <strong>the</strong> period 2006-2009 82 . This wasfunded by UNFPA; <strong>the</strong> production of <strong>the</strong> booklet wasjo<strong>in</strong>tly done by PSI/Myanmar <strong>and</strong> MMA youth teammembers.UNICEF <strong>and</strong> <strong>the</strong> M<strong>in</strong>istry of Education <strong>in</strong>troduced<strong>the</strong> School-based Healthy Liv<strong>in</strong>g <strong>and</strong> AIDS PreventionEducation programme (SHAPE) <strong>in</strong>to school curriculastart<strong>in</strong>g <strong>in</strong> 1997. The National Strategic Plan forAdolescent Health <strong>and</strong> Development (2008-2012)addresses general issues of adolescent health <strong>and</strong> def<strong>in</strong>esstrategies for adolescents’ reproductive health <strong>in</strong> particularby support<strong>in</strong>g adolescent-friendly health services 83 .The latter <strong>in</strong>cludes, among o<strong>the</strong>r th<strong>in</strong>gs, provision ofdiagnosis <strong>and</strong> treatment of STIs, provision of voluntarycounsel<strong>in</strong>g <strong>and</strong> test<strong>in</strong>g for HIV, provision of counsel<strong>in</strong>g<strong>and</strong> contraceptive services, antenatal, delivery, postnatal<strong>and</strong> post-abortion care.Un<strong>in</strong>tended pregnanciesAccord<strong>in</strong>g to <strong>the</strong> 2007 FRHS, almost 5 per cent of allpregnancies end <strong>in</strong> abortion. The abortion rate was highest<strong>in</strong> <strong>the</strong> age group 15-19 years <strong>and</strong> university-educatedyouth, with 11.39 per cent <strong>and</strong> 9.07 per cent of <strong>the</strong> totalrespectively 84 .Induced abortion is illegal <strong>in</strong> Myanmar. Accord<strong>in</strong>g to <strong>the</strong>2004 <strong>Family</strong> <strong>and</strong> Youth Survey, 78 per cent of <strong>in</strong>terviewedyouth expressed <strong>the</strong> view that homes of traditional birthattendants constituted <strong>the</strong> ma<strong>in</strong> place where abortionswere performed. The majority of <strong>the</strong>se procedures arelikely to be unsafe. Abortion is <strong>the</strong> third most commoncause of maternal death <strong>and</strong>, with <strong>the</strong> grow<strong>in</strong>g proportionof never married <strong>and</strong> high abortion rate of youth, sexual<strong>and</strong> reproductive health education <strong>and</strong> contraceptiveservices should cover not only married women but also betargeted towards youth, adolescents <strong>and</strong> <strong>the</strong> unmarried.Some patients with complications from <strong>in</strong>duced abortionpresent at hospitals; thus, <strong>in</strong> addition to FRHS <strong>and</strong> <strong>the</strong><strong>Family</strong> <strong>and</strong> Youth Survey, hospital statistics can also reflect<strong>the</strong> abortion rate <strong>in</strong> Myanmar. Hospital statistics revealedthat septic abortion contributed to 53 per cent of allmaternal deaths 85 .A hospital-based cross-sectional descriptive study on<strong>the</strong> sociodemographic determ<strong>in</strong>ants of abortion <strong>and</strong>assessment of contraception knowledge showed that, for100 patients admitted for abortion, <strong>the</strong> determ<strong>in</strong>ants ofrepeated abortion were very early age of marriage, longduration of marriage, <strong>in</strong>creas<strong>in</strong>g number of children alive<strong>and</strong> multiparity. Determ<strong>in</strong>ants of <strong>in</strong>duced abortion wereduration of marriage, desire not to have more children,unplanned or chance pregnancy <strong>and</strong> poor practice ofbirth-spac<strong>in</strong>g methods. From <strong>the</strong>se f<strong>in</strong>d<strong>in</strong>gs <strong>in</strong>formation,education <strong>and</strong> communication activities were essential toprevent abortion <strong>and</strong> its complications 86 .Antenatal care coverage improved from 63.1 per cent<strong>in</strong> 2005 to 64.6 per cent <strong>in</strong> 2007. The proportion ofbirths delivered by a traditional birth attendant droppedmarg<strong>in</strong>ally from 8.8 per cent <strong>in</strong> 2005 to 8.6 per cent <strong>in</strong>2007. The proportion of deliveries attended by skilled birthattendants (doctors, nurses <strong>and</strong> midwives) reached 64 percent <strong>in</strong> 2007, compared with 57 per cent <strong>in</strong> 2001. Theproportions of births attended by skilled birth attendantswas highest <strong>in</strong> <strong>the</strong> age group 45-49 years old, followed byfemales <strong>in</strong> <strong>the</strong> age group 15-19 years old. Most (76.4%)deliveries occurred at home, 16.6 per cent at governmentfacilities <strong>and</strong> <strong>the</strong> rest at private cl<strong>in</strong>ics.L<strong>in</strong>kages <strong>and</strong> timely referralThe majority (62%) of maternal deaths occurred at home.Only 38 per cent of women with complications werereferred to a hospital <strong>and</strong> only 24 per cent reached <strong>the</strong>hospital for proper management, while 14 per cent died on<strong>the</strong> way due to late referral <strong>and</strong> delays <strong>in</strong> transportation 87 .Quality of reproductive health careThis is one of <strong>the</strong> greatest barriers <strong>in</strong> <strong>the</strong> midwifery services<strong>and</strong> is augmented by <strong>in</strong>adequate supplies of essentialdrugs, non-adherence to established st<strong>and</strong>ards due to lackof knowledge <strong>and</strong> skills, unavailability of supplies <strong>and</strong> nonavailabilityof authorization of midwives to perform lifesav<strong>in</strong>g <strong>in</strong>terventions 88 .Health workforceAccord<strong>in</strong>g to WHO estimates, 23 health-care providers(doctors, nurses <strong>and</strong> midwives) per 10,000 people is<strong>the</strong> threshold to achieve 80 per cent coverage for skilledattendance dur<strong>in</strong>g deliveries. Countries with fewer than278

23 human resources for health (physicians, nurses <strong>and</strong>midwives) per 10,000 people are likely to experienceshortages <strong>in</strong> <strong>the</strong> coverage rates for <strong>the</strong> basic primaryhealth-care <strong>in</strong>terventions prioritized by <strong>the</strong> MillenniumDevelopment Goals 89 . In Myanmar, <strong>the</strong> doctor-topopulationratio is 1:3315, while <strong>the</strong> nurse/midwife-topopulationratio is 1:1195 90 . There are about 14 healthcareproviders per 10,000 people. The majority of highlyskilled medical doctors are concentrated <strong>in</strong> urban locations,where only 30 per cent of <strong>the</strong> total population resides. Tomeet <strong>the</strong> <strong>in</strong>ternational threshold <strong>and</strong> secure availabilityof skilled birth attendants at deliveries, strategic plann<strong>in</strong>gshould be done to ensure <strong>the</strong> susta<strong>in</strong>ability of <strong>the</strong> healthworkforce.HIV/AIDSThe estimated prevalence of HIV <strong>in</strong> Myanmar is 0.61per cent. The estimated number of people liv<strong>in</strong>g withHIV between 15 to 49 years of age is 230,000 (35%female) <strong>in</strong> 2009. The ma<strong>in</strong> mode of <strong>in</strong>fection of HIVis sexual transmission (73%). HIV prevalence is highamong vulnerable groups: 37.5 per cent among <strong>in</strong>ject<strong>in</strong>gdrug users, 28.8 per cent among men who have sex withmen, 18.4 per cent among female sex workers <strong>and</strong> 5.4 percent among males with an STD. HIV prevalence amongpregnant mo<strong>the</strong>rs was 1.26 per cent <strong>in</strong> 2009; prevalenceamong blood donors was 0.48 per cent, <strong>in</strong> new militaryrecruits 2.5 per cent <strong>and</strong> <strong>in</strong> new tuberculosis patients 11.1per cent.HIV prevalence among pregnantwomenIn relation to MDG <strong>in</strong>dicator 6.1 on HIV prevalenceamong <strong>the</strong> population aged 15-24 years, HIV prevalenceamong pregnant women <strong>in</strong> that age group decl<strong>in</strong>ed from2.78 per cent <strong>in</strong> 2000 to 1.01 per cent <strong>in</strong> 2008. However,a large gap rema<strong>in</strong>s before MDG target 6B on achiev<strong>in</strong>g,by 2010, universal access to treatment for HIV/AIDS forall those who need it is achieved. The proportion of <strong>the</strong>population with advanced HIV <strong>in</strong>fection hav<strong>in</strong>g accessto antiretroviral drugs is only 20 per cent. In addition,only 38.7 per cent of women <strong>in</strong> need of preventionof mo<strong>the</strong>r-to-child transmission treatment received acomplete course of antiretroviral prophylaxis <strong>in</strong> 2008.There is a chronic fund<strong>in</strong>g gap, which currently st<strong>and</strong>s ata shortfall of approximately 38 per cent, accord<strong>in</strong>g to <strong>the</strong>operational plan of <strong>the</strong> National Strategic Plan <strong>in</strong> 2008.The health system needs streng<strong>the</strong>n<strong>in</strong>g, <strong>and</strong> <strong>the</strong>re needs tobe a reduction <strong>in</strong> stigma <strong>and</strong> discrim<strong>in</strong>ation aga<strong>in</strong>st peopleliv<strong>in</strong>g with HIV/AIDS, <strong>and</strong> <strong>in</strong>creased outreach to remotepopulation groups.RH <strong>and</strong> HIV support for <strong>the</strong> migrantpopulationProgrammes also need to be targeted at <strong>the</strong> large mobilepopulation of <strong>in</strong>ternal <strong>and</strong> <strong>in</strong>ternational migrants. Thereis an <strong>in</strong>adequate range of services, with low coverage ofvoluntary confidential counsel<strong>in</strong>g <strong>and</strong> test<strong>in</strong>g, for thosegroups.Condoms for HIV prevention <strong>and</strong>gender issuesIn Myanmar, based on an estimation workshop report<strong>in</strong> 2009, <strong>the</strong> epidemic also spread to women where anestimated 35 per cent of <strong>the</strong> cases are female. The rout<strong>in</strong>emonitor<strong>in</strong>g report of <strong>the</strong> National AIDS Programme<strong>in</strong>dicated that <strong>the</strong> ratio of female-to-male AIDS cases had<strong>in</strong>creased from 1:3.6 <strong>in</strong> 2000 to 1:2.4 <strong>in</strong> 2008 91 , while <strong>the</strong>HIV prevalence rate among pregnant mo<strong>the</strong>rs attend<strong>in</strong>gantenatal cl<strong>in</strong>ics <strong>in</strong> 32 sites had decreased.Women’s personal risk perception was also low <strong>in</strong> spiteof <strong>the</strong> existence of high-risk behaviour of some men <strong>and</strong><strong>the</strong> prevalence of HIV <strong>in</strong>fection <strong>in</strong> <strong>the</strong>ir community 92 . In2007, <strong>the</strong> Behavioural Surveillance Survey of <strong>the</strong> generalpopulation noted that women had lower knowledge of HIVtransmission than men <strong>and</strong> uneducated women dependenton <strong>the</strong>ir partners were even less knowledgeable 93 .In common with o<strong>the</strong>r countries <strong>in</strong> <strong>Asia</strong>, a 2009 draftdesk review of gender <strong>and</strong> HIV <strong>in</strong> Myanmar <strong>in</strong>dicatedthat <strong>the</strong> <strong>in</strong>creas<strong>in</strong>g rate of HIV transmission to femalesis thought to be due to sexual relationships with <strong>the</strong>irhusb<strong>and</strong>s or long-term sexual partners who have alsopatronized sex workers. This process is termed “<strong>in</strong>timatepartner transmission” <strong>and</strong> can be prevented by consistentcondom use.Social norms <strong>and</strong> unequal gender roles <strong>in</strong> <strong>the</strong> family <strong>in</strong>Myanmar 94 may render women more vulnerable to HIV<strong>in</strong>fection as women generally fail to negotiate condomuse with <strong>the</strong>ir partners 95 . A culture of submissiveness <strong>and</strong><strong>the</strong> one-sided faithfulness of wives may lead to women’sheightened risk of HIV <strong>in</strong>fection. Ow<strong>in</strong>g to fear ofaccusations of <strong>in</strong>fidelity, <strong>in</strong>clud<strong>in</strong>g fear of be<strong>in</strong>g labeled assexually promiscuous, disclosure of HIV status to sexualpartners <strong>and</strong> spouses is thought to be low 96 .The majority of Myanmar women are economicallydependent on men <strong>and</strong> this means that <strong>the</strong>y have lessdecision-mak<strong>in</strong>g power than men. Moreover, women havemore responsibility for look<strong>in</strong>g after children, as well as <strong>the</strong>care of o<strong>the</strong>r family members, such as <strong>the</strong> elderly, orphanedrelatives <strong>and</strong> those liv<strong>in</strong>g with long-term illnesses, <strong>in</strong>clud<strong>in</strong>g279

FigureHIV/AIDS. An HIV-positive woman who is pregnant isdef<strong>in</strong>itely more disadvantaged, s<strong>in</strong>ce she must look afterboth herself <strong>and</strong> her unborn child 97 .Although <strong>the</strong>re is no <strong>in</strong>-depth study of female condomuse among sex workers, <strong>the</strong> 2008 Behavioural Sent<strong>in</strong>elSurveillance found that, among <strong>in</strong>terviewed female sexworkers, 71 per cent of <strong>the</strong>m had heard of <strong>the</strong> femalecondom while only one third of <strong>the</strong>m had used it. Femalesex workers expressed <strong>the</strong> wish that <strong>the</strong>y could experienceus<strong>in</strong>g female condoms <strong>and</strong>, of those who used <strong>the</strong>m, if <strong>the</strong>yhad enough time, <strong>the</strong>y would usually use female condomswhen <strong>the</strong>y could not negotiate with <strong>the</strong>ir clients to usemale condoms <strong>and</strong> when <strong>the</strong>y were hav<strong>in</strong>g <strong>the</strong>ir menstrualperiod. However, <strong>the</strong>y noted that <strong>the</strong>y faced barriers <strong>in</strong>both <strong>the</strong> availability of female condoms <strong>and</strong> <strong>the</strong>ir price, asfemale condoms are more costly than <strong>the</strong> male versions. 98Special areas need<strong>in</strong>g attentionBirth spac<strong>in</strong>g <strong>and</strong> reproductive healthservices for <strong>the</strong> migrant populationThe scale, composition <strong>and</strong> causes of population mobilityare not accurately known <strong>in</strong> Myanmar <strong>and</strong> as of today,no nationally representative migration surveys have beenconducted. The Department of Population is plann<strong>in</strong>gto undertake a migration survey <strong>in</strong> 2011 with assistancefrom UNFPA. Accord<strong>in</strong>g to official counts, <strong>the</strong> number ofpeople depart<strong>in</strong>g from <strong>in</strong>ternational airports, seaports <strong>and</strong>l<strong>and</strong>-border checkpo<strong>in</strong>ts exceeds arrival by 1-4 million,start<strong>in</strong>g from 2001 to 2007. Figure 9 from <strong>the</strong> StatisticalYearbook, 2008 provides data on population movement<strong>in</strong>to <strong>and</strong> out of <strong>the</strong> country for persons hold<strong>in</strong>g varioustypes of visas, except tourist visas.The <strong>International</strong> Organization for Migration (IOM)estimated that <strong>the</strong>re are 2 million migrants <strong>in</strong> Thail<strong>and</strong>,<strong>the</strong> majority of who are <strong>the</strong>re <strong>in</strong> irregular status 99 . Thegreat majority of Myanmar migrants <strong>in</strong> Thail<strong>and</strong> areof reproductive age <strong>and</strong> <strong>the</strong>ir lack of legal identificationrenders <strong>the</strong>m hard pressed to access affordable healthcareservices. There are many significant health risks formigrants, <strong>in</strong>clud<strong>in</strong>g STIs <strong>and</strong> HIV <strong>in</strong>fection. They arrive<strong>in</strong> Thail<strong>and</strong> with very little knowledge of health risks,weak social <strong>and</strong>/or family support networks, <strong>and</strong> areconfronted with new pressures, experiences <strong>and</strong> situationsthat may cloud <strong>the</strong>ir ability to consistently choose healthybehaviours 100 .Major <strong>and</strong> critical gaps <strong>in</strong> RH programm<strong>in</strong>g for migrantMyanmar population <strong>in</strong>clude a lack of HIV/AIDSeducation, condoms, voluntary counsel<strong>in</strong>g <strong>and</strong> test<strong>in</strong>g,treatment <strong>and</strong> care for persons liv<strong>in</strong>g with HIV/AIDS. Ahigh percentage of <strong>in</strong>duced abortions among <strong>the</strong>se womenreflect <strong>the</strong> unmet need for contraception. In addition,<strong>the</strong>re is a lack of tra<strong>in</strong>ed health workers <strong>and</strong> supplies foremergency obstetric care (EmOC). Early marriage <strong>and</strong>adolescent pregnancy are common 101 .Nor<strong>the</strong>rn Rakh<strong>in</strong>e StateIn most villages <strong>in</strong> Nor<strong>the</strong>rn Rakh<strong>in</strong>e State, 90-95 percent of <strong>the</strong> population are Muslim. As <strong>in</strong> many religiouscommunities around <strong>the</strong> world, family plann<strong>in</strong>g <strong>and</strong>Figure10Movement of population <strong>in</strong> <strong>and</strong> out of <strong>the</strong> countryarrivaldeparturePopula tion ('000)60005000400030002000100001990199520002001200220032004200520062007YearSource: Central Statistical Organization, Statistical Yearbook, 2008, Nay Pyi Taw: CSO, 2009280

condom use were met with some resistance <strong>in</strong> Nor<strong>the</strong>rnRakh<strong>in</strong>e state thoughRH services <strong>and</strong> family plann<strong>in</strong>g,can reduce prenatal mortality <strong>and</strong> improved maternal<strong>and</strong> child health. The work of Médec<strong>in</strong>s Sans Frontières(MSF), <strong>and</strong> Malteser, play a vital role <strong>in</strong> RH <strong>in</strong> Nor<strong>the</strong>rnRakh<strong>in</strong>e State. It was critical to ga<strong>in</strong> trust <strong>and</strong> tra<strong>in</strong> <strong>the</strong>mullahs (Muslim men educated <strong>in</strong> Islamic <strong>the</strong>ology whoare religious leaders of <strong>the</strong> community) to help <strong>in</strong> foster<strong>in</strong>ghealth education activities. The local mullahs were veryresponsive <strong>and</strong> glad that MSF had come to discuss <strong>the</strong>seideas <strong>and</strong> issues with <strong>the</strong>m 102 . UNFPA <strong>in</strong> collaborationwith Department of Health implement RH program <strong>in</strong>Buditaung <strong>and</strong> Maungdaw townships <strong>and</strong> <strong>in</strong> Re<strong>the</strong>taungUNFPA works with MMA <strong>in</strong> NRS.Poverty <strong>and</strong> birth spac<strong>in</strong>gThe <strong>in</strong>cidence of poverty <strong>in</strong> Myanmar was 23 per cent <strong>in</strong>2001, while <strong>the</strong> poverty headcount <strong>in</strong>dex at <strong>the</strong> nationallevel was 32 per cent. About 10 per cent of Myanmar peoplefall under <strong>the</strong> food poverty l<strong>in</strong>e. The l<strong>and</strong>less rate of peoplework<strong>in</strong>g <strong>in</strong> agriculture is 25.7 per cent at <strong>the</strong> national level<strong>and</strong> 31.8 per cent among poor <strong>in</strong>dividuals. These numbershelp to illustrate <strong>the</strong> struggles of <strong>the</strong> l<strong>and</strong>less poor <strong>and</strong>small-scale farmers who are at <strong>the</strong> mercy of high-<strong>in</strong>terestmoneylenders. Typically, <strong>the</strong>y require capital for loans tobuy seeds <strong>and</strong> fertilizer <strong>in</strong> order to break out of <strong>the</strong> viciouscycle of poverty. It is this proportion of <strong>the</strong> population thatrequires essential RH care <strong>and</strong> birth-spac<strong>in</strong>g commodities,which should be made available at affordable prices or evenfree of cost <strong>and</strong> be easily accessible.Status of reproductive rights <strong>in</strong>national law <strong>and</strong> policiesThe description below organizes <strong>the</strong> discussion arounddata describ<strong>in</strong>g <strong>the</strong> status of <strong>the</strong> above-mentioned variables<strong>in</strong> 1990, 2000 <strong>and</strong> 2010:Law perta<strong>in</strong><strong>in</strong>g to <strong>in</strong>duced abortionThe Union of Myanmar Penal Code section 312 statesthat“whoever voluntarily causes a womanwith child to miscarry shall, if suchmiscarriage be not caused <strong>in</strong> good faithfor <strong>the</strong> purpose of sav<strong>in</strong>g <strong>the</strong> life of <strong>the</strong>woman, be punished with imprisonmentof ei<strong>the</strong>r description for a term whichmay extend to three years, or withf<strong>in</strong>e, or with both; <strong>and</strong> if <strong>the</strong> woman bequick with child, shall be punished withimprisonment of ei<strong>the</strong>r description for aterm which may extend to seven years<strong>and</strong> shall be liable to f<strong>in</strong>e”.This law is still <strong>in</strong> force. As <strong>in</strong> o<strong>the</strong>r countries women withan un<strong>in</strong>tended pregnancy f<strong>in</strong>d it difficult to seek skilledhelp at health facilities.The fact is that <strong>the</strong>re is a high unmet need for birth-spac<strong>in</strong>gservices <strong>and</strong> a significant number of unwanted pregnancieswhich result <strong>in</strong> a large number of <strong>in</strong>duced abortions underunsafe conditions 103 , lead<strong>in</strong>g to complications, maternalmorbidity <strong>and</strong> mortality. Accord<strong>in</strong>g to hospital statistics,<strong>the</strong> number of abortions per 100 deliveries decl<strong>in</strong>ed slightlyfrom 27 <strong>in</strong> 2005 to 24.7 <strong>in</strong> 2007 104 . Evidence suggests thatwomen undergo abortion under unsafe conditions <strong>and</strong> tendto approach health-care providers late for management ofcomplications. Provision of services for management ofcomplicated abortions, post-abortion counsel<strong>in</strong>g <strong>and</strong> postabortionbirth-spac<strong>in</strong>g services have improved slightly.However, <strong>the</strong>se factors still pose a challenge.Adolescent un<strong>in</strong>tended pregnanciesAdolescent pregnancies <strong>in</strong> 1998 accounted for 2.9 per centof total pregnancies <strong>in</strong> Yangon 105 . One of <strong>the</strong> outst<strong>and</strong><strong>in</strong>gchallenges of adolescents with an unwanted pregnancy isunsafe <strong>in</strong>duced abortion. When asked about un<strong>in</strong>tendedpregnancies all of <strong>the</strong> young people at <strong>the</strong> MMA YangonYouth Centre expressed <strong>the</strong> view that term<strong>in</strong>ation ofpregnancy should not be an option; both partners shouldtake responsibility <strong>and</strong> jo<strong>in</strong>t decision-mak<strong>in</strong>g should beencouraged so that <strong>the</strong>y both face <strong>the</strong> consequences. Theyknew at least six methods of contraception, as mentioned<strong>in</strong> <strong>the</strong> situation analysis with regard to HIV <strong>and</strong> STIs, <strong>and</strong>young people are aware of <strong>the</strong> mode of transmission <strong>and</strong>prevention of HIV <strong>and</strong> STIs. Social norms have changed<strong>and</strong> universities located <strong>in</strong> <strong>the</strong> outskirts of cities haveproblems <strong>in</strong> respect of pre-marital sex lead<strong>in</strong>g to unwantedpregnancies <strong>and</strong> complications due to unsafe abortions,which <strong>in</strong> some cases might lead to maternal mortality 106 .When asked about <strong>the</strong>ir greatest needs, adolescents saidthat <strong>the</strong>re is no sufficient service tailored for adolescents’sexual <strong>and</strong> reproductive health <strong>and</strong> for unmarried girls/young women, as <strong>the</strong> current RH programme <strong>in</strong> Myanmargenerally caters to <strong>the</strong> needs of married women 107 .UNFPA <strong>in</strong>itiated a project with assistance from Germany(2009-2011) for reduction of MMR <strong>and</strong> prevention ofHIV/AIDS <strong>in</strong> five townships us<strong>in</strong>g <strong>the</strong> MCH communitypromoter modality to improve RH knowledge throughbehavioural change communication <strong>in</strong>terventions amongcommunity adolescents 108 .281

National Population PolicyMyanmar is relatively sparsely populated <strong>and</strong>, with its richnatural resources, particularly its broad agricultural base, itcan support a far larger population than <strong>the</strong> current size 109 .Hence <strong>the</strong> government has ma<strong>in</strong>ta<strong>in</strong>ed a pronatalist policy.Among its several reasons for do<strong>in</strong>g so, <strong>the</strong> most importantones are:(a) The country is considered to be under populated,compared with o<strong>the</strong>r countries <strong>in</strong> <strong>the</strong> region;(b) The abundant availability of natural resources, arablel<strong>and</strong>, forests <strong>and</strong> mar<strong>in</strong>e resources;(c) The country’s currently low population density;(d) The perception that population growth is an asset fornational development.The draft National Population Policy was developed<strong>in</strong> 1992 under <strong>the</strong> guidance of <strong>the</strong> National HealthCommittee, discussed <strong>and</strong> deliberated at different levels of<strong>the</strong> government departments concerned. The draft policyhighlighted <strong>the</strong> need for birth spac<strong>in</strong>g as an importantissue for a "Happy Healthy <strong>Family</strong>" on health grounds.The draft policy recognized <strong>the</strong> fact that “<strong>the</strong> improvement<strong>in</strong> <strong>the</strong> quality of life would <strong>in</strong>evitably come from reducedpopulation growth”, so it was aimed at improv<strong>in</strong>g <strong>the</strong> healthstatus of women <strong>and</strong> children by ensur<strong>in</strong>g <strong>the</strong> availability<strong>and</strong> accessibility of birth-spac<strong>in</strong>g services among allmarried couples that voluntarily seek such services 110 .It is envisaged that revision <strong>and</strong> <strong>the</strong> formal adoption of<strong>the</strong> draft Population Policy-1992 would enhance <strong>the</strong>implementation of <strong>the</strong> ICPD Programme of Action, aswell as programmes for achiev<strong>in</strong>g MDGs by 2015 <strong>and</strong> <strong>in</strong>promot<strong>in</strong>g population <strong>and</strong> development concerns.NGO activities with regard to birth-spac<strong>in</strong>g servicesallowed with caution <strong>in</strong> 2001; health authorities endorsed<strong>the</strong> use of <strong>the</strong> term birth spac<strong>in</strong>g <strong>in</strong>stead of FP. In general,UNFPA <strong>and</strong> its implement<strong>in</strong>g partners had to be flexiblewith its birth-spac<strong>in</strong>g plans <strong>and</strong> activities <strong>and</strong> move along<strong>the</strong> directions set by <strong>the</strong> Department of Health <strong>and</strong> <strong>the</strong>M<strong>in</strong>istry of Health <strong>and</strong> not exp<strong>and</strong> on meet<strong>in</strong>g <strong>the</strong> dem<strong>and</strong>for <strong>in</strong>novative FP activities 111 .Cultural sensitivity still prevails <strong>in</strong> Myanmar with regard to<strong>the</strong> topic of pre-marital sexual activities <strong>and</strong> <strong>the</strong> utilizationof contraceptives by unmarried adults <strong>and</strong> young people.At <strong>the</strong> level of policymak<strong>in</strong>g, <strong>the</strong> fact that an <strong>in</strong>creas<strong>in</strong>gproportion of adolescents <strong>and</strong> never married persons maybe sexually active <strong>and</strong> need contraceptives to be preventun<strong>in</strong>tended pregnancies was not addressed effectively.Current challenges for birthspac<strong>in</strong>g(1) Availability of contraceptives at affordable prices,accessible for <strong>the</strong> whle population.(2) Accessibility of <strong>the</strong> commodities <strong>and</strong> services by remotevillages <strong>and</strong> ethnic m<strong>in</strong>orities, <strong>the</strong> poor, migrants, <strong>and</strong>vulnerable <strong>and</strong> mobile people.(3) Involvement of adolescents at all levels of plann<strong>in</strong>g<strong>and</strong> implementation of <strong>the</strong> programme.(4) For those unmarried, <strong>the</strong>re are barriers, such as culturalsensitivity <strong>and</strong> judgmental attitude of community <strong>and</strong>health care providers (although UNFPA-supportedRH tra<strong>in</strong><strong>in</strong>gs clearly <strong>in</strong>dicate <strong>the</strong> need for equalaccess).The age group 14-49 years, which comprises <strong>the</strong> largestproportion of reproductive-age women, is at risk. Unsafeabortion is one of <strong>the</strong> major causes of high MMR <strong>in</strong>Myanmar. Accord<strong>in</strong>g to <strong>the</strong> 2007 FRHS, abortion ishighest <strong>in</strong> <strong>the</strong> age group 15-19 years, account<strong>in</strong>g for 11.4per cent of <strong>the</strong> total pregnancies <strong>in</strong> that age group. Womenseek unsafe abortion because <strong>the</strong>y cannot afford to br<strong>in</strong>gup a new addition to <strong>the</strong> family <strong>in</strong> addition to us<strong>in</strong>g it asa method for birth spac<strong>in</strong>g. If this practice cont<strong>in</strong>ues <strong>and</strong>if women <strong>and</strong> adolescents cont<strong>in</strong>ue to face limitations dueto f<strong>in</strong>ancial, logistical or sociocultural barriers <strong>in</strong> access<strong>in</strong>gbirth-spac<strong>in</strong>g services, <strong>the</strong> Millennium DevelopmentGoals will be hard to reach.L<strong>in</strong>kages between <strong>the</strong> Maternal<strong>and</strong> Child Health Programme<strong>and</strong> HIV/AIDS <strong>and</strong> sexuallytransmitted disease servicedeliveryNational levelIn Myanmar <strong>the</strong> Department of Health (DOH) under<strong>the</strong> M<strong>in</strong>istry of Health (MOH) is headed by a Director-General <strong>and</strong> provides comprehensive health care for <strong>the</strong>whole country. The Maternal <strong>and</strong> Child Health (MCH),Women <strong>and</strong> Child Development (WCHD), PrimaryHealth Care, <strong>and</strong> Tra<strong>in</strong><strong>in</strong>g of Basic Health Staff (BHS) areunder DOH <strong>and</strong> each is headed by a Deputy Director 112 .The MCH division is responsible for <strong>the</strong> RH <strong>and</strong> birthspac<strong>in</strong>gprogrammes <strong>and</strong> works <strong>in</strong> collaboration withUNFPA , WHO <strong>and</strong> <strong>in</strong>ternational NGO partners,whereas WCHD emphasizes care of <strong>the</strong> newborn <strong>and</strong>282

women development activities, <strong>and</strong> works with UNICEF<strong>and</strong> NGOs. Safe mo<strong>the</strong>rhood <strong>and</strong> child survival <strong>in</strong>itiativesare <strong>in</strong>tegrated under <strong>the</strong> WCHD programme, as is <strong>the</strong>Prevention of Mo<strong>the</strong>r-to-Child Transmission (PMCT)programme, with <strong>the</strong> National AIDS Programme.Complementarity is encouraged, to avoid overlaps, atdifferent levels of <strong>the</strong> programme.L<strong>in</strong>kage with School Health TeamsIn towns with a population over 10,000, <strong>in</strong> addition toMCH centres <strong>the</strong>re are School Health Teams (featur<strong>in</strong>gdoctors, nurses, dental surgeons, medical social workers,pharmacists <strong>and</strong> clerical staff ) tak<strong>in</strong>g charge of <strong>the</strong> MCHactivities, as well as school health work. There are 80 suchteams operat<strong>in</strong>g <strong>in</strong> 51 towns across <strong>the</strong> country. MOH<strong>in</strong>cluded school health programme activities with<strong>in</strong> ARH<strong>in</strong> its 2001-2006 National Health Plan. Dur<strong>in</strong>g this time,MOH collaborated with o<strong>the</strong>r m<strong>in</strong>istries, such as M<strong>in</strong>istryof Education, M<strong>in</strong>istry of Sports <strong>and</strong> Physical Education,M<strong>in</strong>istry of Immigration <strong>and</strong> Population <strong>and</strong> M<strong>in</strong>istry ofInformation. To <strong>in</strong>tegrate school health <strong>and</strong> adolescentsexual <strong>and</strong> reproductive health, <strong>the</strong> national five-yearAdolescent Health <strong>and</strong> Development Strategic Plan(2009-2013) 113 was developed to address priority issuesaffect<strong>in</strong>g <strong>the</strong> health of young people across <strong>the</strong> nation.L<strong>in</strong>kages at primary health-care levelRural Health CentresRHCs are each responsible for a population of about26,000 <strong>in</strong> 7-14 villages (national average) 114 . The typicalRHC consists of 1 health assistant as team leader, 1 ladyhealth visitor, 5 midwives <strong>and</strong> 1-5 public health supervisors(Grade II – multipurpose health worker) <strong>and</strong> 1 watchman.MCH care <strong>and</strong> birth-spac<strong>in</strong>g services are provided at <strong>the</strong>RHC level <strong>and</strong> urban MCH by <strong>the</strong> lady health visitors<strong>and</strong> midwives. There are 1,481 RHCs throughout <strong>the</strong>country 115 . More than 18,000 basic health service providersat <strong>the</strong> township level were given tra<strong>in</strong><strong>in</strong>gs on maternal,newborn <strong>and</strong> child health care dur<strong>in</strong>g 2009 116 .Sub-centresUnder each RHC, <strong>the</strong>re are usually five sub-RHCs <strong>and</strong>each midwife is given charge of one to three village tractswith a population rang<strong>in</strong>g from 2,000 to 4,000. Thus, <strong>the</strong>four midwives at <strong>the</strong> periphery of <strong>the</strong> ma<strong>in</strong> RHC workthrough four Rural Health Sub-centres, which functionallyserve as MCH centres. There are 5,824 117 such sub-centres<strong>in</strong> Myanmar.Auxiliary midwivesAMWs are selected from underserved villages, tra<strong>in</strong>ed forthree months <strong>in</strong> <strong>the</strong> hospital <strong>and</strong> <strong>the</strong>n for three monthsserve <strong>in</strong> <strong>the</strong> nearest RHC. While AMWs are not regardedas skilled birth attendants, <strong>the</strong>re is a heavy reliance on<strong>the</strong>m <strong>in</strong> Myanmar <strong>in</strong> <strong>the</strong> absence of o<strong>the</strong>r health personnel<strong>in</strong> rural remote villages. Work<strong>in</strong>g under <strong>the</strong> supervisionof <strong>the</strong> midwife <strong>and</strong> Village Health Committee, <strong>the</strong> ma<strong>in</strong>activities of AMWs <strong>in</strong>volve serv<strong>in</strong>g as volunteers <strong>in</strong> fill<strong>in</strong>g<strong>the</strong> gap <strong>in</strong> <strong>the</strong> provision of MCH <strong>and</strong> birth-spac<strong>in</strong>gservices <strong>in</strong> hard-to-reach areas. AMW recruitment wasup to 31,787 for a total of 64,910 villages; <strong>the</strong> AMW-tovillageratio is almost 1:2 118 .It is <strong>the</strong> above-mentioned basic health workers who,dur<strong>in</strong>g <strong>the</strong>ir field visits, provide antenatal care, assist <strong>in</strong>deliveries, provide postnatal care <strong>and</strong> conduct weigh<strong>in</strong>g <strong>and</strong>immunization of children under three years of age. Theyalso provide health education regard<strong>in</strong>g safe mo<strong>the</strong>rhood<strong>and</strong> nutrition, <strong>and</strong> promote breast-feed<strong>in</strong>g <strong>and</strong> birthspac<strong>in</strong>geducation <strong>and</strong> provision. These multi-purposeworkers conduct RH, as well as birth-spac<strong>in</strong>g <strong>and</strong> HIV-STI prevention activities; however, <strong>the</strong>re is no tra<strong>in</strong><strong>in</strong>g oradvocacy for <strong>the</strong> dual use of condoms for <strong>the</strong> preventionof STIs <strong>and</strong> birth spac<strong>in</strong>g. L<strong>in</strong>kages between RH, birthspac<strong>in</strong>g <strong>and</strong> HIV-STI care are present, as township medicalofficers arrange for lady health volunteers or midwives toprovide cont<strong>in</strong>u<strong>in</strong>g education <strong>and</strong> supervision to update<strong>the</strong> knowledge of AMWs <strong>and</strong> upgrade <strong>the</strong>ir skills.National AIDS ProgrammeNAP is responsible for HIV/AIDS activities, whereas <strong>the</strong>Director (Disease Control), headed by a Deputy Director<strong>in</strong> Nay Pyi Taw, is responsible for STI activities. NAPfields 46 AIDS/STD teams nationwide, <strong>in</strong>clud<strong>in</strong>g 6 at <strong>the</strong>State <strong>and</strong> Divisional levels, where <strong>the</strong> prevalence of AIDS/STDs is high, or if <strong>the</strong> townships are vulnerable. Each of <strong>the</strong>AIDS/STD teams has a staff of 3-15 members, <strong>in</strong>clud<strong>in</strong>ga medical doctor (team leader), nurses, counselors,<strong>in</strong>vestigator/outreach workers, laboratory technicians <strong>and</strong>support staff.The AIDS/STD teams implement projects at <strong>the</strong> locallevel <strong>in</strong> harmony with national public health strategies.Medical officers are <strong>in</strong> charge of <strong>the</strong> team <strong>and</strong> providecounsel<strong>in</strong>g, management of STIs, <strong>and</strong> with <strong>the</strong> help ofnurses some basic HIV/AIDS treatment <strong>and</strong> care. Theteams refer to physicians people liv<strong>in</strong>g with HIV who needantiretroviral <strong>the</strong>rapy, <strong>and</strong> <strong>the</strong>y also perform monitor<strong>in</strong>g,supervision <strong>and</strong> report<strong>in</strong>g as necessary. Investigators <strong>and</strong>outreach workers provide contact trac<strong>in</strong>g for STI cases<strong>and</strong> people liv<strong>in</strong>g with HIV, <strong>and</strong> <strong>the</strong>y support outreachactivities. Laboratory technicians carry out tests related toSTIs <strong>and</strong> HIV. In townships without AIDS/STD teams,HIV/AIDS <strong>in</strong>terventions are implemented by o<strong>the</strong>rresponsible officers, notably <strong>the</strong> township medical officer.Township hospitals provide basic services on HIV/AIDScl<strong>in</strong>ical management to outpatients where AIDS/STDteams are not present <strong>and</strong> to patients with advanced HIV<strong>and</strong> AIDS.283

L<strong>in</strong>kages with o<strong>the</strong>r departments <strong>and</strong>at <strong>the</strong> programme levelNAP is l<strong>in</strong>ked with <strong>the</strong> Division of Public Health,<strong>in</strong>clud<strong>in</strong>g <strong>the</strong> Maternal <strong>and</strong> Child Health section, <strong>the</strong>Reproductive Health section for PMCT, State/Divisionhealth committees, health laboratories at each level to carryout its programmes. In addition o<strong>the</strong>r related m<strong>in</strong>istries,United Nations agencies, NGOs <strong>and</strong> community-basedorganization are concerned with provid<strong>in</strong>g HIV prevention<strong>and</strong> care services <strong>in</strong> collaboration with NAP. While <strong>the</strong>NAP <strong>and</strong> MCH programmes are <strong>in</strong> place, with verticalorganizational mechanisms, separate fund<strong>in</strong>g <strong>and</strong> budgetl<strong>in</strong>es, all are under DOH. This makes communication <strong>and</strong>coord<strong>in</strong>ation easier now that all sectors <strong>in</strong> <strong>the</strong> capital cityNay Pyi Taw. However, at <strong>the</strong> programme level, advocacyfor <strong>the</strong> use of condoms as a dual protection contraceptive<strong>and</strong> <strong>in</strong>tervention for <strong>the</strong> prevention of HIV <strong>and</strong> STIs is nota common practice 119 . As for NGO staff, PSI claims thatall Sun providers are tra<strong>in</strong>ed <strong>in</strong> SRH, HIV <strong>and</strong> STIs.Studies on birth-spac<strong>in</strong>g activitiesIn-depth studies on population <strong>and</strong> birth-spac<strong>in</strong>g at <strong>the</strong>national level <strong>in</strong>clude <strong>the</strong> Fertility <strong>and</strong> Reproductive HealthSurveys conducted by <strong>the</strong> Department of Population <strong>and</strong>UNFPA. DOH conducts <strong>the</strong> Contraceptive MethodMix study <strong>and</strong> prepares small-scale research paperson contraceptive method choice <strong>and</strong> adolescent peerpregnancies 120 . UNFPA conducts regular programmeevaluations <strong>and</strong> midterm reviews of country programmeassistance.Reference to <strong>the</strong> <strong>International</strong>Conference on Population<strong>and</strong> Development <strong>and</strong> <strong>the</strong>Millennium Development GoalsPr<strong>in</strong>ciple 8 of ICPD states that “everyone has <strong>the</strong> rightto <strong>the</strong> enjoyment of <strong>the</strong> highest atta<strong>in</strong>able st<strong>and</strong>ard ofphysical <strong>and</strong> mental health”. ICPD also encouraged “Statesshould take all appropriate measures to ensure, on a basisof equality of men <strong>and</strong> women, universal access to healthcareservices, <strong>in</strong>clud<strong>in</strong>g those related to reproductive healthcare, which <strong>in</strong>cludes family plann<strong>in</strong>g <strong>and</strong> sexual health”. Inthis regard Myanmar as a develop<strong>in</strong>g country is committedto fulfill <strong>the</strong> basis of this pr<strong>in</strong>ciple <strong>and</strong> has mechanisms <strong>in</strong>place <strong>and</strong> is implement<strong>in</strong>g its second Five-Year NationalStrategic Plan for Reproductive Health (2009-2013).Reproductive health-care programmes are provided at<strong>the</strong> level of a basic essential package. However, <strong>the</strong>y havenot reached <strong>the</strong> stage of universal coverage, especially <strong>in</strong>regions where transportation is difficult <strong>and</strong> geographicterra<strong>in</strong> prevents easy access to health care. There is no formof coercion <strong>in</strong> provid<strong>in</strong>g <strong>the</strong> wide range of services with<strong>in</strong>Myanmar’s economic <strong>and</strong> cultural context with regard tobirth spac<strong>in</strong>g, which is <strong>in</strong> l<strong>in</strong>e with pr<strong>in</strong>ciple 8. All couples<strong>and</strong> <strong>in</strong>dividuals do have <strong>the</strong> basic right to decide freely <strong>and</strong>responsibly <strong>the</strong> number <strong>and</strong> spac<strong>in</strong>g of <strong>the</strong>ir children <strong>and</strong><strong>the</strong>y do have <strong>the</strong> <strong>in</strong>formation <strong>and</strong> education, to a certa<strong>in</strong>extent, to do so but <strong>the</strong>se need fur<strong>the</strong>r streng<strong>the</strong>n<strong>in</strong>g.The table 3 below shows Myanmar’s progress towardsachiev<strong>in</strong>g selected ICPD Programme of Action <strong>in</strong>dicatorsas analyzed by various issues of <strong>the</strong> UNFPA State of WorldPopulation reports to enable comparison <strong>in</strong> relation to<strong>in</strong>dicators from national sources as well as United Nationssources <strong>in</strong> relation to progress towards achiev<strong>in</strong>g <strong>the</strong> ICPDProgramme of Action goals <strong>and</strong> MDGs.Millennium Development Goal5 121 : Improv<strong>in</strong>g maternal healthTarget B of Goal 5 is to "achieve, by <strong>the</strong> year 2015, universalaccess to reproductive health". This <strong>and</strong> <strong>the</strong> related<strong>in</strong>dicators under MDG5 (see table below) recognize <strong>the</strong>centrality of reproductive health <strong>and</strong> reproductive rights<strong>in</strong> improv<strong>in</strong>g maternal <strong>and</strong> <strong>in</strong>fant health <strong>and</strong> <strong>in</strong> reduc<strong>in</strong>gpoverty. To promote universal access to comprehensivereproductive health services, <strong>the</strong> M<strong>in</strong>istry of Health ofMyanmar toge<strong>the</strong>r with its United Nations <strong>and</strong> NGOpartners implemented its first Five-year National RHStrategic Plan (2004-2008). The implementation of <strong>the</strong>plan had a shortfall of approximately 75 per cent aga<strong>in</strong>st<strong>the</strong> planned budget of US$ 30.1 million 122 . Thus, some of<strong>the</strong> components of <strong>the</strong> plan were ei<strong>the</strong>r not implementedor implemented on a very limited scale. Thus, progresstowards achiev<strong>in</strong>g <strong>the</strong> ICPD goals <strong>and</strong> MDG5 (Target5A) of reduc<strong>in</strong>g maternal mortality has proven to be slow<strong>and</strong> unequal among population groups. The ma<strong>in</strong> strategyof <strong>the</strong> second Five-year National RH Strategic Plan (2009-2013) is to scale-up <strong>the</strong> essential package of reproductivehealth services with improved coord<strong>in</strong>ation <strong>and</strong> resourcepool<strong>in</strong>g. The second such plan set <strong>the</strong> national targets tomonitor implementation aga<strong>in</strong>st <strong>the</strong> MDG5 <strong>in</strong>dicators.MMR, one of <strong>the</strong> important <strong>in</strong>dicators, is targeted todecl<strong>in</strong>e to 145 per 100,000 births <strong>in</strong> 2015, which willrequire aggressive <strong>in</strong>puts <strong>in</strong>to emergency obstetric care <strong>and</strong>support if universal access to birth spac<strong>in</strong>g <strong>and</strong> RH careis to be provided. The target for <strong>the</strong> proportion of birthsattended by skilled health personnel is currently 64 percent, which is a long way from <strong>the</strong> target of 80 per centby 2015.284

TableTable3Myanmar’s progress towards selected Programme of Action <strong>in</strong>dicators, as analyzed by UNFPAReproductive HealthProportion of births withskilled attendantInfant mortality, total per1,000 live birthsState of WorldPopulation 2000State of WorldPopulation 2002State of WorldPopulation 200957 - 57State of WorldPopulation 201079 87 72 70Life expectancy (M/F) 58.5 / 61.8 53.8 / 58.8 59.9 / 64.4 60.5 / 65.0Maternal mortality ratio 230 170 380Births per 1,000 women,ages 15-19Contraceptive prevalence(any method)Contraceptive prevalence(modern methods)HIV prevalence rate (%)ages 15-49*2009 estimation workshop, Myanmar.(240: UnitedNations) 38026 29 18 1817 33 37 3714 28 33 33- -0.7 (2007) 0.61(2009)*0.7Gender-based violenceThis occurs more frequently where poverty <strong>and</strong> social<strong>in</strong>stability are prevalent – for <strong>in</strong>stance, <strong>in</strong> emergencysituation <strong>and</strong> early recovery situations 124 . Gender-basedviolence reflects <strong>and</strong> re<strong>in</strong>forces gender <strong>and</strong> social <strong>in</strong>equities<strong>and</strong> compromises <strong>the</strong> health, security, autonomy <strong>and</strong>dignity of its victims. At least one out of every threewomen around <strong>the</strong> world has been beaten, coerced <strong>in</strong>tosex, or o<strong>the</strong>rwise abused <strong>in</strong> her lifetime. The abuser isusually someone known to her.In Myanmar, ow<strong>in</strong>g to <strong>the</strong> fact that <strong>the</strong>re are no officialnational-level data on gender-based violence <strong>and</strong> that <strong>in</strong>general women <strong>and</strong> girls do not experience many of <strong>the</strong>extreme manifestations of discrim<strong>in</strong>ation <strong>and</strong> seclusion, ithas become normal for many gender gaps <strong>and</strong> <strong>in</strong>equalitiesto be often overlooked by both national <strong>and</strong> <strong>in</strong>ternationalorganizations work<strong>in</strong>g <strong>in</strong> Myanmar’s development sector.A study carried out by <strong>the</strong> Myanmar Women’s AffairsFederation (MWAF) on reported cases of sexual assaultrevealed that, <strong>in</strong> 17 states <strong>and</strong> divisions of Myanmar, <strong>the</strong>rewere 209 such cases <strong>in</strong> 2001 <strong>and</strong> 338 cases <strong>in</strong> 2004. Astudy on marital violence aga<strong>in</strong>st women revealed that <strong>the</strong>most common causes were f<strong>in</strong>ancial difficulties, alcoholconsumption <strong>and</strong> <strong>in</strong>compatibility with <strong>in</strong>-laws 125 .Programmatic measures taken by MWAF to elim<strong>in</strong>ateviolence aga<strong>in</strong>st women <strong>in</strong>clude:(a) Counsel<strong>in</strong>g centres set up to help women ga<strong>the</strong>rtoge<strong>the</strong>r <strong>and</strong> solve <strong>the</strong>ir own problems;(b) Tra<strong>in</strong><strong>in</strong>g for service providers on violence aga<strong>in</strong>stwomen <strong>in</strong> all states <strong>and</strong> divisions.Natural disasters destabilize <strong>the</strong> social <strong>in</strong>frastructure,leav<strong>in</strong>g many young people, particularly young women,vulnerable to sexual violence, exploitative labour <strong>and</strong>traffick<strong>in</strong>g. M<strong>in</strong>imal services <strong>and</strong> support are availableto gender-based violence survivors <strong>and</strong> <strong>the</strong> limited lawenforcement available can result <strong>in</strong> impunity for <strong>the</strong>perpetrators. The Women’s Protection Sub-cluster ofCyclone Nargis reported that, as is common <strong>in</strong> many o<strong>the</strong>rcountries, many women present at cl<strong>in</strong>ics with symptomsconsistent with gender-based violence but report that<strong>the</strong>y have had an accident, ra<strong>the</strong>r than been victims ofabuse126. This makes creat<strong>in</strong>g a gender-based violenceresponse mechanism particularly challeng<strong>in</strong>g. Presumablythis is due to <strong>the</strong> reluctance of women <strong>and</strong> girls to reportviolence to <strong>the</strong> authorities. A major po<strong>in</strong>t of concern is <strong>the</strong>legal h<strong>and</strong>l<strong>in</strong>g of such cases: when a victim reports to acl<strong>in</strong>ic, <strong>the</strong> medical service provider is required to report<strong>the</strong> case to <strong>the</strong> police before treat<strong>in</strong>g <strong>the</strong> survivor. Thus,most survivors are reluctant to make a report <strong>in</strong> order toga<strong>in</strong> access to health care. In addition, young people arealso at a formative stage <strong>in</strong> <strong>the</strong>ir transition to adulthoodwhen harmful experiences can have long-last<strong>in</strong>g physical,psychological <strong>and</strong> social effects.285

TableTable4Achievements of Myanmar <strong>and</strong> gaps <strong>in</strong> achiev<strong>in</strong>g Millennium Development Goal 5Indicator 1990-1994 1996-2001 2005-2007 2015 target SourceTargetsTarget 5.A:Reduce bythree quarters,between 1990<strong>and</strong> 2015,<strong>the</strong> maternalmortality ratioTarget 5.B:Achieve, by2015, universalaccess toreproductivehealth5.1. Maternalmortality ratio(number ofmaternal deathsper 100,000 livebirths)5.2. Proportionof birthsattended byskilled healthpersonnel (%)5.3.Contraceptiveprevalence rate(%)5.4 Adolescentbirth rate5.5. Antenatalcare coverage(at least onevisit <strong>and</strong> at leastfour visits)*5.6. Unmetneed for familyplann<strong>in</strong>g232 255 316 14551 57 64 8016.8 37 41 60Five yearStrategicPlan for RH(2009-2013) =(RH-SP)RH-SP 2009-2013RH-SP 2009-201329 22.7, 16.9* Not set *2007 FRHS42.2 64.5 8019.1 17.7

Explore alternative f<strong>in</strong>anc<strong>in</strong>g options, <strong>in</strong>clud<strong>in</strong>g f<strong>in</strong>d<strong>in</strong>gways to <strong>in</strong>crease <strong>the</strong> role of <strong>the</strong> private sector <strong>and</strong> NGOpartners.Improve <strong>the</strong> quality of RH <strong>and</strong> birth-spac<strong>in</strong>g servicesby ensur<strong>in</strong>g skills tra<strong>in</strong><strong>in</strong>g, <strong>the</strong> issuance of, <strong>and</strong> follow<strong>in</strong>gthrough with, st<strong>and</strong>ard operational procedures <strong>and</strong>guidel<strong>in</strong>es <strong>in</strong> practice.Support supervision <strong>and</strong> <strong>in</strong>centives for basic healthworkers who serve <strong>in</strong> hard-to-reach rural areas.Ensure better stewardship of exist<strong>in</strong>g resources bystreng<strong>the</strong>n<strong>in</strong>g <strong>the</strong> "supply cha<strong>in</strong>" through capacitybuild<strong>in</strong>gmeasures to forecast, f<strong>in</strong>ance, procure <strong>and</strong>deliver high-quality <strong>and</strong> reliable supplies <strong>and</strong> services.Provide policy guidel<strong>in</strong>es for effective utilization of <strong>the</strong>“revolv<strong>in</strong>g fund” accumulated at <strong>the</strong> township level forbirth-spac<strong>in</strong>g commodity security <strong>and</strong> give exemptionsfor payment to <strong>the</strong> neediest citizens.Work with United Nations <strong>and</strong> national NGOs toestablish an <strong>in</strong>centive system for <strong>in</strong>tr<strong>in</strong>sic motivation toempower community-support groups to create betterl<strong>in</strong>kages between community <strong>and</strong> health-care providersfor better RH <strong>and</strong> birth-spac<strong>in</strong>g care <strong>and</strong> support.Streng<strong>the</strong>n logistics management <strong>and</strong> ensure RH<strong>and</strong> birth-spac<strong>in</strong>g commodity security through subcommitteeon RHCS of <strong>the</strong> national work<strong>in</strong>g committeeon RH <strong>in</strong> coord<strong>in</strong>at<strong>in</strong>g efforts to meet <strong>the</strong> needs for RHcommodities.Stipulate policy directions for utilization of OAo<strong>the</strong>raccount funds accumulated for RHCS <strong>and</strong>cost-recovery schemes for RHC (build<strong>in</strong>g on <strong>the</strong> drugrevolv<strong>in</strong>g fund).<strong>International</strong> non-governmentalorganizationsPSI, MSI, AZG, AMI, ADRA, Save <strong>the</strong> Children <strong>and</strong>all o<strong>the</strong>r actors <strong>in</strong> <strong>the</strong> RH programme need to lobby<strong>the</strong>ir national governments to commit an adequate <strong>and</strong>stable supply of RH <strong>and</strong> birth-spac<strong>in</strong>g commodities,along with high-quality services, <strong>and</strong> to pledge fund<strong>in</strong>gsupport as projected <strong>in</strong> <strong>the</strong> second Five-year NationalStrategic Plan for RH (2009-2013).Educate members, constituents, or clients about <strong>the</strong>need for high-quality services, <strong>in</strong>clud<strong>in</strong>g a consistentsupply of contraceptives <strong>and</strong> condoms, <strong>and</strong> about <strong>the</strong>importance of voic<strong>in</strong>g concern over <strong>in</strong>adequate supplies<strong>and</strong> services.Test <strong>and</strong> evaluate <strong>in</strong>novative strategies for provid<strong>in</strong>ghigh-quality, cost-effective products <strong>and</strong> servicessensitive to <strong>the</strong> country’s cultural norms <strong>and</strong> practices.DonorsMeet <strong>the</strong> need for RH <strong>and</strong> birth-spac<strong>in</strong>g commoditiesgiven <strong>the</strong> government's limited <strong>in</strong>vestment <strong>in</strong> <strong>the</strong> healthsector. Bilateral donors, such as Germany, USAID <strong>and</strong>AusAid, may wish to support maternal health.Consortia of donors, such as <strong>the</strong> GAVI Alliance, WorldBank, Global Fund, Three Disease Fund, need to directefforts to streng<strong>the</strong>n <strong>the</strong> health system for better RH<strong>and</strong> birth-spac<strong>in</strong>g services.Actively review <strong>the</strong> second Five-year National StrategicPlan <strong>and</strong> discuss with MOH priority needs <strong>in</strong> orderto make available more fund<strong>in</strong>g for cont<strong>in</strong>uouscontraceptive supplies. Strive for greater consistency<strong>and</strong> coherence <strong>in</strong> policies <strong>and</strong> programmes to allowfor longer-term plann<strong>in</strong>g on <strong>the</strong> part of recipientgovernments.Develop flexible <strong>and</strong> simplified procedures forpurchas<strong>in</strong>g commodities <strong>and</strong> explore new mechanismsfor pool<strong>in</strong>g <strong>and</strong> coord<strong>in</strong>at<strong>in</strong>g <strong>in</strong>ternational commoditypurchases.Address RHCS through <strong>the</strong> provision of low-costcontraceptives, shar<strong>in</strong>g of experiences <strong>and</strong> provisionof technical assistance through <strong>the</strong> South-Southcooperation modality.Changes needed before <strong>the</strong> wayforward <strong>in</strong> <strong>the</strong> reproductive health<strong>and</strong> birth-spac<strong>in</strong>g programmebecomes clearSupportive attitude of all partnersMyanmar is unique <strong>in</strong> its political, economic, socio-cultural<strong>and</strong> ethnic diversity <strong>and</strong> has unique religious <strong>and</strong> ethicalvalues, diverse ethnicity <strong>and</strong> philosophical convictions.Thus, when implement<strong>in</strong>g <strong>the</strong> ICPD Programme ofAction it is important to take <strong>in</strong>to account <strong>the</strong> factorswhich govern <strong>the</strong> population <strong>and</strong> its development, <strong>and</strong> <strong>the</strong><strong>in</strong>tensified efforts needed to improve <strong>the</strong> quality of life of<strong>the</strong> population of Myanmar <strong>and</strong> its future generations. It isobvious that, as with any health system, <strong>the</strong>re are strengths<strong>and</strong> weaknesses. However, it is timely <strong>and</strong> appropriate toadopt a positive attitude for, work<strong>in</strong>g toge<strong>the</strong>r <strong>and</strong> pool<strong>in</strong>gresources, stimulat<strong>in</strong>g more collaboration, coord<strong>in</strong>ation<strong>and</strong> trust between MOH, <strong>the</strong> United Nations <strong>and</strong><strong>in</strong>ternational NGOs as equal partners work<strong>in</strong>g towards acommon goal for <strong>the</strong> good of <strong>the</strong> population of Myanmar<strong>in</strong> order to achieve MDGs.Transparency <strong>in</strong> shar<strong>in</strong>g of data <strong>and</strong><strong>in</strong>formationAt all levels of plann<strong>in</strong>g, programme implementation <strong>and</strong>287

monitor<strong>in</strong>g <strong>and</strong> evaluation <strong>the</strong>re should be transparencybetween <strong>the</strong> government, UN <strong>and</strong> NGOs with shar<strong>in</strong>g ofgood-quality data <strong>and</strong> <strong>in</strong>formation <strong>and</strong> even resources ifurgent need arises to effectively achieve common goals.Common platform of actionA common platform of action is needed to generatean <strong>in</strong>creased level of <strong>in</strong>terest, <strong>and</strong> <strong>the</strong> <strong>in</strong>itiation of <strong>the</strong>government, work<strong>in</strong>g toge<strong>the</strong>r with <strong>the</strong> United Nations,NGOs <strong>and</strong> civil society for implementation of <strong>the</strong> secondFive-year Strategic Plan for Reproductive Health (2009-2013) so that all partners will engage <strong>and</strong> pool resourcesto work <strong>in</strong> partnership towards achiev<strong>in</strong>g <strong>the</strong> ICPDProgramme of Action <strong>and</strong> MDGs.Use of media <strong>and</strong> adolescent friendlySRH educationDemographics show that <strong>the</strong> proportion of <strong>the</strong> population<strong>in</strong> <strong>the</strong> age group 14-59 is <strong>in</strong>creas<strong>in</strong>g along with <strong>the</strong>proportion never married. There is a need for improv<strong>in</strong>gadolescent sexual <strong>and</strong> reproductive health education toprevent un<strong>in</strong>tended pregnancies <strong>and</strong> complications dueto abortions. It is also necessary to ensure widespreadavailability <strong>and</strong> access to contraceptives for <strong>the</strong> unmarriedwomen <strong>and</strong> young people <strong>and</strong> at <strong>the</strong> same time address<strong>the</strong> need to provide SRH education through use of media.“Prime-time” television <strong>and</strong> radio broadcast<strong>in</strong>g services forSRH health education are needed to reach <strong>the</strong> populationnationwide. For better conceptualization <strong>and</strong> acceptanceof RH messages, it is necessary to use ethnic languages toreach m<strong>in</strong>orities.IEC materials for ethnic m<strong>in</strong>oritiesThere is a need to establish a sense of <strong>in</strong>clusiveness <strong>in</strong>all doma<strong>in</strong>s of execution of <strong>the</strong> RH <strong>and</strong> birth-spac<strong>in</strong>gservices. Language barriers may impose considerableconstra<strong>in</strong>ts for ethnic m<strong>in</strong>orities; <strong>the</strong>y may need translation<strong>and</strong> <strong>in</strong>terpretation to underst<strong>and</strong> IEC materials <strong>and</strong>broadcasts. Pictorial presentation of RH messages needsto be developed for <strong>the</strong> less literate population.Focus<strong>in</strong>g on priority areasRH <strong>and</strong> birth spac<strong>in</strong>g are not st<strong>and</strong>-alone entities <strong>and</strong><strong>the</strong> MDGs <strong>and</strong> ICPD goals cannot be reached by justMOH <strong>in</strong> isolation. A paradigm shift from project modeto long-term programme implementation mode isnecessary <strong>and</strong> should be l<strong>in</strong>ked with national populationdevelopment strategies <strong>and</strong> poverty-reduction strategies.All stakeholders <strong>and</strong> m<strong>in</strong>istries concerned need tocooperate with <strong>the</strong> authorities; flexibility is given at <strong>the</strong>regional <strong>and</strong> township levels so that birth-spac<strong>in</strong>g <strong>and</strong>RH commodities can be managed close to clients.The most vulnerable population that needs <strong>the</strong> mostsupport <strong>in</strong> RH <strong>and</strong> birth spac<strong>in</strong>g, as identified by <strong>the</strong>situation analysis are <strong>the</strong> hard to reach population ofSaga<strong>in</strong>g Division, Magway Division, Nor<strong>the</strong>rn Shan,Kayah states, Nor<strong>the</strong>rn Rakh<strong>in</strong>e State, <strong>and</strong> also <strong>the</strong>peri-urban population surround<strong>in</strong>g <strong>the</strong> large cities ofYangon <strong>and</strong> M<strong>and</strong>alay where MMR is high. Theseareas need priority attention for RH <strong>and</strong> birth-spac<strong>in</strong>gservices.New advocacy paradigmPartnerships need to be built, resources pooled <strong>and</strong> allparties work<strong>in</strong>g toge<strong>the</strong>r as equal partners towards jo<strong>in</strong>timplementation of second Five-year National StrategicPlan for RH (2009-2013).There should be no stock-outs for birth-spac<strong>in</strong>gcommodities <strong>and</strong> every pregnancy should be wanted,treasured <strong>and</strong> planned by both partners with skilledsupport from health-service providers.Transparency about needs is required; resources are<strong>the</strong>re to be tapped.The dictum “waste not, want not” should be advocatedfor proper logistical management of commoditiesso that no commodity is thrown away because it hasreached its expiration date.Report<strong>in</strong>g to donors should be done <strong>in</strong> a timely <strong>and</strong>effective basis.ConclusionAll public health programmes require commitment, fund<strong>in</strong>g<strong>and</strong> coord<strong>in</strong>ated efforts. In particular, <strong>the</strong> grow<strong>in</strong>g dem<strong>and</strong>for family plann<strong>in</strong>g <strong>and</strong> <strong>the</strong> grow<strong>in</strong>g AIDS epidemic<strong>in</strong> many parts of <strong>the</strong> world will require attention to <strong>the</strong>most basic of tasks: provid<strong>in</strong>g appropriate products to <strong>the</strong>people who need <strong>the</strong>m. Although <strong>the</strong> ICPD Programmeof Action recommends that governments should“meet <strong>the</strong> family plann<strong>in</strong>g needs of <strong>the</strong>irpopulations as soon as possible <strong>and</strong>should, <strong>in</strong> all cases by <strong>the</strong> year 2015,seek to provide universal access to a fullrange of safe <strong>and</strong> reliable family-plann<strong>in</strong>gmethods…”,no governments of countries around <strong>the</strong> globe can beexpected to meet <strong>the</strong> goals <strong>and</strong> objectives of ICPD s<strong>in</strong>gleh<strong>and</strong>edly.All members of <strong>and</strong> groups <strong>in</strong> society have <strong>the</strong>right, <strong>and</strong> <strong>in</strong>deed <strong>the</strong> responsibility, to play an active part <strong>in</strong><strong>the</strong> efforts to reach those goals 128 . While it is true that highqualityservice delivery, counsel<strong>in</strong>g <strong>and</strong> educational efforts288

are needed to make reproductive health programmeseffective, without <strong>the</strong> necessary supplies, such programmescannot operate. A loss of <strong>the</strong>se programmes means a lossof reproductive choices <strong>and</strong> an <strong>in</strong>crease <strong>in</strong> health risks forwomen <strong>and</strong> men.End Note1 United Nations Population Fund/Myanmar, Report on SituationAnalysis of Population <strong>and</strong> Development, Reproductive Health<strong>and</strong> Gender <strong>in</strong> Myanmar, Yangon: UNFPA/Myanmar, 2010.2 M<strong>in</strong>istry of Health, Health <strong>in</strong> Myanmar: 2010, Nay Pyi Taw:MOH, 2010.3 2010, Population Reference Bureau, http://www.prb.org/pdf10/10wpds_eng.pdf accessed on 15.9.114 United Nations Economic <strong>and</strong> Social Commission for <strong>Asia</strong> <strong>and</strong><strong>the</strong> <strong>Pacific</strong>, ESCAP Population Data Sheet 2009, Bangkok:ESCAP.5 Population Reference Bureau, World Population Data Sheet2009, Wash<strong>in</strong>gton, D.C.: PRB, 2009.6 Analysis of population trends, Census Division, Immigration,National Registration <strong>and</strong> Census Department, Yangon.7 Central Statistical Organization, Statistical Yearbook, 2008, NayPyi Taw: CSO, 2009. See footnote 1.8 Department of Population <strong>and</strong> UNFPA, Country Report on2007 Fertility <strong>and</strong> Reproductive Health Survey.9 Department of Population <strong>and</strong> UNFPA, 2009, Country Reporton 2007 Fertility <strong>and</strong> Reproductive Health Survey.10 Maternal mortality <strong>in</strong> 1995, estimates developed by WHO,UNICEF <strong>and</strong> UNFPA.11 Country Report, 1997 FRHS, Department of Population, NayPyi Taw, <strong>and</strong> UNFPA.12 National Mortality Survey, 1999, Central StatisticalOrganization, Nay Pyi Taw.13 Nationwide Cause-specific Maternal Mortality Survey (2004-2005), Department of Health <strong>and</strong> UNICEF.14 Health Management Information System, 2008, DHP.15 Central Statistical Organization, Statistical Yearbook, 2008, NayPyi Taw: CSO, 2009.16 M<strong>in</strong>istry of Health, Health <strong>in</strong> Myanmar: 2009, Nay Pyi Taw:MOH, 2009.17 Nationwide Cause-specific Maternal Mortality Survey (2004-2005), Yangon: MOH, UNICEF, 2006.18 M.C. Hogan et al., “Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards MillenniumDevelopment Goal 5”, The Lancet, 375(9726):1609-1623.See also http://press.<strong>the</strong>lancet.com/mmm.pdf, accessed on 7November 2010.19 Five-year Strategic Plan for Reproductive Health, 2009-2013.20 See footnote 1.21 Ibid.22 See footnote 2.23 Draft population policy, DOP, 1992.24 Department of Health, MOH <strong>and</strong> UNFPA, Myanmar, 2010.25 Department of Population <strong>and</strong> UNFPA, 2009, Country Reporton 2007 Fertility <strong>and</strong> Reproductive Health Survey.26 Fertility <strong>and</strong> Reproductive Health Survey, 2007, DOP <strong>and</strong>UNFPA, October 2009.27 M<strong>in</strong>istry of Immigration <strong>and</strong> Population, UNFPA. DetailedAnalysis on Fertility <strong>and</strong> Reproductive Health Survey, Yangon,2004.28 J. Bongaarts <strong>and</strong> E. Johansson, “Future trends <strong>in</strong> contraceptiveprevalence <strong>and</strong> method mix <strong>in</strong> <strong>the</strong> develop<strong>in</strong>g world”, Studies <strong>in</strong><strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>, 33(1):24-36. See also http://www.popcouncil.org/pdfs/councilarticles/sfp/SFP331Bongaarts.pdf, accessed on8 November 2010.29 PSI/Myanmar <strong>and</strong> Myanmar Medical Association, 2010.30 Situation Analysis Field Assessment, UNFPA, 2010.31 Myanmar Birth Spac<strong>in</strong>g Overview, http://www.searo.who.<strong>in</strong>t/l<strong>in</strong>kfiles/family_plann<strong>in</strong>g_fact_sheets_myanmar.pdf, accessed on27 October 2010.32 National Programme Officer, UNFPA, 2010.33 Ibid.34 PSI/Myanmar, 2010.35 Response to self-adm<strong>in</strong>istered questionnaire, Dr. Nyo NyoM<strong>in</strong>n, Deputy Country Representative, Population Services<strong>International</strong>/Myanmar, 2010.36 Population Services <strong>International</strong>/Myanmar, 2010.37 MSI annual report to UNFPA, 2009.38 RH Stakeholder Analysis <strong>in</strong> Myanmar, 2006, WHO.39 http://www.mmcwa.org/organization.htm accessed on 9 Dec,2010.40 Dr. The<strong>in</strong>gi My<strong>in</strong>t, MCH, DOH, 2010.41 Global Consultation on South-South Cooperation, UNFPA tripreport, Pansy Tun The<strong>in</strong>, 2010.42 Reproductive Health Commodity Security – Challenges,statement by Thoraya Ahmed Obaid, former Executive Director,UNFPA, http://www.unfpa.org/public/News/pid/151.Accessed on 25 November 2010.43 Ibid.44 Dr. The<strong>in</strong>gi My<strong>in</strong>t, Deputy Director, Maternal <strong>and</strong> Child Health,Department of Health, Myanmar.45 Ibid.46 Situation Analysis, annex 3, UNFPA, 2010.47 PSI/Myanmar, self-adm<strong>in</strong>istered questionnaire response, 2010.48 UNFPA/MMR, self-adm<strong>in</strong>istered questionnaire response, 2010.49 See footnote 1.50 Attended by T<strong>in</strong> T<strong>in</strong> Nyunt, 2010.51 UNFPA, Reproductive Health Commodity Security Report,2009.52 Second meet<strong>in</strong>g of <strong>the</strong> National RH work<strong>in</strong>g committee meet<strong>in</strong>g,289

Nay Pyi Taw, 26 October 2010.53 Situation Analysis field report, UNFPA, 2010.54 Community-operated RH/BCC project <strong>in</strong> Myanmar,documentation of <strong>the</strong> model project outcomes, national levelassessment reports, 2003.55 Ibid.56 Townships supported by UNFPA project, 2010.57 See footnote 1.58 F<strong>in</strong>d<strong>in</strong>gs of Report on Situation Analysis, UNFPA, 2010, annex3.59 See footnote 1.60 Situation Analysis report, annex 3, F<strong>in</strong>d<strong>in</strong>gs, 2010.61 UNFPA-Myanmar, Assistant Country Representative. 2010.62 PSI, Deputy Country Representative, Dr. Nyo Nyo M<strong>in</strong>n, 2010.63 ditto.64 Ibid.65 1983 Population Census, Burma, Department of Immigration<strong>and</strong> Manpower, 1986.66 Household survey <strong>in</strong> NRS, UNHCR, 2006.67 Reproductive Health Assessment, Nor<strong>the</strong>rn Rakh<strong>in</strong>e State,Myanmar, UNHCR-UNFPA, 2006.68 Self-adm<strong>in</strong>istered questionnaires response, 2010.69 UNFPA, RH National Programme Officer, 2010.70 Self-adm<strong>in</strong>istered questionnaires response PSI/Myanmar, 2010.71 MCH Division, DOH <strong>and</strong> UNFPA, 2010.72 <strong>Family</strong> <strong>and</strong> Youth Survey, 2004, MIP, DOP. 2006.73 See footnote 4.74 Myanmar Reproductive Health Basel<strong>in</strong>e Community Survey,2002.75 Fertility <strong>and</strong> Reproductive Health Survey, 2007.76 <strong>Family</strong> <strong>and</strong> Youth Survey, 2004 country report, Yangon, October2006, Department of Population, M<strong>in</strong>istry of Immigration <strong>and</strong>Population <strong>and</strong> UNFPA.77 See footnote 1.78 See footnote 80.79 Behavioural Surveillance Survey 2008 (out of school youth),National AIDS Programme, Department of Health, M<strong>in</strong>istry ofHealth, Myanmar.80 Information from <strong>the</strong> PSI drop-<strong>in</strong> centres supported by UNFPA,2009.81 Than Nu Shwe, Socio-economic background <strong>and</strong> behaviour ofadolescent pregnancy, 1999, Yangon.82 PSI/Myanmar, 2010.83 Department of Health, School Health Division, NationalStrategic Plan for Adolescent Health <strong>and</strong> Development (2008-2012).84 Department of Population <strong>and</strong> UNFPA, 2009, Country Reporton 2007 Fertility <strong>and</strong> Reproductive Health Survey.85 W<strong>in</strong> W<strong>in</strong> Mya, Causes of maternal death, North OkkalapaGeneral Hospital (1992-1998).86 The<strong>in</strong>gi Maung Maung, Determ<strong>in</strong>ants of abortion <strong>in</strong>Th<strong>in</strong>gangyun San Pya Hospital, 2003.87 Nationwide Cause-specific Maternal Mortality Survey (2004-2005), Yangon, MOH-UNICEF, 2006.88 See footnote 1.89 World Health Organization, World Health Report 2006:Work<strong>in</strong>g Toge<strong>the</strong>r for Health, Geneva: WHO, 2006.90 M<strong>in</strong>istry of Health, Health <strong>in</strong> Myanmar: 2009, Nay Pyi Taw:MOH, 2009.91 National Strategic Plan for HIV <strong>and</strong> AIDS <strong>in</strong> Myanmar, progressreport 2008, M<strong>in</strong>istry of Health.92 Report on basel<strong>in</strong>e data collection <strong>and</strong> behaviour study on male<strong>in</strong>volvement <strong>in</strong> Reproductive Health Myanmar.93 Dr. Aye Myat Soe, Daw Aye Aye Se<strong>in</strong>, Dr. Kh<strong>in</strong> Ohnmar San,Behavioural Surveillance Survey 2007 (general population)National AIDS Programme, Department of Health, M<strong>in</strong>istry ofHealth, Myanmar.94 Dr. Aye Myat Soe, Draft Desk Review of Gender <strong>and</strong> HIV <strong>in</strong>Myanmar, September 2009.95 Kyu Kyu Than, Poe Poe Aung, Ht<strong>in</strong> Aung Saw, T<strong>in</strong> T<strong>in</strong> Wai,The Maung Maung <strong>and</strong> Nyo Aung, “Reproductive health needsof HIV-positive women: client perspective”, Myanmar HealthScience Research Journal, 19(3).96 Draft report of Desk Review of Gender <strong>and</strong> HIV <strong>in</strong> Myanmar,Dr. Aye Myat Soe, 2009.97 See footnote 1.98 Ibid.99 <strong>International</strong> Organization for Migration, Situation Report on<strong>International</strong> Migration <strong>in</strong> East <strong>and</strong> South-East <strong>Asia</strong>: RegionalThematic Work<strong>in</strong>g Group on <strong>International</strong> Migration <strong>in</strong>clud<strong>in</strong>gHuman Traffick<strong>in</strong>g, Bangkok: IOM, 2008.100 <strong>International</strong> Organization for Migration, Migration <strong>and</strong> HIV/AIDS <strong>in</strong> Thail<strong>and</strong>: A Desk Review of Migrant Labour Sectors,Bangkok: IOM, 2009.101 http://www.rhrc.org/resources/Thail<strong>and</strong>_Assessment_06.pdf Thai-Myanmar border Reproductive Health assessment.Accessed 13.9.11102 http://www.doctorswithout borders.org/publication/alert/article_pr<strong>in</strong>t, accessed on 26 October 2010.103 Improv<strong>in</strong>g Maternal, Newborn <strong>and</strong> Child Health <strong>in</strong> <strong>the</strong> South-East <strong>Asia</strong> Region- Myanmar, WHO, 2005. http://www.searo.who.<strong>in</strong>t/L<strong>in</strong>kFiles/Improv<strong>in</strong>g_maternal_newborn_<strong>and</strong>_child_health_myanmar.pdf accessed on 15.9.2011104 Annual Hospital Statistics Report, 2007, MOH, DHP, p. 32,Table 11: Number <strong>and</strong> percent of deliveries, live births, still births<strong>and</strong> abortions from 2005 to 2007 (States, Divisions <strong>and</strong> Union).105 ARH at a glance, accord<strong>in</strong>g to a study by WHO-SEARO, 2007.106 In-depth <strong>in</strong>terview with service providers,SA report,UNFPA,2010.107 See footnote 1.108 UNFPA-German Fund project for Reduction of MMR <strong>and</strong>290

prevention of HIV/AIDS, 2010-2013, project document.109 1994 National Report on Population to 1994 ICPD, Cairo,National Population Commission, Myanmar.110 See footnote 1.11 1 Response to self-adm<strong>in</strong>istered questionnaire, PSI/Myanmar,2010.112 Maternal <strong>and</strong> Child Health division, Department of Health,MOH, 2009113 Adolescent Health <strong>and</strong> Development Strategic Plan (2009-2013),School Health Division, Department of Health, 2008114 National Health Plan, 2006-2011.115 See footnote 19.116 See footnote 2.117 See footnote 119.118 Ibid.119 MCH, DOH, 2010.120 Ibid.121 Revised Millennium Development Goal monitor<strong>in</strong>g framework,<strong>in</strong>clud<strong>in</strong>g new targets <strong>and</strong> <strong>in</strong>dicators, as recommended by <strong>the</strong>Inter-Agency <strong>and</strong> Expert Group on Millennium DevelopmentGoal Indicators, Sixty-second of <strong>the</strong> United Nations GeneralAssembly, Official Records, annex II, Supplement No. 1(A/62/1).122 Five-year Strategic plan for reproductive health, 2004-2008.123 There are data gaps concern<strong>in</strong>g <strong>the</strong> adolescent birth rate;<strong>in</strong>formation can be obta<strong>in</strong>ed from surveys such as FRHS <strong>and</strong>MICS; however, ei<strong>the</strong>r it is not normally calculated as such or isnot mentioned <strong>in</strong> reports.124 For examples, see <strong>the</strong> film Youth Zones: Voices fromEmergencies, which was produced by Governess Films forUNFPA <strong>and</strong> <strong>the</strong> Women’s Refugee Commission, <strong>and</strong> <strong>the</strong> State of<strong>the</strong> World Population, 2010.125 Gender Statistics <strong>in</strong> Myanmar, Myanmar Women’s affairsFederation, 2006.126 Field <strong>in</strong>terviews with more than 40 women <strong>in</strong> <strong>the</strong> delta over a6-month period, 2008-2009, Shanny Cambell.127 UNDP Gender Track<strong>in</strong>g Study (draft <strong>in</strong>terim report, February2009).128 The film Youth Zones: Voices from Emergencies, which wasproduced by Governess Films for UNFPA <strong>and</strong> <strong>the</strong> Women’sRefugee Commission, <strong>and</strong> State of World Population, 2010.129 Programme of Action of <strong>the</strong> <strong>International</strong> Conference onPopulation <strong>and</strong> Development, http://www.iisd.ca/Cairo/program/p00000.html.291

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Philipp<strong>in</strong>esPhilipp<strong>in</strong>es<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>esJunice Demeterio Melgar* , Alfredo R. Melgar ¤ , Josef<strong>in</strong>a V. Cabigon #* Executive Director, Likhaan Center for Women’s Health (office@likhaan.org.)¤ Research Coord<strong>in</strong>ator, Likhaan Center for Women’s Health.# Former Director (deceased), University of <strong>the</strong> Philipp<strong>in</strong>es Population Institute.293

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BackgroundThe Philipp<strong>in</strong>es is an archipelago of 7,107 isl<strong>and</strong>s – some4,000 of which are named <strong>and</strong> 1,000 <strong>in</strong>habited – located off<strong>the</strong> south-eastern coast of ma<strong>in</strong>l<strong>and</strong> <strong>Asia</strong>. The country hasa total l<strong>and</strong> area of some 300,000 square kilometres. Thedispersed character of <strong>the</strong> country is fur<strong>the</strong>r heightenedby its diverse <strong>and</strong> difficult terra<strong>in</strong>: numerous mounta<strong>in</strong>s,volcanoes <strong>and</strong> plateaus broken up by pla<strong>in</strong>s, valleys, rivers<strong>and</strong> lakes 1 .The country’s population was estimated 2 to beapproximately 94 million <strong>in</strong> 2010; 171 languages arespoken <strong>in</strong> <strong>the</strong> country, <strong>the</strong> top 15 of which are <strong>in</strong> use by500,000 or more people each 3 . The official languages areEnglish <strong>and</strong> Filip<strong>in</strong>o (a l<strong>in</strong>gua franca m<strong>and</strong>ated by <strong>the</strong>1987 constitution). Filip<strong>in</strong>os value education as a way ofescap<strong>in</strong>g poverty; hence, <strong>the</strong> country has a relatively highfunctional literacy rate (86%), with females enjoy<strong>in</strong>g a 4.5percentage po<strong>in</strong>t advantage over males 4 .The country had a gross national <strong>in</strong>come per capita of US$1,890 <strong>in</strong> 2008, slightly below <strong>the</strong> average of US$ 2,078 forlower middle-<strong>in</strong>come countries accord<strong>in</strong>g to <strong>the</strong> WorldBank classification, <strong>and</strong> 28 per cent beh<strong>in</strong>d <strong>the</strong> average for<strong>the</strong> East <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> region: US$ 2,631 5 .The Philipp<strong>in</strong>es has an urban population that <strong>in</strong>creasedfrom 27 per cent of <strong>the</strong> total population <strong>in</strong> 1950 to 48 percent <strong>in</strong> 2000, <strong>and</strong> is predicted to cont<strong>in</strong>ue ris<strong>in</strong>g to about65 per cent of <strong>the</strong> total by 2020. Consistent with thisurbaniz<strong>in</strong>g trend, <strong>the</strong> proportion of persons employed <strong>in</strong>agriculture, forestry <strong>and</strong> fisheries has gone down from 45per cent <strong>in</strong> 1989 7 to 34 per cent <strong>in</strong> 2009 8 .About 83 per cent of <strong>the</strong> people identify <strong>the</strong>mselves asCatholics, 5 per cent as Muslims <strong>and</strong> <strong>the</strong> rest variouso<strong>the</strong>r Christian faiths. 9 Catholicism was <strong>in</strong>troduced bySpanish colonists; <strong>the</strong> colonial period lasted for more than300 years, from <strong>the</strong> mid-1500s to 1898. The operation ofCatholic hospitals <strong>and</strong> medical schools that began <strong>in</strong> <strong>the</strong>1800s cont<strong>in</strong>ues until today <strong>and</strong> plays an important role<strong>in</strong> <strong>the</strong> provision of health-care services <strong>and</strong> – throughgraduates that enter <strong>the</strong> Department of Health <strong>and</strong> o<strong>the</strong>rgovernment agencies – <strong>the</strong> craft<strong>in</strong>g of health policies.Catholicism <strong>and</strong> <strong>the</strong> church hierarchy play a critical role <strong>in</strong>respect of family plann<strong>in</strong>g policies.The Philipp<strong>in</strong>es has a unitary presidential form ofgovernment with universal suffrage. State powers aredivided among three coequal <strong>and</strong> separate branches – <strong>the</strong>executive, legislative <strong>and</strong> judicial – patterned after <strong>the</strong>United States of America, which took over from Spa<strong>in</strong>as <strong>the</strong> colonial power <strong>in</strong> <strong>the</strong> early 1900s. Election-based,autonomous governance <strong>in</strong> localities was thoroughlydeveloped dur<strong>in</strong>g <strong>the</strong> American colonial period 10 .Currently, tens of thous<strong>and</strong>s of local government officials –all elected every three years – wield extensive executive <strong>and</strong>legislative powers <strong>in</strong> numerous <strong>and</strong> complex layers of localgovernment units (LGUs), mirror<strong>in</strong>g <strong>the</strong> geographically<strong>and</strong> l<strong>in</strong>guistically fragmented character of <strong>the</strong> country.From highest to lowest level, LGUs are composed of 80prov<strong>in</strong>ces, 138 cities, 1,496 municipalities <strong>and</strong> 42,025barangays (villages) 11 .Nodal po<strong>in</strong>ts <strong>in</strong> <strong>the</strong> familyplann<strong>in</strong>g programmeThe official Philipp<strong>in</strong>e <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Program wascreated by <strong>the</strong> Population Act (Republic Act 6365), a lawpassed <strong>in</strong> 1971. From 1988 to <strong>the</strong> present, <strong>the</strong> programmehas been led by <strong>the</strong> Department of Health <strong>and</strong> framed asa public health programme with a desirable demographicimpact. With<strong>in</strong> this broad framework, major variationsoccurred as a result of three ma<strong>in</strong> factors: <strong>the</strong> position of<strong>the</strong> President with regard to artificial contraception, anissue that has been elevated to <strong>the</strong> highest office ow<strong>in</strong>g to<strong>the</strong> strong opposition of <strong>the</strong> Catholic hierarchy; devolutionof health personnel, facilities, budget <strong>and</strong> decision-mak<strong>in</strong>gto local government units (LGUs); <strong>and</strong> <strong>the</strong> reproductivehealth framework <strong>and</strong> <strong>in</strong>ternational commitments madeat <strong>the</strong> <strong>International</strong> Conference on Population <strong>and</strong>Development (ICPD) <strong>in</strong> Cairo <strong>in</strong> 1994.The first period (1988-1991)was a transition phase <strong>in</strong> many ways: <strong>the</strong> wholegovernment was rebuild<strong>in</strong>g old <strong>and</strong> new <strong>in</strong>stitutions <strong>and</strong>processes after 14 years of authoritarian rule*, <strong>and</strong> a lawthat would radically change <strong>the</strong> health sector throughdevolution was proposed <strong>and</strong> ultimately passed <strong>in</strong>1991. The constitutionality of <strong>and</strong> <strong>the</strong> need for a familyplann<strong>in</strong>g programme were debated 12 at <strong>the</strong> highest levelof government. From a population programme under <strong>the</strong>Commission on Population (POPCOM), family plann<strong>in</strong>gsurvived <strong>and</strong> was redef<strong>in</strong>ed as a health programme under<strong>the</strong> Department of Health.The second period (1992-2000)was dom<strong>in</strong>ated by health devolution <strong>and</strong> ICPD. Theactual transfer of health personnel, facilities <strong>and</strong> resourcesoccurred from 1993 to 1994; legal efforts <strong>and</strong> masscampaigns by public health workers <strong>and</strong> some governmentofficials to renationalize <strong>the</strong> sector cont<strong>in</strong>ued until <strong>the</strong> late1990s; <strong>and</strong> a new health sector strategy to “make devolutionwork” was released <strong>in</strong> 2000. 13 High-level commitments<strong>and</strong> efforts to promote family plann<strong>in</strong>g <strong>and</strong> reproductivehealth were slowed down by <strong>the</strong> very new <strong>and</strong> fragmentedstructure of <strong>the</strong> health sector.295

TableTableA296

First period: 1988-1991 Second period: 1992-2000Third period: 2001-2010The third period (2001-2010)was def<strong>in</strong>ed by <strong>the</strong> President's consistent support for<strong>the</strong> Catholic Church's doctr<strong>in</strong>e on contraception: <strong>the</strong>promotion of natural family plann<strong>in</strong>g (NFP) <strong>and</strong> lackof commitment to artificial contraception <strong>and</strong> <strong>the</strong> RHagenda of Cairo. Witt<strong>in</strong>gly or unwitt<strong>in</strong>gly, <strong>the</strong> Presidentalso pushed local autonomy to an extraord<strong>in</strong>ary degree<strong>and</strong> weakened her own national Department of Healthby allow<strong>in</strong>g LGUs to ban artificial contraceptives <strong>in</strong> <strong>the</strong>irjurisdiction, as was done <strong>in</strong> <strong>the</strong> city of Manila.Table A below provides details to <strong>the</strong>se three periods, <strong>and</strong><strong>the</strong> succeed<strong>in</strong>g section lists important events <strong>in</strong> familyplann<strong>in</strong>g history.Important events <strong>in</strong> familyplann<strong>in</strong>g <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>esEarly years <strong>and</strong> <strong>the</strong> beg<strong>in</strong>n<strong>in</strong>g of <strong>the</strong>family plann<strong>in</strong>g programme1957: Tariff <strong>and</strong> Customs Law prohibited <strong>the</strong> importationof anyth<strong>in</strong>g for “prevent<strong>in</strong>g human conception orproduc<strong>in</strong>g unlawful abortion”, <strong>in</strong>clud<strong>in</strong>g pr<strong>in</strong>tedmatter giv<strong>in</strong>g direct or <strong>in</strong>direct <strong>in</strong>formation.1964: The University of <strong>the</strong> Philipp<strong>in</strong>es PopulationInstitute (UPPI) was established.1965: Revised Adm<strong>in</strong>istrative Code declared as “absolutelynon-mailable” anyth<strong>in</strong>g for “prevent<strong>in</strong>g conceptionor produc<strong>in</strong>g abortion, or for any <strong>in</strong>decent orimmoral use”, <strong>in</strong>clud<strong>in</strong>g anyth<strong>in</strong>g that gives direct or<strong>in</strong>direct <strong>in</strong>formation.1966: Republic Act (RA) 4729 restricted <strong>the</strong> dispensationor distribution of contraceptive drugs <strong>and</strong> devices tolicensed drug stores <strong>and</strong> pharmaceutical companies,even if done for free (e.g., as practised by non-profitorganizations).1967: President Ferd<strong>in</strong><strong>and</strong> Marcos <strong>and</strong> 17 o<strong>the</strong>r headsof state signed <strong>the</strong> United Nations Declaration onPopulation.1969: A policy study group on population was created(Commission on Population).1969: Catholic bishops released a pastoral letter on <strong>the</strong>encyclical Humanae Vitae <strong>and</strong> called on Filip<strong>in</strong>oCatholics <strong>and</strong> clergy to obey <strong>the</strong> Pope's decisionuphold<strong>in</strong>g <strong>the</strong> ban on artificial birth control <strong>and</strong>sterilization. 141971: The Population Act (RA 6365) was passed,which created a family plann<strong>in</strong>g programme toreduce population growth rate for economic <strong>and</strong>development goals, <strong>and</strong> established <strong>the</strong> Commissionon Population (POPCOM) under <strong>the</strong> Office of<strong>the</strong> President. The POPCOM was tasked “to putup family plann<strong>in</strong>g cl<strong>in</strong>ics <strong>in</strong> cooperation” with <strong>the</strong>Department of Health (DOH).1972: Martial law was declared over <strong>the</strong> entire country.President Marcos gave himself executive, legislative<strong>and</strong> judicial powers.1972: President Marcos issued Presidential Decree(PD) 79 <strong>and</strong> revised <strong>the</strong> Population Act. UnderPD 79, POPCOM was given added authority to“employ physicians, nurses, midwives to provide,297

dispense <strong>and</strong> adm<strong>in</strong>ister all acceptable methods ofcontraception”; “utilize cl<strong>in</strong>ics, pharmacies as wellas o<strong>the</strong>r commercial channels of distribution for<strong>the</strong> distribution of family plann<strong>in</strong>g <strong>in</strong>formation<strong>and</strong> contraceptives”; <strong>and</strong> “call upon <strong>and</strong> utilize anydepartment, bureau, office, agency or <strong>in</strong>strumentalityof <strong>the</strong> Government for such assistance as itmay require”. <strong>Family</strong> plann<strong>in</strong>g became a verticalprogramme under POPCOM.1973: Catholic bishops started to label as abortion allartificial methods which act <strong>in</strong> <strong>the</strong> “<strong>in</strong>terval betweenfertilization <strong>and</strong> implantation of <strong>the</strong> embryo” 15<strong>and</strong> pa<strong>in</strong>ted <strong>the</strong> population programme as apart of martial law's violation of human rights, a“contraceptive mentality” movement that will turnfrom “<strong>the</strong> voluntary towards <strong>the</strong> compulsory”. 161978: The contraceptive prevalence rate (CPR) formodern methods rose to 17 per cent from 2.9per cent <strong>in</strong> 1968, <strong>the</strong> fastest pace of growth (20%annually) that would be achieved by <strong>the</strong> familyplann<strong>in</strong>g programme. From that po<strong>in</strong>t on, growthof CPR for modern methods slowed down to 2-3per cent annually. 171979: Card<strong>in</strong>al Jaime S<strong>in</strong>, <strong>the</strong> recognised leader of <strong>the</strong>Catholic hierarchy <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es, steppedup criticism of martial law's human rightsviolations <strong>and</strong> “anti-life” record, which he said<strong>in</strong>clude <strong>the</strong> promotion of “abortifacient” IUDs <strong>and</strong><strong>in</strong>jectables. 181986: Marcos fled <strong>the</strong> country after massive “peoplepower” protests <strong>and</strong> military defections. CorazonAqu<strong>in</strong>o became <strong>the</strong> new President. Card<strong>in</strong>al S<strong>in</strong>played a key role <strong>in</strong> <strong>the</strong> ouster of Marcos.1987: A new Philipp<strong>in</strong>e Constitution was ratified. Aprovision <strong>in</strong> <strong>the</strong> martial law constitution thatjustified population control was removed (“Itshall be <strong>the</strong> responsibility of <strong>the</strong> State to achieve<strong>and</strong> ma<strong>in</strong>ta<strong>in</strong> population levels most conduciveto <strong>the</strong> national welfare”). In its place, <strong>the</strong> 1987Constitution now says that <strong>the</strong> State shall defend“<strong>the</strong> right of spouses to found a family <strong>in</strong> accordancewith <strong>the</strong>ir religious convictions <strong>and</strong> <strong>the</strong> dem<strong>and</strong>s ofresponsible parenthood”.Catholic bishops succeeded <strong>in</strong> <strong>the</strong> <strong>in</strong>clusion of thisprovision <strong>in</strong> <strong>the</strong> 1987 Constitution: “[<strong>the</strong> State]shall equally protect <strong>the</strong> life of <strong>the</strong> mo<strong>the</strong>r <strong>and</strong> <strong>the</strong>life of <strong>the</strong> unborn from conception”. The proponentof this provision now says that this was also meantto prohibit “abortifacient” methods of familyplann<strong>in</strong>g. 19The 1988 to 1991 period1988: The family plann<strong>in</strong>g programme was transferred to<strong>the</strong> Department of Health after an <strong>in</strong>tense debatewith<strong>in</strong> <strong>the</strong> new government on whe<strong>the</strong>r or not tocont<strong>in</strong>ue with it. The Secretary of Health managedto rescue <strong>the</strong> programme <strong>and</strong>, consistent with <strong>the</strong>ongo<strong>in</strong>g democratization processes, framed familyplann<strong>in</strong>g as a rights-based health programme toreduce maternal <strong>and</strong> child mortality <strong>and</strong> morbiditiesthat would lead to desirable demographic changesas a matter of course. 201990: Catholic bishops began campaign<strong>in</strong>g aga<strong>in</strong>stcontraceptives for be<strong>in</strong>g unsafe for both <strong>the</strong> mo<strong>the</strong>r<strong>and</strong> foetus. 211991: DOH Adm<strong>in</strong>istrative Order (AO) 114 codified<strong>the</strong> place of FP <strong>in</strong> its range of health programmesby classify<strong>in</strong>g family plann<strong>in</strong>g “accord<strong>in</strong>g to couple'schoice” as part of “services for <strong>the</strong> reproductivehealth of mo<strong>the</strong>rs” – a basic maternal <strong>and</strong> childhealth service to be delivered by all frontl<strong>in</strong>e healthunits1991: The Local Government Code, which <strong>in</strong>cludes <strong>the</strong>devolution of <strong>the</strong> health sector, was passed <strong>in</strong>tolaw.The 1992 to 2000 period1992-1994: Health services were devolved to more than1,600 local government units (LGUs). Prov<strong>in</strong>ces<strong>and</strong> big cities got control of hospitals. Municipalities<strong>and</strong> cities got health centres (rural health units)<strong>and</strong> health posts (barangay health stations). <strong>Family</strong>plann<strong>in</strong>g became <strong>the</strong> responsibility of LGUs. Thetransfer of personnel, facilities <strong>and</strong> resources was24, 23completed <strong>in</strong> 1994.1994: The agreement of <strong>the</strong> <strong>International</strong> Conferenceon Population <strong>and</strong> Development to move familyplann<strong>in</strong>g away from demographic targets <strong>and</strong>reframe it with<strong>in</strong> reproductive health <strong>and</strong> rights wasreadily accepted, s<strong>in</strong>ce this was <strong>the</strong> general directiontaken by <strong>the</strong> country's FP programme after martiallaw.1998: AO 1-A, “Creation of a Philipp<strong>in</strong>e ReproductiveHealth Program”. A reproductive health (RH)programme with 10 elements was created; a leadoffice for each element identified; <strong>and</strong> a coord<strong>in</strong>at<strong>in</strong>gmechanism was set up to run <strong>the</strong> programme.2000: AO 24-A, “Streng<strong>the</strong>n<strong>in</strong>g of <strong>the</strong> DOH ReproductiveHealth Program”. A regular structure for manag<strong>in</strong>g<strong>the</strong> RH programme was formed under <strong>the</strong> Centerfor <strong>Family</strong> Health. A Contraceptive IndependenceInitiative (CII) was established to <strong>in</strong>tegrate RH298

fund<strong>in</strong>g, <strong>in</strong>clud<strong>in</strong>g <strong>the</strong> purchase of contraceptives,<strong>in</strong>to <strong>the</strong> health f<strong>in</strong>anc<strong>in</strong>g <strong>and</strong> social <strong>in</strong>surance plans<strong>and</strong> programmes of <strong>the</strong> Department of Health.Funds to purchase contraceptives – a first for <strong>the</strong>country – were <strong>in</strong>cluded <strong>in</strong> <strong>the</strong> 2001 DOH budgetrequest. The RH programme was fur<strong>the</strong>r detailed<strong>in</strong> AO 43, “Reproductive Health Policy”.The 2001 to 2010 period2001: A new government headed by President GloriaMacapagal Arroyo came to power after massprotests triggered by events <strong>in</strong> a corruption trial ofPresident Joseph Ejercito Estrada forced him out ofoffice. The new President was a follower of CatholicChurch doctr<strong>in</strong>es on contraception, <strong>and</strong> would holdon to power for <strong>the</strong> next n<strong>in</strong>e years. The budget forcontraceptives <strong>and</strong> <strong>the</strong> CII were never implemented.Later, <strong>the</strong> national effort was shifted to promot<strong>in</strong>gNatural <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> (NFP).2001: AO 50-A, “National <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Policy”. Astrong, detailed <strong>and</strong> comprehensive FP programmewas outl<strong>in</strong>ed <strong>in</strong> this AO, but <strong>the</strong> 2000 RHprogramme <strong>and</strong> structure was replaced. Nationalfund<strong>in</strong>g for <strong>the</strong> FP programme, <strong>in</strong>clud<strong>in</strong>g <strong>the</strong>purchase of contraceptives, was <strong>in</strong>cluded <strong>and</strong>framed as part of elim<strong>in</strong>at<strong>in</strong>g dependence on foreigndonors through CII. An ambitious target of 50 percent modern CPR by 2004 was set, from a basel<strong>in</strong>eof 28 per cent <strong>in</strong> 1998 (10% annual CPR growth,equivalent to 4-5 times <strong>the</strong> annual rate of growths<strong>in</strong>ce 1978). It is unclear why this AO – neverseriously implemented – was crafted at all.2001-2004: House Bill 4110, “The Reproductive HealthCare Agenda Act of 2001” was filed at <strong>the</strong> Houseof Representatives. The bill was passed by <strong>the</strong>Committee on Health after prolonged deliberations,but was not acted upon by <strong>the</strong> Committee onAppropriations.2002: AO 125, “National NFP Strategic Plan Year2002-2006”. This marked <strong>the</strong> shift of <strong>the</strong> nationalgovernment to focus almost exclusively on naturalfamily plann<strong>in</strong>g. An ambitious target was set toraise NFP use from a basel<strong>in</strong>e of less than 1 percent, to 20 per cent by 2006.2003: <strong>and</strong> later years: Legislators prod <strong>the</strong> Departmentof Health to purchase contraceptives by allocat<strong>in</strong>g<strong>the</strong>ir discretionary development funds <strong>and</strong> pass<strong>in</strong>gbudgets for this specific purpose. Most of <strong>the</strong> fundswere simply left unused by <strong>the</strong> Department. Thesmall proportion of funds utilized went to a fairlycomplex fund<strong>in</strong>g w<strong>in</strong>dow (established by DOHMemo 2008-0100) that LGUs must apply <strong>and</strong>qualify for.2004: AO 132, “Creat<strong>in</strong>g <strong>the</strong> DOH Natural <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Programme <strong>and</strong> its ProgrammeManagement”. The NFP programme was fur<strong>the</strong>renlarged by separat<strong>in</strong>g it from <strong>the</strong> regular FPprogramme, <strong>and</strong> its narrow focus was re<strong>in</strong>forcedby direct<strong>in</strong>g it to work more closely with groups“which want to promote NFP exclusively”. <strong>Family</strong>plann<strong>in</strong>g was now based on “four pillars: responsibleparenthood, birth spac<strong>in</strong>g, <strong>in</strong>formed choice <strong>and</strong>respect for life”, a phrase used by <strong>the</strong> President todistance herself from <strong>the</strong> ICPD language.2004: AO 158, “Guidel<strong>in</strong>es on <strong>the</strong> Management ofDonated Commodities under <strong>the</strong> ContraceptiveSelf-Reliance Strategy”. This marked <strong>the</strong> formalpass<strong>in</strong>g of responsibility for family plann<strong>in</strong>g fromDOH to LGUs. The health secretary clarifiedthat self-reliance is not <strong>in</strong>dicative of a need for <strong>the</strong>national government to beg<strong>in</strong> purchas<strong>in</strong>g its ownsupplies, but of “<strong>the</strong> end-users <strong>and</strong> <strong>the</strong> [LGUs]outgrow<strong>in</strong>g <strong>the</strong>ir dependence on <strong>the</strong> donors of<strong>the</strong>se contraceptives”. 242008: The CPR for modern methods was measured at 34per cent by <strong>the</strong> National Demographic <strong>and</strong> HealthSurvey. It took 30 years to double <strong>the</strong> 17 per centCPR <strong>in</strong> 1978, equivalent to a slow 2.3 per centannual growth rate.2008-2009: House Bill 5043, “An Act Provid<strong>in</strong>g for aNational Policy on Reproductive Health, ResponsibleParenthood <strong>and</strong> Population Development, <strong>and</strong> forO<strong>the</strong>r Purposes” 25 , reached plenary debates at <strong>the</strong>House of Representatives, <strong>the</strong> fur<strong>the</strong>st that a law onreproductive health or population had gone s<strong>in</strong>cevarious bills were filed after ICPD. The bill was notvoted upon due to lack of time, a result of delay<strong>in</strong>gtactics by those oppos<strong>in</strong>g it.2010: AO 2010-0027, “Amendment to Adm<strong>in</strong>istrativeOrder No. 158, Series of 2004 entitled Guidel<strong>in</strong>eson <strong>the</strong> Management of Donated Commoditiesunder <strong>the</strong> Contraceptive Self-Reliance Strategy”.This AO streng<strong>the</strong>ned <strong>the</strong> role <strong>and</strong> responsibilityof <strong>the</strong> national government <strong>in</strong> ensur<strong>in</strong>g <strong>the</strong>availability of <strong>and</strong> access to family plann<strong>in</strong>g <strong>and</strong>RH commodities. However, this was issued a weekbefore <strong>the</strong> scheduled change of government.Mid-2010 <strong>and</strong> beyond2010: Benigno Aqu<strong>in</strong>o III took over <strong>the</strong> presidency on 30June 2010. His term of office will last until 2016.The President has publicly announced a five-po<strong>in</strong>tposition on family plann<strong>in</strong>g:299

(1) I am aga<strong>in</strong>st abortion; (2) I am <strong>in</strong>favor of giv<strong>in</strong>g couples <strong>the</strong> right to choosehow best to manage <strong>the</strong> families so that<strong>in</strong> <strong>the</strong> end <strong>the</strong>ir welfare <strong>and</strong> that of <strong>the</strong>irchildren are best served; (3) <strong>the</strong> state mustrespect each <strong>in</strong>dividual’s right to follow hisor her conscience <strong>and</strong> religious convictionon matters <strong>and</strong> issues perta<strong>in</strong><strong>in</strong>g to <strong>the</strong>unity of <strong>the</strong> family <strong>and</strong> <strong>the</strong> sacredness ofhuman life from conception to naturaldeath; (4) <strong>in</strong> a situation where couples,especially <strong>the</strong> poor <strong>and</strong> <strong>the</strong> disadvantagedones are <strong>in</strong> no position to make an<strong>in</strong>formed judgment, <strong>the</strong> state has aresponsibility to so provide; <strong>and</strong> lastly, (5)<strong>in</strong> <strong>the</strong> range of options <strong>and</strong> <strong>in</strong>formationprovided to couples, natural familyplann<strong>in</strong>g <strong>and</strong> modern method shall bepresented as equally available. 26The new Secretary of Health has <strong>in</strong>cluded a requestfor 400 million pesos to purchase contraceptives <strong>in</strong><strong>the</strong> regular budget of <strong>the</strong> Department of Healthfor 2011. The new Speaker of <strong>the</strong> House ofRepresentatives has pledged that <strong>the</strong> RH Bill willf<strong>in</strong>ally be put to a vote.Current issues <strong>in</strong> <strong>the</strong> familyplann<strong>in</strong>g programmeModern contraceptive useModern contraceptive use is low to moderate, with steadybut slow growth s<strong>in</strong>ce 1978. The latest survey shows thatonly a third of married women of reproductive age areus<strong>in</strong>g any modern method. The average annual growth was19 per cent from 1968 to 1978 <strong>and</strong> 2-3 per cent from 1978to 2003. The fastest annual growth <strong>in</strong> <strong>the</strong> last 30 years was3.4 per cent from 1998 to 2003. Even if this peak growthrate is susta<strong>in</strong>ed, it would take <strong>the</strong> country until 2020 toreach a contraceptive prevalence rate (CPR) of 60 per centfor modern methods, a decade beh<strong>in</strong>d <strong>the</strong> government's2010 target27 (see Figure 1). From 2003 to 2008, <strong>the</strong>growth rate dropped steeply to 0.36 per cent which, if leftunchanged, would mean that a CPR of 60 per cent formodern methods could be reached only after 160 years.Modern method CPR was 34 per cent <strong>in</strong> 2008, while <strong>the</strong>total dem<strong>and</strong> for family plann<strong>in</strong>g was 73 per cent, whichmeans that less than half of <strong>the</strong> dem<strong>and</strong> was met throughmodern methods.(Note for all figures: <strong>the</strong> support<strong>in</strong>g data <strong>and</strong> sources areavailable at <strong>the</strong> Appendix – Data Tables.)Trends <strong>in</strong> modern contraceptiveuseBy age groupS<strong>in</strong>ce 1993, contraceptive use by age had an <strong>in</strong>verted Ushape, with peak use by women <strong>in</strong> <strong>the</strong>ir 30s for any modernmethod (see Figure 2). All age groups had an <strong>in</strong>crease <strong>in</strong>percentage use from 1993 to 2008, but at different rates of<strong>in</strong>crease. The largest ga<strong>in</strong>s came from <strong>the</strong> three youngestage groups, led by those aged 20-24, hav<strong>in</strong>g <strong>in</strong>creased atan average of 3.7 per cent per year for 15 years. The oldest,those aged 45-49, had <strong>the</strong> smallest ga<strong>in</strong> at 1.3 per cent peryear. It is <strong>the</strong> only age group that had a reversal <strong>in</strong> currentuse dur<strong>in</strong>g <strong>the</strong> 15-year period, dipp<strong>in</strong>g from 26.4 per centmodern methods CPR <strong>in</strong> <strong>the</strong> 2003 survey to 22.4 per cent<strong>in</strong> 2008.By number of liv<strong>in</strong>g childrenS<strong>in</strong>ce 1993, <strong>the</strong> use of modern contraception <strong>in</strong>creasedsteadily as <strong>the</strong> number of liv<strong>in</strong>g children <strong>in</strong>creased fromzero to three; <strong>and</strong> went down <strong>the</strong>reafter (see Figure 3).Over <strong>the</strong> past 15 years, those with one child showed <strong>the</strong>most significant annual average rate of growth at 5 percent, almost 2½ times <strong>the</strong> average for all. Those with nochildren had a 6 per cent growth rate, but this generatedlittle impact as <strong>the</strong> basel<strong>in</strong>e figure was near zero. Thosewith three or more children had below average growthrates; those with three children even registered a slightdrop <strong>in</strong> use from 2003 to 2008.Women employed <strong>in</strong> agriculture tend to have more childrenthan those employed <strong>in</strong> o<strong>the</strong>r sectors (see Figure 4). Thosewith only one to two children tend to be employed <strong>in</strong>professional, technical <strong>and</strong> managerial work (31%) <strong>and</strong><strong>in</strong> sales <strong>and</strong> services (31%), while those with five or morechildren work <strong>in</strong> agriculture (33%) <strong>and</strong>, slightly less butstill substantial, <strong>in</strong> sales <strong>and</strong> service (26%). It is also worthnot<strong>in</strong>g that, among women with children, domestic service(household help) is <strong>the</strong> only o<strong>the</strong>r occupation that stillrises as <strong>the</strong> number of children <strong>in</strong>creases.By wealth qu<strong>in</strong>tileIn 1993, women <strong>in</strong> <strong>the</strong> highest wealth qu<strong>in</strong>tile were 2.1300

FigureFigureFigure1Trends <strong>in</strong> current use of modern methods by married women aged 15-49602010 Target2020504030160 years to reach 60%201001968 1973 1978 1983 1988 1993 1998 2003 2008 2013 2018 2023times more likely to use modern contraception than those<strong>in</strong> <strong>the</strong> lowest qu<strong>in</strong>tile. Fifteen years later <strong>in</strong> 2008, <strong>the</strong>ratio had gone down to just 1.3. Over <strong>the</strong> past 15 years,<strong>the</strong> two poorest qu<strong>in</strong>tiles had larger <strong>and</strong> more consistentCPR growth rates, averag<strong>in</strong>g close to 3-4 per cent annually.In contrast, those <strong>in</strong> <strong>the</strong> highest qu<strong>in</strong>tile <strong>in</strong>creased CPRby less than 1 per cent annually <strong>and</strong> <strong>the</strong>re were even twoperiods of decl<strong>in</strong>e <strong>in</strong> contraceptive use (see Figure 5). CPRuse <strong>in</strong> <strong>the</strong> middle qu<strong>in</strong>tile grew at <strong>the</strong> same rate as <strong>the</strong>average for all married women.Summary of growth trendsFrom <strong>the</strong> preced<strong>in</strong>g <strong>in</strong>formation, it appears that, from1993 to 2008, growth <strong>in</strong> contraceptive use among marriedwomen was led by those who were poor but not <strong>in</strong>agricultural work, <strong>in</strong> <strong>the</strong>ir twenties <strong>and</strong> hav<strong>in</strong>g one or twochildren. These are <strong>the</strong> segments of <strong>the</strong> population thathad lower rates of use <strong>in</strong> <strong>the</strong> past <strong>and</strong> caught up to someextent <strong>in</strong> <strong>the</strong> last 15 years. However, <strong>the</strong> rates of CPRgrowth achieved by <strong>the</strong>se best-perform<strong>in</strong>g segments arestill slow <strong>in</strong> absolute terms. For example, <strong>the</strong> 2008 NDHSshows that women <strong>in</strong> <strong>the</strong> poorest wealth qu<strong>in</strong>tile needto <strong>in</strong>crease CPR from <strong>the</strong> current 26 per cent to 68 percent <strong>in</strong> order to elim<strong>in</strong>ate <strong>the</strong>ir unmet need <strong>and</strong> <strong>the</strong> use ofunreliable, traditional methods. At <strong>the</strong> 3.9 per cent annualgrowth rate that <strong>the</strong> poorest women have achieved – <strong>the</strong>fastest among all qu<strong>in</strong>tiles – it will still take 25 years toreach 68 per cent.Modern contraceptive method mixFrom 1993 to 2008, <strong>the</strong> top two methods – pills <strong>and</strong> femalesterilization (tubal ligation) – have consistently accountedfor 71 per cent or more of all modern method use (see Figure6). Both methods are, however, undergo<strong>in</strong>g substantialchanges. Tubal ligation has gone down from first to secondFigure240%30%Use of modern contraception by age group, married women2008200319981993Annual Growth20%10%2.7%3.7% 2.8% 2.0% 2.0% 1.9% 1.3%0%15-19 20-24 25-29 30-34 35-39 40-44 45-49Age Group301

FigureFigureFigure3Use of modern contraception by number of liv<strong>in</strong>g children, married women aged 15-4950%40%30%20%10%0%None 1 2 3 4+2008200319981993Annual Growth5.8%5.0%2.9%1.5% 1.9%Figure4Percentage distribution of women aged 15-49 employed <strong>in</strong> <strong>the</strong> 12 months preced<strong>in</strong>g 2008 NDHSsurvey, by occupation <strong>and</strong> number of liv<strong>in</strong>g children353025201510500 1-2 3-4 5+No. of ChildrenClericalUnskilledmanualSkilledmanualDomesticserviceProfessional/technical/managerialSales <strong>and</strong>servicesAgricultureplace, chang<strong>in</strong>g place with <strong>the</strong> pill. The movement is dueto an 85 per cent <strong>in</strong>crease <strong>in</strong> pill use for <strong>the</strong> past 15 years<strong>and</strong> a 23 per cent drop <strong>in</strong> tubal ligations. The proportion ofwomen who have had tubal ligation <strong>and</strong> have moved out of<strong>the</strong> reproductive years has not been adequately replaced by<strong>the</strong> programme. Although <strong>the</strong> <strong>in</strong>crease <strong>in</strong> pill use has morethan made up for <strong>the</strong> drop <strong>in</strong> tubal ligations, <strong>the</strong> usefulnessof <strong>the</strong> latter to women who want no more children shouldnot be underestimated. Discont<strong>in</strong>uation is also a problemwith <strong>the</strong> pill. In <strong>the</strong> 2003 NDHS, more than a third ofwomen on <strong>the</strong> pill, exclud<strong>in</strong>g those who wanted to getpregnant, stopped with<strong>in</strong> 12 months: 17.4 per cent due toside effects <strong>and</strong> health reasons; 3.7 per cent due to methodfailure; <strong>and</strong> 14.6 per cent due to o<strong>the</strong>r reasons.The next three methods – IUDs, <strong>in</strong>jections (re<strong>in</strong>troduced<strong>in</strong> 1994) <strong>and</strong> condoms – make up <strong>the</strong> next cluster,account<strong>in</strong>g for some 25-27 per cent of modern methoduse <strong>in</strong> <strong>the</strong> last 15 years. All three have registered <strong>in</strong>creases<strong>in</strong> current use over <strong>the</strong> past 15 years, but <strong>the</strong> base levels <strong>in</strong>1993 are too small (3% or less), which means <strong>the</strong> measuredupward trend may not be stable. For example, from 2003to 2008, <strong>the</strong> use of IUDs had actually gone down from12.3 to 10.9 per cent, <strong>and</strong> <strong>in</strong>jections dipped from 9.3 to7.6 per cent use.The last two methods – modern NFP <strong>and</strong> male sterilization(vasectomy) – have consistently registered less than 1 percent use over <strong>the</strong> last 15 years. These methods have been302

FigureFigureFigure5Percentage distribution of women aged 15-49 employed <strong>in</strong> <strong>the</strong> 12 months preced<strong>in</strong>g 2008 NDHSsurvey, by occupation <strong>and</strong> number of liv<strong>in</strong>g children40%2008200319981993Annual Growth30%20%10%3.9% 2.9% 2.1% 1.5% 0.5%0%Lowest Second Middle Fourth HighestFigure6 Percentage share of each method to total modern method use, married women aged 15-49part of <strong>the</strong> government's programme for a long time, muchearlier than <strong>the</strong> <strong>in</strong>jectable, which has overtaken <strong>the</strong> two.Specific studies should be done to expla<strong>in</strong> <strong>the</strong> very lowuptake, <strong>and</strong> policies adjusted accord<strong>in</strong>gly <strong>the</strong>reafter. Alarge-scale, dist<strong>in</strong>ct (i.e., separate from <strong>the</strong> regular familyplann<strong>in</strong>g programme) <strong>and</strong> nationwide push for modernNFP was done by <strong>the</strong> national government <strong>in</strong> 2002,with <strong>the</strong> goal of reach<strong>in</strong>g 20 per cent current use by 2006(DOH AO 125, 2002). This campaign should be evaluatedpromptly <strong>and</strong> thoroughly s<strong>in</strong>ce <strong>the</strong> end-results have beencompleted <strong>and</strong> an extremely large gap exists between <strong>the</strong>target (20%) <strong>and</strong> accomplishment (0.5%).Traditional method useTraditional methods – ma<strong>in</strong>ly <strong>the</strong> rhythm method(periodic abst<strong>in</strong>ence, or tim<strong>in</strong>g by ovulation) <strong>and</strong>withdrawal – have had a long history of use by a significantproportion of married women. The country's first NationalDemographic Survey <strong>in</strong> 1968 recorded 11.5 per cent useof <strong>the</strong>se methods, which rose almost constantly, albeit ata slow pace (under 1% annually), until it reached 16.3 percent <strong>in</strong> 2008. This level is relatively high compared with<strong>the</strong> recent rates of neighbour<strong>in</strong>g countries <strong>in</strong> South-East<strong>Asia</strong> (see Figure 7), such as Thail<strong>and</strong> (1% <strong>in</strong> 2006), Timor-Leste (3% <strong>in</strong> 2003), Lao People’s Democratic Republic(3% <strong>in</strong> 2000), Indonesia (4% <strong>in</strong> 2007), Viet Nam (11% <strong>in</strong>2008) <strong>and</strong> Cambodia (13% <strong>in</strong> 2005). 28The rhythm method has been an official part of <strong>the</strong>Philipp<strong>in</strong>e family plann<strong>in</strong>g programme s<strong>in</strong>ce <strong>the</strong> <strong>in</strong>ceptionof <strong>the</strong> programme but was officially discont<strong>in</strong>ued by <strong>the</strong>Department of Health <strong>in</strong> 1994. 29 Among rhythm users,however, only a m<strong>in</strong>ority know <strong>the</strong> correct tim<strong>in</strong>g of a303

FigureFigure7Traditional method use <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es <strong>and</strong> neighbour<strong>in</strong>g <strong>Asia</strong>n countrieswoman's fertile period – from 26 per cent to 48 per cent<strong>in</strong> <strong>the</strong> four surveys from 1993 to 2008. This <strong>in</strong>dicates thatmost users have not had any formal orientation, much lesstra<strong>in</strong><strong>in</strong>g, about <strong>the</strong> method.The Department's goal 30 of 80 per cent total CPR <strong>and</strong> 60per cent modern-method CPR by 2010 implies a target of20 per cent use rate for traditional methods, which meansthat <strong>the</strong> current high levels will be raised fur<strong>the</strong>r. Thiscontradicts <strong>the</strong> Department's own family plann<strong>in</strong>g methodmix. Policy clarification is needed <strong>in</strong> this area.Unmet need for modern methodsUnmet need measures <strong>the</strong> proportion of married womenwho are able to get pregnant (fecund), want to space <strong>the</strong>next pregnancy by two years or more or stop childbear<strong>in</strong>galtoge<strong>the</strong>r, but are not us<strong>in</strong>g any method of contraception.Accord<strong>in</strong>g to this def<strong>in</strong>ition, users of traditional methodsare classified as hav<strong>in</strong>g “met” <strong>the</strong>ir need for prevent<strong>in</strong>gpregnancy. Ow<strong>in</strong>g to <strong>the</strong> large risks posed by traditionalmethods <strong>in</strong> lead<strong>in</strong>g to un<strong>in</strong>tended pregnancies <strong>and</strong> <strong>the</strong>exclusion of <strong>the</strong>se methods <strong>in</strong> official family plann<strong>in</strong>gprogrammes, organizations such as <strong>the</strong> GuttmacherInstitute (“unmet need for effective contraception” 31 ) <strong>and</strong>ICF Macro of <strong>the</strong> MEASURE DHS project (“unmet needfor modern methods” 32 ) have began releas<strong>in</strong>g comb<strong>in</strong>edcounts of women with unmet need toge<strong>the</strong>r with thoseus<strong>in</strong>g traditional methods. This is especially useful forcountries such as <strong>the</strong> Philipp<strong>in</strong>es with high levels oftraditional method use. These comb<strong>in</strong>ed counts will beused <strong>in</strong> <strong>the</strong> present report.Unmet need for modern methods provides a simple basisfor target<strong>in</strong>g levels of contraceptive use that is groundedon <strong>the</strong> expressed desires of women to regulate <strong>the</strong>irchildbear<strong>in</strong>g. With <strong>the</strong> unmet need approach, however,a problem occurs if women <strong>and</strong> couples desire a largenumber of children that, when aggregated, would lead tounsusta<strong>in</strong>able population growth. This desire may havebeen true for <strong>the</strong> Philipp<strong>in</strong>es <strong>in</strong> <strong>the</strong> earlier decades, but <strong>the</strong>latest studies show a different picture.Westoff 33 calculated <strong>in</strong> a 2006 multi-country study that<strong>the</strong> Philipp<strong>in</strong>es would have a total fertility rate (TFR) of2.4 to 2.8 children per woman if <strong>the</strong> unmet need based on2003 DHS data were elim<strong>in</strong>ated or substantially reduced.Shift<strong>in</strong>g <strong>the</strong> large number of traditional method usersto modern methods would fur<strong>the</strong>r reduce <strong>the</strong> predictedTFR.In a 2006 study us<strong>in</strong>g cross-tabulations <strong>and</strong> multivariateanalyses of socio-economic status <strong>and</strong> demographicbehaviour, Orbeta 34 concluded that “it is not <strong>the</strong> dem<strong>and</strong>for more children that is <strong>the</strong> reason for [<strong>the</strong> poor's] largefamily size but <strong>the</strong>ir use of <strong>in</strong>effective fertility controlmeasures”. He proposed three factors or mechanisms thatcould expla<strong>in</strong> this outcome: “(a) <strong>the</strong> crowd<strong>in</strong>g out of womenfrom poor households by a significant percentage of womenfrom richer households that are gett<strong>in</strong>g <strong>the</strong>ir supplies ofmodern contraception also from public sources, (b) <strong>the</strong>lower education of women from poorer households, <strong>and</strong>(c) <strong>the</strong> lower capacity of women from poorer householdsto pay for private supplies”.Proportion of women withunmet needThe Philipp<strong>in</strong>e government does not have a target forreduction of unmet need but gave a CPR target of 80 percent for all methods <strong>and</strong> 60 per cent for modern methodsby 2010, <strong>and</strong> a CPR of 100 per cent by 2015. 35 The 100per cent CPR target is likely a mistake because <strong>the</strong>re willalways be women who do want to get pregnant. This is anarea that needs policy clarification from <strong>the</strong> government.304

FigureFigureFigure8Total dem<strong>and</strong> for family plann<strong>in</strong>g <strong>and</strong> its various components1009080Pregnant &wanted, want toget pregnantsoon, <strong>in</strong>fecundTotal dem<strong>and</strong> forfamily plann<strong>in</strong>g7060504041%Unmet need formodern method38%Unmet need (nomethod used)Traditionalmethod user32%39%302010Modern methoduser01993 1998 2003 2008Figure9Estimated number of married women aged 15-49 with unmet need for modern methodsFrom 1993 to 2003, <strong>the</strong> proportion of women with unmetneed for modern methods went down from 41 to 32 percent (see Figure 8). The improvement came almost solelyfrom a drop <strong>in</strong> those not us<strong>in</strong>g any method; traditionalmethod use rema<strong>in</strong>ed practically <strong>the</strong> same. From 2003to 2008, however, unmet need for modern contraceptionwent up aga<strong>in</strong> to 39 per cent. The <strong>in</strong>crease came from bothnon-users <strong>and</strong> traditional method users, with <strong>the</strong> formercontribut<strong>in</strong>g <strong>the</strong> larger hike.MagnitudeThe s<strong>in</strong>gle-digit movements <strong>in</strong> unmet need percentagesmask <strong>the</strong> huge number of women affected. The countryhas millions of married women <strong>in</strong> <strong>the</strong>ir reproductiveyears because <strong>the</strong> population is young <strong>and</strong> grow<strong>in</strong>g, <strong>and</strong><strong>the</strong> proportion of women <strong>in</strong> union (married or <strong>in</strong> a live<strong>in</strong>arrangement) has not gone down. For example, a rise<strong>in</strong> <strong>the</strong> average age at marriage could br<strong>in</strong>g <strong>the</strong> proportiondown, but this has not occurred. There is evidence that <strong>the</strong>proportion has gone up slightly: <strong>the</strong> proportion of women<strong>in</strong> union was 58.2 per cent <strong>in</strong> <strong>the</strong> 2000 census <strong>and</strong> 61.9 percent <strong>in</strong> <strong>the</strong> 2008 NDHS.Figure 9 presents an estimate of <strong>the</strong> number of marriedwomen who do not want a pregnancy now or ever, butare not us<strong>in</strong>g any modern method of contraception. Ituses <strong>the</strong> medium scenario population projections nearesta survey year (i.e., <strong>the</strong> 1993 survey was matched to <strong>the</strong>1995 population projection, <strong>the</strong> 1998 survey to <strong>the</strong> 2000305

Figureprojection, <strong>and</strong> so on). The estimate used <strong>the</strong> census-basedpercentage of women <strong>in</strong> union (58.2%), which is lowerthan <strong>the</strong> NDHS percentage.The estimates show that <strong>the</strong>re were 3.19 million marriedwomen of reproductive age with an unmet need <strong>in</strong> 2010,up by 0.97 million from <strong>the</strong> number <strong>in</strong> 2005; <strong>and</strong> 2.33million us<strong>in</strong>g traditional methods, up by 0.42 million.Overall, <strong>the</strong> family plann<strong>in</strong>g programme needs to reach asmany as 5.52 million women <strong>in</strong> 2010 to help <strong>the</strong>m accessmodern methods of contraception. About 42 per cent of<strong>the</strong>se women 36 – some 2.32 million – belong to <strong>the</strong> twolowest wealth qu<strong>in</strong>tiles as classified by NDHS.Women users of traditional methods <strong>and</strong> those withunmet need contribute to 24 <strong>and</strong> 68 per cent, respectively,of un<strong>in</strong>tended pregnancies <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es. Darroch 37<strong>and</strong> colleagues estimated that, <strong>in</strong> 2008, if all women atrisk of un<strong>in</strong>tended pregnancies were able to use a modernmethod of contraception, <strong>the</strong>re would have been:0.8 million fewer unplanned births0.5 million fewer <strong>in</strong>duced abortions0.2 million fewer spontaneous abortions2,100 fewer maternal deaths120,000 fewer DALYs *1 of womenfewer <strong>in</strong>fant deaths s<strong>in</strong>ce births spaced by 2 years ormore have <strong>the</strong> best chance of survival, but 33 per cent ofall births do not meet this idealReasons for not <strong>in</strong>tend<strong>in</strong>g to usemodern contraceptionAmong women not us<strong>in</strong>g any method, 53 per cent stated<strong>in</strong> 2008 that <strong>the</strong>y did not <strong>in</strong>tend to use one <strong>in</strong> <strong>the</strong> future,up from 46 per cent <strong>in</strong> 1993. These are relatively highrates. In a 2007 study 38 of 34 countries with 2000 to 2005DHS surveys, <strong>the</strong> range of <strong>in</strong>tended non-use was 23 to 79per cent. The Philipp<strong>in</strong>es ranked fourth from <strong>the</strong> top, afterMauritania, Eritrea <strong>and</strong> Nigeria (see Figure 10). However,unlike most of <strong>the</strong> o<strong>the</strong>r top countries <strong>in</strong> <strong>in</strong>tended nonuse,<strong>the</strong> Philipp<strong>in</strong>es fared better <strong>in</strong> terms of current useof any modern contraception (3rd among <strong>the</strong> 15 countries<strong>in</strong> Figure 10). This cross-country comparison can shedlight on <strong>the</strong> Philipp<strong>in</strong>e's pattern of contraceptive use. The<strong>in</strong>creas<strong>in</strong>g total dem<strong>and</strong> for family plann<strong>in</strong>g (seen <strong>in</strong> Figure8) probably <strong>in</strong>dicates a widespread desire to control fertilitythat is matched by strong resistance or barriers to modernmethod use. The result is low to moderate levels <strong>and</strong> slowgrowth of modern contraceptive use, a large reliance ontraditional means to control fertility, <strong>and</strong> a high percentageof those not plann<strong>in</strong>g to use any method at all.Figure10Intended future non-use among married women not us<strong>in</strong>g any method, top 15 countries with2000–2005 DHS, compared with percentage use of modern methods306

FigureFigure11Reasons for not <strong>in</strong>tend<strong>in</strong>g to use contraception, married women aged 15-4940%30%With unmet needWants to get pregnantor cannot getpregnant anymore20%10%0%Safety Low fecundity Opposed to FP Access & <strong>in</strong>fo. O<strong>the</strong>r issues Menopausal,hysterectomizedWants morechildren1993 1998 2003 2008TableTableB307

Figure 11 summarizes <strong>the</strong> explanations*2 provided bywomen when asked for one ma<strong>in</strong> reason why <strong>the</strong>y did not<strong>in</strong>tend to use any method of contraception <strong>in</strong> four surveysdone from 1993 to 2008. About one third did not <strong>in</strong>tend touse a method simply because <strong>the</strong>y wanted to get pregnantor <strong>the</strong>y could not get pregnant anymore due to menopauseor hysterectomy. The rema<strong>in</strong><strong>in</strong>g two thirds gave o<strong>the</strong>rreasons, which <strong>in</strong>dicate that <strong>the</strong>y had an unmet need, <strong>and</strong>would cont<strong>in</strong>ue to have an unmet need unless barriers touse are successfully addressedSafety concernsThe top concern is about safety, cited by half of thosewith an unmet need. The issues with<strong>in</strong> this group revolvearound doubts about <strong>the</strong> <strong>in</strong>tr<strong>in</strong>sic safety of contraceptiveproducts or <strong>the</strong>ir suitability or fit (hiyang <strong>in</strong> Filip<strong>in</strong>o)to <strong>the</strong> user. Focus group discussions typically open upconcerns about cancer, weight loss, dangerous levels ofchemical build-up due to prolonged use, excessive bleed<strong>in</strong>g,<strong>the</strong> build-up of unclean blood if menstruation stops, lossof physical strength which leads to <strong>in</strong>ability to work,debilitat<strong>in</strong>g headaches or stomach aches, devices that getlost or entangled <strong>in</strong>side, among many more such concerns.A study39 done <strong>in</strong> 2003 has documented many of <strong>the</strong>sefears (see Table B).Filip<strong>in</strong>o women have relatively high levels of formaleducation: 71 per cent of women not us<strong>in</strong>g any method <strong>in</strong><strong>the</strong> 2008 NDHS had a high school or college/universityeducation. However, contraception is not a st<strong>and</strong>ard partof <strong>the</strong> curriculum. The Department of Education hada much publicized attempt to pilot-test <strong>the</strong> <strong>in</strong>clusion ofsexuality <strong>and</strong> family plann<strong>in</strong>g topics <strong>in</strong> some public highschools <strong>in</strong> <strong>the</strong> last few months of <strong>the</strong> previous government,but this effort was blocked by lobby<strong>in</strong>g conducted byCatholic bishops <strong>and</strong> clergy. A policy of <strong>in</strong>tegrat<strong>in</strong>g ageappropriatereproductive health <strong>and</strong> sexuality education<strong>in</strong>to <strong>the</strong> formal school system is also part of numerousreproductive health bills filed <strong>in</strong> Congress s<strong>in</strong>ce 2001, butall such attempts have been successfully blocked by <strong>in</strong>tense<strong>and</strong> widespread lobby<strong>in</strong>g by <strong>the</strong> Catholic hierarchy.Ano<strong>the</strong>r factor for <strong>the</strong> prom<strong>in</strong>ence of safety questions is<strong>the</strong> open <strong>and</strong> cont<strong>in</strong>u<strong>in</strong>g campaign by Catholic bishops, laygroups, some Catholic medical practitioners <strong>and</strong> politiciansto raise doubts about <strong>the</strong> safety of contraceptives. 40 Some of<strong>the</strong> worst documented cases occurred <strong>in</strong> <strong>the</strong> city of Manila(population 1.7 million). In a 2006 video documentary 41 ,<strong>the</strong> city mayor justified his ban of contraceptives with <strong>the</strong>follow<strong>in</strong>g assertion: “Contraceptive materials actually arepoison to <strong>the</strong> woman's body. You look at <strong>the</strong> <strong>in</strong>ternet, it'seven described as a pesticide. Why should I be teach<strong>in</strong>gpeople how to take pesticide?” In 2007, medical doctorsemployed by <strong>the</strong> city government admitted <strong>in</strong> <strong>in</strong>terviewsabout <strong>the</strong> contraceptive ban <strong>in</strong> <strong>the</strong> city that <strong>the</strong>y teachpeople that contraceptives are unsafe or <strong>in</strong>effective, thatoral pills conta<strong>in</strong> pesticides <strong>and</strong> cause cancer, <strong>and</strong> thatcondoms are not effective <strong>in</strong> prevent<strong>in</strong>g HIV because <strong>the</strong>virus is smaller than <strong>the</strong> condom’s pores <strong>and</strong> can penetratethrough. 42In a focus group discussion by one of <strong>the</strong>authors with long-time community healthworkers, some of <strong>the</strong>m tried four modernmethods – usually pills, DMPA, condom,breastfeed<strong>in</strong>g <strong>and</strong> IUD – <strong>in</strong> differentorders, before <strong>the</strong>y settled on a methodthat was most comfortable for <strong>the</strong>m. A fewused a comb<strong>in</strong>ation of modern methods<strong>and</strong> herbal “menstrual regulators”, such asroots of achuete, makahiya, makabuhay<strong>and</strong> marabilos. The shift to differentmethods is triggered by side effects, suchas headaches, ligh<strong>the</strong>adedness, gastritis;unexpected effects, such as cessationof menses with pills <strong>and</strong> IUD; <strong>and</strong>cont<strong>in</strong>uous method failure, usually withpills <strong>and</strong> DMPA; <strong>and</strong> heavy bleed<strong>in</strong>gwith DMPA. A few used withdrawal.Despite <strong>the</strong> difficulties, women persist <strong>in</strong>us<strong>in</strong>g <strong>the</strong>se methods for many reasons.In <strong>the</strong>ir experience, clients who havedifficulty susta<strong>in</strong><strong>in</strong>g use are those whoexperience side effects, some of whichare contrary to <strong>the</strong> postulated effects ofmethods – amenorrhoea with IUD <strong>and</strong>pills, monthly bleed<strong>in</strong>g with <strong>in</strong>jectables– or symptoms which are not logicallyrelated to <strong>the</strong> methods, such as chestpa<strong>in</strong>, mass <strong>and</strong> asthma. There are thosewho fear experienc<strong>in</strong>g pa<strong>in</strong> on gett<strong>in</strong>gan IUD because <strong>the</strong>y th<strong>in</strong>k it is asurgical procedure, or because of previousexperiences with pa<strong>in</strong>ful <strong>in</strong>sertion,<strong>in</strong>fection <strong>and</strong> abscess formation, <strong>and</strong>perforation.308

Low fecundityFocus group discussions 43 revealed misconceptionsabout fertility that might lull women <strong>in</strong>to a false senseof be<strong>in</strong>g protected from pregnancy. Some beliefs arerooted <strong>in</strong> tradition, <strong>and</strong> some are probably due to <strong>the</strong>absence of sexual health topics <strong>in</strong> <strong>the</strong> school curriculumdiscussed previously. A common traditional practice, stillflourish<strong>in</strong>g, is called pagpahilis ng matris (misalign<strong>in</strong>g <strong>the</strong>uterus) which <strong>in</strong>volves a hilot (traditional birth attendant<strong>and</strong> healer) manipulat<strong>in</strong>g <strong>the</strong> lower abdomen, supposedlyto reposition <strong>the</strong> uterus <strong>in</strong> such a way that <strong>the</strong> womanbecomes safe from pregnancy. O<strong>the</strong>r beliefs <strong>in</strong>cludeTableTableC309

correlat<strong>in</strong>g <strong>the</strong> number of children to women's naturalresistance or propensity to pregnancy (h<strong>in</strong>di buntis<strong>in</strong> orbuntis<strong>in</strong>); <strong>and</strong> that a woman's fertility decreases as <strong>the</strong> ageof her youngest child <strong>in</strong>creases.In <strong>the</strong> 2008 NDHS, 93 per cent of those who cited<strong>in</strong>fecundity, subfecundity or <strong>in</strong>frequent sex as <strong>the</strong>ir reasonfor not us<strong>in</strong>g contraception were 30 years old <strong>and</strong> older.For sexual frequency, it is possible that women may beoverestimat<strong>in</strong>g <strong>the</strong> decl<strong>in</strong>e <strong>in</strong> sexual activity s<strong>in</strong>ce <strong>the</strong>percentage of women report<strong>in</strong>g sexual <strong>in</strong>tercourse with<strong>in</strong>four weeks of <strong>the</strong> survey showed an almost constant 66 to64 per cent for those aged 30-44, <strong>and</strong> a not so large drop to56 per cent for those aged 45-49.Opposition to family plann<strong>in</strong>gReligion-based opposition to family plann<strong>in</strong>g is low,rang<strong>in</strong>g from 3 to 6 per cent dur<strong>in</strong>g <strong>the</strong> four surveys. On<strong>the</strong> issue of family plann<strong>in</strong>g, it appears that o<strong>the</strong>r issuesare more important to women even though <strong>the</strong> majority of<strong>the</strong>m are Catholics. It is possible, however, that <strong>the</strong> Catholichierarchy's campaign aga<strong>in</strong>st contraception may be hav<strong>in</strong>gan effect through o<strong>the</strong>r routes, such as heighten<strong>in</strong>g women'sworries about <strong>the</strong> safety of contraceptives.Those who cited opposition by <strong>the</strong>ir husb<strong>and</strong>s were few,about <strong>the</strong> same as that from religious beliefs. However,<strong>the</strong> 2008 NDHS showed that 20 per cent of women hadhusb<strong>and</strong>s who wanted more children than <strong>the</strong>y did. Thepercentage peaked at 27 per cent for women <strong>in</strong> <strong>the</strong> lowestwealth qu<strong>in</strong>tile. This could mean that some women whosay that <strong>the</strong>ir non-use is due to a desire for more childrenare merely echo<strong>in</strong>g <strong>the</strong> wishes of <strong>the</strong>ir husb<strong>and</strong>, <strong>the</strong>rebyunderestimat<strong>in</strong>g <strong>the</strong> role of men's opposition as a factor <strong>in</strong><strong>the</strong> non-use of contraception.A community health worker participant <strong>in</strong> a focus groupdiscussion stated: “We had a patient, her husb<strong>and</strong> wouldfeel her up <strong>in</strong>side to check for <strong>the</strong> IUD str<strong>in</strong>gs. Once heknew for sure, he had <strong>the</strong>m removed. As a result, someof <strong>the</strong> women stopped us<strong>in</strong>g <strong>the</strong> IUD”. O<strong>the</strong>r women,however, responded by “devis<strong>in</strong>g ways” to circumvent <strong>the</strong>irhusb<strong>and</strong>’s dictates, such as putt<strong>in</strong>g contraceptive pills <strong>in</strong>vitam<strong>in</strong> bottles, hid<strong>in</strong>g <strong>the</strong>m <strong>in</strong> <strong>the</strong>ir mo<strong>the</strong>r’s house, orhav<strong>in</strong>g <strong>the</strong>ir DMPA shots while br<strong>in</strong>g<strong>in</strong>g <strong>the</strong>ir childrenfor treatment <strong>in</strong> <strong>the</strong> cl<strong>in</strong>ic.Access <strong>and</strong> <strong>in</strong>formation issuesAccess <strong>and</strong> related issues are low, rang<strong>in</strong>g from 2 to 7 percent dur<strong>in</strong>g <strong>the</strong> four surveys. It is possible, however, thatmany non-users have not tried any method at all or for asignificant amount of time to be able to comment on accessproblems, such as cost, distance <strong>and</strong> availability. It is alsopossible that, when women are able to overcome <strong>the</strong>ir ma<strong>in</strong>barrier such as safety issues, o<strong>the</strong>r problems such as accessmay <strong>the</strong>n come to <strong>the</strong> fore, especially for poor women.Evidence for access problems exist <strong>in</strong> ano<strong>the</strong>r section of <strong>the</strong>2008 NDHS. When women were asked about problems<strong>in</strong> gett<strong>in</strong>g health care for <strong>the</strong>mselves when ill, 65-74 percent <strong>in</strong> <strong>the</strong> two poorest qu<strong>in</strong>tiles identified “money fortreatment” as <strong>the</strong>ir top problem, <strong>and</strong> 59-71 per cent picked“no drugs available” as <strong>the</strong>ir second highest concern.Quantity <strong>and</strong> quality of careInsufficient quantity <strong>and</strong> quality of contact <strong>and</strong> <strong>in</strong>teractionwith health-care providers on family plann<strong>in</strong>g matters maycontribute to <strong>the</strong> persistently high safety concerns of women<strong>and</strong> possibly o<strong>the</strong>r problems that can be remedied by faceto-facecounsell<strong>in</strong>g <strong>and</strong> education. In <strong>the</strong> 2008 NDHS, 31per cent of women non-users visited a health facility <strong>in</strong> <strong>the</strong>previous 12 months, <strong>and</strong> only 32 per cent of those womenwere at least told about <strong>the</strong> availability of family plann<strong>in</strong>g.*Ano<strong>the</strong>r 8 per cent of all women surveyed were visited byFP workers at <strong>the</strong>ir homes. Overall, only 18 per cent ofwomen non-users had a family plann<strong>in</strong>g*3 <strong>in</strong>teraction <strong>in</strong>one year.Aim<strong>in</strong>g for good quality <strong>in</strong> health care is a vital goal <strong>in</strong>itself, built on shared values of car<strong>in</strong>g for <strong>the</strong> vulnerable,<strong>and</strong> on fairness <strong>and</strong> equity. In addition, good qualityencourages susta<strong>in</strong>ed use of services <strong>and</strong> expansion of <strong>the</strong>user base. In family plann<strong>in</strong>g, <strong>the</strong> first empirical evidenceon <strong>the</strong> practical value of good-quality care came from astudy by RamaRao 44 <strong>and</strong> colleagues published <strong>in</strong> 2003on 1,460 new family plann<strong>in</strong>g users at 80 service deliverypo<strong>in</strong>ts <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es.*4 They found that <strong>the</strong> quality ofcare received at <strong>the</strong> time a woman adopted a contraceptivemethod <strong>in</strong>fluenced her contraceptive use at follow-up,with probabilities of cont<strong>in</strong>ued use <strong>in</strong>creas<strong>in</strong>g as quality<strong>in</strong>creased: 55 per cent for low-quality care, 62 per cent formedium-quality care <strong>and</strong> 67 per cent for high-quality care.The quasi-experimental operations research componentof this study done by Costello 45 <strong>and</strong> colleagues provided avery detailed look at how family plann<strong>in</strong>g services measureup to a proposed quality of care framework by JudithBruce, shown as categories <strong>in</strong> Table C. In facilities whereno <strong>in</strong>tervention was done (control sites, represent<strong>in</strong>g <strong>the</strong>typical situation <strong>in</strong> <strong>the</strong> areas studied), 859 family plann<strong>in</strong>gclients were <strong>in</strong>terviewed about whe<strong>the</strong>r or not each detailedaspect of high-quality care was met. The top one fourth of<strong>the</strong> quality of care list shows that public health facilities<strong>in</strong> <strong>the</strong>se areas do very well on friendly <strong>and</strong> satisfy<strong>in</strong>g<strong>in</strong>terpersonal relations, clean facilities <strong>and</strong> respect<strong>in</strong>g<strong>and</strong> support<strong>in</strong>g <strong>the</strong>ir clients' chosen methods. However,<strong>the</strong>y performed quite poorly <strong>in</strong> address<strong>in</strong>g clients' safetyconcerns – side effects, warn<strong>in</strong>g signs, how to manageproblems <strong>and</strong> even IEC materials that could tackle <strong>the</strong>seissues – which l<strong>and</strong>ed at or near <strong>the</strong> bottom fourth of <strong>the</strong>quality of care list.310

In <strong>the</strong> 2008 NDHS three similar questions were askedon <strong>the</strong> <strong>in</strong>formation given to women who started a methodwith<strong>in</strong> <strong>the</strong> previous five years. The results roughly matched<strong>the</strong> percentages for equivalent items <strong>in</strong> Costello's study:68 per cent were <strong>in</strong>formed about possible side effects orproblems; 67 per cent were told about what to do <strong>in</strong> caseside effects developed; <strong>and</strong> 63 per cent were <strong>in</strong>formedabout o<strong>the</strong>r methods that could be used.The Department of Health recognizes <strong>the</strong> key role ofquality of care <strong>and</strong> has identified as one of its three ma<strong>in</strong>goals a “more responsive health system” – one which respectspatients' dignity, privacy <strong>and</strong> autonomy; <strong>and</strong> gives promptcare, adequate amenities, access to social support network<strong>and</strong> freedom to choose a health provider. In its 2005-2010 National Objectives for Health, <strong>the</strong> Departmentc<strong>and</strong>idly described <strong>the</strong> public's poor perception of primaryfacilities (rural health units, health centres <strong>and</strong> barangayhealth stations), which provide <strong>the</strong> bulk of non-surgicalfamily plann<strong>in</strong>g. Perception <strong>and</strong> reality have impacts onone ano<strong>the</strong>r, so this basel<strong>in</strong>e observation is important.Accord<strong>in</strong>g to <strong>the</strong> Department, “Public primary facilitiesare perceived [to be of ] low quality. Those who bypass <strong>the</strong>primary health facilities are not satisfied with <strong>the</strong>ir services.Diagnosis is poor, result<strong>in</strong>g <strong>in</strong> repeat visits. Medic<strong>in</strong>es <strong>and</strong>supplies are <strong>in</strong>ferior <strong>and</strong> rarely available. The personnelare often not available, especially <strong>in</strong> rural areas, <strong>and</strong> areperceived to lack both medical <strong>and</strong> people skills. Wait<strong>in</strong>gtime is long, facility schedule is very <strong>in</strong>convenient, <strong>and</strong>facilities are rundown”.O<strong>the</strong>r barriers to seek<strong>in</strong>g familyplann<strong>in</strong>g shared by focus groupdiscussion participants:• Requirements for patients to presenta donation <strong>and</strong> barangay clearance a<strong>the</strong>alth centres or any identification <strong>and</strong>prescription at <strong>the</strong> drugstore• Patients overhear some providerscompla<strong>in</strong><strong>in</strong>g that <strong>the</strong> patients “lookshabby, dirty, like <strong>the</strong>y came straightfrom <strong>the</strong> garbage dump”• Some providers “do not like to servethose com<strong>in</strong>g from a different barangay,so what <strong>the</strong>y do is ask for barangayclearance to prove that you are with<strong>in</strong><strong>the</strong> health centre's area of responsibility”,which leads to hoard<strong>in</strong>g <strong>and</strong> waste ofavailable supplies• Some providers require proof ofmenstruation as assurance of nonpregnancyprior to method provision,especially IUD <strong>and</strong> tubal ligation:“They will ask you to swab a cotton ball<strong>and</strong> show it to <strong>the</strong>m”. For <strong>in</strong>jectables,“patients must do <strong>the</strong> pregnancy test,drop ur<strong>in</strong>e, <strong>in</strong> front of <strong>the</strong>m”. A womanwho did <strong>the</strong> test <strong>in</strong> <strong>the</strong> toilet was scolded.• “I saw a patient who was probablyat one month after childbirth <strong>and</strong> shewanted to have a method. A midwifetold her, ‘Just come back after your sixthmonth’. That's all she said”.• “I had a friend who was <strong>in</strong> a maternityhospital who told a young girl, ‘So whatdo you do now, <strong>the</strong>y won't let you gohome without an IUD’. The young girldid not want an IUD”.• “They do not cut <strong>the</strong> IUD str<strong>in</strong>gs after<strong>in</strong>sertion. They tell you to return forfollow-up so <strong>the</strong>y will cut <strong>the</strong> str<strong>in</strong>gs”.InequityInequities <strong>in</strong> <strong>the</strong> use of modern contraception to fulfill<strong>the</strong> dem<strong>and</strong> for family plann<strong>in</strong>g are less severe than <strong>the</strong><strong>in</strong>equities exhibited <strong>in</strong> maternal care, as exemplified by<strong>the</strong> use of skilled attendants at birth (see Figure 12). Forexample, <strong>in</strong> <strong>the</strong> 2008 NDHS, use of skilled attendantsby women <strong>in</strong> <strong>the</strong> richest qu<strong>in</strong>tile was 3.6 times <strong>the</strong> rateof use by those <strong>in</strong> <strong>the</strong> poorest qu<strong>in</strong>tile. In <strong>the</strong> use ofcontraceptives, however, <strong>the</strong> richest versus poorest ratiowas only 1.2. Urban women had 1.6 times higher use ofskilled attendants compared with rural women, but <strong>in</strong>311

Figure<strong>the</strong> use of contraceptives, urban woman had almost noadvantage over rural women. The same pattern is found <strong>in</strong><strong>in</strong>equities based on education <strong>and</strong> region.For contraception, it is apparent that percentages for<strong>the</strong> usually advantaged sectors are unusually dampened.Whereas <strong>the</strong>se high-perform<strong>in</strong>g sectors got 78-94 per cent<strong>in</strong> skilled attendants, <strong>the</strong>y achieved only moderate levels of47-62 per cent <strong>in</strong> contraception. As a result, better equitywas achieved through roughly equal levels of dampenedcontraceptive use.Unwanted fertilityAlthough <strong>in</strong>equities <strong>in</strong> contraceptive use are somewhatmoderated, <strong>the</strong>re are large <strong>in</strong>equities <strong>in</strong> unwanted birthsor fertility. In <strong>the</strong> 2008 NDHS, 37 per cent of all births bywomen <strong>in</strong> <strong>the</strong> lowest qu<strong>in</strong>tile were unwanted, comparedwith 16 per cent <strong>in</strong> <strong>the</strong> highest. There are two possibleexplanations shown <strong>in</strong> Figure 13. First, wealthier womenare better at avoid<strong>in</strong>g early pregnancy. Only 13 per cent ofwomen <strong>in</strong> <strong>the</strong> highest qu<strong>in</strong>tile began childbear<strong>in</strong>g between<strong>the</strong> ages of 15 <strong>and</strong> 24, compared with 44 per cent of women<strong>in</strong> <strong>the</strong> poorest qu<strong>in</strong>tile. This may be related to <strong>the</strong> lengthof time <strong>the</strong>y spent <strong>in</strong> school – 66 per cent of <strong>the</strong> richestwomen f<strong>in</strong>ished high school or reached college, comparedwith only 11 per cent of <strong>the</strong> poorest women. Second, poorwomen had lower rates of us<strong>in</strong>g sterilization to limit <strong>the</strong>irchildbear<strong>in</strong>g*5 – 7 per cent for <strong>the</strong> poorest comparedwith 20 per cent for <strong>the</strong> richest – most likely due to <strong>the</strong>higher costs of <strong>the</strong> procedure compared with o<strong>the</strong>r familyplann<strong>in</strong>g methods. The median cost of female sterilizationwas recorded by <strong>the</strong> 2008 NDHS at 1,476 pesos <strong>in</strong> <strong>the</strong>public sector <strong>and</strong> 9,929 pesos <strong>in</strong> <strong>the</strong> private sector, some30-33 times <strong>the</strong> cost of an IUD*6 <strong>in</strong> <strong>the</strong> same sector.Voluntary sterilization <strong>and</strong> <strong>in</strong>equityInequity <strong>in</strong> rates of tubal ligation has been observed s<strong>in</strong>cewealth qu<strong>in</strong>tiles were added to <strong>the</strong> DHS. In <strong>the</strong> 1998 <strong>and</strong>2003 surveys, among women who do not want any morechildren, <strong>the</strong> percentage that got a tubal ligation <strong>in</strong>creasedat a constant rate with every rise <strong>in</strong> wealth qu<strong>in</strong>tile, with <strong>the</strong>highest gett<strong>in</strong>g four times <strong>the</strong> rate of <strong>the</strong> lowest (see Figure14). This pattern changed <strong>in</strong> 2008. The percentage among<strong>the</strong> highest, fourth <strong>and</strong> middle fell while <strong>the</strong> second <strong>and</strong>lowest qu<strong>in</strong>tiles rema<strong>in</strong>ed <strong>the</strong> same. The highest ended upwith just three times <strong>the</strong> rate of <strong>the</strong> lowest. The lessen<strong>in</strong>gof <strong>in</strong>equity came from decl<strong>in</strong>es <strong>in</strong> <strong>the</strong> better-off qu<strong>in</strong>tiles,not from any improvement for <strong>the</strong> poor.To both elim<strong>in</strong>ate <strong>in</strong>equity <strong>and</strong> return to <strong>the</strong> 2003 peakrate achieved by <strong>the</strong> highest qu<strong>in</strong>tile, that is, 27 per centof all those who wanted no more children, regardless ofwealth, <strong>and</strong> are able to get tubal ligation, it is estimatedthat for 2010, some 1.13 million procedures were needed:370,000 for <strong>the</strong> lowest; 260,000 for <strong>the</strong> second; 240,000for <strong>the</strong> middle; 136,000 for <strong>the</strong> fourth; <strong>and</strong> 126,000 for<strong>the</strong> highest qu<strong>in</strong>tile. The two poorest qu<strong>in</strong>tiles need 55 percent (630,000) of all <strong>the</strong>se procedures <strong>and</strong> required easieraccess to subsidies from public health funds to elim<strong>in</strong>ate<strong>the</strong> equity gap. In October 2008, <strong>the</strong> country's nationalFigure12Comparison of <strong>in</strong>equities <strong>in</strong> maternal care <strong>and</strong> family plann<strong>in</strong>g, married women (15-49)312

FigureFigureFigure13Inequities <strong>in</strong> unwanted fertility, <strong>and</strong> possible contribut<strong>in</strong>g factorshealth <strong>in</strong>surance programme (PhilHealth) raised itsFigureMorocco (93%). O<strong>the</strong>r <strong>Asia</strong>n countries <strong>in</strong> <strong>the</strong> study had14Percentage able to get tubal ligation among married women who do not want any more childrenbenefit for tubal ligation <strong>and</strong> vasectomy to 4,000 pesos perprocedure, 46 which means that <strong>the</strong> two poorest qu<strong>in</strong>tilesneeded about 2.5 billion pesos (US$ 59 million) toelim<strong>in</strong>ate <strong>the</strong> accumulated need for sterilization services.Steps are also needed to correct <strong>the</strong> <strong>in</strong>equity <strong>in</strong> access tohealth <strong>in</strong>surance. In <strong>the</strong> 2008 NDHS, only 21 per cent ofwomen <strong>in</strong> <strong>the</strong> lowest qu<strong>in</strong>tile <strong>and</strong> 32 per cent <strong>in</strong> <strong>the</strong> secondqu<strong>in</strong>tile had any type of health <strong>in</strong>surance, compared with58 per cent of women <strong>in</strong> <strong>the</strong> highest qu<strong>in</strong>tile.AdolescentsAdolescents aged 15-19 <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es have relativelylow pregnancy rates compared with <strong>the</strong>ir peers <strong>in</strong> o<strong>the</strong>rdevelop<strong>in</strong>g countries. In a 2008 study by Khan <strong>and</strong> Mishra 47compar<strong>in</strong>g 38 countries with recent DHS surveys (2001-2005), <strong>the</strong> Philipp<strong>in</strong>es at 92 per cent ranked sixth <strong>in</strong> <strong>the</strong>percentage of adolescents who had never been pregnant.Slightly ahead of <strong>the</strong> Philipp<strong>in</strong>es were Viet Nam (96%),Rw<strong>and</strong>a (96%), Armenia (95%), Moldova (94%) <strong>and</strong>far lower percentages: Nepal at 44 per cent, Bangladeshat 28 per cent <strong>and</strong> Indonesia at 27 per cent (ranked 37th).The 2008 NDHS recorded a slight decl<strong>in</strong>e to 90 per cent,which would leave unchanged <strong>the</strong> country's rank<strong>in</strong>g <strong>in</strong> thisstudy.The low rate of teenage pregnancy is not due to <strong>the</strong> highuse of effective contraception. On <strong>the</strong> contrary, married*7adolescents have <strong>the</strong> lowest use of modern methods at14 per cent compared with 23-40 per cent for o<strong>the</strong>r agegroups, <strong>and</strong> <strong>the</strong> highest rate of unmet need at 36 per centcompared with 18-26 per cent for <strong>the</strong> o<strong>the</strong>r groups. Thereare plenty of anecdotal reports of public health facilitiesrefus<strong>in</strong>g to provide adolescents with contraceptives. Itis possible that health providers do not know or haveno guidel<strong>in</strong>es on how to h<strong>and</strong>le young couples <strong>in</strong> live-<strong>in</strong>relationships, <strong>and</strong> 7 of 10 married adolescents are <strong>in</strong> thistype of marital arrangement.Sexual abst<strong>in</strong>ence is <strong>the</strong> ma<strong>in</strong> strategy used by adolescent313

FigureFigure15Sexual behaviour <strong>and</strong> pregnancy rates among adolescent women aged 15-19women to avoid an un<strong>in</strong>tended pregnancy (see Figure 15).In <strong>the</strong> 2008 NDHS, among all women 15-19, 86 per centhad never had sexual <strong>in</strong>tercourse, which is almost equivalentto <strong>the</strong> 90 per cent that had never been pregnant.Abst<strong>in</strong>ence is also a key strategy for unmarried youngwomen aged 15-24. In <strong>the</strong> Khan <strong>and</strong> Mishra study, <strong>the</strong>Philipp<strong>in</strong>es ranked third at 97 per cent <strong>in</strong> <strong>the</strong> percentage ofnever-married young women practis<strong>in</strong>g primary abst<strong>in</strong>ence,mean<strong>in</strong>g that <strong>the</strong>y never had sex. Armenia <strong>and</strong> Viet Namare ranked first, both with 100 per cent rates. Countrieswith 50 per cent or less of unmarried young womenpractis<strong>in</strong>g primary abst<strong>in</strong>ence <strong>in</strong>clude Zambia (50%),Ben<strong>in</strong> (49%), Mozambique (39%) <strong>and</strong> <strong>the</strong> DemocraticRepublic of <strong>the</strong> Congo (34%).The sexual behaviours of men are different. Only 75per cent of never-married young men practise primaryabst<strong>in</strong>ence, enough to rank <strong>the</strong> Philipp<strong>in</strong>es <strong>in</strong> fourth place,but substantially different from <strong>the</strong> practice of youngwomen. The same study showed that, among all youth(married or unmarried) who had sex <strong>in</strong> <strong>the</strong> previous 12months, 49 per cent of young men had higher-risk sex, or“sex with a non-spousal, non-cohabit<strong>in</strong>g partner”, with 24per cent condom use among those who had higher-risk sex.Only 6 per cent of young women had higher-risk sex, with11 per cent condom use. Among all young men*8 who hadsex <strong>in</strong> <strong>the</strong> previous 12 months, 25 per cent had multiplesex partners.It is unclear how long unmarried adolescents can cont<strong>in</strong>ueto rely on very high abst<strong>in</strong>ence rates to prevent un<strong>in</strong>tendedpregnancies. From 1993 to 2008, <strong>the</strong> percentage of womenaged 15-19 that had begun childbear<strong>in</strong>g <strong>in</strong>creased from6.5 to 9.9 per cent, a growth rate of 2.8 per cent per year.However, 69 per cent of those births <strong>and</strong> pregnancieswere wanted <strong>and</strong> most occurred among women <strong>in</strong> union.If abst<strong>in</strong>ence rates go down <strong>and</strong> <strong>the</strong> poor use of moderncontraception <strong>in</strong> this age group cont<strong>in</strong>ues, <strong>the</strong>n rates ofun<strong>in</strong>tended pregnancies will surely go up. What is clear isthat women <strong>and</strong> men <strong>in</strong> this age group have diverse <strong>and</strong>possibly chang<strong>in</strong>g behaviours that must be addressed us<strong>in</strong>gtailor-fit strategies.Contraceptive self-relianceAccord<strong>in</strong>g to <strong>the</strong> Department of Health, <strong>the</strong> United StatesAgency for <strong>International</strong> Development (USAID) hadbeen shoulder<strong>in</strong>g 80 per cent of <strong>the</strong> total requirementsfor FP commodities; <strong>the</strong> amount is estimated to havebeen US$ 3 million annually for 36 years, with <strong>the</strong> restshouldered by o<strong>the</strong>r <strong>in</strong>ternational donor agencies.48 In<strong>the</strong> late 1990s, USAID <strong>and</strong> <strong>the</strong> Department of Healthstarted discussions about end<strong>in</strong>g <strong>the</strong>se donations <strong>and</strong><strong>the</strong> Philipp<strong>in</strong>e government tak<strong>in</strong>g over fund<strong>in</strong>g forcontraceptive supplies. This eventually resulted <strong>in</strong> <strong>the</strong>issuance <strong>in</strong> March 2000 of an adm<strong>in</strong>istrative order (AO 24-A) called “Streng<strong>the</strong>n<strong>in</strong>g <strong>the</strong> DOH Reproductive HealthProgram”, where<strong>in</strong> <strong>the</strong> National Program on ReproductiveHealth with its own national programme manager wasorganized under <strong>the</strong> Center for <strong>Family</strong> Health unit of <strong>the</strong>Department. The “Contraceptive Independence Initiative”was created; it was described as a special multisectoral<strong>in</strong>itiative that would be a priority of <strong>the</strong> nationalprogramme. The general objective was to make all relevantRH services, <strong>in</strong>clud<strong>in</strong>g family plann<strong>in</strong>g, available <strong>in</strong> allDepartment <strong>and</strong> local government*9 unit health facilities.The f<strong>in</strong>anc<strong>in</strong>g of RH services would be <strong>in</strong>tegrated <strong>in</strong>to <strong>the</strong>general health f<strong>in</strong>anc<strong>in</strong>g <strong>and</strong> social <strong>in</strong>surance programmes.Funds for <strong>the</strong> purchase of contraceptives were <strong>in</strong>cluded<strong>in</strong> <strong>the</strong> Department's regular budget for 2001 – a firstfor <strong>the</strong> country. However, a premature replacement of<strong>the</strong> Philipp<strong>in</strong>e President occurred <strong>in</strong> 2001, with a newone*10 who was a follower of Catholic Church doctr<strong>in</strong>eson contraception. The budget for contraceptives was notrealized <strong>and</strong> <strong>the</strong> Initiative was not implemented.314

FigureFigure16Public sector share, most recent source of pills <strong>and</strong> condomsIn 2004, a new adm<strong>in</strong>istrative order was issued entitled“Guidel<strong>in</strong>es on <strong>the</strong> Management of Donated Commoditiesunder <strong>the</strong> Contraceptive Self-Reliance Strategy (CSR)”.Most of <strong>the</strong> order's content was on <strong>the</strong> phase-out scheduleof USAID donations <strong>and</strong> mechanisms for divid<strong>in</strong>g up <strong>the</strong>dim<strong>in</strong>ish<strong>in</strong>g supplies: end of condom donations <strong>in</strong> 2004;phase-out of pills from 10.55 million cycles <strong>in</strong> 2004 tozero <strong>in</strong> 2008; phase-out of <strong>in</strong>jectables from 1.17 millionvials <strong>in</strong> 2004 to zero <strong>in</strong> 2009; <strong>and</strong> <strong>the</strong> eventual phase-outof IUDs.*11 CSR was fundamentally different from <strong>the</strong>Initiative <strong>in</strong> that responsibility for fund<strong>in</strong>g contraceptiveswas assigned to LGUs.CSR rapid assessment 49The first attempt to assess CSR revealed that more than half(67 of 122) of LGUs (75 prov<strong>in</strong>ces, 1 region <strong>and</strong> ARMMrepresent<strong>in</strong>g all its component prov<strong>in</strong>ces <strong>and</strong> 46 cities)procured oral contraceptive pills <strong>in</strong> 2007, with 27 LGUsprocur<strong>in</strong>g at a level higher than or equal to <strong>the</strong> estimatedfull requirement of <strong>the</strong>ir constituents. The rema<strong>in</strong><strong>in</strong>g40 LGUs procured at levels below what were required.These figures, augmented by <strong>the</strong> fact that 64 of <strong>the</strong> total67 LGUs that procured used local budgets to f<strong>in</strong>ance <strong>the</strong>irprocurement of pills, <strong>in</strong>dicated encourag<strong>in</strong>g <strong>in</strong>itial CSRresponse <strong>in</strong>itiatives. There is also some <strong>in</strong>dication that<strong>the</strong>se LGUs plan to ma<strong>in</strong>ta<strong>in</strong> or <strong>in</strong>crease <strong>the</strong>ir currentlevel of pill procurement. However, <strong>the</strong> ability to susta<strong>in</strong><strong>the</strong>se promis<strong>in</strong>g trends <strong>in</strong> <strong>the</strong> longer term rema<strong>in</strong>s to beseen, especially with <strong>the</strong> stark reality that often FP is nota priority for some LGUs <strong>and</strong> it is easily <strong>in</strong>fluenced by <strong>the</strong>personal religious convictions of LGU chiefs or a strongChurch lobby. Moreover, more pert<strong>in</strong>ent local barriersto <strong>in</strong>creas<strong>in</strong>g CPR <strong>in</strong>clude geographic isolation, poverty,contraceptive supply shortcom<strong>in</strong>gs, LGUs without a strongcommitment to procur<strong>in</strong>g <strong>and</strong> allocat<strong>in</strong>g FP commodities,<strong>and</strong> lack of male <strong>in</strong>volvement <strong>in</strong> FP.Fall <strong>in</strong> <strong>the</strong> public sector shareThe 2008 NDHS revealed a disturb<strong>in</strong>g trend that beganto be detected <strong>in</strong> 2003: substantial reductions <strong>in</strong> <strong>the</strong> shareof public outlets as <strong>the</strong> source of condoms <strong>and</strong> pills. Fromhigh levels <strong>in</strong> 1993, <strong>the</strong> public sector share <strong>in</strong> condomshas been fall<strong>in</strong>g cont<strong>in</strong>uously s<strong>in</strong>ce 1998, <strong>the</strong> same wayas pills did s<strong>in</strong>ce 2003 (see Figure 16). It is unsafe toignore <strong>the</strong>se trends as a simple redistribution between <strong>the</strong>private <strong>and</strong> public sectors because <strong>the</strong> country's CPR formodern methods is just half <strong>the</strong> targeted level for 2010<strong>and</strong> growth has been very slow <strong>and</strong> has stopped <strong>in</strong> <strong>the</strong> lastfive years. S<strong>in</strong>ce national condom supplies were stoppedfirst, followed by pills, <strong>and</strong> <strong>the</strong>se actions took place priorto <strong>the</strong> 2008 NDHS, <strong>the</strong> decl<strong>in</strong>e exhibited by <strong>the</strong> two maybe repeated with <strong>the</strong> o<strong>the</strong>r methods that were recentlyphased out, namely <strong>in</strong>jectables <strong>and</strong> IUDs. It is possiblethat prov<strong>in</strong>cial <strong>and</strong> city LGUs cannot adequately forecast,fund, coord<strong>in</strong>ate <strong>and</strong> deliver <strong>the</strong> contraceptive needs ofa grow<strong>in</strong>g population. About 1,500 municipalities havedirect responsibility <strong>and</strong> control over all health centres <strong>and</strong>health posts that provide non-surgical supply methods.Thus, it is also possible that <strong>the</strong> impact of <strong>the</strong> CSR policyon municipal family plann<strong>in</strong>g supplies <strong>and</strong> services has notbeen studied enough.In June 2010, Adm<strong>in</strong>istrative Order 2010-0027 was issuedby <strong>the</strong> outgo<strong>in</strong>g Secretary of Health to replace <strong>the</strong> CSRorder of 2004. The goal was made clearer: availability <strong>and</strong>access to all FP methods <strong>and</strong> RH commodities. Objectiveswere focused towards ensur<strong>in</strong>g RH commodity securityto elim<strong>in</strong>ate unmet needs for FP <strong>and</strong> RH services; freecommodities for poor women; a national procurementsystem; <strong>and</strong> a logistics management <strong>in</strong>formation system to315

track <strong>the</strong> distribution, storage <strong>and</strong> utilization of supplies.The new order conta<strong>in</strong>s explicit language that <strong>the</strong> nationalgovernment will directly f<strong>in</strong>ance or ensure <strong>the</strong> f<strong>in</strong>anc<strong>in</strong>g ofFP <strong>and</strong> RH commodities, not as an option of last resort,but as part of its regular role to build safety nets for <strong>the</strong>poor.Abortion overtak<strong>in</strong>gcontraception <strong>in</strong> regulat<strong>in</strong>gfertilityIn a 2008 study, Cabigon adopted Bongaarts’ proximatedeterm<strong>in</strong>ants to decompose <strong>the</strong> contribution of marriage,contraception, <strong>in</strong>duced abortion <strong>and</strong> post-partum<strong>in</strong>fecundability*12 to <strong>the</strong> slow fertility change, us<strong>in</strong>g <strong>the</strong>1993, 1998 <strong>and</strong> 2003 NDHSs. The analysis was done at<strong>the</strong> national <strong>and</strong> regional levels, with <strong>the</strong> national updat<strong>in</strong>gof earlier work, us<strong>in</strong>g all surveys carried out before 1993.The study clearly demonstrated that, overall, contraceptionhas been <strong>the</strong> primary factor expla<strong>in</strong><strong>in</strong>g <strong>the</strong> decelerat<strong>in</strong>gdecl<strong>in</strong>e <strong>in</strong> fertility from <strong>the</strong> 1960s to early 1990s but hasbeen outranked by <strong>in</strong>duced abortion s<strong>in</strong>ce <strong>the</strong> late 1990s.The m<strong>in</strong>or fertility-<strong>in</strong>hibit<strong>in</strong>g effect of marriage <strong>and</strong> <strong>the</strong>counteract<strong>in</strong>g effect of breastfeed<strong>in</strong>g from <strong>the</strong> 1960s toearly 1990s were reversed <strong>in</strong> <strong>the</strong> most recent period.Broader issues that haveimpacts on family plann<strong>in</strong>gLegal issues on abortion,contraception <strong>and</strong> <strong>the</strong> 1987ConstitutionOne of <strong>the</strong> major legal issues hold<strong>in</strong>g up <strong>the</strong> passageof a reproductive health law is a provision <strong>in</strong> <strong>the</strong> 1987Constitution: “[<strong>the</strong> State] shall equally protect <strong>the</strong> life of<strong>the</strong> mo<strong>the</strong>r <strong>and</strong> <strong>the</strong> life of <strong>the</strong> unborn from conception”.This is commonly <strong>in</strong>terpreted as merely a safeguardaga<strong>in</strong>st any future attempt to change <strong>the</strong> strict clauses <strong>in</strong><strong>the</strong> penal code which crim<strong>in</strong>alize abortion without anyexplicit exception. 50 However, Catholic representatives <strong>in</strong><strong>the</strong> Constitutional Commission <strong>in</strong>terpret <strong>the</strong> phrase asencompass<strong>in</strong>g even contraceptives that <strong>the</strong>y suspect actaga<strong>in</strong>st a fertilized ovum – <strong>the</strong> “unborn from conception”. Fr.Joaqu<strong>in</strong> Bernas, a Catholic priest, <strong>in</strong>fluential constitutionallaw expert <strong>and</strong> member of <strong>the</strong> Commission, argued thisposition clearly: 51Our constitutional provision wasdiscussed <strong>and</strong> crafted at a time whenmany were aware of <strong>the</strong> United StatesSupreme Court decision <strong>in</strong> Roe v. Wadewhich allowed abortion up to <strong>the</strong> sixthmonth of pregnancy. This is contrary toboth our Penal Code <strong>and</strong> Canon Law.The prevention of <strong>the</strong> adoption of <strong>the</strong>doctr<strong>in</strong>e <strong>in</strong> Roe v. Wade was certa<strong>in</strong>lyone of <strong>the</strong> purposes of <strong>the</strong> provision. ButCommission deliberations <strong>in</strong>dicate that<strong>the</strong> provision goes beyond Roe v. Wade.The unborn’s entitlement to protectionbeg<strong>in</strong>s “from conception,” that is, from <strong>the</strong>moment of conception. The moment ofconception is popularly understood as <strong>the</strong>moment of fertilization which takes placeoutside <strong>the</strong> mo<strong>the</strong>r’s womb. The <strong>in</strong>tentionof <strong>the</strong> Constitution is to protect life fromits beg<strong>in</strong>n<strong>in</strong>g, <strong>and</strong> <strong>the</strong> assumption is that<strong>the</strong> gradual development of human lifebeg<strong>in</strong>s at conception <strong>and</strong> that conceptiontakes place at fertilization (even if medicalliterature seems to see conception as <strong>the</strong>moment of implantation). …The practical implication of this isthat <strong>the</strong>re may be a need to analyzescientifically what k<strong>in</strong>d of contraceptivemeans are now be<strong>in</strong>g dispensed todeterm<strong>in</strong>e whe<strong>the</strong>r <strong>the</strong>y are merelycontraceptive or already have <strong>the</strong> effect ofprevent<strong>in</strong>g implantation <strong>and</strong> consequentloss of a fertilized zygote.While Fr. Bernas concedes that scientific analysis ofcontraceptives is needed before declar<strong>in</strong>g which onesmay be prohibited by his <strong>in</strong>terpretation of <strong>the</strong> 1987constitution, Catholic bishops have already made up <strong>the</strong>irm<strong>in</strong>ds on which ones are “abortifacients”. Bishop TeodoroBacani, a Constitutional Commission member <strong>and</strong> oneof <strong>the</strong> ma<strong>in</strong> authors of “<strong>the</strong> unborn” clause, def<strong>in</strong>es <strong>and</strong>identifies “abortifacients” as follows: 52316

If [fertilization of <strong>the</strong> egg by <strong>the</strong> sperm] be<strong>the</strong> correct underst<strong>and</strong><strong>in</strong>g of conception,<strong>the</strong>n abortifacients can be def<strong>in</strong>ed asdevices or drugs whose action prevent <strong>the</strong>conceptus (<strong>the</strong> conceived unborn) fromcom<strong>in</strong>g to term. …All <strong>the</strong> measures which impair <strong>the</strong>viability of <strong>the</strong> zygote at any timebetween <strong>the</strong> <strong>in</strong>stant of fertilization <strong>and</strong><strong>the</strong> completion of labour constitute, <strong>in</strong><strong>the</strong> strict sense, procedures for <strong>in</strong>duc<strong>in</strong>gabortion.Hence, <strong>the</strong> IUD, <strong>in</strong>jectables like Depo-Provera, <strong>and</strong> <strong>the</strong> emergency contraceptivepill (morn<strong>in</strong>g after pill) Levonorgestrel,RU-486, <strong>and</strong> implants like Norplantshould be classified as abortifacients, for<strong>the</strong>y do not only prevent fertilization(conception), but also prevent <strong>the</strong>implantation of <strong>the</strong> fertilized ovum.A bill called <strong>the</strong> “Protection of <strong>the</strong> Unborn Child Act of2010” is currently filed at <strong>the</strong> House of Representatives<strong>and</strong> <strong>the</strong> Senate. It def<strong>in</strong>es conception as fertilization;gives human personality <strong>and</strong> protection to an “unbornchild” from fertilization; <strong>and</strong> declares that anyth<strong>in</strong>g which<strong>in</strong>terferes with its natural development from fertilizationuntil birth is an act of abortion, punishable with <strong>in</strong>creasedprison terms. This bill is currently supported by formerPresident Arroyo, now a representative <strong>in</strong> Congress, <strong>and</strong>by <strong>the</strong> president of <strong>the</strong> Senate.“Middle ground” proposals are also be<strong>in</strong>g floated toapprove an RH bill m<strong>in</strong>us “abortifacients”, which typicallypo<strong>in</strong>t to hormonal contraceptives <strong>and</strong> IUDs. If passed<strong>in</strong>to law, millions of current users of <strong>the</strong>se methods willbe affected.Health devolutionFrom <strong>the</strong>ir establishment <strong>in</strong> <strong>the</strong> early 1900s until 1991,public health services <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es have always beenled <strong>and</strong> managed by a corps of medical professionals <strong>and</strong> civilservants, where policies, personnel <strong>and</strong> resources emanatefrom a central body. 53 With <strong>the</strong> 1991 Local GovernmentCode, more than 100 years of practice was changed almostovernight, <strong>and</strong> <strong>the</strong> health sector is still cop<strong>in</strong>g with <strong>the</strong>new set-up. After 16 years of full implementation, basicproblems like limited capacity, lack of priority <strong>and</strong> vary<strong>in</strong>g<strong>in</strong>terpretations of responsibility abound, as described bya 2010 evaluation of <strong>the</strong> health sector by <strong>the</strong> Departmentof Health: 54The implementation of national healthprograms at <strong>the</strong> local level has becomecomplex due to devolution. Althoughsome LGUs have accepted <strong>the</strong> challengewith m<strong>in</strong>imal assistance from <strong>the</strong> nationalgovernment, a majority have limitedf<strong>in</strong>ancial <strong>and</strong> technical capacity to managehealth with<strong>in</strong> <strong>the</strong>ir catchment areas. Somelocal chief executives prioritize projectswith results that can [be] seen by <strong>the</strong>irconstituents. Some LGUs are unawareof <strong>the</strong> k<strong>in</strong>d of health services that LGUsshould deliver. For <strong>in</strong>stance, RHUs<strong>in</strong> Ilocos Sur have not been provid<strong>in</strong>gcommunicable <strong>and</strong> non-communicablecontrol services because health workersassumed that such programs were <strong>the</strong>responsibility of <strong>the</strong> DOH.Health f<strong>in</strong>anc<strong>in</strong>g by local governmentunitsUnder <strong>the</strong> Local Government Code (LGC), funds fromnational revenues are transferred to LGUs without anyearmark<strong>in</strong>g, except for <strong>the</strong> general proviso that at least 20per cent be devoted to “local development projects”. In its2005-2010 National Objectives for Health, <strong>the</strong> Departmentof Health set a target that LGUs should shoulder 32 percent of <strong>the</strong> country's total health expenditures by 2010,from a basel<strong>in</strong>e of a 17.5 per cent share <strong>in</strong> 2003. Thiswould <strong>the</strong>n help reduce out-of-pocket health spend<strong>in</strong>g to20 per cent by 2010, from 44 per cent <strong>in</strong> 2003. Instead of<strong>in</strong>creas<strong>in</strong>g, however, <strong>the</strong> share of LGUs actually went downto 13.3 per cent <strong>in</strong> 2007, mak<strong>in</strong>g <strong>the</strong> target impossible tomeet (see Figure 17). Evidence from <strong>the</strong> national healthaccounts <strong>in</strong>dicates that LGUs as a group may have beenunderspend<strong>in</strong>g for health.Under <strong>the</strong> LGC, family plann<strong>in</strong>g is listed as a “basic service”of municipalities <strong>and</strong> cities. Prov<strong>in</strong>ces are supposed toprovide “population development” services <strong>and</strong> hospital317

Figureservices, which should <strong>in</strong>clude functions such as surgicalFP that were be<strong>in</strong>g done by public hospitals prior todevolution. When donated FP commodities were reduced<strong>and</strong> stopped dur<strong>in</strong>g <strong>the</strong> previous six years, family plann<strong>in</strong>gservices became vulnerable to any underspend<strong>in</strong>g <strong>in</strong> health.This may expla<strong>in</strong> <strong>the</strong> drop <strong>in</strong> modern CPR growth ratesfrom 2003 to 2008, <strong>and</strong> <strong>the</strong> steep drop <strong>in</strong> <strong>the</strong> public sectorshare of pills <strong>and</strong> condoms.Local government unit bans oncontraceptionHealth devolution also opened up a new arena foranti-contraceptive forces to ban or restrict <strong>the</strong> use ofcontraceptives. In 1995, a prov<strong>in</strong>cial governor <strong>in</strong> Laguna(population 1.6 million) who was a board member ofPro-Life Philipp<strong>in</strong>es*13 banned supplies of artificialcontraceptives <strong>and</strong> related services <strong>in</strong> all health facilitiescontrolled by <strong>the</strong> prov<strong>in</strong>cial LGU.*14 This was followed <strong>in</strong>2000 by <strong>the</strong> city mayor of Manila (population 1.7 million),who was also an officer of Pro-Life Philipp<strong>in</strong>es. The banwas severe s<strong>in</strong>ce all public health facilities <strong>in</strong> a city arecontrolled by <strong>the</strong> mayor, <strong>and</strong> he extended <strong>the</strong> ban to NGOs<strong>and</strong> private practitioners through harassment <strong>and</strong> <strong>the</strong>regulatory power of LGUs. 56 Similar bans are reported tobe <strong>in</strong> place <strong>in</strong> <strong>the</strong> prov<strong>in</strong>ce of Nor<strong>the</strong>rn Samar (population0.5 million) <strong>and</strong> Bulacan (population 2.8 million).While <strong>the</strong>se bans arguably violate <strong>the</strong> 1991 LGC, <strong>and</strong> acase by poor Manila residents has been filed <strong>in</strong> court tooverturn <strong>the</strong> policy, <strong>the</strong> issue has not yet been settled by<strong>the</strong> judiciary. The past president has publicly approved<strong>the</strong> Manila contraception ban as with<strong>in</strong> <strong>the</strong> powers ofautonomy conferred by law to LGUs, which expla<strong>in</strong>s why<strong>the</strong> Department of Health has not exercised its duty as ast<strong>and</strong>ard-sett<strong>in</strong>g body aga<strong>in</strong>st <strong>the</strong>se LGUs.Compla<strong>in</strong>ts have also been lodged at local <strong>and</strong> <strong>in</strong>ternationalhuman rights bodies. On 7 October 2010, <strong>the</strong> Commissionon Human Rights (CHR) of <strong>the</strong> Philipp<strong>in</strong>es ruled <strong>in</strong>favour of compla<strong>in</strong><strong>in</strong>g Manila residents. 57 The CHRfound <strong>the</strong> City of Manila <strong>in</strong> breech of obligations under<strong>the</strong> Convention on <strong>the</strong> Elim<strong>in</strong>ation of All Forms ofDiscrim<strong>in</strong>ation aga<strong>in</strong>st Women. Specifically, <strong>the</strong> CHRstated that <strong>the</strong> City of Manila “reneged on <strong>the</strong> obligation toprotect health <strong>in</strong>clud<strong>in</strong>g <strong>the</strong> safeguard<strong>in</strong>g of <strong>the</strong> functionof reproduction, to provide health care <strong>and</strong> enable womento access services related to family plann<strong>in</strong>g, <strong>and</strong> to allowwomen to decide freely <strong>and</strong> responsibly on <strong>the</strong> number<strong>and</strong> spac<strong>in</strong>g of children”. CHR decisions do not have <strong>the</strong>power of court decisions, but do have persuasive moralforce. It rema<strong>in</strong>s to be seen whe<strong>the</strong>r this rul<strong>in</strong>g will beenough to persuade <strong>the</strong> city government to follow <strong>the</strong>CHR recommendations <strong>and</strong> beg<strong>in</strong> provid<strong>in</strong>g all familyplann<strong>in</strong>g methods <strong>in</strong> <strong>the</strong>ir health facilities.Impact on population growthFigure 18 clearly shows that <strong>the</strong> Philipp<strong>in</strong>es has notkept pace with significant changes <strong>in</strong> <strong>the</strong> <strong>in</strong>ternationalscene <strong>in</strong> terms of demographic experience. The country'spopulation tripled <strong>in</strong> 47 years, from 27 million <strong>in</strong> 1960 to89 million <strong>in</strong> 2007. The population growth rates show apeak <strong>in</strong> 1970, a decl<strong>in</strong><strong>in</strong>g trend until 1990, a slacken<strong>in</strong>g ofFigure17Share of local government units <strong>and</strong> out-of-pocket health spend<strong>in</strong>g to total health spend<strong>in</strong>g,1991-2007318

decl<strong>in</strong>e dur<strong>in</strong>g <strong>the</strong> 1990-2000 period <strong>and</strong> <strong>the</strong>n a reductiondur<strong>in</strong>g <strong>the</strong> latest seven-year <strong>in</strong>terval (2000-2007). Despite<strong>the</strong> seem<strong>in</strong>g fall, <strong>the</strong> Philipp<strong>in</strong>e population is still grow<strong>in</strong>gabove 2 per cent per year, still a fast-grow<strong>in</strong>g populationsuch that globally, <strong>the</strong> country is projected to advance frombe<strong>in</strong>g <strong>the</strong> twelfth most populous country <strong>in</strong> 2010 to <strong>the</strong>n<strong>in</strong>th by 2050 (see Table 19).Moreover, <strong>the</strong> apparent fall <strong>in</strong> <strong>the</strong> average annual growthrate from 2.36 to 2.04 per cent dur<strong>in</strong>g <strong>the</strong> latest periodshould be taken with reservation as <strong>the</strong> trend <strong>in</strong> fertilityappears <strong>in</strong>consistent, as seen <strong>in</strong> <strong>the</strong> slowly decl<strong>in</strong><strong>in</strong>gtrend shown <strong>in</strong> Figure 19. Fertility as measured by totalfertility rate (TFR) has decl<strong>in</strong>ed very slowly <strong>in</strong> <strong>the</strong> 41-yearperiod 1965-2006, that is, by about 48 per cent, from 6.3children per woman to 3.3. Dur<strong>in</strong>g <strong>the</strong> period 2001-2006,Philipp<strong>in</strong>e fertility has gone down m<strong>in</strong>imally from 3.5 to3.3.The 2008 NDHS, which shows a TFR a little above 3children per woman, implies that <strong>the</strong> population is stillgrow<strong>in</strong>g at a rate of a little more than 2 per cent annuallybecause of population momentum, or <strong>the</strong> tendency of ayoung population to cont<strong>in</strong>ue grow<strong>in</strong>g for a number ofyears. If a population is young, with many people <strong>in</strong> <strong>the</strong>younger age groups, even two-child families will meana grow<strong>in</strong>g population for several generations. This alsomeans that <strong>the</strong> country cont<strong>in</strong>ues to face a large youthdependency burden <strong>and</strong> a small proportion of work<strong>in</strong>gageadults generat<strong>in</strong>g <strong>in</strong>come <strong>and</strong> sav<strong>in</strong>gs.Recommendations1. Restore family plann<strong>in</strong>g as a pillar of <strong>the</strong> health <strong>and</strong>development programme under <strong>the</strong> Departmentof Health, at <strong>the</strong> same level as maternal <strong>and</strong> childhealth, exp<strong>and</strong>ed programme on immunization, <strong>and</strong>tuberculosis <strong>and</strong> malaria control. FP services can bestbe <strong>in</strong>tegrated with MCH, post-abortion care <strong>and</strong> <strong>the</strong>prevention <strong>and</strong> treatment of STIs <strong>and</strong> HIV-AIDSunder a revitalized reproductive health programme.For this policy framework, two steps are necessary:(a) Clarify <strong>the</strong> medical, scientific, legal <strong>and</strong> socialgrounds of a strong family plann<strong>in</strong>g programme,particularly <strong>in</strong> relation to health <strong>and</strong> developmentgoals, such as <strong>the</strong> Millennium DevelopmentGoals. This is important <strong>in</strong> <strong>the</strong> light of cont<strong>in</strong>u<strong>in</strong>gmis<strong>in</strong>formation dissem<strong>in</strong>ated by religiousopposition <strong>and</strong> a decade of muted <strong>in</strong>formationfrom government agencies. Cit<strong>in</strong>g evidence fromauthoritative sources, such as WHO, UnitedNations human rights <strong>in</strong>struments <strong>and</strong> academicexperts from respected universities, would clarify<strong>the</strong> facts.(b) Streng<strong>the</strong>n human rights, social equity <strong>and</strong>women’s empowerment pr<strong>in</strong>ciples <strong>in</strong> <strong>the</strong> provisionof FP <strong>in</strong>formation <strong>and</strong> services. Operatively, thismeans that no coercion or discrim<strong>in</strong>ation wouldbe allowed to <strong>in</strong>fluence people’s choices ei<strong>the</strong>r foror aga<strong>in</strong>st <strong>the</strong> use of FP services. Additionally, itmeans that affirmative action, particularly from <strong>the</strong>government, will be taken to correct long-st<strong>and</strong><strong>in</strong>g<strong>in</strong>equities towards <strong>the</strong> poor, women, young people,ethnic groups <strong>and</strong> o<strong>the</strong>r disadvantaged groups. Thest<strong>and</strong>ards <strong>and</strong> protocols <strong>and</strong> actual <strong>in</strong>teractionsbetween FP providers <strong>and</strong> clients must affirm <strong>the</strong>secore pr<strong>in</strong>ciples.2. Streng<strong>the</strong>n <strong>the</strong> delivery of <strong>and</strong> access to FP services,especially <strong>in</strong> <strong>the</strong> primary <strong>and</strong> secondary levels of publichealth care, <strong>in</strong> all geographic locations. This will require<strong>the</strong> follow<strong>in</strong>g steps:(a) Tra<strong>in</strong> <strong>and</strong> or deploy a mix of primary <strong>and</strong> secondarylevelFP providers adept <strong>in</strong> basic comprehensiveFP skills, particularly to areas with high unmetneed. The current it<strong>in</strong>erant teams can be re<strong>in</strong>forcedwith <strong>the</strong> long view of consciously develop<strong>in</strong>g localpersonnel capacities for FP/RH, especially IUD<strong>and</strong> surgical contraception.(b) Raise <strong>the</strong> quality of FP providers through tra<strong>in</strong><strong>in</strong>g<strong>in</strong> client-centred care <strong>and</strong> patients’ human rights,timely monitor<strong>in</strong>g <strong>and</strong> evaluation, provision ofadequate <strong>and</strong> cont<strong>in</strong>u<strong>in</strong>g FP logistics, <strong>and</strong> o<strong>the</strong>rprovider-enabl<strong>in</strong>g mechanisms, <strong>the</strong> most basic ofwhich is adequate compensation.(c) Harmonize <strong>the</strong> current conflict<strong>in</strong>g protocols <strong>in</strong> <strong>the</strong><strong>in</strong>itiation of <strong>and</strong> follow-up to FP methods. Ensurethat medical barriers are m<strong>in</strong>imized <strong>and</strong> st<strong>and</strong>ardpractice, such as <strong>the</strong> use of <strong>the</strong> Medical EligibilityCriteria <strong>in</strong>stitutionalized.(d) For <strong>the</strong> long-term supply of FP/RH providers, FP/RH must be <strong>in</strong>tegrated <strong>in</strong>to <strong>the</strong> medical, nurs<strong>in</strong>g<strong>and</strong> midwifery curricula.3. There needs to be a strong <strong>and</strong> susta<strong>in</strong>ed national public<strong>in</strong>formation campaign expla<strong>in</strong><strong>in</strong>g <strong>the</strong> health <strong>and</strong> socialbenefits of family plann<strong>in</strong>g, <strong>in</strong>clud<strong>in</strong>g <strong>the</strong> effectiveness<strong>and</strong> safety of <strong>the</strong> various methods. This is necessary<strong>in</strong> <strong>the</strong> light of massive, systematic <strong>and</strong> cont<strong>in</strong>u<strong>in</strong>gdis<strong>in</strong>formation from opponents of family plann<strong>in</strong>g.The public campaign could <strong>in</strong>clude <strong>the</strong> follow<strong>in</strong>g:(a) Mass media, particularly television <strong>and</strong> radio, whichare <strong>the</strong> most effective media for <strong>the</strong> target sectors –poor women, poor youth, <strong>and</strong> ethnic groups – haveto be maximized.(b) Communication messages must be crafted thatrespond to <strong>the</strong> needs <strong>and</strong> queries of <strong>the</strong> particular319

FigureFigureFigure18 Population <strong>and</strong> average annual growth rate, census years 1903-2007Figure19 Total fertility rate, 1965-2006320

target group. In Metro Manila, for example,women listen to television <strong>and</strong> radio programmeswhere medical resource persons discuss commonproblems <strong>and</strong> respond to questions from <strong>the</strong>audience.4. Research must be cont<strong>in</strong>ually undertaken to assess <strong>the</strong>effectiveness <strong>and</strong> responsiveness of FP programmes,especially to <strong>the</strong> most marg<strong>in</strong>alized groups, <strong>and</strong><strong>the</strong>ir impact on o<strong>the</strong>r social <strong>in</strong>dicators, such aspoverty, employment, gender equality, migration <strong>and</strong>environment, among o<strong>the</strong>rs. Research can <strong>in</strong>clude <strong>the</strong>follow<strong>in</strong>g:(a) The National Statistics Office must be supported<strong>in</strong> <strong>the</strong>ir cont<strong>in</strong>u<strong>in</strong>g surveys on <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> use<strong>and</strong> its l<strong>in</strong>kage to o<strong>the</strong>r health <strong>in</strong>dicators, especiallymaternal mortality, maternal health <strong>and</strong> access tohealth care services.(b) The Commission on Population (POPCOM)must streng<strong>the</strong>n its m<strong>and</strong>ate of monitor<strong>in</strong>g <strong>the</strong>demographic impact of FP, <strong>in</strong>clud<strong>in</strong>g its l<strong>in</strong>kageto <strong>the</strong> social <strong>and</strong> physical environment. It can alsoassist <strong>the</strong> Department of Health <strong>in</strong> ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g<strong>the</strong> contraceptive management <strong>in</strong>formationsystem, contraceptive procurement, storage <strong>and</strong>distribution.5. F<strong>in</strong>ancial resources must be mobilized, especially bynational government, to meet <strong>the</strong> large unmet needthat accrued from a decade of neglect <strong>and</strong> which affectspoor <strong>and</strong> disadvantaged groups <strong>the</strong> most. The follow<strong>in</strong>gsources must be mobilized:(a) Congress needs to allocate a significant budgetto cover for commodities, <strong>the</strong> reestablishmentof a centralized procurement, warehous<strong>in</strong>g <strong>and</strong>distribution centre <strong>in</strong> <strong>the</strong> Department of Health,<strong>and</strong> <strong>the</strong> cascaded tra<strong>in</strong><strong>in</strong>g of enough FP providers.(b) PhilHealth needs to improve its system <strong>and</strong> makeits benefits, particularly on IUD <strong>in</strong>sertion <strong>and</strong>bilateral tubal ligation, more accessible to local FPpractitioners <strong>and</strong> RHU facilities.(c) Private companies must do <strong>the</strong>ir share <strong>in</strong> operat<strong>in</strong>gFP/RH cl<strong>in</strong>ics with functional services for <strong>the</strong>iremployees accord<strong>in</strong>g to <strong>the</strong> labour law.6. The right to family plann<strong>in</strong>g, which is enshr<strong>in</strong>ed <strong>in</strong><strong>in</strong>ternational as well as national laws (e.g. <strong>the</strong> Philipp<strong>in</strong>econstitution of 1987), must be actively wielded <strong>in</strong>defense of disadvantaged citizens <strong>and</strong> aga<strong>in</strong>st <strong>the</strong>derogation by powerful <strong>in</strong>stitutions such as <strong>the</strong> Catholichierarchy. To <strong>in</strong>sure <strong>the</strong> cont<strong>in</strong>ued preservation of thishuman right, <strong>the</strong> follow<strong>in</strong>g steps are necessary:(a) The passage of a reproductive health law, whichhas been stalled <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>e Congress for atleast n<strong>in</strong>e years, would <strong>in</strong>stitutionalize <strong>the</strong> rightsbased<strong>and</strong> <strong>in</strong>tegrated health approach to FP,<strong>in</strong>clud<strong>in</strong>g several FP provisions, such as deliveryof all modern FP methods, subsidized provision ofsurgical sterilization for <strong>the</strong> poor, <strong>the</strong> <strong>in</strong>tegrationof FP among o<strong>the</strong>r subjects <strong>in</strong> secondary schools<strong>and</strong> <strong>the</strong> classification of contraceptives as “essentialmedic<strong>in</strong>es” to ensure susta<strong>in</strong>ed procurement.(b) The cont<strong>in</strong>u<strong>in</strong>g cultivation of a social movement onreproductive health with a strong focus on FP <strong>and</strong>which ga<strong>the</strong>rs toge<strong>the</strong>r a broad base of constituents– RH practitioners <strong>and</strong> advocates; government,non-government <strong>and</strong> private sectors; professionals<strong>and</strong> grass-roots communities is <strong>in</strong>strumentalnot only for advanc<strong>in</strong>g <strong>the</strong> RH bill but also foreducat<strong>in</strong>g <strong>and</strong> empower<strong>in</strong>g people to control <strong>the</strong>irfertility <strong>and</strong> to enshr<strong>in</strong>e this entitlement <strong>in</strong> <strong>the</strong>country's laws, policies <strong>and</strong> programmes.AppendixSurveysUnless o<strong>the</strong>rwise specified, <strong>the</strong> Philipp<strong>in</strong>e surveyscommonly referred to as (year) NDHS <strong>in</strong> this reportrefer to <strong>the</strong> 1993, 1998, 2003 <strong>and</strong> 2008 (National)Demographic <strong>and</strong> Health Surveys jo<strong>in</strong>tly published by<strong>the</strong> National Statistics Office (Philipp<strong>in</strong>es) <strong>and</strong> Macro<strong>International</strong>/ORC Macro/ICF Macro of <strong>the</strong> DHSMeasures Project. These are available at http://www.measuredhs.com/countries/country_ma<strong>in</strong>.cfm?ctry_id=34&c=Philipp<strong>in</strong>es.1993 NDSNational Statistics Office (NSO) <strong>and</strong> Macro <strong>International</strong>Inc. (MI). 1994. National Demographic Survey 1993.Calverton, Maryl<strong>and</strong>: NSO <strong>and</strong> MI.1998 NDHSNational Statistics Office, Department of Health <strong>and</strong>Macro <strong>International</strong> Inc. 1999. National Demographic<strong>and</strong> Health Survey 1998. Manila: NSO <strong>and</strong> MI.2003 NDHSNational Statistics Office, <strong>and</strong> ORC Macro. 2004. NationalDemographic <strong>and</strong> Health Survey 2003. Calverton,Maryl<strong>and</strong>: NSO <strong>and</strong> ORC Macro.2008 NDHS321

National Statistics Office, <strong>and</strong> ICF Macro. 2009. NationalDemographic <strong>and</strong> Health Survey 2008. Calverton,Maryl<strong>and</strong>: NSO <strong>and</strong> ICF Macro.The data on wealth qu<strong>in</strong>tiles for <strong>the</strong> 1993 NDS <strong>and</strong>1998 NDHS come from <strong>the</strong> follow<strong>in</strong>g source: ExaltacionE. Lamberte, Nanette R. Lee, Desiree Concepcion U.Garganian <strong>and</strong> Andrew Kantner (2000). <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Service Utilization <strong>and</strong> Market Segmentation <strong>in</strong> <strong>the</strong>Philipp<strong>in</strong>es, Calverton, Maryl<strong>and</strong>: ORC Macro. Availablefrom www.measuredhs.com/pubs/pdf/FA34/FA34.pdf.Data tablesThe figures <strong>in</strong> <strong>the</strong> ma<strong>in</strong> text <strong>and</strong> <strong>the</strong> tables shown beloware matched through <strong>the</strong>ir numbers; e.g., The data used <strong>in</strong>Figure 1 come from Table 1, <strong>in</strong> Figure 2 from Table 2, <strong>and</strong>so on. All growth rates <strong>in</strong> <strong>the</strong>se tables, unless o<strong>the</strong>rwisespecified, were calculated by <strong>the</strong> authors from <strong>the</strong> publisheddata.TableTable1TableTable2322

TableTable3TableTable4TableTable5323

TableTable6TableTable7TableTable8324

TableTable9TableTable10325

TableTable11326

TableTable12TableTable13327

TableTable14TableTable15TableTable16328

TableTable17TableTable18329

TableTable19Laws <strong>and</strong> o<strong>the</strong>r regulations1973 Philipp<strong>in</strong>e Constitution. Available at http://elibrary.judiciary.gov.ph/<strong>in</strong>dex7.php?doctype=Constitutions&docid=a45475a11ec72b843d74959b60fd7bd64558f6f05f5e61987 Philipp<strong>in</strong>e Constitution. Available at http://elibrary.judiciary.gov.ph/<strong>in</strong>dex7.php?doctype=Constitutions&docid=a45475a11ec72b843d74959b60fd7bd64558f82c40d9dDOH AO 114 (31 October 1991). Bengzon, AlfredoR.A., Adm<strong>in</strong>istrative Order 114 s. 1991 – Revised/Added Roles <strong>and</strong> Functions of <strong>the</strong> Municipal HealthOfficer, <strong>the</strong> Public Health Nurse <strong>and</strong> <strong>the</strong> Rural HealthMidwife. http://home.doh.gov.ph/ao/ao114-91.pdf,retrieved on 11 November 2010.DOH AO 125 (5 June 2002). Dayrit, Manuel, DOHAO 125 s. 2002 – National NFP Strategic Plan Year2002-2006. http://home.doh.gov.ph/ao/ao125-02.pdf, retrieved on 24 November 2010.DOH AO 132 (7 January 2004). Dayrit, Manuel, DOHAO 132 s. 2004 – Creat<strong>in</strong>g <strong>the</strong> DOH Natural <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Program <strong>and</strong> its Program Management.http://home.doh.gov.ph/ao/ao132-04.pdf, retrievedon 24 November 2010.DOH AO 158 (9 July 2004). Dayrit, Manuel, DOHAO 158 s. 2004 – Guidel<strong>in</strong>es on <strong>the</strong> Management ofDonated Commodities under <strong>the</strong> Contraceptive Self-Reliance Strategy. http://home.doh.gov.ph/ao/ao158-04.pdf, retrieved on 24 November 2010.DOH AO 1-A (15 January 1998). Noreiga-Reodica,Carmencita, DOH AO 1-A s. 1998 – Creation ofa Philipp<strong>in</strong>e Reproductive Health Program. http://home.doh.gov.ph/ao/ao1a-98.pdf, retrieved on 24November 2010.DOH AO 2010-0027 (25 June 2010). Cabral,Esperanza, DOH AO 2010-0027 Amendment toAdm<strong>in</strong>istrative Order No. 158, Series of 2004 entitledGuidel<strong>in</strong>es on <strong>the</strong> Management of Donated Commoditiesunder <strong>the</strong> Contraceptive Self-Reliance Strategy. http://home.doh.gov.ph/ao/ao2010-0027.pdf, retrieved on23 November 2010.DOH AO 24-A (8 March 2000). Romualdez, Alberto,DOH AO 24-A s. 2000 - Streng<strong>the</strong>n<strong>in</strong>g <strong>the</strong> DOHReproductive Health Program. http://www2.doh.gov.ph/ao/ao24A.pdf, retrieved on 24 November 2010.DOH AO 43 (24 April 2000). Romualdez, Alberto,DOH AO 43 s. 2000 - Reproductive Health Policy.http://home.doh.gov.ph/ao/ao43-00.pdf, retrievedon 24 November 2010.DOH AO 50-A (17 September 2001). Dayrit, Manuel,DOH AO 50-A s. 2001 – National <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Policy. http://home.doh.gov.ph/ao/ao50A-01.pdf,retrieved on 24 November 2010.330

DOH Memo 2008-0100 (7 May 2008). Villaverde MarioC., Department Memor<strong>and</strong>um 2008-0100 – Suballotmentof funds to Centers for Health Development forgrants to local government units (LGUs) for reproductivehealth (RH) commodities <strong>and</strong> reproductive healthtra<strong>in</strong><strong>in</strong>g activities. http://home.doh.gov.ph/dm/dm2008-0100.pdf, retrieved 23 November 2010.EO 119 (30 January 1987). Aqu<strong>in</strong>o, Corazon C.,Executive Order No. 119 - Reorganiz<strong>in</strong>g <strong>the</strong> M<strong>in</strong>istry ofHealth, its Attached Agencies <strong>and</strong> for O<strong>the</strong>r Purposes.http://www.chanrobles.com/executiveorders/1987/executiveorderno119-1987.html, retrieved on 9November 2010.PD 79 (8 December 1972). Marcos, Ferd<strong>in</strong><strong>and</strong> E.,Presidential Decree No. 79 - Revis<strong>in</strong>g <strong>the</strong> PopulationAct of N<strong>in</strong>eteen Hundred <strong>and</strong> Seventy-One. http://www.lawphil.net/statutes/presdecs/pd1972/pd_79_1972.html, retrieved on 9 November 2010.RA 1937 or Tariff <strong>and</strong> Customs Law (22 June 1957).Philipp<strong>in</strong>e Congress, Republic Act No. 1937 - AnAct to Revise <strong>and</strong> Codify <strong>the</strong> Tariff <strong>and</strong> CustomsLaws of <strong>the</strong> Philipp<strong>in</strong>es. http://www.chanrobles.com/republicactno1937book1.htm, retrieved on 9November 2010.RA 4623 or Revised Adm<strong>in</strong>istrative Code (19 June1965). Philipp<strong>in</strong>e Congress, Republic Act No. 4623 -An Act to Amend Sections N<strong>in</strong>eteen Hundred <strong>and</strong> Fifty-Four <strong>and</strong> N<strong>in</strong>eteen Hundred <strong>and</strong> Seventy-Eight-A of <strong>the</strong>Revised Adm<strong>in</strong>istrative Code. http://www.chanrobles.com/republicacts/republicactno4623.html, retrievedon 9 November 2010.RA 4729 (18 June 1966). Philipp<strong>in</strong>e Congress,Republic Act No. 4729 - An Act to Regulate <strong>the</strong> Sale,Dispensation, <strong>and</strong>/or Distribution of ContraceptiveDrugs <strong>and</strong> Devices. http://www.chanrobles.com/republicacts/republicactno4729.html, retrieved on 9November 2010.RA 6365 or Population Act (16 August 1971).Philipp<strong>in</strong>e Congress, Republic Act No. 6365 - AnAct Establish<strong>in</strong>g a National Policy on Population,Creat<strong>in</strong>g <strong>the</strong> Commission on Population <strong>and</strong> for o<strong>the</strong>rPurposes. http://www.chanrobles.com/republicacts/republicactno6365.html, retrieved on 9 November2010.End Note*1 DALY – disability adjusted life years. One DALY can be thoughtof as one lost year of “healthy” life.*2 The reasons <strong>in</strong> DHS were reorganized <strong>in</strong>to major groups by <strong>the</strong>authors. Table 11 provides <strong>the</strong> component details for all groups.*3 32 per cent of <strong>the</strong> 31 per cent of all women non-users that visiteda health facility equals 10 per cent of all women non-users*4 Davao del Norte <strong>and</strong> Compostela Valley*5 The percentage use of female sterilization was divided by <strong>the</strong>percentage of women who wanted no more children.*6 There is no <strong>in</strong>equity by wealth qu<strong>in</strong>tiles <strong>in</strong> IUD use: 4 per centof <strong>the</strong> lowest to <strong>the</strong> fourth qu<strong>in</strong>tile, <strong>and</strong> 2 per cent of <strong>the</strong> highestqu<strong>in</strong>tile used <strong>the</strong>m.*7 Unless qualified with <strong>the</strong> word “formal/formally”, <strong>the</strong> termmarried <strong>in</strong>cludes those liv<strong>in</strong>g toge<strong>the</strong>r <strong>in</strong> <strong>in</strong>formal unions.*8 Data are unavailable for young women.*9 Referr<strong>in</strong>g to elected <strong>and</strong> autonomous government structures at <strong>the</strong>prov<strong>in</strong>ce, city, municipality <strong>and</strong> village (barangay) levels.*10 President Gloria Macapagal Arroyo replaced President JosephEjercito Estrada <strong>in</strong> January 2001 after anti-corruption massprotests forced him out of office. The new President held powerfor more than n<strong>in</strong>e years.*11 The f<strong>in</strong>al shipment reportedly arrived <strong>in</strong> 2010.*12 The temporary loss or lower<strong>in</strong>g of fertility of breastfeed<strong>in</strong>g womenup to about six months after childbirth.*13 An active anti-abortion <strong>and</strong> anti-contraception organization.*14 Under LGC, Rural Health Units (health centres) <strong>and</strong> BarangayHealth Stations (health posts) are controlled by municipalgovernments, so it is possible that services <strong>and</strong> supplies werema<strong>in</strong>ta<strong>in</strong>ed <strong>in</strong> some localities.1 National Statistical Coord<strong>in</strong>ation Board ( January 2004). A Viewof <strong>the</strong> Philipp<strong>in</strong>es – Geography. http://www.nscb.gov.ph/view/geography.asp, retrieved on 8 November 2010.2 National Statistics Office (8 December 2006). “Table 1. Summaryof projected population by sex <strong>and</strong> by s<strong>in</strong>gle-calendar year <strong>in</strong>terval,Philipp<strong>in</strong>es: 2000 – 2010, Medium assumption”, 2000 CensusbasedPopulation Projection <strong>in</strong> collaboration with <strong>the</strong> Inter-Agency Work<strong>in</strong>g Group on Population Projections. http://www.census.gov.ph/data/sectordata/popproj_tab1r.html, retrieved on 8November 2010.3 Lewis, M. Paul (ed.) (2009). Ethnologue: Languages of <strong>the</strong> World,Sixteenth edition. Dallas, Texas: SIL <strong>International</strong>. Onl<strong>in</strong>e version,http://www.ethnologue.com/show_country.asp?name=PH,retrieved on 8 November 2010.4 National Statistics Office (9 September 2010). Almost n<strong>in</strong>e out often Filip<strong>in</strong>os are functionally literate (f<strong>in</strong>al results from <strong>the</strong> 2008Functional Literacy <strong>and</strong> Mass Media Survey). http://www.census.gov.ph/data/pressrelease/2010/pr10142tx.html, retrieved on 8November 2010. In this survey, a functionally literate person isone who can read, write <strong>and</strong> compute or one who can read, write,compute <strong>and</strong> comprehend. Persons who completed high school ora higher level of education are also considered functionally literate.5 World Bank (2009). Philipp<strong>in</strong>es at a Glance. http://devdata.worldbank.org/AAG/phl_aag.pdf, retrieved on 23 November2010.6 Commission on Population (2004). “Chapter 1: The urbansprawl”, State of <strong>the</strong> Philipp<strong>in</strong>e Population Report 2004. http://www.popcom.gov.ph/sppr/sppr03/pdfs/_Chapter%20I_NEW.pdf, retrieved on 8 November 2010.7 Bureau of Labor <strong>and</strong> Employment Statistics (August 1999).“Agricultural employment trends <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es: <strong>the</strong> decadepast”, Labstat Updates, 3(14). http://www.bles.dole.gov.ph/PUBLICATION-ARCHIVES/LABSTAT%20UPDATES%20%28NEW%20CATEGORY%29/issues/vol3_14.pdf, retrievedon 8 November 2010.8 National Statistics Office (21 January 2010). “Table 1. Annualestimates for employed persons by <strong>in</strong>dustry, occupation, class of331

worker <strong>and</strong> hours worked, Philipp<strong>in</strong>es: 2009 <strong>and</strong> 2008”, AnnualLabor <strong>and</strong> Employment Estimates for 2008 <strong>and</strong> 2009. http://www.census.gov.ph/data/sectordata/2009/pr103801.htm,retrieved on 8 November 2010.9 National Statistical Coord<strong>in</strong>ation Board ( January 2004). A Viewof <strong>the</strong> Philipp<strong>in</strong>es – People. http://www.nscb.gov.ph/view/people.asp, retrieved on 8 November 2010.10 Hutchcroft, Paul D. (2010). “Dreams of redemption: localiststrategies of political reform <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es”, In: Yuko Kasuya<strong>and</strong> Nathan Gilbert Quimpo, eds., The Politics of Change <strong>in</strong> <strong>the</strong>Philipp<strong>in</strong>es. Pasig City: Anvil.11 National Statistical Coord<strong>in</strong>ation Board (30 June 2010).Prov<strong>in</strong>cial Summary - Number of Prov<strong>in</strong>ces, Cities, Municipalities<strong>and</strong> Barangays, by Region. http://www.nscb.gov.ph/activestats/psgc/NSCB_PSGC_SUMMARY_2010Jun30.pdf, retrieved on8 November 2010.12 Ramon Magsaysay Award Foundation (1991). The 1991 RamonMagsaysay Award for Government Service - Biography of AlfredoR. A. Bengzon. http://www.rmaf.org.ph/Awardees/Biography/BiographyBengzonAlf.htm, retrieved on 9 November 2010.13 Grundy J, Healy V, Gorgolon L, S<strong>and</strong>ig E (2003). "Overview ofdevolution of health services <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es". In Rural <strong>and</strong>Remote Health 3 (onl<strong>in</strong>e). Deak<strong>in</strong> University, Australia. http://www.rrh.org.au/publishedarticles/article_pr<strong>in</strong>t_220.pdf, retrievedon 8 November 2010.14 Gonzaga, L<strong>in</strong>o R., for CBCP (12 October 1968). “Pastoral letterof <strong>the</strong> Catholic hierarchy of <strong>the</strong> Philipp<strong>in</strong>es on <strong>the</strong> encyclicalletter Humanae Vitae”, In: Catholic Bishops' Conference of <strong>the</strong>Philipp<strong>in</strong>es – Pastoral Letters <strong>and</strong> Statements 1945-1995. http://www.pcfroma.org/collegio/docustor/PL19452003.doc, retrievedon 9 November 2010.15 Alberto, Teopisto V., for CBCP (8 December 1973). “Moralnorms for Catholic hospitals <strong>and</strong> Catholics <strong>in</strong> health services”, In:Catholic Bishops' Conference of <strong>the</strong> Philipp<strong>in</strong>es – Pastoral Letters<strong>and</strong> Statements 1945-1995. http://www.pcfroma.org/collegio/docustor/PL19452003.doc, retrieved on 9 November 2010.16 Alberto, Teopisto V., for CBCP (8 December 1973). “Pastoralletter of <strong>the</strong> Catholic hierarchy of <strong>the</strong> Philipp<strong>in</strong>es on <strong>the</strong>population problem <strong>and</strong> family life”, In: Catholic Bishops'Conference of <strong>the</strong> Philipp<strong>in</strong>es – Pastoral Letters <strong>and</strong> Statements1945-1995. http://www.pcfroma.org/collegio/docustor/PL19452003.doc, retrieved on 9 November 2010.17 National Statistics Office (NSO) [Philipp<strong>in</strong>es], <strong>and</strong> ICF Macro(2009). National Demographic <strong>and</strong> Health Survey 2008,Calverton, Maryl<strong>and</strong>: National Statistics Office <strong>and</strong> ICF Macro.http://www.measuredhs.com/pubs/pdf/FR224/FR224.pdf18 S<strong>in</strong>, Jaime L., for CBCP (29 January 1979). “‘Thou Shalt NotKill’ (a jo<strong>in</strong>t pastoral letter of <strong>the</strong> Philipp<strong>in</strong>e hierarchy on <strong>the</strong> lifeof <strong>the</strong> unborn child)”, In: Catholic Bishops' Conference of <strong>the</strong>Philipp<strong>in</strong>es – Pastoral Letters <strong>and</strong> Statements 1945-1995. http://www.pcfroma.org/collegio/docustor/PL19452003.doc, retrievedon 9 November 2010.19 Bacani, Teodoro. The State Shall Protect <strong>the</strong> Unborn. http://www.rcam.org/RH_Bill/commentaries/bishop_bacani/<strong>the</strong>_state_shall_protect_<strong>the</strong>_unborn.html, retrieved on 22 November2010.20 Ramon Magsaysay Award Foundation (1991). The 1991 RamonMagsaysay Award for Government Service - Biography of AlfredoR. A. Bengzon. http://www.rmaf.org.ph/Awardees/Biography/BiographyBengzonAlf.htm, retrieved on 9 November 2010.21 Legaspi, Leonardo Z. for CBCP (7 October 1990). “Love IsLife – a pastoral letter on <strong>the</strong> population control activities of <strong>the</strong>Philipp<strong>in</strong>e Government <strong>and</strong> Planned Parenthood Associations”,In: Catholic Bishops' Conference of <strong>the</strong> Philipp<strong>in</strong>es – PastoralLetters <strong>and</strong> Statements 1945-1995. http://www.pcfroma.org/collegio/docustor/PL19452003.doc, retrieved on 9 November2010.22 Lakshm<strong>in</strong>arayanan, Rama (2003). “Decentralisation <strong>and</strong> itsimplications for reproductive health: <strong>the</strong> Philipp<strong>in</strong>es experience”,p. 104, In: Reproductive Health Matters, 11(21):96–107. http://<strong>in</strong>fo.worldbank.org/etools/docs/library/99169/CD_CC/precourse/CCFY04CDRom/Week2/2Tuesday/S1%20Org%20Reforms/Lakshm<strong>in</strong>arayanan.pdf, retrieved on 9 November 2010.23 Bossert, Thomas J <strong>and</strong> Joel C. Beauvais (2002). “Decentralizationof health systems <strong>in</strong> Ghana, Zambia, Ug<strong>and</strong>a <strong>and</strong> <strong>the</strong> Philipp<strong>in</strong>es:a comparative analysis of decision space”, In: Health Policy<strong>and</strong> <strong>Plann<strong>in</strong>g</strong>, 17(1):14-31. http://heapol.oxfordjournals.org/content/17/1/14.full.pdf, retrieved on 11 November 2010. Inthis study, <strong>the</strong> authors found that <strong>the</strong> Philipp<strong>in</strong>es had “<strong>the</strong> widestrange of choice over many functions that were devolved to localgovernment units”.24 Dayrit Manuel M. (17 September 2004). Letter to <strong>the</strong> editor:Philipp<strong>in</strong>e Daily Inquirer. http://www.doh.gov.ph/national_FP.html, retrieved on 23 November 2010.25 House Bill 5043 – 14th Congress (2008). http://www.likhaan.org/content/14th-congress-house-bill-5043, retrieved on 23November 2010.26 Lacierda, Edw<strong>in</strong> (19 November 2010). Press brief<strong>in</strong>g withSecretary Lacierda after <strong>the</strong> meet<strong>in</strong>g between CBCP <strong>and</strong> membersof <strong>the</strong> Cab<strong>in</strong>et. Office of <strong>the</strong> Presidential Spokesperson. http://www.gov.ph/2010/11/19/<strong>in</strong>terview-with-secretary-lacierda-after<strong>the</strong>-meet<strong>in</strong>g-between-<strong>the</strong>-cbcp-<strong>and</strong>-members-of-<strong>the</strong>-cab<strong>in</strong>etnovember-19-2010/,retrieved on 23 November 2010.27 Department of Health ( June 2010). “Bridg<strong>in</strong>g to future reforms”,p.34. Health Sector Reform Agenda Monograph No. 9.28 United Nations, Department of Economic <strong>and</strong> SocialAffairs, Population Division (2010). 2010 Update for <strong>the</strong>MDG Database: Contraceptive Prevalence (POP/DB/CP/A/MDG2010). http://www.un.org/esa/population/publications/2010_MDGDatabase/2010_Update_MDG_CP.xls, retrieved on 15 November 2010.29 Flavier, Juan ( June 1994). DOH Department Circular 101-A s.1994 – Philipp<strong>in</strong>e <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Program Method Mix. http://www.doh.gov.ph/files/dc101-A-94.pdf, retrieved on 17 November2010.30 Department of Health ( June 2010). “Bridg<strong>in</strong>g to future reforms”,p.34. Health Sector Reform Agenda Monograph No. 9.31 Guttmacher Institute <strong>and</strong> <strong>International</strong> Planned ParenthoodFederation (November 2010). Facts on Satisfy<strong>in</strong>g <strong>the</strong> Need forContraception In Develop<strong>in</strong>g Countries. http://www.guttmacher.org/pubs/FB-Unmet-Need-Intl.pdf, retrieved on 18 November2010.32 Westoff Charles F. (December 2006). "New Estimates ofUnmet Need <strong>and</strong> <strong>the</strong> Dem<strong>and</strong> for <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>", p. 19.DHS Comparative Reports No. 14. Calverton, Maryl<strong>and</strong>, USA.Macro <strong>International</strong> Inc. http://www.measuredhs.com/pubs/pub_details.cfm?ID=636&srchTp=advanced, retrieved on 17November 2010.33 Note number 34, pp. 48-49.34 Orbeta Aniceto C. (2006). “Poverty, Fertility Preferences, <strong>and</strong><strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Practices <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es”. In Philipp<strong>in</strong>eJournal of Development, No. 61, 1st & 2nd Semesters2006 Volume XXXIII, Nos. 1 & 2. Philipp<strong>in</strong>e Institute forDevelopment Studies. http://dirp4.pids.gov.ph/ris/pjd/pidspjd06-poverty.pdf, retrieved on 10 November 2010.332

35 Department of Health ( June 2010). “Bridg<strong>in</strong>g to future reforms”,p.35. Health Sector Reform Agenda Monograph No. 9. The CPRtarget of 100% by 2015 can be read at <strong>the</strong> National StatisticalCoord<strong>in</strong>ation Board ( July 2010). MDG Watch: Philipp<strong>in</strong>eprogress based on <strong>the</strong> MDG <strong>in</strong>dicators. http://www.nscb.gov.ph/mdg/NSCB_MDGPoster_July2010.pdf, retrieved on 15November 2010.36 Calculated from 2008 NDHS.37 Darroch, Jacquel<strong>in</strong>e E., Susheela S<strong>in</strong>g, Haley Ball <strong>and</strong> Josf<strong>in</strong>a V.Cabigon (2009). “Meet<strong>in</strong>g women’s contraceptive needs <strong>in</strong> <strong>the</strong>Philipp<strong>in</strong>es”, In Brief, New York: Guttmacher Institute, No. 1.http://www.likhaan.org/content/meet<strong>in</strong>g-womens-contraceptiveneeds-philipp<strong>in</strong>es38 Khan, Shane, V<strong>in</strong>od Mishra, Fred Arnold, <strong>and</strong> Nouredd<strong>in</strong>eAbderrahim (2007). “Contraceptive Trends <strong>in</strong> Develop<strong>in</strong>gCountries”, pp. 27-28 & 59-60. DHS Comparative Reports No.16. Calverton, Maryl<strong>and</strong>, USA: Macro <strong>International</strong> Inc. http://www.measuredhs.com/pubs/pdf/CR16/CR16.pdf, retrieved on10 November 2010.39 Academy for Educational Development (2003). “The Quality of<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Information <strong>in</strong> <strong>the</strong> Philipp<strong>in</strong>es”. In Sketches, TheSocial Acceptance Project – <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>. Vol. 1 No. 7 Seriesof 2003. http://pdf.dec.org/pdf_docs/PNACX430.pdf, retrievedon 20 November 2010.40 The earliest case we know of is from a pastoral letter <strong>in</strong> 1990which stated that “pregnancy is not an illness”, that <strong>the</strong> birthregulation method acceptable to Christians “follows <strong>the</strong> naturalprocesses of <strong>the</strong> human body, without unduly <strong>in</strong>terfer<strong>in</strong>g, withoutpollut<strong>in</strong>g <strong>the</strong> human body with chemicals <strong>and</strong> o<strong>the</strong>r substances”,<strong>and</strong> called on medical practitioners to be honest <strong>in</strong> <strong>the</strong>ir evaluationof “products of contraceptive technology [that] are under a cloudas to <strong>the</strong>ir safety for <strong>the</strong> life <strong>and</strong> health of fetus <strong>and</strong> mo<strong>the</strong>r”.Legaspi, Leonardo Z. for CBCP (7 October 1990). “Love IsLife – A pastoral letter on <strong>the</strong> population control activities of <strong>the</strong>Philipp<strong>in</strong>e Government <strong>and</strong> Planned Parenthood Associations”,In: Catholic Bishops' Conference of <strong>the</strong> Philipp<strong>in</strong>es – PastoralLetters <strong>and</strong> Statements 1945-1995. http://www.pcfroma.org/collegio/docustor/PL19452003.doc, retrieved on 9 November2010.41 Barnwell, Rob<strong>in</strong> <strong>and</strong> Obaid-Ch<strong>in</strong>ay, Sharmeen (2006).“Philipp<strong>in</strong>es: City of Guilt” <strong>in</strong> Unreported World Series 11.http://sharmeenobaidfilms.com/2006/08/city-of-guilt-2/Transcribed by authors from video file, 20:07 – 20:22.42 Demeterio-Melgar Junice, Pacete Jocelyn C, Aguil<strong>in</strong>g-PangalanganElizabeth, Lu Anna Victoria M, Sabundayo Maria Lourdes,Kebriaei Pardiss [ed.] (2007). Impos<strong>in</strong>g Misery: The Impact ofManila’s Ban on Contraception. Likhaan, ReproCen <strong>and</strong> Centerfor Reproductive Rights. http://www.likhaan.org/content/impos<strong>in</strong>g-misery-impact-manilas-ban-contraceptionon 15 November 2010.47 Khan, Shane <strong>and</strong> V<strong>in</strong>od Mishra (2008). “Youth reproductive <strong>and</strong>sexual health”, DHS Comparative Reports No. 19, Calverton,Maryl<strong>and</strong>: Macro <strong>International</strong>, Inc. http://www.measuredhs.com/pubs/pdf/CR19/CR19.pdf, retrieved on 10 November2010.48 Cabigon, Josef<strong>in</strong>a V. (2009). Contraceptive self-reliance <strong>and</strong> localgovernments’ responses to family plann<strong>in</strong>g commodity phaseout:technical report on <strong>the</strong> results of <strong>the</strong> CSR rapid assessment,Manila, Philipp<strong>in</strong>es: Health Policy Development Program <strong>and</strong>Foundation for <strong>the</strong> Advancement of Cl<strong>in</strong>ical Epidemiology.49 Cabigon, Josef<strong>in</strong>a V. (2009).50 Government of <strong>the</strong> Philipp<strong>in</strong>es (8 December 1930). ActNo. 3815 – The Revised Penal Code of <strong>the</strong> Philipp<strong>in</strong>es,Articles 256-259. http://www.un.org/Depts/los/LEGISLATIONANDTREATIES/PDFFILES/PHL_revised_penal_code.pdf, retrieved on 11 November 2010.51 Bernas, Joaqu<strong>in</strong> (18 October 2010). “The right to life of <strong>the</strong>unborn”, In: Sound<strong>in</strong>g Board, Philipp<strong>in</strong>e Daily Inquirer. http://op<strong>in</strong>ion.<strong>in</strong>quirer.net/<strong>in</strong>quirerop<strong>in</strong>ion/columns/view/20101018-298341/The-right-to-life-of-<strong>the</strong>-unborn, retrieved on 23November 2010.52 Bacani, Teodoro (13 September 2008). The State shall protect <strong>the</strong>unborn, In: Manila St<strong>and</strong>ard Today, as posted on <strong>the</strong> website of<strong>the</strong> Roman Catholic Archdiocese of Manila. http://www.rcam.org/RH_Bill/commentaries/bishop_bacani/<strong>the</strong>_state_shall_protect_<strong>the</strong>_unborn.html, retrieved on 23 November 2010.53 Society of Philipp<strong>in</strong>e Health History (2004). Decades <strong>in</strong> Health.http://www.doh.gov.ph/sphh/decades.htm, retrieved on 11November 2010.54 Department of Health ( June 2010). “Bridg<strong>in</strong>g to future reforms”,p.35, Health Sector Reform Agenda Monograph No. 9.55 Chapter II, Section 17 of <strong>the</strong> Local Government Code.56 Demeterio-Melgar Junice, Pacete Jocelyn C, Aguil<strong>in</strong>g-PangalanganElizabeth, Lu Anna Victoria M, Sabundayo Maria Lourdes,Kebriaei Pardiss [ed.] (2007). Impos<strong>in</strong>g Misery: The Impact ofManila’s Ban on Contraception. Likhaan, ReproCen <strong>and</strong> Centerfor Reproductive Rights. http://www.likhaan.org/content/impos<strong>in</strong>g-misery-impact-manilas-ban-contraception57 Commission on Human Rights of <strong>the</strong> Philipp<strong>in</strong>es. CHR (IV)A2010-005: “EO No. 003: discrim<strong>in</strong>atory or rights-based? CHRadvisory on <strong>the</strong> local ord<strong>in</strong>ance by <strong>the</strong> City of Manila”. 7 October2010. Available at http://www.likhaan.org/sites/default/files/pdf/CHR-IV-A2010-005-manila-contraceptives-ban.pdf.43 Demeterio-Melgar Junice (facilitator), conducted <strong>in</strong> Basilan <strong>and</strong>Manila (2009).44 RamaRao, Saumya, Marl<strong>in</strong>a Lacuesta, Marilou Costello, BlesildaPangolibay <strong>and</strong> Heidi Jones (2003). “The l<strong>in</strong>k between qualityof care <strong>and</strong> contraceptive use”, In: <strong>International</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Perspectives, 29(2):76-83. http://www.popcouncil.org/pdfs/frontiers/journals/IFPPRamaRao.pdf, retrieved on 20 November2010.45 Costello, Marilou, Marl<strong>in</strong>a Lacuesta, Saumya RamaRao <strong>and</strong>Anrudh Ja<strong>in</strong> (2001). “A client-centered approach to familyplann<strong>in</strong>g: <strong>the</strong> Davao project”, In: Studies <strong>in</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>,32[4]:302–314. http://www.popcouncil.org/pdfs/councilarticles/sfp/SFP324Costello.pdf, retrieved on 10 November 2010.46 PhilHealth Circular No. 16 (2008). 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Timor LesteTimor LesteThe Status of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> Reproductive Health<strong>in</strong> Timor-Leste:An ICPD Success Story <strong>in</strong> <strong>the</strong> Mak<strong>in</strong>gAdrian C. Hayes** Adjunct Professor, Australia Demographic <strong>and</strong> Social Research Institute, The Australian National University335

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FigureAims of <strong>the</strong> reportThe Programme of Action adopted by <strong>the</strong> <strong>International</strong>Conference on Population <strong>and</strong> Development (ICPD) <strong>in</strong>Cairo <strong>in</strong> 1994 put forward an ambitious goal:All countries should take steps to meet family-plann<strong>in</strong>gneeds of <strong>the</strong>ir populations as soon as possible <strong>and</strong> should,<strong>in</strong> all cases by <strong>the</strong> year 2015, seek to provide universalaccess to a full range of safe <strong>and</strong> reliable family-plann<strong>in</strong>gmethods <strong>and</strong> to related reproductive health services whichare not aga<strong>in</strong>st <strong>the</strong> law (United Nations, 1994: para 7.16;emphasis added).Today <strong>the</strong>re is a widespread view that nei<strong>the</strong>r <strong>the</strong><strong>in</strong>ternational community nor <strong>the</strong> majority of nationalgovernments have pursued <strong>the</strong> ICPD Programme ofAction with <strong>the</strong> level of commitment it requires <strong>and</strong>deserves. Many national family plann<strong>in</strong>g programmesappear to have lost focus <strong>and</strong> momentum.Aga<strong>in</strong>st this background, <strong>the</strong> <strong>International</strong> <strong>Council</strong> onManagement of Population Programmes (ICOMP) <strong>and</strong><strong>the</strong> <strong>Asia</strong> <strong>and</strong> <strong>Pacific</strong> Regional Office of <strong>the</strong> United NationsPopulation Fund (UNFPA) are undertak<strong>in</strong>g a reviewof <strong>the</strong> status of family plann<strong>in</strong>g <strong>in</strong> selected countries of<strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong>. The present country report is onecomponent of this broader undertak<strong>in</strong>g.The aims of this report are to:Provide a succ<strong>in</strong>ct review of <strong>the</strong> overall status of familyplann<strong>in</strong>g (FP) <strong>and</strong> related reproductive health (RH)programmes <strong>in</strong> Timor-Leste today;Identify key issues <strong>and</strong> obstacles which may be limit<strong>in</strong>guniversal access to good-quality FP services;Make recommendations (where appropriate) regard<strong>in</strong>ghow <strong>the</strong> provision of services <strong>and</strong> <strong>the</strong> practice of FPcould be improved by “reposition<strong>in</strong>g”, “revitaliz<strong>in</strong>g” oro<strong>the</strong>rwise adjust<strong>in</strong>g <strong>the</strong> national FP programme.Past achievements <strong>in</strong> familyplann<strong>in</strong>g <strong>and</strong> reproductivehealthTimor-Leste is currently <strong>the</strong> youngest new nation <strong>in</strong> <strong>the</strong>world, hav<strong>in</strong>g ga<strong>in</strong>ed full <strong>in</strong>dependence after a bitter <strong>and</strong>protracted struggle only <strong>in</strong> 2002. It is estimated that <strong>the</strong>violence follow<strong>in</strong>g <strong>the</strong> 1999 referendum destroyed about80 per cent of all health cl<strong>in</strong>ics <strong>and</strong> schools, as well as muchof <strong>the</strong> country’s electricity generat<strong>in</strong>g capacity. All <strong>the</strong>normal political <strong>and</strong> adm<strong>in</strong>istrative <strong>in</strong>stitutions needed bya modern state had to be created virtually from scratch.Demographic contextThere is not an abundance of demographic data for Timor-Leste but <strong>the</strong> broad picture is clear 1 . Relative to <strong>the</strong> restof South-East <strong>Asia</strong>, Timor-Leste is still <strong>in</strong> an early stageof its demographic transition: while death rates have beencom<strong>in</strong>g down steadily for more than half a century, birthrates have rema<strong>in</strong>ed high (see Figure 1). The United Nationshas estimated that <strong>the</strong> average crude death rate dur<strong>in</strong>g <strong>the</strong>period 2005-2010 was 8.8 deaths per 1,000 population,<strong>and</strong> <strong>the</strong> average crude birth rate dur<strong>in</strong>g <strong>the</strong> same periodwas 40.2 births per 1,000 population. The 2003 Timor-Leste Demographic <strong>and</strong> Health Survey (DHS) recordeda total fertility rate (TFR) of 7.8 children per woman, <strong>the</strong>highest <strong>in</strong> <strong>the</strong> world 2 . The grow<strong>in</strong>g difference between <strong>the</strong>number of births <strong>and</strong> <strong>the</strong> number of deaths every yearresults <strong>in</strong> a high population growth rate (estimated by <strong>the</strong>United Nations to be 3.3 per cent per annum dur<strong>in</strong>g <strong>the</strong>period 2005-2010).Figure50403020101Crude birth <strong>and</strong> death rates, Timor-Leste,1950-201001950-55 1960-65 1970-75 1980-85 1990-95 2000-05National <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> PolicyThe National <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Policy was established <strong>in</strong>2004, after significant consultations with stakeholders,<strong>in</strong>clud<strong>in</strong>g religious leaders. It is noteworthy that an FPprogramme was established so early <strong>in</strong> <strong>the</strong> history of <strong>the</strong>new nation. The Prime M<strong>in</strong>ister at <strong>the</strong> time lent his activesupport. The policy enjoys good support <strong>in</strong> parliament, <strong>and</strong>is deliberately designed so as not to offend <strong>the</strong> teach<strong>in</strong>gs of<strong>the</strong> Roman Catholic Church.The rationale for <strong>the</strong> national FP policy builds on <strong>the</strong>country’s constitution, which states (section 57): “everyonehas <strong>the</strong> right to health <strong>and</strong> medical care <strong>and</strong> <strong>the</strong> duty toprotect <strong>and</strong> promote <strong>the</strong>m”. Given <strong>the</strong> very high level offertility <strong>in</strong> <strong>the</strong> country at <strong>the</strong> time, it was clear dur<strong>in</strong>gconsultations held <strong>in</strong> 2003 that <strong>the</strong> “majority of <strong>the</strong> people,CDRCBR337

<strong>in</strong>clud<strong>in</strong>g <strong>the</strong> Catholic Church leaders of Timor Leste,have expressed <strong>the</strong>ir support for implementation of [a]family plann<strong>in</strong>g programme” (MOH, 2004a: 4). Thepolicy document makes explicit reference to <strong>the</strong> ICPDProgramme of Action, not<strong>in</strong>g that <strong>the</strong> latter “shifted <strong>the</strong>population debate away from a demographic framework,with its focus on population control, to a reproductivehealth framework, with a focus on meet<strong>in</strong>g <strong>the</strong> needs of<strong>in</strong>dividuals <strong>and</strong> couples” (MOH, 2004a: 6). The “guid<strong>in</strong>gpr<strong>in</strong>ciple” of <strong>the</strong> policy is “‘plann<strong>in</strong>g a family’ with<strong>in</strong> <strong>the</strong>context of responsible parenthood” (MOH, 2004a: 7) 3 .Among its clauses <strong>the</strong> policy states: “In order to ensurethat all couples <strong>and</strong> <strong>in</strong>dividuals <strong>in</strong> Timor-Leste have <strong>the</strong>means <strong>and</strong> <strong>in</strong>formation needed to make <strong>in</strong>formed <strong>and</strong> freechoices about <strong>the</strong> number <strong>and</strong> spac<strong>in</strong>g of <strong>the</strong>ir children,<strong>the</strong> Government undertakes to make accessible at all levelsof <strong>the</strong> public health system, with technical <strong>and</strong> f<strong>in</strong>ancialassistance from <strong>the</strong> <strong>in</strong>ternational community if necessary,family plann<strong>in</strong>g, <strong>in</strong>clud<strong>in</strong>g natural family plann<strong>in</strong>g,<strong>in</strong>formation, counsel<strong>in</strong>g <strong>and</strong> services” (MOH, 2004a:9-10). The policy covers service delivery (both healthcentre-basedservices <strong>and</strong> outreach activities), humanresources <strong>and</strong> <strong>in</strong>formation, education <strong>and</strong> communication(IEC).The M<strong>in</strong>istry of Health has overall responsibility forimplement<strong>in</strong>g <strong>the</strong> national family plann<strong>in</strong>g policy. Thisresponsibility rests with <strong>the</strong> Department of Maternal <strong>and</strong>Child Health, ensur<strong>in</strong>g that FP is <strong>in</strong>tegrated with o<strong>the</strong>rreproductive health services (as advocated by ICPD).Implementation is also guided by <strong>the</strong> M<strong>in</strong>istry’s NationalReproductive Health Strategy 2004-2015 (MOH, 2004b).The strategy has four ma<strong>in</strong> components:Young people’s sexual <strong>and</strong> reproductive healthReproductive choice (family plann<strong>in</strong>g)Safe mo<strong>the</strong>rhoodGeneral reproductive health.FP <strong>and</strong> RH programmes are implemented <strong>in</strong> partnershipwith o<strong>the</strong>r stakeholders, <strong>in</strong>clud<strong>in</strong>g communities <strong>and</strong>o<strong>the</strong>r relevant government departments, <strong>and</strong> threenational work<strong>in</strong>g groups have been established (one eachon FP, RH, <strong>and</strong> adolescent reproductive health) withbroad stakeholder representation to provide a forum fordiscussion <strong>and</strong> debate <strong>and</strong> facilitate wide ownership of<strong>the</strong> programme. Timor-Leste’s system of governance isadm<strong>in</strong>istratively decentralized so much of <strong>the</strong> responsibilityfor implementation of programme activities lies with <strong>the</strong>districts <strong>and</strong> <strong>the</strong>ir local communities. Accord<strong>in</strong>g to <strong>the</strong>strategy document:As with education, community actionfor health is critical <strong>in</strong> all <strong>the</strong> priorityareas of <strong>in</strong>terventions outl<strong>in</strong>ed below.The community has a particularly strongrole to play <strong>in</strong> streng<strong>the</strong>n<strong>in</strong>g l<strong>in</strong>kagewith health services, <strong>in</strong> <strong>in</strong>creas<strong>in</strong>gawareness of reproductive health needs<strong>and</strong> <strong>in</strong> improv<strong>in</strong>g <strong>the</strong> quality of care. In<strong>the</strong>se areas, <strong>in</strong>creased knowledge of <strong>the</strong>community results <strong>in</strong> <strong>in</strong>creased actionfor health <strong>and</strong> <strong>in</strong>creased participation <strong>in</strong>problem-solv<strong>in</strong>g to meet maternal <strong>and</strong>newborn health needs.As decentralization streng<strong>the</strong>ns, efforts<strong>and</strong> plann<strong>in</strong>g will <strong>in</strong>clude streng<strong>the</strong>n<strong>in</strong>gof district <strong>and</strong> community forums sothat community representatives canactively assume ownership of reproductivestrategies <strong>and</strong> pass this ownership on [to]<strong>the</strong> community <strong>in</strong> general. For community<strong>in</strong>terventions, skills for communitymobilization, community dialogue,communication, research, educationalapproaches <strong>and</strong> for <strong>in</strong>teract<strong>in</strong>g with <strong>the</strong>community, need to be assessed.Community efforts should work closelywith advocacy efforts of reproductivehealth programs. Several community<strong>in</strong>terventions are advocacy-oriented,<strong>in</strong>creas<strong>in</strong>g <strong>the</strong> “dem<strong>and</strong>” fromcommunities, rais<strong>in</strong>g communityawareness about reproductive health issues<strong>and</strong> participation <strong>in</strong> <strong>the</strong> decisions taken at<strong>the</strong> district level for f<strong>in</strong>d<strong>in</strong>g solutions <strong>and</strong>allocat<strong>in</strong>g resources.The various levels of <strong>the</strong> district healthservices (DHS) are directly responsible for338

plann<strong>in</strong>g, implement<strong>in</strong>g, <strong>and</strong> manag<strong>in</strong>gRH program activities. The structureof <strong>the</strong> MOH DHS extends from <strong>the</strong>first po<strong>in</strong>t of contact, <strong>the</strong> Health Post,to more advanced services <strong>in</strong> <strong>the</strong> HealthCentre with small mobile cl<strong>in</strong>ics provid<strong>in</strong>gservices to significant population groups <strong>in</strong><strong>the</strong> absence of fixed facilities. …With<strong>in</strong> <strong>the</strong> District Health ManagementTeam (DHMT) <strong>the</strong>re will be appo<strong>in</strong>teda focal po<strong>in</strong>t for RH who shouldcoord<strong>in</strong>ate <strong>and</strong> <strong>in</strong>tegrate <strong>the</strong> componentsof Reproductive Health. These districtofficers will work with o<strong>the</strong>r DHMTofficers to establish mechanisms for RHSactivities with<strong>in</strong> <strong>the</strong> district framework.It is <strong>the</strong> RH focal po<strong>in</strong>t responsibility, asa component of <strong>the</strong> DHMT, to ensuretechnical guidance, support (flow ofsupplies, tra<strong>in</strong><strong>in</strong>g needs <strong>and</strong> delivery,access to guidel<strong>in</strong>es <strong>and</strong> protocols) <strong>and</strong>monitor<strong>in</strong>g of RH are <strong>in</strong>corporated <strong>in</strong>to<strong>the</strong> DHP plann<strong>in</strong>g, processes, monitor<strong>in</strong>g<strong>and</strong> evaluation. …A referral system feeds from <strong>the</strong> front l<strong>in</strong>ehealth services through to referral hospitalsfor ei<strong>the</strong>r anticipated cases of complicateddeliveries or for emergency obstetricservices <strong>and</strong> certa<strong>in</strong> types of familyplann<strong>in</strong>g methods, <strong>and</strong> eventually to <strong>the</strong>National Hospital <strong>in</strong> Dili for highest levelof service when required (MOH, 2004b:33-34).In 2007 <strong>the</strong> National Reproductive Health BehaviourChange Communication Strategy 2008-2012 wasdeveloped, which identified behavioural objectives foreach of <strong>the</strong> four components of <strong>the</strong> National ReproductiveHealth Strategy. The objective (“key behaviour”) for FPis for women <strong>and</strong> men of reproductive age to space <strong>the</strong>irchildren by at least three years.The key policy documents for FP <strong>and</strong> RH are remarkablefor <strong>the</strong>ir clarity of purpose <strong>and</strong> objectives, <strong>and</strong> for <strong>the</strong>succ<strong>in</strong>ct yet comprehensive way <strong>the</strong>y outl<strong>in</strong>e wellthought-outstrategies for atta<strong>in</strong><strong>in</strong>g <strong>the</strong>se objectives.Many lessons learned from <strong>in</strong>ternational experience havebeen <strong>in</strong>corporated. Also apparent is <strong>the</strong> conviction withwhich ICPD pr<strong>in</strong>ciples have been embraced <strong>and</strong> are be<strong>in</strong>gacted upon. Unlike many countries <strong>in</strong> <strong>the</strong> region witholder FP programmes which were established pre-ICPD,Timor-Leste has been spared <strong>the</strong> difficulty of convert<strong>in</strong>ga population control programme <strong>in</strong>to a programmepromot<strong>in</strong>g reproductive rights. Timor-Leste’s programmehas been firmly grounded <strong>in</strong> a human rights perspectivefrom its <strong>in</strong>ception.As <strong>the</strong> passage from <strong>the</strong> Strategy document quoted aboveillustrates, those plann<strong>in</strong>g FP/RH programmes are alsoeager that community “ownership” of services should beencouraged.Changes <strong>in</strong> fertility behaviour<strong>and</strong> fertility outcomesThe first Demographic <strong>and</strong> Health Survey <strong>in</strong> <strong>in</strong>dependentTimor-Leste was conducted <strong>in</strong> 2003. Ano<strong>the</strong>r wasconducted <strong>in</strong> 2009/10, but at <strong>the</strong> time of writ<strong>in</strong>g <strong>the</strong>present report only limited prelim<strong>in</strong>ary results are available(MEASURE DHS, 2010). Table 1 summarizes relevantchanges between <strong>the</strong> two surveys. We have also <strong>in</strong>cludedsimilar statistics from previous DHS when East Timorwas considered part of Indonesia, although it should beremembered that at that time many of those counted aspractis<strong>in</strong>g FP <strong>in</strong> <strong>the</strong> territory were actually Indonesiansliv<strong>in</strong>g <strong>and</strong> work<strong>in</strong>g <strong>in</strong> East Timor, many of <strong>the</strong>m civilservants.The very low knowledge level about contraception recorded<strong>in</strong> 2003 is ano<strong>the</strong>r sign of how atypical Timor-Leste is of<strong>the</strong> region. It will be <strong>in</strong>terest<strong>in</strong>g to see how this statistic mayhave changed <strong>in</strong> <strong>the</strong> 2009/10 survey. The 2009 Basel<strong>in</strong>eStudy for RH Behaviour Change Communication foundthat just over 50 per cent of married women 15-49 hadheard of birth spac<strong>in</strong>g but only 11 per cent of <strong>the</strong> samplecould identify three or more methods of contraception(Mosquera et al., 2009a).The DHS data suggest that <strong>the</strong> contraceptive prevalencerate (CPR) (all methods) has <strong>in</strong>creased by at least 12percentage po<strong>in</strong>ts <strong>in</strong> 6 years, that is, an average of 2 po<strong>in</strong>tsper year. 4 This is a respectable rate of <strong>in</strong>crease <strong>in</strong> CPR,339

TableTable1Contraceptive prevalence rate, awareness of at least one modern method of contraception <strong>and</strong> totalfertility rate, Timor-Leste, by year of survey: 1991, 1997, 2003 <strong>and</strong> 2009/10Know at least onemodern method of contraception (%)Contraceptive prevalence rate1994 1997 2003 2009/1048.3 61.9 38.2 --All methods (%) 22.6 26.7 10.0 22.4Modern methods (%) 20.7 25.1 8.9 21.2Total fertility rate(children per woman)4.7 4.4 7.8 5.7Source: Data from Indonesia <strong>and</strong> Timor-Leste DHS.Note: “Know at least one modern method” <strong>and</strong> CPR are for all currently married women aged 15-49 years, except for 2003 where“Knowledge” is for ever-married women; TFR is average for three years preced<strong>in</strong>g <strong>the</strong> survey.although admittedly beg<strong>in</strong>n<strong>in</strong>g from a very low base.Also, presumably before <strong>the</strong> new FP programme waslaunched, <strong>the</strong>re was a small but significant pent-up “latentdem<strong>and</strong>” for FP. We will be able to assess recent trends<strong>in</strong> fertility <strong>and</strong> fertility behaviour <strong>in</strong> far more depth when<strong>the</strong> complete 2009/10 DHS f<strong>in</strong>d<strong>in</strong>gs are published. TheRH Behavioural Change Communication Basel<strong>in</strong>e Study<strong>in</strong> 2009 found that roughly 25 per cent of <strong>the</strong> sample werecurrently practis<strong>in</strong>g family plann<strong>in</strong>g. Of those who hadgiven birth dur<strong>in</strong>g <strong>the</strong> previous 5 years, slightly less than30 per cent had practised birth spac<strong>in</strong>g.The two-child decl<strong>in</strong>e <strong>in</strong> TFR should not be <strong>in</strong>terpretedas a simple <strong>in</strong>dicator of <strong>the</strong> “success” of <strong>the</strong> FP programme.Fertility had undoubtedly been very high <strong>in</strong> <strong>the</strong> East Timorpopulation for a long time, but <strong>the</strong> extremely high fertilitylevels measured <strong>in</strong> 2003 were probably exceptional evenfor East Timor. They most likely reflect <strong>in</strong> part a so-called“tempo effect” where for a while fertility decl<strong>in</strong>ed becauseof political unrest <strong>and</strong> violence <strong>and</strong> <strong>the</strong>n, when relativecalm was restored dur<strong>in</strong>g <strong>the</strong> adm<strong>in</strong>istration of <strong>the</strong> UnitedNations Transitional Adm<strong>in</strong>istration <strong>in</strong> East Timor (2000-2002), those who had postponed childbear<strong>in</strong>g made up forlost time, 5 result<strong>in</strong>g <strong>in</strong> a temporary baby-boom6. Whendata from <strong>the</strong> 2010 population census <strong>and</strong> <strong>the</strong> latest DHSbecome available we will be <strong>in</strong> a position to give a moredef<strong>in</strong>itive account of fertility outcomes.Current issues <strong>in</strong> <strong>the</strong> nationalprogrammeThis country study does not attempt a detailed assessmentof specific components of <strong>the</strong> national FP <strong>and</strong> relatedRH programmes. An <strong>in</strong>-depth analysis will be availablefrom <strong>the</strong> UNFPA Programme Review which is due tobe completed about <strong>the</strong> same time as <strong>the</strong> present report.The purpose of our report is to flag issues concern<strong>in</strong>g <strong>the</strong>current status of FP <strong>in</strong> Timor-Leste.Develop<strong>in</strong>g an FP programme from scratch is an enormousundertak<strong>in</strong>g. Service providers <strong>and</strong> programme managershave to be recruited <strong>and</strong> tra<strong>in</strong>ed; service delivery po<strong>in</strong>tshave to be staffed, equipped, stocked, resourced <strong>and</strong>sometimes built; procurement <strong>and</strong> logistics systems have tobe designed <strong>and</strong> put <strong>in</strong>to place; quality assurance as well asmonitor<strong>in</strong>g <strong>and</strong> evaluation systems have to be established;<strong>and</strong> above all potential clients have to be <strong>in</strong>formed <strong>and</strong>educated <strong>in</strong> <strong>the</strong> use of FP <strong>and</strong> how <strong>the</strong>y can make an<strong>in</strong>formed choice – for all this <strong>the</strong>re needs to be a range ofoutreach <strong>and</strong> communication programmes. Accomplish<strong>in</strong>gall <strong>the</strong>se tasks is a tall order, especially <strong>in</strong> a poor countrywith poor communications <strong>and</strong> where education levels arelow. New systems cannot be established <strong>and</strong> expected tofunction perfectly overnight.Position<strong>in</strong>g <strong>the</strong> programmeThere are no major issues regard<strong>in</strong>g <strong>the</strong> way <strong>the</strong> nationalFP programme is currently “positioned” <strong>in</strong> Timoresesociety. The programme is already “positioned” <strong>in</strong> <strong>the</strong>most appropriate location <strong>in</strong> <strong>the</strong> M<strong>in</strong>istry of Health.FP services are provided <strong>in</strong> concert with o<strong>the</strong>r RH<strong>and</strong> maternal <strong>and</strong> child health (MCH) services, <strong>and</strong><strong>the</strong> recently <strong>in</strong>troduced Integrated Community HealthServices outreach programme (known as “SISCa”)promises to fur<strong>the</strong>r <strong>in</strong>tegrate FP/RH <strong>in</strong>to basic healthservices. Work<strong>in</strong>g groups <strong>and</strong> o<strong>the</strong>r mechanisms are <strong>in</strong>place to ensure that programme officials work well withrelevant stakeholders; <strong>and</strong> with<strong>in</strong> <strong>the</strong> state apparatus <strong>the</strong>programme’s adm<strong>in</strong>istration is suitably decentralized, <strong>and</strong><strong>the</strong>re are plans to streng<strong>the</strong>n this aspect as <strong>the</strong> programme340

exp<strong>and</strong>s <strong>and</strong> matures. In short, <strong>the</strong>re is no reason why <strong>the</strong>FP programme needs to be “repositioned” <strong>in</strong> any majorway.Evidence-based policy developmentOne impressive feature of <strong>the</strong> FP/RH programme is <strong>the</strong>commitment at <strong>the</strong> M<strong>in</strong>istry of Health to make sure thatpolicy development is evidence-based. There is currentlya shortage of relevant <strong>and</strong> reliable data, however. A fewof <strong>the</strong> ma<strong>in</strong> data sources to date, both quantitative <strong>and</strong>qualitative, are as follows:Timor-Leste Demographic <strong>and</strong> Health Survey 2003(MOH et al., 2003). This household survey wasconducted from May to August 2003; it is a nationallyrepresentative sample of 4,320 households.2009 Basel<strong>in</strong>e Study for RH Behavior ChangeCommunication (Mosquera et al., 2009a <strong>and</strong> 2009b).Designed to provide necessary data for monitor<strong>in</strong>g <strong>and</strong>evaluation of <strong>the</strong> National RH Behavioural ChangeCommunication Strategy 2008-2012. Quantitativedata were collected by conduct<strong>in</strong>g 1,088 structured<strong>in</strong>terviews <strong>in</strong> 65 villages (sucos) <strong>in</strong> all 13 districtsdur<strong>in</strong>g February <strong>and</strong> March 2009. Qualitative datawere generated through 36 focus group discussions(FGDs). The published data are extremely <strong>in</strong>terest<strong>in</strong>g<strong>and</strong> relevant for RH BCC programme development.Timor-Leste Health-care Seek<strong>in</strong>g Behaviour Study2009 (Zwi et al., 2009). Data on health-care seek<strong>in</strong>gbehaviour were collected from 771 <strong>in</strong>dividuals <strong>in</strong> anationally representative sample of 535 households<strong>in</strong> all 13 districts. These data were supplemented by38 FDGs <strong>and</strong> <strong>in</strong>-depth <strong>in</strong>terviews with health-careproviders <strong>and</strong> village heads (xefe suco).The supply of relevant statistical data will soon beexp<strong>and</strong>ed significantly with <strong>the</strong> results of <strong>the</strong> 2009/10DHS <strong>and</strong> <strong>the</strong> 2010 population census. As fur<strong>the</strong>r studiesare commissioned <strong>in</strong> response to <strong>the</strong> evolv<strong>in</strong>g data needsof <strong>the</strong> programme, it is important that wherever possible acommon sampl<strong>in</strong>g frame (adapted <strong>in</strong> <strong>the</strong> future from <strong>the</strong>2010 population census) <strong>and</strong> comparable questionnaireitems (i.e., not arbitrarily chang<strong>in</strong>g <strong>the</strong> word<strong>in</strong>g of keyquestions <strong>in</strong> each new study) be used so that <strong>the</strong> supplyof data does not become unduly fragmented over time <strong>and</strong>maximum synergy among <strong>the</strong> studies is nurtured.Exp<strong>and</strong><strong>in</strong>g <strong>and</strong> matur<strong>in</strong>g <strong>the</strong>programmeThe prelim<strong>in</strong>ary f<strong>in</strong>d<strong>in</strong>gs from <strong>the</strong> 2009/10 DHS suggestrapid growth <strong>in</strong> unmet dem<strong>and</strong> for FP s<strong>in</strong>ce <strong>the</strong> 2003survey (see Table 2). The percentage of married womenwho say <strong>the</strong>y want ano<strong>the</strong>r child soon (i.e., with<strong>in</strong> <strong>the</strong>next 2 years) has decl<strong>in</strong>ed from 32.4 to 8.5 per cent, <strong>and</strong><strong>the</strong> percentage say<strong>in</strong>g <strong>the</strong>y want no more children has<strong>in</strong>creased from 17.1 to 34.7 per cent. 7 A major change <strong>in</strong><strong>the</strong> dem<strong>and</strong> for children has clearly occurred.TableTable2Desire for children, Timor-Leste, 2003 <strong>and</strong> 2009/10Desire for children 2003(%) 2009/10(%)Have ano<strong>the</strong>r soon 32.4 8.5Have ano<strong>the</strong>r later 10.5 35.1Have ano<strong>the</strong>r, undecided when 7.0 1.2Undecided 23.6 17.1Want no more 17.1 34.7Sterilized -- 0.8Declared <strong>in</strong>fecund 9.4 2.7Total 100.0 100.1Number of women 4,066 7,922Source: Demographic <strong>and</strong> Health Surveys.341

These results suggest that about 70 per cent of marriedwomen have a need for FP, yet CPR for <strong>the</strong>se women isonly 22.4 per cent. If <strong>the</strong>se f<strong>in</strong>d<strong>in</strong>gs are robust, <strong>the</strong>n <strong>the</strong>rehas clearly been massive growth <strong>in</strong> unmet need for FP s<strong>in</strong>ce2003 (both for spac<strong>in</strong>g <strong>and</strong> limit<strong>in</strong>g). The most strik<strong>in</strong>gfeature of <strong>the</strong> 2003 f<strong>in</strong>d<strong>in</strong>gs was how little dem<strong>and</strong> forFP <strong>the</strong>re appeared to have been; <strong>the</strong> most amaz<strong>in</strong>g th<strong>in</strong>gsabout <strong>the</strong> 2009/10 f<strong>in</strong>d<strong>in</strong>gs are how huge <strong>the</strong> dem<strong>and</strong> istoday <strong>and</strong> how rapidly that dem<strong>and</strong> has grown.There may be a “dem<strong>and</strong> for FP” <strong>in</strong> <strong>the</strong> way DHS def<strong>in</strong>es“dem<strong>and</strong>”, but that does not mean that <strong>the</strong>se women willnecessarily want to be part of <strong>the</strong> national FP programme.There is an enormous opportunity here, but at <strong>the</strong> sametime an equally enormous challenge as well. The availabledata on why women who say <strong>the</strong>y do not want ano<strong>the</strong>rchild now, yet who are not practis<strong>in</strong>g FP, are fragmentarybut <strong>the</strong> qualitative data <strong>in</strong>dicate that all <strong>the</strong> usual factorsplay a role: lack of knowledge or underst<strong>and</strong><strong>in</strong>g about FP;husb<strong>and</strong> does not agree to use of modern contraception;fear of side effects; distance to nearest health centre <strong>and</strong><strong>the</strong> cost of travel; o<strong>the</strong>r real or perceived cost factors,<strong>in</strong>clud<strong>in</strong>g opportunity costs; hav<strong>in</strong>g a previous unfortunateexperience at a health centre; preferred method notavailable etc. (Mosquera et al., 2009a; Zwi et al., 2009).The new RH BCC programme is designed to address suchconcerns, but it has not been fully rolled out yet. Part of<strong>the</strong> challenge – to which programmes <strong>in</strong> o<strong>the</strong>r countrieshave sometimes not risen – is to treat women <strong>and</strong> <strong>the</strong>irpartners with equal respect whe<strong>the</strong>r <strong>the</strong>y choose to jo<strong>in</strong><strong>the</strong> programme or not.Important partners <strong>in</strong> <strong>the</strong> programme’s advocacy <strong>and</strong> BCCcomponents are Timor-Leste Asistensia Integradu Saude(TAIS), which is funded by <strong>the</strong> United States Agencyfor <strong>International</strong> Development (USAID) <strong>and</strong> <strong>the</strong> HealthAlliance <strong>International</strong> (HAI), funded by <strong>the</strong> AustralianAgency for <strong>International</strong> Development (AusAID) <strong>and</strong>USAID.Dur<strong>in</strong>g <strong>the</strong> past few years much effort has necessarilyfocused on develop<strong>in</strong>g <strong>the</strong> supply side of <strong>the</strong> FP programme.Exp<strong>and</strong><strong>in</strong>g <strong>the</strong> supply of services <strong>in</strong> a way which ensuresquality yet is cost-efficient, <strong>and</strong> which is nei<strong>the</strong>r too farahead nor too far beh<strong>in</strong>d <strong>the</strong> curve of grow<strong>in</strong>g dem<strong>and</strong> forservices, rema<strong>in</strong>s a constant challenge. Tra<strong>in</strong><strong>in</strong>g midwives,doctors <strong>and</strong> programme staff is an ongo<strong>in</strong>g task. Qualityassurance is ano<strong>the</strong>r constant challenge.A cadre of largely volunteer fieldworkers who will provideFP/RH education <strong>and</strong> counsell<strong>in</strong>g at <strong>the</strong> village level isenvisioned for <strong>the</strong> com<strong>in</strong>g years.Manag<strong>in</strong>g contraceptive supplies to ensure “contraceptivesecurity” is yet ano<strong>the</strong>r constant challenge. There havebeen some “stock-outs” (events that occur when <strong>in</strong>ventoryhas been exhausted) <strong>and</strong> maldistribution of commodities<strong>in</strong> <strong>the</strong> past (Belton, 2010). Lessons have been learned <strong>and</strong>applied. RH commodities are listed on <strong>the</strong> M<strong>in</strong>istry ofHealth’s Essential Drug List; Belton (2010) recommendedthat <strong>the</strong>y be upgraded to “vital” commodities s<strong>in</strong>ce“maternal <strong>and</strong> <strong>in</strong>fant mortality are high <strong>and</strong> access toemergency obstetric care very limited”. It is certa<strong>in</strong>ly crucialthat l<strong>in</strong>ger<strong>in</strong>g problems with supply systems be addressedpromptly <strong>in</strong> <strong>the</strong> light of recent <strong>in</strong>dications that dem<strong>and</strong> forservices may be at <strong>the</strong> po<strong>in</strong>t of ris<strong>in</strong>g rapidly.Currently UNFPA pays for all FP commodities, witha major f<strong>in</strong>ancial contribution from AusAID, but <strong>the</strong>government has <strong>in</strong>dicated it is prepar<strong>in</strong>g to share <strong>the</strong> bill,start<strong>in</strong>g perhaps <strong>in</strong> 2011.An important partner <strong>in</strong> service provision is Marie Stopes<strong>International</strong>, 8 funded partly by AusAID. Caritas providescounsell<strong>in</strong>g, has nuns tra<strong>in</strong>ed <strong>in</strong> FP (all methods) <strong>and</strong> willopen <strong>the</strong> new Centre for <strong>Family</strong> <strong>in</strong> Dili next year. 9Underst<strong>and</strong><strong>in</strong>g <strong>the</strong> currentsituationIf <strong>the</strong> f<strong>in</strong>al report of <strong>the</strong> 2009/10 DHS confirms that <strong>the</strong>rehas been massive growth <strong>in</strong> unmet dem<strong>and</strong> for FP, <strong>the</strong>n thisfactor has major implications for FP/RH programm<strong>in</strong>g.Where women say <strong>the</strong>y do not want ano<strong>the</strong>r child <strong>in</strong><strong>the</strong> next 2-3 years but are not practis<strong>in</strong>g FP, we need tounderst<strong>and</strong> <strong>the</strong> situation clearly. Tractable obstacles toaccess<strong>in</strong>g FP services need to be removed. The M<strong>in</strong>istry ofHealth recognizes <strong>the</strong> challenge of gett<strong>in</strong>g <strong>the</strong> services “out<strong>the</strong>re” as close as possible to <strong>the</strong> people who need <strong>the</strong>m.There are some subtle dimensions to this challenge too.A strong po<strong>in</strong>t <strong>in</strong> <strong>the</strong> M<strong>in</strong>istry’s tentative plan to have avolunteer fieldworker <strong>in</strong> every village; such volunteerswill be “counsellors” not “recruiters”. If <strong>the</strong> outreach <strong>and</strong>communication programmes are too forceful, <strong>the</strong>y mightraise memories of <strong>the</strong> “strong persuasion” tactics of <strong>the</strong>Indonesian programme.The Catholic Church <strong>in</strong> East Timor had been a staunchdefender of human rights dur<strong>in</strong>g <strong>the</strong> country’s recenthistory. The Church is currently mak<strong>in</strong>g a valuablecontribution to <strong>the</strong> national FP/RH programme by<strong>in</strong>sist<strong>in</strong>g that <strong>the</strong> programme should be structured <strong>in</strong>such a way that people are encouraged to th<strong>in</strong>k deeply<strong>and</strong> responsibly about what it means to plan <strong>the</strong>ir families<strong>and</strong> not accept “modern practices” uncritically. O<strong>the</strong>rs maysee this <strong>in</strong>sistence as a h<strong>in</strong>drance <strong>and</strong> may believe that<strong>in</strong>stitutionaliz<strong>in</strong>g “<strong>in</strong>formed consent” is sufficient. Therehas been a healthy dialogue between programme officials<strong>and</strong> <strong>the</strong> Church, <strong>and</strong> among o<strong>the</strong>r stakeholders. This342

dialogue needs to cont<strong>in</strong>ue to prevent misunderst<strong>and</strong><strong>in</strong>gsfrom tak<strong>in</strong>g root <strong>and</strong> potentially underm<strong>in</strong><strong>in</strong>g <strong>the</strong> widesupport that <strong>the</strong> programme currently enjoys.RecommendationsThe FP/RH programme <strong>in</strong> Timor-Leste is still young. Thema<strong>in</strong> concerns are not so much whe<strong>the</strong>r <strong>the</strong> programmeneeds to be “repositioned” or “revitalized” but how it canavoid common problems <strong>and</strong> pitfalls as <strong>the</strong> programmegrows <strong>and</strong> matures. (The follow<strong>in</strong>g recommendationswere presented as discussion po<strong>in</strong>ts for <strong>the</strong> UNFPA <strong>and</strong>ICOMP Regional Consultation on <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>in</strong><strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong>: Address<strong>in</strong>g <strong>the</strong> Challenges, whichwas held <strong>in</strong> Bangkok, from 8 to 10 December 2010.)Recommendation 1Streng<strong>the</strong>n <strong>the</strong> dialogue among allstakeholders, especially with <strong>the</strong>Catholic Church.Such a dialogue already exists through <strong>the</strong> Work<strong>in</strong>g Groupfor FP/RH <strong>and</strong> o<strong>the</strong>r mechanisms, but <strong>the</strong> work<strong>in</strong>g groupdoes not meet regularly, <strong>and</strong> while <strong>the</strong> collaboration among<strong>the</strong> programme’s partners is truly commendable, agreementsreached <strong>in</strong> <strong>the</strong> past should not be taken for granted butra<strong>the</strong>r built on <strong>and</strong> exp<strong>and</strong>ed. There is some discussion <strong>in</strong>Dili currently regard<strong>in</strong>g “how fast <strong>the</strong> programme shouldmove forward”, for example. For some, this is essentiallya technical question about deliver<strong>in</strong>g health services; foro<strong>the</strong>rs it is <strong>in</strong>separable from o<strong>the</strong>r questions regard<strong>in</strong>gchang<strong>in</strong>g values <strong>and</strong> spiritual development. There iscommon ground but it seems to depend significantly ontacit underst<strong>and</strong><strong>in</strong>gs at present. This leaves <strong>the</strong> programmevulnerable to unforeseen “shocks” <strong>in</strong> <strong>the</strong> future.Recommendation 2Streng<strong>the</strong>n <strong>the</strong> focus on encourag<strong>in</strong>gbirth spac<strong>in</strong>g <strong>and</strong> meet<strong>in</strong>g unmetdem<strong>and</strong> through evidence-based<strong>in</strong>itiatives.The dem<strong>and</strong> for FP services is likely to grow considerablydur<strong>in</strong>g <strong>the</strong> next 5 years if approximately 50 per cent of allmarried women do not want a child <strong>in</strong> <strong>the</strong> next 2-3 years yetare not us<strong>in</strong>g any method of contraception. There is a needfor more data (quantitative <strong>and</strong> qualitative) on who <strong>the</strong>sewomen are, what <strong>the</strong>ir values <strong>and</strong> aspirations (especiallyregard<strong>in</strong>g family life) are, <strong>and</strong> what factors determ<strong>in</strong>e <strong>the</strong>irfertility behaviour. The programme needs to be focused, butit is important for policymakers to remember that people’sfertility behaviour responds to many social, cultural <strong>and</strong>economic factors (which <strong>the</strong>mselves are likely to changerapidly <strong>in</strong> com<strong>in</strong>g years), not just to a national FP/RHprogramme. Fur<strong>the</strong>r, it is crucial that <strong>the</strong>se women shouldplay an important role <strong>in</strong> <strong>the</strong> design <strong>and</strong> monitor<strong>in</strong>g of <strong>the</strong>services <strong>the</strong>y are offered. Policymakers <strong>and</strong> programmemanagers can learn from <strong>in</strong>ternational best practices <strong>and</strong>can contribute to <strong>the</strong> latter too.ConclusionThe aim of family-plann<strong>in</strong>g programmesmust be to enable couples <strong>and</strong> <strong>in</strong>dividualsto decide freely <strong>and</strong> responsibly <strong>the</strong>number <strong>and</strong> spac<strong>in</strong>g of <strong>the</strong>ir children<strong>and</strong> to have <strong>the</strong> <strong>in</strong>formation <strong>and</strong> meansto do so <strong>and</strong> to ensure <strong>in</strong>formed choices<strong>and</strong> make available a full range of safe<strong>and</strong> effective methods. … The pr<strong>in</strong>cipleof <strong>in</strong>formed choice is essential to <strong>the</strong>long-term success of family-plann<strong>in</strong>gprogrammes. … Government goals forfamily plann<strong>in</strong>g should be def<strong>in</strong>ed <strong>in</strong>terms of unmet needs for <strong>in</strong>formation <strong>and</strong>services (United Nations, 1994: para7.12).Timor-Leste’s national FP/RH programme is relatively new<strong>and</strong> it is off to a good start. It enjoys strong political supportfrom <strong>the</strong> government, parliament <strong>and</strong> key stakeholders,<strong>in</strong>clud<strong>in</strong>g <strong>the</strong> Catholic Church. The programme is unique<strong>in</strong> <strong>the</strong> region <strong>in</strong> <strong>the</strong> way it was established after ICPD<strong>and</strong> fully embraces <strong>the</strong> pr<strong>in</strong>ciples advocated <strong>in</strong> <strong>the</strong> 1994Programme of Action. It needs no “reposition<strong>in</strong>g”, <strong>and</strong>it is too young to talk of its “revitalization”. The ma<strong>in</strong>challenges are exp<strong>and</strong><strong>in</strong>g <strong>the</strong> programme to meet grow<strong>in</strong>gdem<strong>and</strong> <strong>and</strong> at <strong>the</strong> same time ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g <strong>the</strong> broad publicsupport <strong>the</strong> programme currently enjoys. The secret is tostay committed to <strong>the</strong> ICPD pr<strong>in</strong>ciples <strong>and</strong> deepen <strong>the</strong>emphasis on client-orientation even as activities are scaledup.End Note1 One needs to be careful <strong>in</strong> us<strong>in</strong>g published statistics on Timor-Leste s<strong>in</strong>ce many are calculated from <strong>in</strong>complete or unreliable datasets, <strong>and</strong> some demographic rates can be calculated only by us<strong>in</strong>g“<strong>in</strong>direct estimation techniques” based on assumptions which mightnot be accurate for Timor-Leste.343

2 The (period) TFR is <strong>the</strong> sum of age-specific fertility rates at agiven time <strong>and</strong> can be <strong>in</strong>terpreted as <strong>the</strong> number of live births <strong>the</strong>average woman would bear dur<strong>in</strong>g her lifetime if she experienced<strong>the</strong> age-specific fertility rates observed at that time throughout herreproductive years.3 The policy also recognizes <strong>the</strong> importance of FP for atta<strong>in</strong><strong>in</strong>g <strong>the</strong>Millennium Development Goals: “The Government … recognizes<strong>the</strong> importance of reduc<strong>in</strong>g <strong>the</strong> country’s high population growthrate <strong>and</strong> of spac<strong>in</strong>g births as a means of reach<strong>in</strong>g its goals oferadicat<strong>in</strong>g poverty, reduc<strong>in</strong>g <strong>the</strong> country’s high levels of maternal<strong>and</strong> <strong>in</strong>fant <strong>and</strong> child mortality, <strong>and</strong> improv<strong>in</strong>g <strong>the</strong> health of mo<strong>the</strong>rs<strong>and</strong> children <strong>in</strong> l<strong>in</strong>e with <strong>the</strong> goals <strong>and</strong> targets set out <strong>in</strong> <strong>the</strong> UnitedNations Millennium Declaration” (MOH, 2004a: 8).4 The 2003 survey was fielded between May <strong>and</strong> August, <strong>and</strong> <strong>the</strong>2009/10 survey between August <strong>and</strong> February; tak<strong>in</strong>g <strong>the</strong> midpo<strong>in</strong>tof each period, this suggests that <strong>the</strong> period between <strong>the</strong> 2surveys is actually 6 years <strong>and</strong> 4.5 months, respectively.5 Also, <strong>the</strong>re was no active promotion of FP dur<strong>in</strong>g <strong>the</strong> UnitedNations Transitional Adm<strong>in</strong>istration <strong>in</strong> East Timor.6 Similar baby-booms have often been observed after periods ofpolitical unrest <strong>and</strong> bloodshed. Some of <strong>the</strong> motivation is selfconsciouslyto “replace” some of those who have been killed. Forexample, see Desbarats (1995).7 In <strong>the</strong> 2003 survey those women (or <strong>the</strong>ir partners) who hadbeen sterilized are not listed as a separate category <strong>in</strong> <strong>the</strong> relevanttable; thus, some women who say <strong>the</strong>y want no more children, forexample, could already be sterilized. However, <strong>the</strong> percentage ofpeople sterilized <strong>in</strong> Timor-Leste is so small that this will not affect<strong>the</strong> overall percentage distribution significantly.8 Except for one cl<strong>in</strong>ic of its own <strong>in</strong> Dili, Marie Stopes <strong>International</strong>provides services <strong>in</strong> close collaboration with <strong>the</strong> M<strong>in</strong>istry of Health,work<strong>in</strong>g through <strong>the</strong> government’s own Community HealthCentres <strong>and</strong> Health Posts.__________ (2004b). National Reproductive HealthStrategy 2004-2015. Dili: MOH.__________ <strong>and</strong> National Statistics Directorate et al.(2003). Timor-Leste Demographic <strong>and</strong> Health Survey 2003,Newcastle, Australia: University of Newcastle.Mosquera, Mario, Rafael Obregon, Lawrence Wood,Marianne Viatour <strong>and</strong> Andrew Carlson (2009a). <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> <strong>and</strong> General Reproductive Health: Quantitative<strong>and</strong> Qualitative Analysis, Dili: UNFPA.__________ (2009b). Youth Reproductive Health Report:Quantitative <strong>and</strong> Qualitative Analysis, Dili: UNFPA.United Nations (1994). Report of <strong>the</strong> <strong>International</strong>Conference on Population <strong>and</strong> Development, Cairo, 5-13September 1994 (United Nations publication, Sales No.E.95.XIII.18), chap. I, resolution 1, annex.__________ (2009). World Population Prospects: The2008 Revision (United Nations publication, Sales No.E.05.XIII.7).Zwi, Anthony B., Ilse Blignault, Diana Glazebrook,Veronica Correia, Ca<strong>the</strong>r<strong>in</strong>e R. Bateman Steel, EliasFerreira <strong>and</strong> Basilio M. P<strong>in</strong>to (2009). Timor-Leste: HealthCare Seek<strong>in</strong>g Behaviour Study 2009, Sydney: University ofNew South Wales.9 An <strong>in</strong>dication of <strong>the</strong> cooperation between <strong>the</strong> Catholic Church<strong>and</strong> <strong>the</strong> national FP programme is that <strong>in</strong> <strong>the</strong> Dili diocese whenyoung couples receive <strong>the</strong>ir premarital counsell<strong>in</strong>g <strong>the</strong> Church hasnow started request<strong>in</strong>g <strong>the</strong> M<strong>in</strong>istry to send along a midwife whocan expla<strong>in</strong> all methods of contraception to <strong>the</strong> soon-to-be marriedcouples. While <strong>the</strong> Church makes it clear it does not approve ofmodern methods it also emphasizes this is a choice that couplesmust make for <strong>the</strong>mselves, freely <strong>and</strong> responsibly. If a young couplechooses a modern method <strong>the</strong>n <strong>the</strong>y are <strong>in</strong>formed where <strong>the</strong>y cango <strong>in</strong> <strong>the</strong> national programme to receive <strong>the</strong> method.ReferencesBelton, Suzanne (2010). UNFPA Strategy to EnhanceReproductive Health Commodity, Consultant’s Report,London: HLSP (Mott MacDonald Limited).Desbarats, Jacquel<strong>in</strong>e (1995). Prolific Survivors: PopulationChange <strong>in</strong> Cambodia 1975-1993, Tempe, Arizona:Arizona State University Press.MEASURE DHS (2010). Timor-Leste Demographic <strong>and</strong>Health Survey 2009-2010: Prelim<strong>in</strong>ary Report (April),. Dili:National Statistics Directorate, M<strong>in</strong>istry of F<strong>in</strong>ance.M<strong>in</strong>istry of Health (2004a). National <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Policy. Dili: MOH.344

Papua New Gu<strong>in</strong>eaPapua New Gu<strong>in</strong>ea<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>in</strong> Papua New Gu<strong>in</strong>ea:Current Status <strong>and</strong> Prospects for Reposition<strong>in</strong>g <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> <strong>in</strong> <strong>the</strong> Development AgendaGeoffrey Hayes** Consultant Demographer, New Zeal<strong>and</strong>.345

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Introduction: family plann<strong>in</strong>g<strong>and</strong> fertility decl<strong>in</strong>eMap of Papua New Gu<strong>in</strong>ea<strong>Family</strong> plann<strong>in</strong>g <strong>and</strong> contraception:Traditional <strong>and</strong> modern conceptsAccord<strong>in</strong>g to <strong>the</strong> <strong>International</strong> Planned ParenthoodFederation (IPPF), family plann<strong>in</strong>g refers to:[T]he conscious effort of couples <strong>and</strong><strong>in</strong>dividuals to plan for <strong>and</strong> atta<strong>in</strong> <strong>the</strong>irdesired number of children <strong>and</strong> to regulate<strong>the</strong> spac<strong>in</strong>g <strong>and</strong> tim<strong>in</strong>g of <strong>the</strong>ir births.<strong>Family</strong> plann<strong>in</strong>g is achieved throughcontraception <strong>and</strong> through <strong>the</strong> treatmentof <strong>in</strong>voluntary <strong>in</strong>fertility 1 .Def<strong>in</strong>ed <strong>in</strong> this way, “family plann<strong>in</strong>g” is not a completelyforeign <strong>in</strong>troduction to Papua New Gu<strong>in</strong>ea’s society <strong>and</strong>culture. Traditional methods of contraception have beenidentified throughout Papua New Gu<strong>in</strong>ea’s many societies<strong>and</strong> cultures (Bulmer, 1971 McDowell, 1988) <strong>and</strong> someof <strong>the</strong>se cont<strong>in</strong>ue to be practised up to today ( Jenk<strong>in</strong>s etal., 1994). In addition to deliberate <strong>and</strong> conscious attemptsto prevent conception, many traditional practices had <strong>the</strong>effect of limit<strong>in</strong>g <strong>the</strong> number or tim<strong>in</strong>g of births that awoman may experience <strong>in</strong> her lifetime, even though thiswas not <strong>the</strong> explicit purpose of <strong>the</strong> practice. Foremostamong <strong>the</strong>se was post-partum sexual abst<strong>in</strong>ence, <strong>the</strong>practice of absta<strong>in</strong><strong>in</strong>g from sexual relations for some yearsafter <strong>the</strong> birth of a child – often for as long as <strong>the</strong> child wasbreastfeed<strong>in</strong>g. In traditional New Gu<strong>in</strong>ea cultures, thisperiod could last up to five years (Heider, 1976), but 2-3years was probably more typical. Abst<strong>in</strong>ence was practisedbecause of a belief that sexual relations before wean<strong>in</strong>g couldharm <strong>the</strong> child by contam<strong>in</strong>at<strong>in</strong>g <strong>the</strong> mo<strong>the</strong>r’s breast milk.As <strong>in</strong> o<strong>the</strong>r traditional cultures, abortion <strong>and</strong> <strong>in</strong>fanticidewere also used <strong>in</strong> Papua New Gu<strong>in</strong>ea as measures of lastresort when <strong>the</strong> birth of a child offended <strong>the</strong> moral order(as with an unmarried woman), threatened <strong>the</strong> survival ofano<strong>the</strong>r child (as with <strong>the</strong> birth of tw<strong>in</strong>s), or was born witha deformity (McRae, 1982).Traditional forms of contraception <strong>and</strong> family limitation,however conscious <strong>the</strong>y may have been, were generallynot “parity-specific” <strong>in</strong> <strong>the</strong> sense encompassed by modernconcepts of family plann<strong>in</strong>g. That is, <strong>in</strong> traditional times itis unlikely that women were <strong>in</strong> a position to formulate apreferred number of children <strong>and</strong> to apply <strong>the</strong> knowledge<strong>and</strong> technical means available to <strong>the</strong>m to achieve exactlySource: EmbassyWorld.comthat number. More likely, women sought to space childrento ensure <strong>the</strong>ir survival <strong>and</strong> to end childbear<strong>in</strong>g when <strong>the</strong>ywere no longer capable, <strong>in</strong> <strong>the</strong>ir estimation, of car<strong>in</strong>g forchildren. In some communities it was considered shamefulfor women to cont<strong>in</strong>ue childbear<strong>in</strong>g when <strong>the</strong>ir first childwas grown up, but not necessarily to have many children(Townsend, 1984).Thus modern family plann<strong>in</strong>g is characterized as much byattitude <strong>and</strong> <strong>in</strong>tention as by <strong>the</strong> use of specifically moderntechniques of contraception. In fact, <strong>in</strong> modern PapuaNew Gu<strong>in</strong>ea, traditional techniques coexist with modernattitudes <strong>and</strong> some attitudes towards contraceptionare derived from experience with or underst<strong>and</strong><strong>in</strong>g oftraditional techniques. Thus, when <strong>the</strong> oral contraceptivepill was <strong>in</strong>troduced, some users understood it as analogousto <strong>the</strong> <strong>in</strong>gestion of traditional herbal medic<strong>in</strong>es madefrom tree bark or <strong>the</strong> fruit of certa<strong>in</strong> plants, as taught by<strong>the</strong>ir ancestors. Concerns about <strong>the</strong> side effects of modernmethods of contraception also have <strong>the</strong>ir counterpart <strong>in</strong><strong>the</strong> effects of traditional contraceptives, which are believedto cause vomit<strong>in</strong>g, bleed<strong>in</strong>g <strong>and</strong> physical weakness, as wellas sterility ( Jenk<strong>in</strong>s et al., 1994). The implication is thatcontraception is not a major cultural <strong>in</strong>novation <strong>and</strong> thatthis should ease <strong>the</strong> way for <strong>the</strong> use of modern methods ofproven effectiveness.However, <strong>the</strong> comment by Townsend (1984) referr<strong>in</strong>gparticularly to <strong>the</strong> situation <strong>in</strong> <strong>the</strong> Goroka district <strong>in</strong> <strong>the</strong>late 1970s should be noted:347

FigureThe existence of traditional magical orherbal methods of family limitation is notnecessarily favourable to <strong>the</strong> acceptance ofmodern family plann<strong>in</strong>g if shame, secrecyor disapproval surround <strong>the</strong>ir use.Until today, however, <strong>the</strong> use of modern forms ofcontraception <strong>in</strong> Papua New Gu<strong>in</strong>ea, such as condoms,oral contraceptives, <strong>in</strong>jections <strong>and</strong> tubal ligation, coexistswidely with traditional forms, such as sexual abst<strong>in</strong>ence,withdrawal, <strong>the</strong> use of herbal medic<strong>in</strong>es, anal sex <strong>and</strong> o<strong>the</strong>rsex acts. Induced abortion by traditional means is ano<strong>the</strong>roption practised today to avoid an unwanted birth. Thechoice of contraceptive method may be determ<strong>in</strong>edby circumstances, such as lack of access to moderncontraceptives <strong>in</strong> remote rural areas or a preference fortraditional ways of manag<strong>in</strong>g family life. Similarly, amongthose who have little underst<strong>and</strong><strong>in</strong>g of how variouscontraceptives work, fears of adverse health consequencesapply to both modern <strong>and</strong> traditional forms. Cost mayalso be a consideration, but it is not necessarily <strong>the</strong> casethat modern methods are expensive while traditionalmethods are not. Traditional methods may be more costlythan modern ones because only older men or women (orpersons skilled <strong>in</strong> sorcery) have <strong>the</strong> knowledge of how toprepare traditional medic<strong>in</strong>es <strong>and</strong> <strong>the</strong>y expect to be paidei<strong>the</strong>r <strong>in</strong> cash or k<strong>in</strong>d. Traditional methods are normallyaccompanied by rituals that give an impression of witchcraft<strong>and</strong> may be shunned by those who adhere to Christianbeliefs. Health policies prohibit <strong>the</strong> use of “witchcraft” or“sorcery” <strong>in</strong> <strong>the</strong> provision of public health.While modern contraception may <strong>in</strong> pr<strong>in</strong>ciple be free ofcost at <strong>the</strong> distribution po<strong>in</strong>t, reach<strong>in</strong>g a service deliverypo<strong>in</strong>t (most often a health centre ra<strong>the</strong>r than a village-basedaid post) 2 <strong>in</strong>volves not only <strong>the</strong> cost of transport but also<strong>the</strong> opportunity costs aris<strong>in</strong>g from <strong>the</strong> neglect of gardensor <strong>the</strong> care of children. In <strong>the</strong> more remote areas, a healthcentre or district hospital may only be accessible on foot<strong>and</strong> after a walk of several days <strong>in</strong> some cases. Where <strong>the</strong>reis a high probability that <strong>the</strong> health centre will not have asupply of contraceptives, such arduous journeys may notbe undertaken, <strong>and</strong> reversion to traditional methods mayoccur. It is also well understood that <strong>the</strong> health centre maycharge fees for <strong>the</strong> consultation, even if <strong>the</strong> contraceptivesare free.The complexity of current practices that show evidenceof <strong>in</strong>term<strong>in</strong>gl<strong>in</strong>g of traditional <strong>and</strong> modern forms ofcontraception needs to be taken <strong>in</strong>to account whenconsider<strong>in</strong>g <strong>the</strong> relationship between <strong>the</strong> contraceptiveprevalence rate (CPR) <strong>and</strong> fertility levels <strong>and</strong> trends. Tosome extent this is <strong>the</strong> case <strong>in</strong> all <strong>Pacific</strong> societies, butnowhere more so than <strong>in</strong> Papua New Gu<strong>in</strong>ea.The slow fertility transition <strong>in</strong> PapuaNew Gu<strong>in</strong>eaThere is no evidence to suggest that average completedfertility per woman <strong>in</strong> Papua New Gu<strong>in</strong>ea at <strong>the</strong> nationallevel reached <strong>the</strong> heights of o<strong>the</strong>r <strong>Pacific</strong> isl<strong>and</strong> countries<strong>in</strong> <strong>the</strong> 1960s <strong>and</strong> 1970s, where total fertility rates (TFRs)peaked at 7 or 8 (Hayes <strong>and</strong> Robertson, 2010). Papua NewGu<strong>in</strong>ea’s TFR reached a historical peak at 6.3 <strong>in</strong> <strong>the</strong> 1960-1965 period (see Figure 1), after which it commenced aFigure1 Fertility transition <strong>in</strong> Papua New Gu<strong>in</strong>ea <strong>and</strong> less developed countries compared, 1950-2005PNGLDCs6.565.55TFR4.543.532.521950-551955-601960-651965-701970-751975-801980-851985-901990-951995-002000-05YearSource: UNDESA (2009).348

Figureslow decl<strong>in</strong>e to its most recently measured level of 4.4 <strong>in</strong><strong>the</strong> 2001-2006 period (National Statistical Office, 2006).However, <strong>the</strong> fertility transition has not proceeded ata consistent pace s<strong>in</strong>ce fertility first began to decl<strong>in</strong>e <strong>in</strong><strong>the</strong> early 1970s. Compared with <strong>the</strong> pace of <strong>the</strong> fertilitytransition <strong>in</strong> less developed countries (LDCs) as a group,<strong>the</strong> rate of fertility decl<strong>in</strong>e <strong>in</strong> Papua New Gu<strong>in</strong>ea has beenslow, as can be seen <strong>in</strong> Figure 1. Fur<strong>the</strong>rmore, Papua NewGu<strong>in</strong>ea experienced a dist<strong>in</strong>ctive slowdown <strong>in</strong> <strong>the</strong> rate of itsfertility decl<strong>in</strong>e from <strong>the</strong> period 1985-1990 to 1995-2000.For <strong>the</strong> 10 years centred on 1987-1997, <strong>the</strong> country’s TFRdropped by only 0.33, compared with a decl<strong>in</strong>e of 0.79 <strong>in</strong><strong>the</strong> LDCs as a group. As of <strong>the</strong> 2000-2005 period, PapuaNew Gu<strong>in</strong>ea’s TFR was about 1.5 children per womanabove <strong>the</strong> TFR for all LDCs – a difference of 51 per cent.As Figure 2 shows, Papua New Gu<strong>in</strong>ea’s reduced rate offertility decl<strong>in</strong>e <strong>in</strong> <strong>the</strong> late 1980s <strong>and</strong> early 1990s opened agap between <strong>the</strong> country <strong>and</strong> o<strong>the</strong>r LDCs that will probablytake a long time to close. The United Nations mediumvariant projections for Papua New Gu<strong>in</strong>ea <strong>and</strong> <strong>the</strong> LDCssuggest that Papua New Gu<strong>in</strong>ea would reach a TFR of 2.5about 20 years after <strong>the</strong> o<strong>the</strong>r LDCs <strong>and</strong> that it would takeuntil 2045 before “replacement” fertility of 2.2 children perwoman was reached. Had Papua New Gu<strong>in</strong>ea’s fertilitytransition not “stalled” prematurely, replacement fertilitymight have been reached much earlier, <strong>and</strong> <strong>the</strong> impact ofpopulation “momentum” that much less. As it is, <strong>the</strong> UnitedNations medium variant population projections suggestthat Papua New Gu<strong>in</strong>ea’s total population would reach12.9 million by 2050, while <strong>the</strong> “low” projection basedon a faster rate of fertility decl<strong>in</strong>e would produce a 2050population of 11.1 million, or 1.8 million fewer people.Research issuesThe relatively slow pace of <strong>the</strong> fertility transition <strong>in</strong> PapuaNew Gu<strong>in</strong>ea relative to LDCs as a group <strong>and</strong> relative too<strong>the</strong>r <strong>Pacific</strong> isl<strong>and</strong> countries is <strong>the</strong> primary issue <strong>in</strong> needof explanation. However, an explanation that is aimedat be<strong>in</strong>g complete, or at least comprehensive, is certa<strong>in</strong>lybeyond <strong>the</strong> scope of <strong>the</strong> present paper as it would require areview of a large number of development <strong>in</strong>dicators <strong>and</strong> aneffort to l<strong>in</strong>k <strong>the</strong>se <strong>in</strong>dicators to a general <strong>the</strong>ory of fertilitychange. What this paper is aimed at do<strong>in</strong>g is to consider<strong>the</strong> specific relationship between fertility decl<strong>in</strong>e <strong>and</strong> <strong>the</strong>use of family plann<strong>in</strong>g, or more precisely, contraception.For example, is <strong>the</strong>re evidence to demonstrate that <strong>the</strong> paceof fertility decl<strong>in</strong>e has been constra<strong>in</strong>ed by various typesof barriers or impediments to <strong>the</strong> use of effective forms ofcontraception? Even this much reduced question presentsanalytical problems aris<strong>in</strong>g from <strong>the</strong> difficulty of adequatelymeasur<strong>in</strong>g <strong>the</strong> dem<strong>and</strong> for <strong>and</strong> <strong>the</strong> supply of familyplann<strong>in</strong>g services. As <strong>in</strong> all analysis us<strong>in</strong>g <strong>the</strong> economicconcepts of “supply” <strong>and</strong> “dem<strong>and</strong>”, supply <strong>and</strong> dem<strong>and</strong><strong>in</strong>teract <strong>in</strong> complex ways. An <strong>in</strong>crease <strong>in</strong> supply can createits own dem<strong>and</strong>, as when <strong>the</strong> diffusion of family plann<strong>in</strong>gservices raises knowledge <strong>and</strong> awareness of <strong>the</strong> possibilityof effectively controll<strong>in</strong>g fertility among populations thatpreviously had little awareness of this, hence <strong>in</strong>creas<strong>in</strong>g<strong>the</strong> dem<strong>and</strong> for it. Conversely, a belief among authoritiesthat <strong>the</strong> dem<strong>and</strong> for family plann<strong>in</strong>g is low <strong>and</strong> <strong>the</strong>refore<strong>the</strong>re is no po<strong>in</strong>t <strong>in</strong> supply<strong>in</strong>g services will almost certa<strong>in</strong>lybe self-re<strong>in</strong>forc<strong>in</strong>g, as <strong>the</strong> best <strong>in</strong>dicator of a dem<strong>and</strong> forfamily plann<strong>in</strong>g is <strong>the</strong> actual use of it.In spite of <strong>the</strong>se analytical difficulties, it is possible to ga<strong>in</strong>some <strong>in</strong>dication of supply <strong>and</strong> dem<strong>and</strong> <strong>in</strong> <strong>the</strong> Papua NewFigure2 Actual <strong>and</strong> projected fertility change <strong>in</strong> Papua New Gu<strong>in</strong>ea <strong>and</strong> less developed countries, 1950-2050PNGLDCs7.56.5Total Fertility Rate5.54.53.52.51950-551960-651970-751980-851990-952000-052010-15Year2020-252030-352040-452050-55Source: UNDESA (2009).349

Gu<strong>in</strong>ea case by <strong>the</strong> use of DHS data along with o<strong>the</strong>rdata sources to shed light on <strong>the</strong> issue of whe<strong>the</strong>r familyplann<strong>in</strong>g services, or <strong>the</strong> lack of <strong>the</strong>m, have played a role<strong>in</strong> Papua New Gu<strong>in</strong>ea’s slow, <strong>and</strong> occasionally, “stalled”fertility transition. Should it be established that <strong>the</strong>re isa l<strong>in</strong>k between slow fertility decl<strong>in</strong>e <strong>and</strong> <strong>the</strong> shortcom<strong>in</strong>gsof family plann<strong>in</strong>g services, ei<strong>the</strong>r because health policieshave not placed sufficient emphasis on family plann<strong>in</strong>g,or because service delivery has been <strong>in</strong>effective, <strong>the</strong>n <strong>the</strong>question arises: What can be done to streng<strong>the</strong>n familyplann<strong>in</strong>g with<strong>in</strong> <strong>the</strong> present paradigm of sexual <strong>and</strong>reproductive health?Explanatory frameworkThe present paper does not embrace or test a specific<strong>the</strong>ory of fertility change but simply employs <strong>the</strong> variables<strong>and</strong> <strong>in</strong>dicators available from DHS conducted <strong>in</strong> PapuaNew Gu<strong>in</strong>ea <strong>in</strong> 1996 <strong>and</strong> 2006, supplemented by o<strong>the</strong>rdata sources. Published DHS tables, however, conta<strong>in</strong> avery limited range of variables <strong>and</strong> <strong>the</strong>se are generallypresented <strong>in</strong> two-way cross-tabulations. Althoughsampl<strong>in</strong>g errors are published <strong>in</strong> both <strong>the</strong> 1996 <strong>and</strong> 2006DHS reports (National Statistical Office, 1997 <strong>and</strong>2009), <strong>the</strong> relationships discussed <strong>in</strong> this paper have notbeen tested for statistical significance. Until such tests aredone, <strong>the</strong> suggested relationships between variables rema<strong>in</strong>tentative.Demographic contextThe demographic situation <strong>in</strong> Papua New Gu<strong>in</strong>ea,particularly its population growth rate, has long been asubject of controversy. This has arisen from <strong>the</strong> fact thatPapua New Gu<strong>in</strong>ea has a short history of census-tak<strong>in</strong>g.The first censuses <strong>in</strong> 1996 <strong>and</strong> 1971 were done on a samplebasis <strong>and</strong> were <strong>the</strong>refore not full enumerations. A beliefdeveloped that <strong>the</strong> 1971 population was underestimatedso it was adjusted upwards, <strong>the</strong>reby elevat<strong>in</strong>g <strong>the</strong> growthrate. It was later found that <strong>the</strong> 1971 estimates had beenoveradjusted. In <strong>the</strong> meantime it became widely believedthat Papua New Gu<strong>in</strong>ea’s growth rate fell between 2.7 <strong>and</strong>3.5 per cent, a high rate of growth relative to that of o<strong>the</strong>rdevelop<strong>in</strong>g countries. Dur<strong>in</strong>g <strong>the</strong> period when <strong>the</strong> firstefforts were be<strong>in</strong>g made to formulate a population policy<strong>in</strong> Papua New Gu<strong>in</strong>ea many politicians believed that <strong>the</strong>growth rate was 3.5 per cent per annum <strong>and</strong> thus a seriousproblem was loom<strong>in</strong>g (Sharpless, 1992). The first censusthat sought to enumerate <strong>the</strong> entire population did nottake place until 1980 <strong>and</strong> <strong>the</strong> second occurred <strong>in</strong> 1990. Thelatter census was considered to have suffered from a largerundercount than ei<strong>the</strong>r <strong>the</strong> 1980 census or <strong>the</strong> next census<strong>in</strong> 2000, thus creat<strong>in</strong>g <strong>the</strong> problem of determ<strong>in</strong><strong>in</strong>g whichcensus <strong>in</strong>terval should be used to calculate <strong>the</strong> growth rate.Aga<strong>in</strong>, population growth rates of 2.7 per cent per annumwere be<strong>in</strong>g suggested us<strong>in</strong>g <strong>the</strong> <strong>in</strong>tercensal period 1980-2000.Allow<strong>in</strong>g for various adjustments to <strong>the</strong> census counts, itis likely that Papua New Gu<strong>in</strong>ea’s population growth ratepeaked at around 2.6 per cent annual growth <strong>in</strong> <strong>the</strong> 1966-1971 period <strong>and</strong> subsequently decl<strong>in</strong>ed to somewhere <strong>in</strong><strong>the</strong> range 2.3-2.4 per cent by <strong>the</strong> mid-1990s. Populationgrowth rates based on <strong>in</strong>direct estimation of birth <strong>and</strong>death rates from census <strong>and</strong> surveys generally resulted<strong>in</strong> lower rates than census counts as <strong>the</strong>y are unaffectedby underenumeration. Based on estimates from <strong>the</strong> 1996DHS, population growth around that time would havebeen about 2.3 per cent per annum – a rapid enough rateof growth but somewhat short of “explosive” (Departmentof <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> Monitor<strong>in</strong>g, 1999).The best estimate of <strong>the</strong> current rate of growth is 2.1 percent annually. This is exactly <strong>the</strong> rate of growth anticipatedfor <strong>the</strong> 2005-2010 period by <strong>the</strong> National PopulationPolicy 2000-2010 based on <strong>the</strong> medium variant populationprojection. However, <strong>the</strong> estimated 2010 population of6.7 million (SPC, 2010) is well above <strong>the</strong> projectionsconta<strong>in</strong>ed <strong>in</strong> <strong>the</strong> population policy. The most likely reasonfor this is that <strong>the</strong> base population for <strong>the</strong> projections wastoo small, given that <strong>the</strong> projections were done before <strong>the</strong>2000 census results were available.Although all projections are uncerta<strong>in</strong>, <strong>the</strong> HIV epidemic<strong>in</strong> Papua New Gu<strong>in</strong>ea adds even greater uncerta<strong>in</strong>ty.Even <strong>in</strong> <strong>the</strong> context of a generalized HIV <strong>and</strong> AIDSepidemic, however, <strong>the</strong> population of Papua New Gu<strong>in</strong>eawill cont<strong>in</strong>ue to grow, but <strong>the</strong> rate of population growthwill be lower <strong>in</strong> view of <strong>the</strong> elevated mortality caused byAIDS than it would o<strong>the</strong>rwise have been (Hayes, 2007).Given that <strong>the</strong> base population used <strong>in</strong> <strong>the</strong> populationpolicy projections was too small, <strong>the</strong> projections used <strong>in</strong><strong>the</strong> national population policy are no longer valid. Revisedprojections suggest that Papua New Gu<strong>in</strong>ea’s populationwill almost certa<strong>in</strong>ly reach 10 million; however, for <strong>the</strong>population to level off at about 10 million, <strong>the</strong> rate offertility decl<strong>in</strong>e would need to be considerably faster thanit has been historically <strong>and</strong> faster than assumed under <strong>the</strong>low-growth scenario United Nations projections.<strong>Family</strong> plann<strong>in</strong>g servicesGovernment family plann<strong>in</strong>g servicesThe first family plann<strong>in</strong>g cl<strong>in</strong>ic <strong>in</strong> Papua New Gu<strong>in</strong>ea wasestablished <strong>in</strong> Port Moresby <strong>in</strong> 1961 by <strong>the</strong> Maternal <strong>and</strong>Child Health Division of <strong>the</strong> Department of Public Health(Bowler, 1968). The <strong>in</strong>itiative came from <strong>the</strong> communityitself, not from <strong>the</strong> Adm<strong>in</strong>istration (Bowler, 1968;350

O’Coll<strong>in</strong>s, 1979). Women <strong>in</strong> <strong>the</strong> villages surround<strong>in</strong>g PortMoresby requested <strong>the</strong> Adm<strong>in</strong>istration to provide <strong>the</strong>mwith <strong>the</strong> same “medic<strong>in</strong>e” that allowed <strong>the</strong> wives of colonialofficers to limit <strong>the</strong>ir family size to three children. Theavailability of <strong>the</strong> service was not publicized but becameknown through word of mouth. Initially oral contraceptiveswere offered free of cost. When <strong>the</strong> so-called <strong>in</strong>trauter<strong>in</strong>econtraceptive device or IUCD was <strong>in</strong>troduced, <strong>the</strong> freesupply of contraceptive pills was withdrawn <strong>and</strong> IUDs(<strong>in</strong>trauter<strong>in</strong>e devices) were offered free of cost <strong>in</strong>stead.In <strong>the</strong> early stages <strong>the</strong> programme was completely“passive”, provid<strong>in</strong>g services to those who requested <strong>the</strong>mbut not actively promot<strong>in</strong>g contraception. However, <strong>the</strong>programme spread to o<strong>the</strong>r centres <strong>in</strong> <strong>the</strong> country ondem<strong>and</strong>. The programme was not aimed at limit<strong>in</strong>g familysize as such but to assist women who wished to space <strong>the</strong>irchildren. Never<strong>the</strong>less, tubal ligation was offered to womenwho wished to stop childbear<strong>in</strong>g, <strong>and</strong> it was <strong>the</strong> womanherself who decided when she should stop – usually whenshe felt too old to take care of children. Tubal ligation waspopular among rural women but as its use spread <strong>the</strong>rewas opposition from <strong>the</strong> Catholic Church, which opposedany form of contraception. . The Church distributedpamphlets warn<strong>in</strong>g people of <strong>the</strong> dangers of tubal ligation<strong>and</strong> husb<strong>and</strong>s came to believe that <strong>the</strong> operation wouldbe harmful to <strong>the</strong>ir wife’s health (Muirden, 1976). Quitelikely <strong>the</strong> belief that men were opposed to <strong>the</strong>ir wives us<strong>in</strong>gfamily plann<strong>in</strong>g methods orig<strong>in</strong>ated <strong>in</strong> this period. For somemen at least, <strong>the</strong>ir opposition to modern family plann<strong>in</strong>garose from <strong>the</strong> same fears about consequences for women’shealth as women <strong>the</strong>mselves experienced. Research <strong>in</strong> <strong>the</strong>Highl<strong>and</strong>s of Papua New Gu<strong>in</strong>ea shows that men arewell aware that childbirth is dangerous but <strong>the</strong>y are alsoconcerned that whatever contraception method <strong>the</strong>ir wivesuse it should be safe (Pataki-Schweizer, 1996).In later years, when medical officers travelled to rural areaswith <strong>the</strong> necessary medical equipment to perform tuballigations, <strong>the</strong> response was spontaneous. Burdon et al.(2002) reported that village women would walk up to fivedays to obta<strong>in</strong> a tubal ligation. The use of tubal ligation<strong>in</strong>creased rapidly at first but <strong>the</strong>n levelled off <strong>in</strong> <strong>the</strong> mid-1970s, possibly <strong>in</strong> response to Church opposition. TheIUD <strong>and</strong> tubal ligation were particularly popular amongrural women but were <strong>the</strong> most difficult to obta<strong>in</strong> because<strong>the</strong> medical skills necessary to provide <strong>the</strong>se methods wererare.The issue of whe<strong>the</strong>r Papua New Gu<strong>in</strong>ea should adopta large-scale family plann<strong>in</strong>g programme was discussedby demographers <strong>in</strong> a 1970 meet<strong>in</strong>g sponsored by <strong>the</strong>Australian National University before <strong>in</strong>dependence. Theconsensus reached was that a massive family plann<strong>in</strong>gprogramme was “not desirable” at that time but mightbecome imperative “with<strong>in</strong> a decade” (Caldwell, 1971).Three reasons were given for not embark<strong>in</strong>g on a large-scalefamily plann<strong>in</strong>g programme: (a) Papua New Gu<strong>in</strong>ea stillhad low population density; (b) a large-scale programmewas not politically acceptable; <strong>and</strong> (c) a family plann<strong>in</strong>gprogramme would not attract enough clients to justify it.There was, however, a consensus that a programme wouldbe necessary eventually <strong>and</strong> that <strong>the</strong> Adm<strong>in</strong>istrationshould ensure that <strong>the</strong> exist<strong>in</strong>g level of dem<strong>and</strong> was met sothat <strong>the</strong> experience ga<strong>in</strong>ed from a “limited” family plann<strong>in</strong>gprogramme could be applied when <strong>the</strong> time came to<strong>in</strong>itiate a larger scheme. A budget allocation was estimated<strong>and</strong> a programme of tra<strong>in</strong><strong>in</strong>g <strong>and</strong> research was proposed(Caldwell, 1971). It is notable that <strong>the</strong> health benefits offamily plann<strong>in</strong>g were not among <strong>the</strong> criteria used to justifya family plann<strong>in</strong>g programme. 4A nationwide family plann<strong>in</strong>g programme was <strong>in</strong> factestablished shortly afterwards by a Cab<strong>in</strong>et decision<strong>in</strong> 1973 under <strong>the</strong> self-govern<strong>in</strong>g Adm<strong>in</strong>istration thatpreceded full <strong>in</strong>dependence. After <strong>in</strong>dependence, however,political opposition to family plann<strong>in</strong>g grew, confirm<strong>in</strong>gearlier concerns that a large programme would not f<strong>in</strong>dpolitical support. The first Governor-General opposedfamily plann<strong>in</strong>g on <strong>the</strong> grounds that Papua New Gu<strong>in</strong>eaneeded a population of 20 million to protect <strong>the</strong> l<strong>and</strong>from <strong>in</strong>vasion (D’Sa, 1988). Some post-<strong>in</strong>dependencepoliticians saw family plann<strong>in</strong>g as a “colonial” imposition.A lively debate <strong>in</strong> <strong>the</strong> newspapers on <strong>the</strong> issue cont<strong>in</strong>uedfor many years. By 1978 posts <strong>and</strong> tra<strong>in</strong><strong>in</strong>g programmeshad never<strong>the</strong>less been created, <strong>in</strong>clud<strong>in</strong>g <strong>the</strong> establishmentof an <strong>in</strong>formation, education <strong>and</strong> communication (IEC)unit.By <strong>the</strong> late 1970s, an active government family plann<strong>in</strong>gprogramme was <strong>in</strong> operation supported by a specificallocation <strong>in</strong> <strong>the</strong> total health budget. The programmefocused on maternal <strong>and</strong> child health (MCH). Womenwere motivated dur<strong>in</strong>g <strong>the</strong> antenatal period, at <strong>the</strong> timeof delivery <strong>and</strong> post-partum to adopt family plann<strong>in</strong>g.Women who did not deliver at a health centre weremotivated dur<strong>in</strong>g visits to child health cl<strong>in</strong>ics (Muirden,1982). Tra<strong>in</strong><strong>in</strong>g of medical officers, aid post orderlies,nurses, nurs<strong>in</strong>g supervisors <strong>and</strong> o<strong>the</strong>r health staffaccelerated dur<strong>in</strong>g <strong>the</strong> late 1970s. <strong>Family</strong> plann<strong>in</strong>g services,<strong>in</strong>clud<strong>in</strong>g <strong>in</strong>jectables, IUDs, condoms, tubal ligation <strong>and</strong>vasectomy, were available at various levels of health-careservice delivery. A range of o<strong>the</strong>r activities support<strong>in</strong>gfamily plann<strong>in</strong>g had also been undertaken, <strong>in</strong>clud<strong>in</strong>g <strong>the</strong>development of IEC materials, radio programmes, familylife education <strong>in</strong> schools (<strong>in</strong>clud<strong>in</strong>g <strong>the</strong> use of studentsto give family plann<strong>in</strong>g education <strong>in</strong> <strong>the</strong>ir home villagesdur<strong>in</strong>g vacations) <strong>and</strong> various sem<strong>in</strong>ars for governmentofficers on population <strong>and</strong> family plann<strong>in</strong>g topics. By 1978it was estimated that 6 per cent of women of reproductiveage were us<strong>in</strong>g family plann<strong>in</strong>g (Muirden, 1982).351

The establishment of prov<strong>in</strong>cial governments after<strong>in</strong>dependence was followed by decentralization ofhealth service provision. Tra<strong>in</strong><strong>in</strong>g of family plann<strong>in</strong>gworkers devolved gradually to <strong>the</strong> prov<strong>in</strong>ces. In 1982,<strong>the</strong> responsibility for family plann<strong>in</strong>g was transferred toprov<strong>in</strong>cial governments <strong>and</strong> funds for family plann<strong>in</strong>gwere withdrawn from <strong>the</strong> national budget (Townsend,1984). The <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Division of <strong>the</strong> Departmentof Health was abolished. Decentralization of healthservices had a negative impact on <strong>the</strong> national familyplann<strong>in</strong>g programme, result<strong>in</strong>g <strong>in</strong> a decl<strong>in</strong>e <strong>in</strong> <strong>the</strong> numberof contraceptive users (Burdon et al., 2002), <strong>and</strong> its effectsare still evident up to today.Church health servicesAn important feature of Papua New Gu<strong>in</strong>ea’s healthcaredelivery system is that a large proportion of ruralhealth centres are operated by churches, primarily <strong>the</strong>Catholic Church, but also <strong>in</strong>clud<strong>in</strong>g Anglican <strong>and</strong> o<strong>the</strong>rdenom<strong>in</strong>ations. This has arisen because mission stationsnormally <strong>in</strong>clude a health centre or hospital. These healthfacilities now receive subsidies from <strong>the</strong> government tosupport <strong>the</strong> provision of primary health care, <strong>in</strong>clud<strong>in</strong>gfamily plann<strong>in</strong>g.In 1974, shortly after a government family plann<strong>in</strong>gprogramme was established, <strong>the</strong> Catholic Churchestablished <strong>the</strong> Catholic <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Office <strong>and</strong> later<strong>the</strong> <strong>Family</strong> Life Association that commenced teach<strong>in</strong>g<strong>the</strong> ovulation (or rhythm) method of family plann<strong>in</strong>g.This method is still taught <strong>in</strong> Catholic-run health centres<strong>and</strong> o<strong>the</strong>r methods are discouraged. In <strong>the</strong> early 1980s<strong>the</strong> Catholic Church distributed a pamphlet aga<strong>in</strong>sttubal ligation (Ayers-Counts, 1981), <strong>and</strong> pamphletswarn<strong>in</strong>g aga<strong>in</strong>st <strong>the</strong> use of modern contraception areallegedly still distributed today. 5 The Anglican Churchhas similarly voiced its opposition to tubal ligation, as wellas <strong>the</strong> provision of contraceptives to young or unmarriedpeople. The latter policy has caused anguish <strong>in</strong> some ruralcommunities where <strong>the</strong> majority of <strong>the</strong> population feelthat <strong>the</strong> Church should relax its restrictions (Maibani-Michie, 1998).The Health Department currently distributes “kits” ofmedic<strong>in</strong>es (funded by AusAID) conta<strong>in</strong><strong>in</strong>g a supplyof contraceptives to all health centres, <strong>in</strong>clud<strong>in</strong>g thoseoperated by Churches. It has been reported that someChurch-operated health centres remove <strong>the</strong> contraceptivesfrom <strong>the</strong> kits <strong>and</strong> destroy <strong>the</strong>m, a practice that is at <strong>the</strong>least wasteful (Midire et al., 2005).Non-governmental organizations <strong>and</strong>community-based distributionThe pr<strong>in</strong>cipal NGO provid<strong>in</strong>g family plann<strong>in</strong>g <strong>in</strong> PapuaNew Gu<strong>in</strong>ea, as <strong>in</strong> o<strong>the</strong>r <strong>Pacific</strong> countries, is <strong>the</strong> <strong>Family</strong>Health Association (FHA). Affiliated with IPPF, <strong>the</strong><strong>Family</strong> Health Association (orig<strong>in</strong>ally <strong>the</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Association) was established <strong>in</strong> Port Moresby <strong>in</strong> 1967.Management difficulties resulted <strong>in</strong> FHA withdraw<strong>in</strong>goperations from Port Moresby <strong>in</strong> <strong>the</strong> mid-1990s <strong>and</strong>re-establish<strong>in</strong>g itself <strong>in</strong> Lae. The Association currentlyoperates cl<strong>in</strong>ics <strong>in</strong> Lae, Goroka <strong>and</strong> Rabaul. It also supportscommunity-based distribution (CBD) of contraceptives<strong>in</strong> six rural districts <strong>in</strong> Morobe Prov<strong>in</strong>ce <strong>and</strong> providesfemale condoms to <strong>the</strong> “Save <strong>the</strong> Children Fund”, whichhas a project for sex workers. The 2006 DHS showed that18 per cent of respondents obta<strong>in</strong>ed oral contraceptivesfrom FHA, 15 per cent obta<strong>in</strong>ed <strong>in</strong>jections <strong>and</strong> 13 percent received condoms through FHA. Thus FHA is asignificant provider of contraceptives <strong>in</strong> <strong>the</strong> country.O<strong>the</strong>r NGOs have become active <strong>in</strong> recent years, <strong>in</strong> partto address <strong>the</strong> HIV epidemic. Marie Stopes <strong>International</strong>operates cl<strong>in</strong>ics <strong>in</strong> Port Moresby <strong>and</strong> three o<strong>the</strong>r cities, aswell as provides outreach support to peri-urban villagesnear Port Moresby. Voluntary counsell<strong>in</strong>g <strong>and</strong> test<strong>in</strong>g,contraception, <strong>in</strong>clud<strong>in</strong>g tubal ligation <strong>and</strong> vasectomy,treatment of sexually transmitted <strong>in</strong>fections (STIs) areavailable <strong>in</strong> Marie Stopes cl<strong>in</strong>ics. This organization is alsooperat<strong>in</strong>g a trial project on Norplant <strong>in</strong> collaboration with<strong>the</strong> Department of Health.<strong>Family</strong> Health <strong>International</strong> (FHI) operates <strong>in</strong> PortMoresby, address<strong>in</strong>g HIV prevention <strong>in</strong> particular,<strong>in</strong>clud<strong>in</strong>g palliative care for term<strong>in</strong>ally ill AIDS patients.FHI provides outreach support for cl<strong>in</strong>ics <strong>in</strong> peri-urbanPort Moresby <strong>and</strong> also operates <strong>in</strong> Madang <strong>and</strong> EasternHighl<strong>and</strong>s. Population Services <strong>International</strong> (PSI)based <strong>in</strong> Port Moresby has programmes focused on HIVprevention, <strong>in</strong>clud<strong>in</strong>g condom distribution. Pathf<strong>in</strong>der<strong>International</strong> operates a community-based family plann<strong>in</strong>gproject centred <strong>in</strong> Madang. A particular focus of thatprogramme is <strong>the</strong> provision of water supplies to cl<strong>in</strong>icsoffer<strong>in</strong>g family plann<strong>in</strong>g.The private sectorOral contraceptives <strong>and</strong> condoms have been approvedfor sale <strong>in</strong> pharmacies for many years <strong>in</strong> Papua NewGu<strong>in</strong>ea. Overall, however, <strong>the</strong> purchase of contraceptivesat pharmacies or through a private physician is negligible<strong>in</strong> Papua New Gu<strong>in</strong>ea <strong>and</strong> accounts for less that 5 per centof oral contraceptives, <strong>in</strong>jectables <strong>and</strong> condoms (NSO,2009). Only 4.4 per cent of males <strong>in</strong> <strong>the</strong> 2006 DHSreported obta<strong>in</strong><strong>in</strong>g condoms from a pharmacy <strong>and</strong> ano<strong>the</strong>r4.9 per cent obta<strong>in</strong>ed <strong>the</strong>m from a shop. A community-352

ased distributor was a source of condoms for 7 per centof condom users, which makes CBD a more importantsource of condoms than pharmacies or doctors.Current status of family plann<strong>in</strong>gservicesBaravilala (2006) described <strong>the</strong> structure of <strong>the</strong> publichealth system <strong>in</strong> Papua New Gu<strong>in</strong>ea <strong>in</strong> <strong>the</strong> follow<strong>in</strong>gterms:Delivery of services through <strong>the</strong> PNGpublic health system is based on a networkof 2400 aid posts (up to 50% of <strong>the</strong>se areor have been closed because of staff <strong>and</strong>supply shortages), 500 health centres, 18prov<strong>in</strong>cial hospitals, a national hospital,<strong>and</strong> 45 urban cl<strong>in</strong>ics. The numbers offacilities that are open or closed variesaccord<strong>in</strong>g to different prov<strong>in</strong>ces. Inaddition to staff <strong>and</strong> supply shortagessome facilities have had to close becauseof disagreements with l<strong>and</strong>owners <strong>and</strong>security concerns. Over <strong>the</strong> last decade<strong>the</strong> number of closures has cont<strong>in</strong>ued to<strong>in</strong>crease. Private health care is deliveredma<strong>in</strong>ly <strong>in</strong> <strong>the</strong> larger urban centres withmost of <strong>the</strong> larger facilities located <strong>in</strong> PortMoresby.While <strong>the</strong> government is <strong>the</strong> largestprovider of health care, <strong>the</strong> Church HealthService operates approximately half of<strong>the</strong> rural health centres <strong>and</strong> sub-centres.The churches also tra<strong>in</strong> <strong>and</strong> educatemany of PNG's health workers, <strong>in</strong>clud<strong>in</strong>gnurses <strong>and</strong> community health workers.Government does not provide anybasic tra<strong>in</strong><strong>in</strong>g programmes for CHWs.The <strong>Pacific</strong> Adventist University has aschool of health sciences, <strong>and</strong> <strong>the</strong> Div<strong>in</strong>eWord University (DWU) runs a healthadm<strong>in</strong>istration programme.It is with<strong>in</strong> <strong>the</strong> context of this system that <strong>the</strong> governmentprovides <strong>the</strong> public with family plann<strong>in</strong>g services.A comprehensive review of family plann<strong>in</strong>g services wasundertaken <strong>in</strong> 2002 (Burdon et al., 2002). Most of <strong>the</strong>f<strong>in</strong>d<strong>in</strong>gs of that review probably rema<strong>in</strong> valid today but fewof its recommendations appear to have been implemented.The ma<strong>in</strong> po<strong>in</strong>ts of <strong>the</strong> review are summarized below,generally referr<strong>in</strong>g to <strong>the</strong> period 1997-2001 <strong>and</strong> draw<strong>in</strong>gspecifically upon data from <strong>the</strong> Health InformationSystem:The distribution of contraception is highly uneven.Exclud<strong>in</strong>g permanent methods, half of all healthfacilities are provid<strong>in</strong>g 95 per cent of oral contraceptives<strong>and</strong> <strong>in</strong>jections (as measured by CYP).Half of <strong>the</strong> health centres <strong>in</strong> Papua New Gu<strong>in</strong>ea are notprovid<strong>in</strong>g any modern contraceptives at all.The government operates 51 per cent of health centres<strong>and</strong> provides nearly 80 per cent of CYP. The CatholicChurch operates 20 per cent of all health centres <strong>and</strong>provides 2 per cent of CYP for modern methods.Prov<strong>in</strong>ces that have been <strong>the</strong> focus of projects fundedby <strong>in</strong>ternational agencies (<strong>in</strong>clud<strong>in</strong>g <strong>the</strong> United NationsPopulation Fund (UNFPA), World Bank, <strong>Asia</strong>nDevelopment Bank <strong>and</strong> AusAID, <strong>in</strong>dividually or <strong>in</strong>collaboration) have not markedly <strong>in</strong>creased <strong>the</strong> use ofcontraception <strong>in</strong> those prov<strong>in</strong>ces, relative to <strong>the</strong> changesobserved <strong>in</strong> prov<strong>in</strong>ces that have not been <strong>the</strong> focus ofsuch projects.In prov<strong>in</strong>ces supported by UNFPA projects,contraceptive use <strong>in</strong>creased for awhile but <strong>the</strong>n decl<strong>in</strong>ed,suggest<strong>in</strong>g that <strong>the</strong> improvements ga<strong>in</strong>ed were notsusta<strong>in</strong>able.The review also employed a questionnaire to ga<strong>the</strong>r<strong>in</strong>formation on <strong>the</strong> beliefs <strong>and</strong> perceptions of healthworkers with regard to <strong>the</strong> delivery of family plann<strong>in</strong>gservices. The results of this survey were reported accord<strong>in</strong>gto three groups of prov<strong>in</strong>ces: (a) those prov<strong>in</strong>ces that hadbeen <strong>in</strong>cluded <strong>in</strong> <strong>the</strong> large-scale Population <strong>and</strong> <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Project (PFPP) that operated from 1993 to 1998;(b) focus prov<strong>in</strong>ces that were <strong>in</strong>cluded <strong>in</strong> <strong>the</strong> UNFPACountry Programme (1996-2002); <strong>and</strong> (c) prov<strong>in</strong>ces thathad not received any support from an externally fundedfamily plann<strong>in</strong>g project.The results of <strong>the</strong> survey of health workers are summarized<strong>in</strong> Table 1, which shows <strong>the</strong> two most important reasonsgiven by health workers as to (a) why health workers did not353

provide family plann<strong>in</strong>g services <strong>and</strong> (b) why communitiesdid not access family plann<strong>in</strong>g services.In all three groups of prov<strong>in</strong>ces, staff attitudes arementioned as a reason why health staff do not dispensecontraceptives. In <strong>the</strong> non-project <strong>and</strong> UNFPA focusprov<strong>in</strong>ces, <strong>the</strong> most important factor is <strong>the</strong> religious beliefsof staff, whereas <strong>in</strong> <strong>the</strong> PFPP prov<strong>in</strong>ces lack of supply is<strong>the</strong> primary reason.So far as <strong>the</strong> reason why communities do not accesscontraceptives is concerned, lack of supply is aga<strong>in</strong>mentioned as <strong>the</strong> ma<strong>in</strong> reason <strong>in</strong> <strong>the</strong> PFPP prov<strong>in</strong>ces,whereas community religious beliefs is <strong>the</strong> ma<strong>in</strong> reasongiven <strong>in</strong> <strong>the</strong> o<strong>the</strong>r groups of prov<strong>in</strong>ces.In Tables 2 <strong>and</strong> 3, <strong>the</strong> responses have been pooled withoutconsideration for particular prov<strong>in</strong>ces. Table 2 shows that<strong>the</strong> attitudes of health providers is perceived by healthstaff <strong>the</strong>mselves as <strong>the</strong> ma<strong>in</strong> reason why health staff do notsupply contraceptives, followed by <strong>the</strong> lack of supply <strong>and</strong>IEC materials. Table 3 <strong>in</strong>dicates that “fear” is perceived byhealth workers to be <strong>the</strong> ma<strong>in</strong> reason why <strong>the</strong> communitydoes not seek access to family plann<strong>in</strong>g services, followedby lack of awareness <strong>and</strong> religious beliefs.Although <strong>the</strong> selection of respondents <strong>in</strong> this survey wasnot based on scientific sampl<strong>in</strong>g methods, <strong>the</strong> healthworkers consulted were all well-<strong>in</strong>formed <strong>and</strong> experienced<strong>in</strong> <strong>the</strong> provision of family plann<strong>in</strong>g services. Aside fromthose com<strong>in</strong>g from prov<strong>in</strong>ces that had never participated <strong>in</strong>a major family plann<strong>in</strong>g project, most of <strong>the</strong>se respondentshad been <strong>in</strong>volved <strong>in</strong> <strong>the</strong> implementation of projectsaimed at improv<strong>in</strong>g access to family plann<strong>in</strong>g <strong>and</strong> o<strong>the</strong>rreproductive health services. It should not be concludedfrom <strong>the</strong>se data that <strong>the</strong> various family plann<strong>in</strong>g projectshad not made positive contributions towards improvedaccess. For example, <strong>the</strong> vasectomy tra<strong>in</strong><strong>in</strong>g provided under<strong>the</strong> UNFPA project provided a foundation for a muchwider vasectomy tra<strong>in</strong><strong>in</strong>g programme throughout <strong>the</strong>country <strong>and</strong> that programme has been quite successful.Similarly, <strong>the</strong> PFPP project contributed substantially to <strong>the</strong>renovation of cl<strong>in</strong>ics, provid<strong>in</strong>g a confidential, private space<strong>in</strong> which nurses were able to discuss issues <strong>and</strong> dispenseadvice. The PFPP project also changed procedures toensure that clients could access services at any time <strong>and</strong>on all suitable opportunities, ra<strong>the</strong>r than FP cl<strong>in</strong>ics be<strong>in</strong>gopen only at certa<strong>in</strong> hours.The <strong>in</strong>terpretation of <strong>the</strong> data <strong>in</strong> Tables 1-3 presents achallenge as <strong>the</strong> questions <strong>in</strong> <strong>the</strong> questionnaire were notdesigned to test a particular approach to service delivery.It is apparent, however, that <strong>the</strong> “attitudes” of healthstaff <strong>the</strong>mselves play a significant role <strong>in</strong> limit<strong>in</strong>g access.Conversely, <strong>the</strong> attitudes of <strong>the</strong> community, particularlyreligious views, constra<strong>in</strong> potential clients from seek<strong>in</strong>gservices. Male attitudes do not feature significantly among<strong>the</strong> most important reasons given for clients not seek<strong>in</strong>gaccess, but <strong>the</strong>y are mentioned. The large number of healthstaff who mentioned “fear” <strong>and</strong> “lack of awareness” as <strong>the</strong>two most important reasons for lack of community accessis consistent with <strong>the</strong> results of <strong>the</strong> two DHS that havebeen conducted (see <strong>the</strong> section below under <strong>the</strong> head<strong>in</strong>g“Current patterns of contraceptive use <strong>and</strong> unmet need”).The significance of attitudes <strong>and</strong> religious beliefs fromboth <strong>the</strong> supply <strong>and</strong> dem<strong>and</strong> side raises issues concern<strong>in</strong>g<strong>the</strong> role of Church-based health facilities <strong>in</strong> restrict<strong>in</strong>gaccess to family plann<strong>in</strong>g. The survey reported that nurses<strong>in</strong> Catholic-run health centres were frustrated <strong>and</strong> angeredby <strong>the</strong>ir <strong>in</strong>ability to offer modern family plann<strong>in</strong>g. 6 Thefact that so many village aid posts had closed or wereunable to offer services meant that more women werego<strong>in</strong>g to Church-operated health centres. The nurs<strong>in</strong>gstaff were unable to provide tubal ligation even to high-riskmultiparous mo<strong>the</strong>rs <strong>in</strong> areas where maternal mortalitywas high. They had also found that <strong>the</strong> ovulation methodthat <strong>the</strong>y were teach<strong>in</strong>g was unsuitable <strong>and</strong> unreliable forilliterate village women. Some nurses secretly distributedcontraceptives that came <strong>in</strong> <strong>the</strong> health kits <strong>and</strong> did notrecord dispens<strong>in</strong>g <strong>the</strong>m. On <strong>the</strong> o<strong>the</strong>r h<strong>and</strong>, supervisorsensured that no order for contraceptives was added tomedical requisitions. O<strong>the</strong>r nurses work<strong>in</strong>g <strong>in</strong> Catholichealth centres reported that <strong>the</strong>y would “get sacked” if <strong>the</strong>ysecretly distributed family plann<strong>in</strong>g methods (Burdon etal., 2002).Government policy is to encourage Church-operated healthcentres to cont<strong>in</strong>ue offer<strong>in</strong>g <strong>the</strong> ovulation method as anacceptable alternative where religious precepts prohibited<strong>the</strong> use of modern contraception. This somewhat passiveapproach is questionable when viewed from a humanrights perspective. One practical solution that has beenachieved <strong>in</strong> at least one prov<strong>in</strong>ce is for Church-run healthcentres to refer potential clients to a nearby aid post where<strong>the</strong>y know that FP services are available. This solution canwork only where <strong>the</strong> Church is at least will<strong>in</strong>g to cooperate<strong>and</strong> where aid posts are actually function<strong>in</strong>g <strong>and</strong> are be<strong>in</strong>gsupplied with commodities.A number of o<strong>the</strong>r issues to do with <strong>the</strong> barriers to accessto contraception were highlighted by <strong>the</strong> 2002 review, <strong>and</strong>still need to be addressed, <strong>in</strong>clud<strong>in</strong>g:Service providers are unaware that <strong>the</strong> family plann<strong>in</strong>gpolicy <strong>and</strong> <strong>the</strong> law allows contraceptives to be suppliedto any person above 16 years of age regardless of maritalstatus.Some family plann<strong>in</strong>g staff are still ask<strong>in</strong>g for writtenconsent from husb<strong>and</strong>s, even though this is nei<strong>the</strong>r a354

TableTable1TableTable2TableTable3355

Figurelegal requirement nor a condition of policy.Adolescents f<strong>in</strong>d it very difficult to access condoms orany form of family plann<strong>in</strong>g. 7Many health staff still hold <strong>the</strong> view that <strong>the</strong> freedistribution of condoms encourages promiscuity <strong>and</strong>prostitution.Some health centres still restrict family plann<strong>in</strong>g servicesto specific days <strong>and</strong> times.Because health <strong>in</strong>frastructure is collaps<strong>in</strong>g, tubal ligationcannot be conducted at health centres <strong>and</strong> clients have totravel to a prov<strong>in</strong>cial hospital, which <strong>the</strong>y cannot affordto do if <strong>the</strong>y are poor or if <strong>the</strong> roads are impassable.Sources of supply of familyplann<strong>in</strong>g servicesThe 1996 <strong>and</strong> 2006 DHS asked respondents where <strong>the</strong>ylast obta<strong>in</strong>ed a form of contraception. The results for bothyears are shown <strong>in</strong> Figure 3. The broad general pattern hadnot changed between <strong>the</strong> two surveys but <strong>the</strong>re were somesignificant shifts <strong>in</strong> <strong>the</strong> use of some service delivery po<strong>in</strong>ts.It is clear that <strong>in</strong> both years health centres <strong>and</strong> hospitalswere <strong>the</strong> ma<strong>in</strong> sources of contraception, but <strong>the</strong>y were alldecl<strong>in</strong><strong>in</strong>g as a proportion of all sources. On <strong>the</strong> o<strong>the</strong>r h<strong>and</strong>,<strong>the</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Association <strong>and</strong> aid posts have been<strong>in</strong>creas<strong>in</strong>g as a source of supply, with both <strong>in</strong>creas<strong>in</strong>g toabout 10 per cent.Private doctors, pharmacies <strong>and</strong> shops are relativelyunimportant sources of contraception, which is surpris<strong>in</strong>g.Also unexpected is <strong>the</strong> small <strong>and</strong> decl<strong>in</strong><strong>in</strong>g proportion ofwomen who received <strong>the</strong>ir last supply of contraceptivesfrom an MCH cl<strong>in</strong>ic. This is surpris<strong>in</strong>g given that familyplann<strong>in</strong>g has been for many years <strong>and</strong> still is to some extentcentred around MCH services. Mo<strong>the</strong>r <strong>and</strong> child cl<strong>in</strong>icsare considered to be <strong>the</strong> ideal place to raise <strong>the</strong> issue offamily plann<strong>in</strong>g, particularly before <strong>in</strong>tensive breastfeed<strong>in</strong>gceases <strong>and</strong> women lose <strong>the</strong> protection provided bylactational amenorrhoea. It may be that <strong>the</strong>se aspects are aresult of <strong>the</strong> way <strong>in</strong> which <strong>the</strong> question was asked <strong>in</strong> DHS.It is possible that MCH cl<strong>in</strong>ics were a source of advice,while supply was provided by a family plann<strong>in</strong>g cl<strong>in</strong>ic <strong>in</strong> ahospital. This issue needs fur<strong>the</strong>r clarification.Current patterns of contraceptiveuse <strong>and</strong> unmet needContraceptive knowledge <strong>and</strong> useAn assessment of national-level trends <strong>in</strong> knowledge <strong>and</strong>use of family plann<strong>in</strong>g <strong>in</strong> Papua New Gu<strong>in</strong>ea has onlybecome possible s<strong>in</strong>ce <strong>the</strong> second DHS us<strong>in</strong>g a comparablequestionnaire was conducted <strong>in</strong> 2006. Health <strong>in</strong>formationsystems are <strong>in</strong>sufficiently reliable to give accurate figureson contraceptive prevalence at <strong>the</strong> national level. Even so,DHS data are available for only two po<strong>in</strong>ts <strong>in</strong> time: 1996<strong>and</strong> 2006, thus long-term trends cannot be exam<strong>in</strong>ed.Fur<strong>the</strong>rmore, <strong>the</strong>re are some methodological differencesbetween <strong>the</strong> 1996 <strong>and</strong> 2006 DHS. The sample size <strong>in</strong>2006 was much larger than <strong>in</strong> 1996, thus sample errorsare smaller. O<strong>the</strong>r th<strong>in</strong>gs be<strong>in</strong>g equal, <strong>the</strong> 2006 DHS datashould be of higher quality (more accurate) than <strong>the</strong> 1996Figure3 Source of supply, last access to contraception, 1996 <strong>and</strong> 2006% of women access<strong>in</strong>g supply504540353025201510501996 2006Aid PostHospitalO<strong>the</strong>rHealth sub-centreRelative or friendPharmacy/shopPrivate doctorMCH cl<strong>in</strong>icFPAHealth centreService delivery po<strong>in</strong>tsSource: DHS reports for 1996 <strong>and</strong> 2006 (National Statistical Office, 1997 <strong>and</strong> 2009).356

data. The analysis <strong>in</strong> this section takes data from <strong>the</strong>sesurveys at face value without consideration of confidence<strong>in</strong>tervals <strong>and</strong> statistical significance.As <strong>in</strong>dicated <strong>in</strong> Table 4, 81 per cent of married womenknew of a modern method of contraception <strong>in</strong> 2006compared with 72 per cent <strong>in</strong> 1996. While this is animprovement <strong>in</strong> <strong>the</strong> right direction, it is a very modestrate of improvement for a 10-year period – less than 1 percent <strong>in</strong>crease per year. A somewhat faster rate of <strong>in</strong>crease<strong>in</strong> contraceptive awareness is evident among women withsome primary education (19% of <strong>the</strong> sample) – <strong>in</strong>creas<strong>in</strong>gfrom 70 to 80 per cent over <strong>the</strong> decade. By contrast, amongwomen with no education, knowledge of contraception<strong>in</strong>creased at a much slower rate: <strong>in</strong> 2006, 70 per cent ofwomen with no education had knowledge of a modernmethod of contraception, but only 62 per cent of womenwith no education knew of a source compared with 87 percent of women who had reached grade 7 or higher. The lackof education clearly rema<strong>in</strong>s an important impediment toknowledge of modern contraception <strong>and</strong> its sources.An unexpected result of <strong>the</strong> comparative analysis is that<strong>the</strong> proportion of women reach<strong>in</strong>g grade 7 <strong>and</strong> higher thatknew of a source of modern methods was lower (87%)<strong>in</strong> 2006 than <strong>in</strong> 1996 (90%). It is possible that <strong>the</strong> largersampl<strong>in</strong>g error <strong>in</strong> 1996 is responsible for this anomaly.As is evident from <strong>the</strong> data <strong>in</strong> Table 5, <strong>the</strong> use ofcontraception is positively associated with education.Whe<strong>the</strong>r all methods or modern methods alone areconsidered, contraceptive use among currently marriedwomen has <strong>in</strong>creased, by 20 <strong>and</strong> 24 per cent, respectively,over <strong>the</strong> decade. Among <strong>the</strong> most educated group, however,<strong>the</strong>re has been little change. Fur<strong>the</strong>rmore, <strong>the</strong> proportionof those us<strong>in</strong>g any method of contraception, that is,us<strong>in</strong>g a modern method, was no different <strong>in</strong> 2006 than<strong>in</strong> 1996 (about 75%). This is an unexpected f<strong>in</strong>d<strong>in</strong>g, asone would normally expect that contraceptive use amongmore educated women would <strong>in</strong>crease through time. Thisis not evident <strong>in</strong> Papua New Gu<strong>in</strong>ea. On <strong>the</strong> contrary,larger <strong>in</strong>creases <strong>in</strong> <strong>the</strong> use of contraception are evidentamong women with no education at all or some primaryeducation.At 24.4 per cent, <strong>the</strong> overall CPR <strong>in</strong> Papua New Gu<strong>in</strong>ea<strong>in</strong> 2006 must be considered as low relative to o<strong>the</strong>r lessdeveloped countries, <strong>in</strong> which <strong>the</strong> average CPR formodern methods is 45 per cent (PRB, 2008). Papua NewGu<strong>in</strong>ea’s current CPR puts it on a par with Haiti, one of<strong>the</strong> poorest countries <strong>in</strong> <strong>the</strong> world. 8 However, comparedwith o<strong>the</strong>r <strong>Pacific</strong> isl<strong>and</strong> countries (see Figure 4), PapuaNew Gu<strong>in</strong>ea’s CPR does not look unreasonably low whenaccount is taken of <strong>the</strong> very great logistical difficulties ofdeliver<strong>in</strong>g health services to <strong>the</strong> country’s large, widelyscattered population which faces such challenges as lowlevels of formal education, low <strong>in</strong>come <strong>and</strong> poor transport<strong>and</strong> communications. Papua New Gu<strong>in</strong>ea’s CPR iscurrently higher than that of Tuvalu or Kiribati, while itis similar to that of Nauru. Although all of <strong>the</strong>se countriesface logistical problems <strong>in</strong> <strong>the</strong> delivery of health services,none of <strong>the</strong>m face obstacles comparable to those fac<strong>in</strong>gPapua New Gu<strong>in</strong>ea’s health-care system. Fur<strong>the</strong>rmore,<strong>the</strong>se countries have an active NGO sector which providesalternative sources of family plann<strong>in</strong>g advice <strong>and</strong> supplies,a situation that is much rarer <strong>in</strong> Papua New Gu<strong>in</strong>ea.Geographical variationsPapua New Gu<strong>in</strong>ea is a country of contrast<strong>in</strong>g regions, eachwith somewhat dist<strong>in</strong>ctive culture, geography <strong>and</strong> history.Colonial history comb<strong>in</strong>ed with resource endowments hashad a particular impact on <strong>the</strong> levels of development with<strong>in</strong>regions <strong>and</strong> patterns of unequal development betweenregions <strong>and</strong> prov<strong>in</strong>ces have persisted to <strong>the</strong> present. Acomparison of regions provides some clue as to <strong>the</strong> impactof economic development on knowledge <strong>and</strong> use of familyplann<strong>in</strong>g.As might be expected, contraceptive knowledge <strong>and</strong>use is highest <strong>in</strong> <strong>the</strong> Isl<strong>and</strong>s region (see Table 6), whichgenerally has better social <strong>in</strong>dicators than o<strong>the</strong>r regionsTableTable4357

FigureTableTable5TableTable6Figure4 Contraceptive prevalence rates <strong>in</strong> seven <strong>Pacific</strong> isl<strong>and</strong> countries45403530CPR (%)2520151050Kiribati Tuvalu PNG Nauru Samoa SolomonIsl<strong>and</strong>sMarshallIsl<strong>and</strong>sSource: DHS reports, respective countries.358

TableTable7TableTable8TableTable9ow<strong>in</strong>g to its strong plantation sector <strong>and</strong> long history ofeducational development. Although <strong>the</strong> region sufferedfrom development setbacks <strong>in</strong> <strong>the</strong> 1980s <strong>and</strong> 1990s <strong>in</strong> <strong>the</strong>form of civil <strong>in</strong>surrection <strong>and</strong> natural disasters, knowledgeof modern methods of contraception is <strong>the</strong> highest <strong>the</strong>reof all regions, with 93 per cent of women express<strong>in</strong>gawareness of a modern method. However, <strong>the</strong> most rapid<strong>in</strong>crease <strong>in</strong> knowledge between 1996 <strong>and</strong> 2006 has been<strong>in</strong> <strong>the</strong> Momase area (<strong>the</strong> North coast prov<strong>in</strong>ces) whereknowledge of a modern method <strong>in</strong>creased from only 58per cent <strong>in</strong> 1996 to 75 per cent <strong>in</strong> 2006. That knowledgelevel was still <strong>the</strong> lowest of any region but much closer to<strong>the</strong> national average than it had been a decade earlier.It is strik<strong>in</strong>g that <strong>in</strong> 1996 only 55 per cent of marriedwomen knew of a source of modern contraception <strong>in</strong> <strong>the</strong>Momase region. Although this proportion had <strong>in</strong>creasedto about two thirds of married women by 2006, <strong>the</strong> o<strong>the</strong>rside of <strong>the</strong> co<strong>in</strong> is that one third of married women <strong>in</strong> thisregion professed to not know<strong>in</strong>g where to f<strong>in</strong>d a modernmethod of contraception <strong>in</strong> 2006.The o<strong>the</strong>r spatial dimension of family plann<strong>in</strong>g knowledge<strong>and</strong> use is <strong>the</strong> rural-urban one. As could be expected,knowledge of contraception was higher <strong>in</strong> urban thanrural areas both <strong>in</strong> 1996 <strong>and</strong> 2006 (see Table 7) but <strong>the</strong>gap appeared to be widen<strong>in</strong>g somewhat, that is, knowledgeof any method had been ris<strong>in</strong>g faster <strong>in</strong> urban areas than<strong>in</strong> rural areas. This is also true of knowledge of modernmethods <strong>and</strong> of <strong>the</strong> percentage of women who knew of anymethod know<strong>in</strong>g a modern method. This proportion rosefaster <strong>in</strong> urban than rural areas, but was quite high <strong>in</strong> both.Essentially 100 per cent of <strong>the</strong> women <strong>in</strong> urban areas whohad knowledge of any method were aware of at least one359

modern method <strong>and</strong> 94 per cent of rural women also fell<strong>in</strong>to this category.So far as <strong>the</strong> use of any method of contraception isconcerned, <strong>the</strong> Isl<strong>and</strong>s region had <strong>the</strong> highest overallprevalence rate both <strong>in</strong> 1996 <strong>and</strong> 2006, while <strong>the</strong> Highl<strong>and</strong>shad <strong>the</strong> lowest rate, with <strong>the</strong> o<strong>the</strong>r regions hav<strong>in</strong>g been <strong>in</strong>between (see Table 8). In 2006 this pattern rema<strong>in</strong>ed <strong>the</strong>same, although CPR rose <strong>in</strong> all regions. So far as modernmethods are concerned, <strong>the</strong> Sou<strong>the</strong>rn region (with<strong>in</strong>which is located <strong>the</strong> nation’s capital city) had <strong>the</strong> highestprevalence rate <strong>in</strong> both 1996 <strong>and</strong> 2006. Between 1996<strong>and</strong> 2006, <strong>the</strong> prevalence rate for modern methods rose at<strong>the</strong> national level (from 19.6 to 24.4%) <strong>and</strong> <strong>in</strong> all regionso<strong>the</strong>r than <strong>the</strong> Isl<strong>and</strong>s (Table 8). In <strong>the</strong> Isl<strong>and</strong>s region,however, CPR for modern methods essentially rema<strong>in</strong>edstatic between 1996 <strong>and</strong> 2006 (a decl<strong>in</strong>e from 27 to 26%would not be statistically significant) <strong>and</strong> <strong>the</strong> proportionof all users who were us<strong>in</strong>g modern methods fell from 68per cent to only 57 per cent. The proportion of marriedwomen <strong>in</strong> <strong>the</strong> Isl<strong>and</strong>s region us<strong>in</strong>g “traditional” methods,particularly periodic abst<strong>in</strong>ence, was highest of all regions<strong>in</strong> 1996 but was even higher <strong>in</strong> 2006. It is likely that thispattern is associated with religion, as <strong>the</strong> “rhythm” methodcan also be described as a form of periodic abst<strong>in</strong>ence <strong>and</strong><strong>the</strong> use of this method is highest <strong>in</strong> <strong>the</strong> Isl<strong>and</strong>s region.It is possible that <strong>the</strong> decl<strong>in</strong>e <strong>in</strong> CPR for modern methodsof contraception <strong>in</strong> <strong>the</strong> Isl<strong>and</strong>s region, accompanied by arise <strong>in</strong> <strong>the</strong> use of any method, was a function of a religiousrevival over <strong>the</strong> period. Although 26 per cent of <strong>the</strong> 2006DHS sample population identified <strong>the</strong>mselves as RomanCatholic, published DHS tables do not provide anyevidence on contraceptive use by different religious groupsthat could be cross-classified by region. 9The use of contraception, like knowledge, is higher <strong>in</strong>urban than rural areas, with <strong>the</strong> proportion of currentlyTableTable10360

married women us<strong>in</strong>g any form of contraception reach<strong>in</strong>g44 per cent <strong>in</strong> 2006 compared with 36 per cent <strong>in</strong> 2006(see Table 9). The use of modern family plann<strong>in</strong>g <strong>in</strong>creased<strong>in</strong> both rural <strong>and</strong> urban areas between 1996 <strong>and</strong> 2006but <strong>the</strong> rate of <strong>in</strong>crease was higher <strong>in</strong> rural areas. CPR formodern methods <strong>in</strong> rural areas <strong>in</strong>creased by 32 per centbetween 1996 <strong>and</strong> 2006 compared with an <strong>in</strong>crease of only19 per cent <strong>in</strong> urban areas.The proportion of all currently married urban women us<strong>in</strong>gcontraception who were us<strong>in</strong>g a modern method decl<strong>in</strong>edbetween <strong>the</strong> last two DHS (from 86 to 83%) suggest<strong>in</strong>gthat more urban women were us<strong>in</strong>g “traditional” methods<strong>in</strong> 2006 relative to a decade earlier. This is an unexpectedresult that may be associated with a more active campaignaga<strong>in</strong>st modern contraception by <strong>the</strong> Catholic Church. Inrural areas <strong>the</strong> use of modern contraception among thoseus<strong>in</strong>g any form of family plann<strong>in</strong>g has <strong>in</strong>creased, but notby much. In 2006, 27 per cent of all rural women us<strong>in</strong>g anyform of contraception were us<strong>in</strong>g a “traditional” method.Age patternsIn Papua New Gu<strong>in</strong>ea, knowledge of modern contraception,which tends to be relatively low among young people (65%of 15-19-year-old females knew of a modern method),rose with age to a maximum of 85 per cent at ages 30-34<strong>and</strong> <strong>the</strong>n fell away among older women aged 35 <strong>and</strong> older(70%). The actual use of contraception showed a similarpattern but reached its maximum (30.4%) among womenaged 40-44 (see Table 10). Trends over <strong>the</strong> 1996-2006decade show <strong>in</strong>creas<strong>in</strong>g contraceptive use among youngerwomen, with somewhat slower <strong>in</strong>creases among womenaged 35 <strong>and</strong> older.Parity is also a significant determ<strong>in</strong>ant of contraceptiveuse, with higher parity women be<strong>in</strong>g more likely to usecontraception. However, even among women of parity4 <strong>and</strong> over, modern contraceptive use was only 34 percent (Table 10). The use of any form of contraception(traditional <strong>and</strong> modern) reached a peak (41%) amongwomen aged 40-44, <strong>and</strong> 10 per cent of this group wereus<strong>in</strong>g a traditional method <strong>in</strong> 2006.Unmet need for family plann<strong>in</strong>gThe ICPD Programme of Action recommends that“Government goals for family plann<strong>in</strong>g should be def<strong>in</strong>ed <strong>in</strong>terms of unmet need for <strong>in</strong>formation <strong>and</strong> services” (UnitedNations, 1995). Subsequently, ICPD+5 recommendedthat “Where <strong>the</strong>re is a gap between contraceptive use <strong>and</strong><strong>the</strong> proportion of <strong>in</strong>dividuals express<strong>in</strong>g a desire to spaceor limit <strong>the</strong>ir families, countries should attempt to closethis gap by at least 50 per cent by 2005, 75 per cent by2010 <strong>and</strong> 100 per cent by 2015” (United Nations, 1999).The concept of “gap” comes from early generation KAP(knowledge, attitude <strong>and</strong> practice) studies from which wasco<strong>in</strong>ed <strong>the</strong> term “KAP-gap” to refer to a situation <strong>in</strong> whicha woman expressed a desire to limit or space births but wasnot us<strong>in</strong>g any form of contraception. Clos<strong>in</strong>g this gap by2015 would be an extremely ambitious goal <strong>in</strong> <strong>the</strong> case ofPapua New Gu<strong>in</strong>ea.The concept of “unmet need” has undergone fur<strong>the</strong>rref<strong>in</strong>ement <strong>in</strong> recent years with <strong>in</strong>creas<strong>in</strong>gly encompass<strong>in</strong>gdef<strong>in</strong>itions of <strong>the</strong> categories of women who can beconsidered as hav<strong>in</strong>g an unmet need. The current def<strong>in</strong>itionof unmet need accord<strong>in</strong>g to <strong>the</strong> United Nations PopulationDivision is:Unmet need for family plann<strong>in</strong>g is <strong>the</strong>number of women with unmet need forfamily plann<strong>in</strong>g expressed as a percentageof women of reproductive age who areTableTable11361

married or <strong>in</strong> union. Women with anunmet need are those who are fecund<strong>and</strong> sexually active but are not us<strong>in</strong>g anymethod of contraception, <strong>and</strong> report notwant<strong>in</strong>g any more children or want<strong>in</strong>gto delay <strong>the</strong> birth of <strong>the</strong>ir next child(UNDESA, 2009).This def<strong>in</strong>ition is identical to that used <strong>in</strong> DHS. Themethod of computation requires that surveys identifywomen who are married or <strong>in</strong> a sexual union <strong>in</strong> variousstatuses requir<strong>in</strong>g a complex branch<strong>in</strong>g process basedupon answers to questions appear<strong>in</strong>g at various po<strong>in</strong>ts of<strong>the</strong> DHS questionnaire.Women who are excluded from <strong>the</strong> numerator <strong>in</strong>cludethose who:(a) Are us<strong>in</strong>g contraception to delay <strong>the</strong>ir next birth;(b) Are us<strong>in</strong>g contraception to stop childbear<strong>in</strong>g;(c) Are currently pregnant or amenorrhoeic <strong>and</strong> <strong>the</strong>pregnancy was:(i) Intended, or(ii) Due to a method failure;(d) Are <strong>in</strong>fecund (accord<strong>in</strong>g to an objective set ofcriteria);(e) Want a child with<strong>in</strong> <strong>the</strong> next two years.By a process of elim<strong>in</strong>ation, a residual is obta<strong>in</strong>ed that<strong>in</strong>cludes women who:(a) Are not us<strong>in</strong>g contraception;(b) Are not pregnant or amenorrhoeic;(c) Do not want ano<strong>the</strong>r child or do not want it with<strong>in</strong> <strong>the</strong>next two years;(d) Are pregnant or amenorrhoeic <strong>and</strong>(i) Did not want <strong>the</strong> child;(ii) Wanted <strong>the</strong> child but at a later date;(e) Are unsure about want<strong>in</strong>g a child at a later date.The denom<strong>in</strong>ator is all women who are married or <strong>in</strong> asexual union. 10The def<strong>in</strong>ition of unmet need employed by variousanalysts is not always consistent with <strong>the</strong> DHS def<strong>in</strong>ition,ei<strong>the</strong>r <strong>in</strong> terms of <strong>the</strong> numerator or <strong>the</strong> denom<strong>in</strong>ator orboth. For example, women who are unsure or “don’t know”whe<strong>the</strong>r <strong>the</strong>y want ano<strong>the</strong>r child can be considered bysome analysts to have an unmet need, whereas o<strong>the</strong>rswould exclude <strong>the</strong>m. Burdon et al. (2002) reported thatunmet need for family plann<strong>in</strong>g based on <strong>the</strong> 1996 DHSwas 62 per cent for currently married women. However,this percentage was not calculated us<strong>in</strong>g <strong>the</strong> <strong>in</strong>ternationalst<strong>and</strong>ard formula <strong>and</strong> is <strong>the</strong>refore not comparable withunmet need <strong>in</strong> o<strong>the</strong>r countries. 11Papua New Gu<strong>in</strong>ea is <strong>the</strong> only <strong>Pacific</strong> isl<strong>and</strong> country tohave two comparable measures of unmet need (1996 <strong>and</strong>2006), thus enabl<strong>in</strong>g <strong>the</strong> analysis of trends over time.However, Papua New Gu<strong>in</strong>ea’s DHS tables do not show<strong>the</strong> unmet need for spac<strong>in</strong>g separately from <strong>the</strong> unmet needfor stopp<strong>in</strong>g. Women are considered to have an unmetneed if <strong>the</strong>y say that <strong>the</strong>y want no more children (or arenot sure or undecided) <strong>and</strong> are not us<strong>in</strong>g contraception.It is possible that total unmet need as measured by DHSwould be higher if <strong>the</strong> unmet need for spac<strong>in</strong>g were to becalculated separately <strong>and</strong> <strong>in</strong>cluded <strong>in</strong> <strong>the</strong> total.Table 11 shows that, while a decl<strong>in</strong>e <strong>in</strong> unmet need isevident at <strong>the</strong> national level (from 45.9 to 43.9%) over <strong>the</strong>decade 1996-2006, <strong>the</strong> rate of decl<strong>in</strong>e was slow <strong>and</strong> unmetneed rema<strong>in</strong>ed quite high. In <strong>the</strong> Isl<strong>and</strong>s region, however,unmet need actually <strong>in</strong>creased over <strong>the</strong> period, while <strong>in</strong> <strong>the</strong>Highl<strong>and</strong>s region it rema<strong>in</strong>ed at <strong>the</strong> same level. In 2006<strong>the</strong> Sou<strong>the</strong>rn region had <strong>the</strong> lowest level of unmet need, aswas also <strong>the</strong> case <strong>in</strong> 1996.Expla<strong>in</strong><strong>in</strong>g patterns of unmet needGeographical variations <strong>in</strong> unmet need are predom<strong>in</strong>antlyreflections of socio-economic, socio-cultural <strong>and</strong> historicalfactors. As previously noted, <strong>the</strong> Isl<strong>and</strong>s region has a largeproportion of Catholics <strong>and</strong> this probably expla<strong>in</strong>s <strong>the</strong>decl<strong>in</strong><strong>in</strong>g trend <strong>in</strong> <strong>the</strong> use of modern methods of familyplann<strong>in</strong>g <strong>in</strong> that region. It is notable that it is only <strong>in</strong> <strong>the</strong>Isl<strong>and</strong>s region that unmet need <strong>in</strong>creased between 1996<strong>and</strong> 2006 (Table 11) <strong>and</strong> it is likely that this is due toefforts by <strong>the</strong> Catholic Church to discourage <strong>the</strong> use ofmodern contraception (Burdon et al., 2002).A valid explanation of <strong>the</strong> socio-economic <strong>and</strong> socioculturaldeterm<strong>in</strong>ants of unmet need would require amultivariate analysis that allowed for some variables, suchas education <strong>and</strong> labour force status, to be controlled.Published tables do not permit such analysis <strong>in</strong> <strong>the</strong> PapuaNew Gu<strong>in</strong>ea case <strong>and</strong> only two-way descriptive analysis ispossible. The only variables available aside from region <strong>and</strong>rural/urban residence are age <strong>and</strong> education.As is evident from Table 12, unmet need rises with age<strong>and</strong> falls with educational achievement. This pattern wasevident <strong>in</strong> both 1996 <strong>and</strong> 2006. The highest level of unmet362

TableTable12TableTable13need is found <strong>in</strong> women aged 45-49 <strong>in</strong> both years, althoughit is very likely that many women <strong>in</strong> this age group believed<strong>the</strong>mselves to be at low risk of conceiv<strong>in</strong>g a child. Amongwomen aged 40-49, unmet need <strong>in</strong>creased somewhatbetween <strong>the</strong> two surveys, whereas <strong>in</strong> all age groups between15 <strong>and</strong> 39 it decl<strong>in</strong>ed, although not by much. In <strong>the</strong> caseof education, unmet need fell among those with less thangrade 6 education but <strong>in</strong>creased among women with grade6 or more, but <strong>in</strong> both years women with no education had<strong>the</strong> highest unmet need – over 50 per cent <strong>in</strong> both years –while women with grade 7 or higher had <strong>the</strong> lowest.Although <strong>the</strong> proportion of women aged 15-49 hav<strong>in</strong>g anunmet need for family plann<strong>in</strong>g decl<strong>in</strong>ed between 1996 <strong>and</strong>2006, <strong>the</strong> decl<strong>in</strong>e was not sufficient to offset <strong>the</strong> growth <strong>in</strong><strong>the</strong> population of women <strong>in</strong> <strong>the</strong> reproductive age range.Consequently, <strong>the</strong> actual number of women with an unmetneed rose significantly over <strong>the</strong> decade (see Table 13 <strong>and</strong>Figure 5). The number of women with an unmet need forFP rose from an estimated 480,000 <strong>in</strong> 1996 to 632,000 <strong>in</strong>2006, an <strong>in</strong>crease of about 30 per cent. As Figure 5 makesclear, <strong>the</strong> <strong>in</strong>crease <strong>in</strong> <strong>the</strong> number of women with an unmetneed is particularly large among women aged 40 years <strong>and</strong>363

Figureolder. Both <strong>the</strong> rate of unmet need <strong>and</strong> <strong>the</strong> number ofwomen <strong>in</strong> this age group <strong>in</strong>creased, lead<strong>in</strong>g to a significant<strong>in</strong>crease <strong>in</strong> <strong>the</strong> number of older women hav<strong>in</strong>g an unmetneed for contraception.Ano<strong>the</strong>r measure of <strong>the</strong> extent to which women are ableto access family plann<strong>in</strong>g is <strong>the</strong> percentage of <strong>the</strong> totaldem<strong>and</strong> for family plann<strong>in</strong>g that is actually satisfied. Totaldem<strong>and</strong> is calculated by add<strong>in</strong>g toge<strong>the</strong>r <strong>the</strong> number ofwomen who are us<strong>in</strong>g contraception <strong>and</strong> <strong>the</strong> number withan unmet need. The percentage of dem<strong>and</strong> satisfied is <strong>the</strong>proportion of this total that is us<strong>in</strong>g contraception. Thepercentage of dem<strong>and</strong> satisfied <strong>in</strong> Papua New Gu<strong>in</strong>ea iscompared <strong>in</strong> Table 14 with that of six o<strong>the</strong>r <strong>Pacific</strong> isl<strong>and</strong>countries that have had a DHS <strong>in</strong> recent years. It may beobserved that <strong>the</strong> percentage of dem<strong>and</strong> satisfied <strong>in</strong> PapuaNew Gu<strong>in</strong>ea is <strong>the</strong> lowest of all <strong>the</strong>se countries. Particularlystrik<strong>in</strong>g is <strong>the</strong> patterns by age. The percentage of dem<strong>and</strong>satisfied <strong>in</strong> Papua New Gu<strong>in</strong>ea for women aged 35 <strong>and</strong>older is very much lower than <strong>in</strong> o<strong>the</strong>r <strong>Pacific</strong> countries,especially Marshall Isl<strong>and</strong>s, Solomon Isl<strong>and</strong>s <strong>and</strong> Tuvalu.In DHS, women who are not us<strong>in</strong>g contraception arenormally asked whe<strong>the</strong>r <strong>the</strong>y <strong>in</strong>tend to use it <strong>in</strong> <strong>the</strong> future.This gives some <strong>in</strong>dication of why women with an unmetneed are not us<strong>in</strong>g contraception, assum<strong>in</strong>g that womenwith an unmet need have similar reasons for not us<strong>in</strong>gcontraception as all women not us<strong>in</strong>g contraception, someof whom do not have an unmet need. Table 15 shows <strong>the</strong>responses to this question <strong>in</strong> seven <strong>Pacific</strong> isl<strong>and</strong> countriesorganized <strong>in</strong> terms of <strong>the</strong> “Ready, Will<strong>in</strong>g <strong>and</strong> Able”framework developed by Lesthaeghe <strong>and</strong> V<strong>and</strong>erhoeft(2001). Women who are ready, will<strong>in</strong>g <strong>and</strong> able are thosewho are already us<strong>in</strong>g family plann<strong>in</strong>g <strong>and</strong> are excludedfrom <strong>the</strong> table. The rema<strong>in</strong><strong>in</strong>g women can be classified asei<strong>the</strong>r “unable” or “unwill<strong>in</strong>g” to use contraception.Although 83 per cent of women of reproductive age <strong>in</strong><strong>the</strong> 2006 DHS sample <strong>in</strong>dicated that <strong>the</strong>y knew abouta method of family plann<strong>in</strong>g, lack of knowledge is <strong>the</strong>primary reason given by women who say that <strong>the</strong>y do not<strong>in</strong>tend to use contraception <strong>in</strong> <strong>the</strong> future. When lack ofknowledge is comb<strong>in</strong>ed with difficulty of access <strong>and</strong> cost,about 51 per cent of women <strong>in</strong> Papua New Gu<strong>in</strong>ea whodo not <strong>in</strong>tend to use contraception <strong>in</strong> <strong>the</strong> future <strong>in</strong>dicatethat <strong>the</strong>y are unable to do so. This contrasts very sharplywith <strong>the</strong> situation <strong>in</strong> o<strong>the</strong>r <strong>Pacific</strong> isl<strong>and</strong> countries where amuch smaller percentage of women cite lack of knowledge<strong>and</strong> lack of access as <strong>the</strong> reason for <strong>the</strong>ir lack of <strong>in</strong>tentionto use contraception. In o<strong>the</strong>r <strong>Pacific</strong> countries, <strong>the</strong> vastmajority of women who do not <strong>in</strong>tend to use conception <strong>in</strong><strong>the</strong> future have access to family plann<strong>in</strong>g but are not will<strong>in</strong>gto use contraception. This is not <strong>the</strong> case <strong>in</strong> Papua NewGu<strong>in</strong>ea, where only 28 per cent <strong>in</strong>dicated an unwill<strong>in</strong>gnessto use contraception.The pr<strong>in</strong>cipal factor underly<strong>in</strong>g an unwill<strong>in</strong>gness to usecontraception <strong>in</strong> <strong>the</strong> future <strong>in</strong> <strong>Pacific</strong> isl<strong>and</strong> countriesis “fear of side effects”, although personal <strong>and</strong> religiousopposition is more important <strong>in</strong> some countries. In PapuaNew Gu<strong>in</strong>ea about 10 per cent of women not <strong>in</strong>tend<strong>in</strong>gto use contraception mentioned “religious opposition” <strong>and</strong>about 14 per cent cited fear of side effects. There was also asignificant number of respondents to this question <strong>in</strong> PapuaNew Gu<strong>in</strong>ea who had “o<strong>the</strong>r reasons” for not <strong>in</strong>tend<strong>in</strong>g touse contraception, although what <strong>the</strong>se reasons might bewere not stated. Given <strong>the</strong> opposition to <strong>the</strong> use of moderncontraception among some churches <strong>in</strong> Papua NewFigure5 Number of women with unmet need for family plann<strong>in</strong>g, 1996 <strong>and</strong> 2006110,000100,0001996 2006Number90,00080,00070,00060,00050,00040,00030,00020,00010,00015-19 20-24 25-29 30-34 35-39 40-44 45-49Age groupSource: Table 13364

Gu<strong>in</strong>ea, it is possible that some of <strong>the</strong> respondents whomentioned “o<strong>the</strong>r reasons” were deterred by <strong>the</strong> attitude of<strong>the</strong>ir church but did not wish to say so openly.Relative to women <strong>in</strong> o<strong>the</strong>r <strong>Pacific</strong> countries, women<strong>in</strong> Papua New Gu<strong>in</strong>ea expressed a strong will<strong>in</strong>gness touse contraception, but lack of knowledge of contraceptivemethods, lack of access to services <strong>and</strong> a range of socioculturalbarriers were prevent<strong>in</strong>g <strong>the</strong>m from do<strong>in</strong>g so. Bycontrast, lack of knowledge <strong>and</strong> poor access were not majorimpediments to <strong>the</strong> use of contraception <strong>in</strong> o<strong>the</strong>r <strong>Pacific</strong>isl<strong>and</strong> countries, whereas opposition on religious, health<strong>and</strong> o<strong>the</strong>r grounds were <strong>the</strong> ma<strong>in</strong> impediments.Health, family plann<strong>in</strong>g,reproductive health <strong>and</strong>population policiesNational Health PlanPapua New Gu<strong>in</strong>ea has had five national health planss<strong>in</strong>ce <strong>in</strong>dependence. In addition, government policy <strong>and</strong>strategies are reflected <strong>in</strong> a range of o<strong>the</strong>r documents. Mostimportant among <strong>the</strong>se is <strong>the</strong> Reproductive Health Policy,<strong>the</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Policy <strong>and</strong> <strong>the</strong> National PopulationPolicy. An important recent addition to <strong>the</strong> array of policydocuments is <strong>the</strong> Report of <strong>the</strong> M<strong>in</strong>isterial Task Forceon Maternal Health (2009), which conta<strong>in</strong>s a number ofproposals <strong>and</strong> recommendations that are relevant to <strong>the</strong>issue of family plann<strong>in</strong>g. In addition to health plans <strong>and</strong>policies, <strong>the</strong>re are several strategic documents that addressimplementation issues <strong>in</strong> greater detail.TableTable14365

TableTable15The immediate past National Health Plan covered <strong>the</strong>period 2001-2010. (A new National Health Plan has beenformulated for <strong>the</strong> period 2011-2020.) Volume I of <strong>the</strong>2001-2010 plan outl<strong>in</strong>es <strong>the</strong> overall policy direction <strong>and</strong>priorities that <strong>the</strong> government has pursued over <strong>the</strong> pastdecade. These are <strong>the</strong> policies underly<strong>in</strong>g <strong>the</strong> patterns <strong>and</strong>trends discussed <strong>in</strong> this paper.The 2001-2010 National Health Plan places familyplann<strong>in</strong>g under <strong>the</strong> general head<strong>in</strong>g of “<strong>Family</strong> Health,with a focus on Women’s <strong>and</strong> Children’s Health”, <strong>and</strong> <strong>the</strong>subhead<strong>in</strong>g “Reproductive Health”. The key statementsare:All couples <strong>and</strong> <strong>in</strong>dividuals shall have access to<strong>in</strong>formation needed to decide freely <strong>and</strong> responsibly <strong>the</strong>number, spac<strong>in</strong>g <strong>and</strong> tim<strong>in</strong>g of <strong>the</strong>ir children.All adolescents shall have access to <strong>in</strong>formation <strong>and</strong>advice on sexual health <strong>and</strong> family plann<strong>in</strong>g.All health facilities shall provide high-quality familyplann<strong>in</strong>g services that emphasize client needs, sensitive366

counsell<strong>in</strong>g, choice of methods <strong>and</strong> comprehensive<strong>in</strong>formation.All family plann<strong>in</strong>g cl<strong>in</strong>ics shall make available treatmentfor sexually transmitted <strong>in</strong>fection <strong>and</strong> screen<strong>in</strong>g servicesfor cancer.Women <strong>and</strong> adolescents shall be <strong>in</strong>volved <strong>in</strong> <strong>the</strong> design<strong>and</strong> implementation of family plann<strong>in</strong>g <strong>and</strong> sexualhealth programmes.It is difficult to assess <strong>the</strong> significance of <strong>the</strong> word<strong>in</strong>g of<strong>the</strong>se statements. For example, <strong>the</strong> reference to adolescentsrefers to <strong>the</strong>ir hav<strong>in</strong>g access to <strong>in</strong>formation <strong>and</strong> advice, butservices are not mentioned. Certa<strong>in</strong>ly <strong>the</strong> statement couldbe <strong>in</strong>terpreted to mean that health facilities were obligedonly to provide <strong>in</strong>formation <strong>and</strong> “advice”, not to providecontraceptives.The Implementation Plan for <strong>the</strong> Strategic Directions <strong>in</strong>Safe Mo<strong>the</strong>rhood, Neonatal <strong>and</strong> Reproductive Healthprovides more details of <strong>the</strong> strategies selected to achieve<strong>the</strong> objectives stated <strong>in</strong> <strong>the</strong> National Health Plan. Thestrategies <strong>in</strong>clude “…a special focus on adolescents toencourage responsible sexual behaviour, family plann<strong>in</strong>g<strong>and</strong> <strong>the</strong> prevention of sexually transmitted <strong>in</strong>fections<strong>in</strong>clud<strong>in</strong>g HIV/AIDS”. It is likely that some healthstaff paid more attention to <strong>the</strong> expression “encourageresponsible sexual behaviour” than <strong>the</strong> provision of familyplann<strong>in</strong>g.On a positive note, one objective of <strong>the</strong> implementationplan was to <strong>in</strong>crease CPR for modern methods to 25 percent – a target that may well have been achieved given that<strong>the</strong> 2006 DHS reported a CPR of 24.4 per cent. Perhaps<strong>the</strong> target was on <strong>the</strong> low side.The current National Health Plan (2011-2020) was <strong>in</strong>draft form at <strong>the</strong> time <strong>the</strong> present paper was be<strong>in</strong>g written,but it is clearly focus<strong>in</strong>g on restructur<strong>in</strong>g health services <strong>in</strong>an effort to recover from <strong>the</strong> consequences of <strong>the</strong> revisionsto <strong>the</strong> organic law on prov<strong>in</strong>cial governments that resulted<strong>in</strong> <strong>the</strong> dis<strong>in</strong>tegration of health service delivery <strong>in</strong> PapuaNew Gu<strong>in</strong>ea. The plan is aimed at rebuild<strong>in</strong>g primaryhealth services <strong>in</strong> rural areas through <strong>the</strong> creation of a newfirst-l<strong>in</strong>e <strong>in</strong>stitution to replace <strong>the</strong> aid post <strong>and</strong> <strong>the</strong> healthsubcentre, to be known as a “community health post”.Ano<strong>the</strong>r change is likely to be <strong>the</strong> creation of regionalspecialist hospitals. All health-care delivery po<strong>in</strong>ts up to<strong>the</strong> level of regional specialist hospitals will come under <strong>the</strong>management of <strong>the</strong> proposed “prov<strong>in</strong>cial health authority”.The challenge of this restructure at <strong>the</strong> primary healthlevel will be to ensure that <strong>the</strong> new community health postis capable of supply<strong>in</strong>g services more effectively than <strong>the</strong>aid post was.The ma<strong>in</strong> objective of <strong>the</strong> National Health Plan (2011-2020) is to “<strong>in</strong>crease family plann<strong>in</strong>g coverage”, with <strong>the</strong>primary strategy be<strong>in</strong>g to ensure that “every health facilityhas <strong>the</strong> capacity to offer family plann<strong>in</strong>g services at all times”.A related objective is to “improve sexual <strong>and</strong> reproductivehealth for adolescents, with <strong>the</strong> primary strategy be<strong>in</strong>g to“Increase <strong>the</strong> knowledge of adolescents about sexual <strong>and</strong>reproductive health”.Reproductive health policyA comprehensive national sexual <strong>and</strong> reproductive healthpolicy was developed <strong>in</strong> 2009 (National Departmentof Health, 2009). One of <strong>the</strong> stated justifications fordevelop<strong>in</strong>g an RH policy is that “reproductive healthservices have concentrated on family plann<strong>in</strong>g to <strong>the</strong>detriment of o<strong>the</strong>r components”. The situational analysisalso notes that “On <strong>the</strong> whole, <strong>the</strong> total dem<strong>and</strong> for familyplann<strong>in</strong>g is still relatively low as only 35.7 per cent ofwomen dem<strong>and</strong>ed for family plann<strong>in</strong>g accord<strong>in</strong>g to <strong>the</strong>2006 DHS report”. 12 Despite this, <strong>the</strong> policy expresses <strong>the</strong><strong>in</strong>tention to:Promote access to <strong>in</strong>formation on familyplann<strong>in</strong>g <strong>and</strong> provide wide choices ofcontraceptive methods <strong>in</strong>clud<strong>in</strong>g surgicalmethods <strong>and</strong> encourage <strong>the</strong> developmentof new <strong>in</strong>itiatives for identify<strong>in</strong>g <strong>and</strong>solv<strong>in</strong>g logistical problems at all levels toensure reproductive health commoditysecurity.The primary policy objective that relates to familyplann<strong>in</strong>g is to reduce unwanted pregnancies, with <strong>the</strong>target be<strong>in</strong>g a 50 per cent reduction by 2012. To achievethis it is proposed to <strong>in</strong>crease CPR from 20 to 60 percent over <strong>the</strong> same period. Needless to say, this is a highlyunrealistic target, given that (based on recent trends) <strong>the</strong>use of modern contraception is <strong>in</strong>creas<strong>in</strong>g only at <strong>the</strong> rateof about 2.4 per cent per year.<strong>Family</strong> plann<strong>in</strong>g policyThe second edition of <strong>the</strong> National <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Policy,Implementation Strategy <strong>and</strong> Technical St<strong>and</strong>ards wasissued <strong>in</strong> 2007 (National Department of Health, 2007).This document covers family plann<strong>in</strong>g policy <strong>in</strong> detail <strong>and</strong>furnishes guidance to health staff on <strong>the</strong> application of <strong>the</strong>policy. The policy notes that access to <strong>and</strong> use of familyplann<strong>in</strong>g has been stagnant over <strong>the</strong> period 1996-2003 asmeasured by <strong>the</strong> “couple years of protection”. It also po<strong>in</strong>ts367

out that <strong>the</strong> “new acceptor rate” over <strong>the</strong> period 2001-2005had also been stagnant <strong>and</strong> that 95 per cent of women werenot be<strong>in</strong>g reached by <strong>the</strong> present family plann<strong>in</strong>g services.The policy reiterates that <strong>the</strong> consent of a partner isnot legally required before provid<strong>in</strong>g any contraceptivemethod. 13 This <strong>in</strong>cludes tubal ligation <strong>and</strong> vasectomy.However, <strong>the</strong> family plann<strong>in</strong>g policy suggests that healthworkers should encourage couples to discuss <strong>the</strong> meritsof adopt<strong>in</strong>g a permanent method of contraceptionbefore do<strong>in</strong>g so. Similarly, a person older than 16 yearsdoes not require parental consent to be provided withcontraception.The national policy allows for contraceptives to be providedfree of charge at a public health facility; however, prov<strong>in</strong>cialhealth authorities may charge a consultation fee for <strong>the</strong>provision of cl<strong>in</strong>ical services up to <strong>the</strong> maximum allowedby national policy. It is <strong>the</strong>se fees that discourage wouldbeusers of family plann<strong>in</strong>g from seek<strong>in</strong>g <strong>the</strong> services,especially low-<strong>in</strong>come rural women.The policy goes on to identify a wide range of strategiesto implement <strong>the</strong> measures <strong>in</strong>tended to achieve itsobjectives, <strong>in</strong>clud<strong>in</strong>g management systems <strong>and</strong> monitor<strong>in</strong>g<strong>and</strong> evaluation of <strong>the</strong> services provided. Detailed servicedelivery <strong>and</strong> technical guidel<strong>in</strong>es are provided for <strong>the</strong> useof family plann<strong>in</strong>g nurses <strong>and</strong> o<strong>the</strong>r health staff. Included<strong>in</strong> <strong>the</strong> recommendations is that condoms should be madeavailable <strong>in</strong> such a way that people can access <strong>the</strong>m withouthav<strong>in</strong>g to ask a health worker directly or to formallyregister a request. Detailed guidel<strong>in</strong>es are also providedon <strong>the</strong> st<strong>and</strong>ards of privacy, hygiene <strong>and</strong> cleanl<strong>in</strong>ess thatfacilities should meet for dispens<strong>in</strong>g family plann<strong>in</strong>gservices. M<strong>in</strong>imal equipment lists are described along with<strong>the</strong> educational materials that should be available for clientuse.In general, <strong>the</strong> National <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Policy (of 2007),especially its service delivery technical guidel<strong>in</strong>es <strong>and</strong> itsspecification of <strong>the</strong> st<strong>and</strong>ards required at family plann<strong>in</strong>gcl<strong>in</strong>ics, hospitals <strong>and</strong> aid posts, is a very useful documentfor health workers, adm<strong>in</strong>istrators <strong>and</strong> supervisors. Asnoted by Burdon et al. (2002) <strong>the</strong> problem <strong>in</strong> <strong>the</strong> past hasbeen that very few health workers are aware of <strong>the</strong> policy orhave a copy of it on h<strong>and</strong>. The o<strong>the</strong>r issue is that, while <strong>the</strong>st<strong>and</strong>ards specified for facilities are reasonable <strong>and</strong> correct,very few family plann<strong>in</strong>g service delivery po<strong>in</strong>ts are able toachieve <strong>the</strong>m.Report of <strong>the</strong> M<strong>in</strong>isterial Taskforce onMaternal Health <strong>in</strong> Papua New Gu<strong>in</strong>eaThis is <strong>the</strong> most important document of relevance tofamily plann<strong>in</strong>g that has been produced by <strong>the</strong> NationalDepartment of Health <strong>in</strong> recent years. 14 It documents<strong>the</strong> maternal health situation <strong>in</strong> some detail, highlight<strong>in</strong>g<strong>in</strong> particular <strong>the</strong> impact that a deteriorat<strong>in</strong>g health<strong>in</strong>frastructure <strong>and</strong> an <strong>in</strong>adequate health budget have hadon maternal health. In <strong>the</strong> report it is noted, for example,that health expenditure as a proportion of GDP is only 0.6per cent <strong>in</strong> Papua New Gu<strong>in</strong>ea compared with 2.1 per cent<strong>in</strong> Indonesia, 4.1 per cent <strong>in</strong> Fiji <strong>and</strong> 4.9 per cent <strong>in</strong> Samoa.Decl<strong>in</strong><strong>in</strong>g real expenditure on health has contributed to<strong>the</strong> closure of 200 aid posts <strong>and</strong> a decl<strong>in</strong>e <strong>in</strong> antenatal carecoverage over <strong>the</strong> period 1997-2004 (NDOH, 2009).Among <strong>the</strong> key circumstances contribut<strong>in</strong>g to maternalmortality <strong>in</strong> Papua New Gu<strong>in</strong>ea, <strong>the</strong> report places strongemphasis on <strong>the</strong> poor access to family plann<strong>in</strong>g <strong>in</strong>formation,services <strong>and</strong> supplies that exists.Accord<strong>in</strong>gly, among <strong>the</strong> seven Taskforce Recommendations,number four concerns family plann<strong>in</strong>g. Thatrecommendation is reproduced <strong>in</strong> full below:That quality of voluntary family plann<strong>in</strong>gservice provision be immediatelystreng<strong>the</strong>ned <strong>in</strong> <strong>the</strong> areas of access <strong>and</strong>coverage for all Papua Niug<strong>in</strong>eans as aprimary <strong>in</strong>tervention to reduce <strong>the</strong> burdenof maternal mortality <strong>and</strong> morbidity<strong>in</strong> PNG. The target should be modernfamily plann<strong>in</strong>g prevalence of 65% by2020 <strong>in</strong> order to achieve a desired TotalFertility Rate of 2.2 by 2020.The recommendation is compromised only by <strong>the</strong>unrealistic 2020 target for CPR <strong>and</strong> TFR. It has taken 30years for CPR to <strong>in</strong>crease from about 6 per cent <strong>in</strong> 1978 to24 per cent <strong>in</strong> 2006, <strong>and</strong> 40 years for TFR to decl<strong>in</strong>e from6 to 4.4. Although it is certa<strong>in</strong>ly possible to <strong>in</strong>crease <strong>the</strong>speed with which women <strong>and</strong> couples are adopt<strong>in</strong>g reliablecontraception, it is highly unlikely that a CPR of 65 percent <strong>and</strong> a TFR of 2.2 could be achieved with<strong>in</strong> 10 years,even with an accelerated programme.In any case, it is worth not<strong>in</strong>g <strong>the</strong> strategies that have beenproposed to achieve this target. These <strong>in</strong>clude:(a) Development <strong>and</strong> resourc<strong>in</strong>g of a national familyplann<strong>in</strong>g strategic plan to support <strong>the</strong> national familyplann<strong>in</strong>g policy.(b) Increas<strong>in</strong>g access to a range of permanent <strong>and</strong> temporarycontraception (long- <strong>and</strong> short-term act<strong>in</strong>g) methods,for males <strong>and</strong> females.368

(c) Susta<strong>in</strong>ed community mobilization <strong>and</strong> healthpromotion efforts to normalize community attitudestowards family plann<strong>in</strong>g as a way to match family <strong>and</strong>community resources to family size <strong>and</strong> spac<strong>in</strong>g needs.(d) Integration of family plann<strong>in</strong>g effectively <strong>in</strong>to allhealth service delivery po<strong>in</strong>ts <strong>in</strong>dependent of <strong>the</strong>agency manag<strong>in</strong>g <strong>the</strong> service. Full fund<strong>in</strong>g to <strong>the</strong>seservices should be l<strong>in</strong>ked to provision of <strong>the</strong> packageof full sexual <strong>and</strong> reproductive health services, with<strong>in</strong>cremental fund<strong>in</strong>g arrangements if full services arenot provided.(e) Support<strong>in</strong>g men as partners <strong>and</strong> adolescen<strong>the</strong>alth services <strong>in</strong> sexual <strong>and</strong> reproductive healthprogrammes.(f ) Improvement <strong>in</strong> <strong>the</strong> quality of all health professionaltra<strong>in</strong><strong>in</strong>g programmes to ensure that graduates have<strong>the</strong> required competencies <strong>in</strong> quality voluntary cl<strong>in</strong>cfocusedfamily plann<strong>in</strong>g service provision.(g) Develop formal post-basic courses <strong>in</strong> sexual <strong>and</strong>reproductive health.(h) Strong monitor<strong>in</strong>g implementation to ensurethat national policy on free services for sexual <strong>and</strong>reproductive health is implemented at all health servicedelivery po<strong>in</strong>ts.Recommendation (d) carries <strong>the</strong> most serious implicationsas it would appear to be aimed at restrict<strong>in</strong>g fund<strong>in</strong>g tothose health-care <strong>in</strong>stitutions that do not support <strong>the</strong> samerange of services that are supported by <strong>the</strong> government’sfamily plann<strong>in</strong>g <strong>and</strong> reproductive health policies. The onlysuch <strong>in</strong>stitutions are those operated by churches.National Population Policy 2000-2010The present policy, which expired <strong>in</strong> 2010, was <strong>the</strong> secondnational population policy to have been adopted by <strong>the</strong>Government of Papua New Gu<strong>in</strong>ea s<strong>in</strong>ce <strong>in</strong>dependence.The first was launched <strong>in</strong> 1991 <strong>and</strong> had a strongerpopulation control approach than <strong>the</strong> current policy.The current policy was prepared <strong>in</strong> <strong>the</strong> light of <strong>the</strong>recommendations of <strong>the</strong> ICPD Programme of Action <strong>and</strong><strong>the</strong>refore placed particular emphasis on <strong>the</strong> cross-sectoralnature of population issues, <strong>in</strong>clud<strong>in</strong>g human rights,gender, education, environment, STIs <strong>and</strong> HIV, maternal<strong>and</strong> child health <strong>and</strong> urbanization.The 2000-2010 policy was very cautious <strong>in</strong> <strong>the</strong> area ofcontraceptive prevalence. In <strong>the</strong> policy it was po<strong>in</strong>ted outthat <strong>the</strong>re was no clear relationship between CPR <strong>and</strong>TFR at <strong>the</strong> prov<strong>in</strong>cial level. It was also noted that fertilitydecl<strong>in</strong>e was evident <strong>in</strong> prov<strong>in</strong>ces <strong>in</strong> which family plann<strong>in</strong>gdelivery was poor or where no specific projects to supportfamily plann<strong>in</strong>g had been implemented. This observationwas subsequently confirmed by <strong>the</strong> 2002 review of familyplann<strong>in</strong>g (Burdon et al., 2002).Never<strong>the</strong>less, <strong>the</strong> policy set objectives that would achieve<strong>the</strong> goal of “accelerat<strong>in</strong>g <strong>the</strong> demographic transition”. These<strong>in</strong>cluded reduc<strong>in</strong>g TFR to 3.8 by 2010 <strong>and</strong> to 3.0 by 2020.These were realistic targets. To achieve <strong>the</strong>se targets <strong>the</strong>policy proposed that <strong>the</strong> coverage <strong>and</strong> quality of familyplann<strong>in</strong>g services should be improved, start<strong>in</strong>g with aspecific focus on those prov<strong>in</strong>ces that had high fertilityrates or low CPR. It was expected that <strong>the</strong>se <strong>and</strong> o<strong>the</strong>rmeasures might <strong>in</strong>crease CPR to at least 40 per cent by2015. If all forms of contraception are <strong>in</strong>cluded, it is notimpossible that this target could <strong>in</strong> fact be reached asCPR for all methods reached 32.4 per cent, but <strong>the</strong> use ofmodern methods reached only 24.4 per cent by 2006.Specific objectives <strong>and</strong> strategies for family plann<strong>in</strong>g wereplaced with<strong>in</strong> <strong>the</strong> broad category of reproductive health.The basic objective was that all health facilities were toprovide by 2010 high-quality family plann<strong>in</strong>g services thatemphasized client needs, sensitive counsell<strong>in</strong>g, choice ofmethods <strong>and</strong> comprehensive <strong>in</strong>formation.The strategies that it was felt could achieve this objective<strong>in</strong>cluded <strong>the</strong> follow<strong>in</strong>g:Streng<strong>the</strong>n <strong>and</strong> exp<strong>and</strong> family plann<strong>in</strong>g tra<strong>in</strong><strong>in</strong>gprogrammes for health workers at all levels.Improve <strong>the</strong> supply <strong>and</strong> distribution of moderncontraceptives by streng<strong>the</strong>n<strong>in</strong>g <strong>the</strong> management, <strong>and</strong>procurement <strong>and</strong> distribution systems.Review <strong>the</strong> user fee policy to ensure provision of “lowcostor free of cost” family plann<strong>in</strong>g services.Integrate family plann<strong>in</strong>g awareness, <strong>in</strong>clud<strong>in</strong>g <strong>the</strong>benefits of modern contraceptives, for reduc<strong>in</strong>gmaternal <strong>and</strong> <strong>in</strong>fant mortality through MCH outreachprogrammes.The pr<strong>in</strong>cipal difficulty associated with <strong>the</strong> NationalPopulation Policy 2000-2010 was not its formulationbut its implementation. As with o<strong>the</strong>r health-relatedprogrammes, <strong>the</strong> implementation of <strong>the</strong> policy cameto a virtual halt because <strong>the</strong> ma<strong>in</strong> responsibility forimplementation was given to prov<strong>in</strong>cial governments.However, prov<strong>in</strong>cial governments preferred to have a fullblownpolicy of <strong>the</strong>ir own ra<strong>the</strong>r than just implement <strong>the</strong>policy of <strong>the</strong> national government. Most prov<strong>in</strong>ces didprepare an implementation plan but it took many yearsto do so; <strong>in</strong> <strong>the</strong> meantime <strong>the</strong> leadership at <strong>the</strong> nationallevel had weakened significantly. Many of <strong>the</strong> strategiesidentified <strong>in</strong> <strong>the</strong> population policy subsequently reappeared<strong>in</strong> <strong>the</strong> Report of <strong>the</strong> M<strong>in</strong>isterial Taskforce on MaternalHealth <strong>in</strong> Papua New Gu<strong>in</strong>ea of 2009.369

Commodity securitySupply cha<strong>in</strong> <strong>and</strong> logisticsmanagementThe status of Reproductive Health Commodity Security <strong>in</strong>Papua New Gu<strong>in</strong>ea must be considered poor. Although itwould be extremely difficult to survey every service deliverypo<strong>in</strong>t <strong>in</strong> <strong>the</strong> country, <strong>the</strong> evidence from several partialassessments <strong>and</strong> many local studies suggests that suppliesof contraceptives are unreliable <strong>and</strong> <strong>in</strong>consistent across <strong>the</strong>full range of health facilities from aid posts to hospitals.At <strong>the</strong> same time, <strong>the</strong> unavailability of contraceptives <strong>in</strong><strong>the</strong> rural health facilities that actually deliver services maycoexist, with large surpluses of commodities <strong>in</strong> area medicalstores or prov<strong>in</strong>cial transit stores. The problem is not that<strong>the</strong> country cannot afford supplies; <strong>the</strong> primary reason for<strong>in</strong>consistent supplies is poor distribution result<strong>in</strong>g fromweak logistics management. This is <strong>in</strong>dicated by <strong>the</strong> factthat <strong>the</strong> government budget allocation for medical supplieswas underspent by 11.3 million k<strong>in</strong>a (US$ 1 = 2.21 k<strong>in</strong>a)<strong>in</strong> 2004 (Midire et al., 2005).The <strong>in</strong>security of supply of contraceptives at variouslevels of <strong>the</strong> health services delivery system is a majorimpediment to <strong>the</strong> cont<strong>in</strong>uous use of modern contraception<strong>in</strong> Papua New Gu<strong>in</strong>ea. Village-level studies, such as thatundertaken by Maibani-Michie (1998), show that lack ofor <strong>in</strong>consistency <strong>in</strong> supply, along with difficulty of access,are <strong>the</strong> primary reasons for discont<strong>in</strong>uation of familyplann<strong>in</strong>g methods <strong>in</strong> rural areas. This arises <strong>in</strong> part because<strong>the</strong> system of village aid posts – <strong>the</strong> lowest level of facility<strong>in</strong> <strong>the</strong> Papua New Gu<strong>in</strong>ea system of rural health care – hasbeen collaps<strong>in</strong>g over <strong>the</strong> past 20 years. It is estimated that,<strong>in</strong> 2000, 37 per cent of aid posts <strong>in</strong> <strong>the</strong> country had ceasedoperat<strong>in</strong>g (NDOH M<strong>in</strong>isterial Task Force, 2009). In someprov<strong>in</strong>ces <strong>the</strong> proportion of aid posts still function<strong>in</strong>g iseven lower. Midire et al. (2005) found that only 59 per centof aid posts <strong>in</strong> Morobe Prov<strong>in</strong>ce were operational.Even if <strong>the</strong> village has a function<strong>in</strong>g aid post, <strong>the</strong> deliveryof contraceptives, as with o<strong>the</strong>r medic<strong>in</strong>es <strong>and</strong> supplies,is generally erratic <strong>and</strong> unreliable. A conscientiousstaff member of an aid post, an “Aid Post Orderly” orCommunity Health Worker (CHW), would need to behighly creative <strong>and</strong> energetic to ensure cont<strong>in</strong>uity of supplyby seek<strong>in</strong>g emergency supplies from a health centre or adistrict hospital when “stock-outs” (an event that causes<strong>in</strong>ventory to be exhausted) occur.In any case, aid posts are normally able to provide onlycondoms, <strong>in</strong>jections <strong>and</strong> pills; however, stock-outs of<strong>the</strong>se commodities are common, frequently last<strong>in</strong>gseveral months. 15 Some aid posts had never provided anyfamily plann<strong>in</strong>g services because staff were not tra<strong>in</strong>ed or<strong>in</strong>terested. The unreliability of supply at <strong>the</strong> rural villagelevel encourages women to go directly to a health centre,district or prov<strong>in</strong>cial hospital where <strong>the</strong> chances of f<strong>in</strong>d<strong>in</strong>g<strong>the</strong> service or commodity wanted are higher. However,even at <strong>the</strong>se levels stock-outs can occur (Midire et al.,2005), although less frequently than at <strong>the</strong> aid post level.The closure of an aid post or <strong>the</strong> unavailability ofcontraceptives <strong>the</strong>re can have dire consequences for womenwho wish to avoid pregnancy <strong>and</strong> have to seek services at<strong>the</strong> next highest service delivery po<strong>in</strong>t. Maibani-Michie(1998) cited <strong>the</strong> case of a woman from a remote part ofMilne Bay Prov<strong>in</strong>ce, who said:I had discont<strong>in</strong>ued depo not by choice butwas forced to by natural circumstances.When my depo <strong>in</strong>jection was due it wasdur<strong>in</strong>g <strong>the</strong> wet season <strong>and</strong> <strong>the</strong> rivers hadflooded so I could not go to <strong>the</strong> healthcentre because to get <strong>the</strong>re I had to gothrough 20 or more river cross<strong>in</strong>gs. As aconsequence of that I fell pregnant to my7th child…Comprehensive reviews of Reproductive HealthCommodity Security (RHCS) <strong>in</strong> Papua New Gu<strong>in</strong>ea wereconducted <strong>in</strong> 2003 <strong>and</strong> 2005. The most recent of <strong>the</strong>se(Midire et al., 2005) described <strong>the</strong> situation that wouldhave prevailed around <strong>the</strong> time of <strong>the</strong> 2006 DHS. Majorproblems identified <strong>in</strong> 2005 <strong>in</strong>cluded <strong>the</strong> follow<strong>in</strong>g:Forecast<strong>in</strong>gThe methods used for forecast<strong>in</strong>g future requirements are<strong>in</strong>adequate. Order<strong>in</strong>g is done annually based on previousyears but no account is taken of <strong>the</strong> “stock-outs” that haveoccurred dur<strong>in</strong>g <strong>the</strong> year, result<strong>in</strong>g <strong>in</strong> a chronic undersupplyof contraceptives. Deliveries to village aid posts are notbased upon an assessment of dem<strong>and</strong> or needs <strong>in</strong> <strong>the</strong>catchment area. Ra<strong>the</strong>r, a fixed quantity of contraceptives is<strong>in</strong>cluded <strong>in</strong> medic<strong>in</strong>e kits that are supposed to be deliveredevery six months.ProcurementGovernment procedures for procur<strong>in</strong>g contraceptives arecomplex, time-consum<strong>in</strong>g <strong>and</strong> poorly implemented. Whilepart of <strong>the</strong> problem is that <strong>the</strong> procedures are cumbersome,<strong>the</strong> ma<strong>in</strong> reason for delays is weak management, which isexacerbated by shortages of staff <strong>and</strong> <strong>in</strong>adequate tra<strong>in</strong><strong>in</strong>g.370

Pipel<strong>in</strong>e managementSurpluses of stock <strong>in</strong> area medical stores coexist withshortages <strong>in</strong> district hospitals, health centres <strong>and</strong> aidposts. The overstock<strong>in</strong>g of supplies at one stage of <strong>the</strong>distribution cha<strong>in</strong> accompanied by <strong>the</strong> understock<strong>in</strong>gof supplies at service delivery po<strong>in</strong>ts is <strong>in</strong>dicative of poorlogistics management.Fund<strong>in</strong>g sourcesIt is not possible to provide a def<strong>in</strong>itive account<strong>in</strong>g of allexpenditure on RH commodities. It is clear, however, that<strong>the</strong> Government of Papua New Gu<strong>in</strong>ea provides <strong>the</strong> bulkof <strong>the</strong> funds to f<strong>in</strong>ance <strong>the</strong> purchase of contraceptives.The purchase of contraceptives is carried out throughm<strong>and</strong>ated procurement systems that require <strong>the</strong> call<strong>in</strong>g oftenders, with <strong>the</strong> f<strong>in</strong>al decision on <strong>the</strong> supplier be<strong>in</strong>g madeby various bodies up to <strong>the</strong> Executive <strong>Council</strong>, depend<strong>in</strong>gon <strong>the</strong> amount. In 2004, <strong>the</strong> Government of Papua NewGu<strong>in</strong>ea spent K1.97 million on contraceptives <strong>and</strong> afur<strong>the</strong>r K1.3 million was provided by AusAID under <strong>the</strong>Health Sector Improvement Programme. These figuressuggest that <strong>the</strong> government furnished 60 per cent of <strong>the</strong>costs of contraceptives. However, if <strong>the</strong> private sector <strong>and</strong>NGOs are <strong>in</strong>cluded, <strong>the</strong> government share would decl<strong>in</strong>eto about 50 per cent.The contraceptives <strong>in</strong>cluded <strong>in</strong> medical kits supplied tohealth centres <strong>and</strong> aid posts are purchased by AusAID <strong>and</strong><strong>the</strong> <strong>Asia</strong>n Development Bank, respectively. The HealthSector Support Programme spent K928,500 <strong>in</strong> 2005 oncondoms <strong>in</strong>cluded <strong>in</strong> <strong>the</strong>se kits. AusAID provided anadditional K9.5 million for condoms <strong>and</strong> o<strong>the</strong>r medicalsupplies through <strong>the</strong> National HIV/AIDS Project(Midire et al., 2005).It is estimated that less than 5 per cent of contraceptivesare purchased directly by <strong>in</strong>dividuals from pharmacies orprovided by private doctors. However, <strong>the</strong>re are <strong>in</strong>stanceswhen hospitals that have run out of supplies send patientsto pharmacies to purchase <strong>the</strong>ir requirements. The PapuaNew Gu<strong>in</strong>ea <strong>Family</strong> Health Association (an IPPF affiliate),which provides contraception free, obta<strong>in</strong>s commoditiesfrom IPPF Headquarters <strong>in</strong> London. O<strong>the</strong>r NGOs nowoperat<strong>in</strong>g <strong>in</strong> Papua New Gu<strong>in</strong>ea, <strong>in</strong>clud<strong>in</strong>g PopulationServices <strong>International</strong>, Marie Stopes <strong>and</strong> <strong>Family</strong> Health<strong>International</strong>, purchase contraceptives locally or fromabroad.There is little or no coord<strong>in</strong>ation between <strong>the</strong>se agencies <strong>in</strong>terms of <strong>the</strong> purchase of contraceptives. It is not possibleto estimate <strong>the</strong> total expenditure, but it is likely that <strong>the</strong>government’s share of <strong>the</strong> total is decl<strong>in</strong><strong>in</strong>g <strong>in</strong> relativeterms.Commodity security planA wide range of recommendations have followed from <strong>the</strong>recent RHCS reviews, but <strong>the</strong> extent to which <strong>the</strong>se havebeen implemented over <strong>the</strong> past few years is not currentlyknown. Foremost among <strong>the</strong>se are:Establishment of <strong>the</strong> National RHCS Coord<strong>in</strong>at<strong>in</strong>gCommittee/Work<strong>in</strong>g GroupDevelopment of <strong>the</strong> National RHCS StrategyStreng<strong>the</strong>n<strong>in</strong>g <strong>the</strong> Logistics Management System (newprocedures, equipment)Capacity-build<strong>in</strong>g (appo<strong>in</strong>t<strong>in</strong>g logistics manager,tra<strong>in</strong><strong>in</strong>g <strong>in</strong> forecast<strong>in</strong>g etc.)Procurement of additional commodities not currentlyavailable (e.g., vasectomy kits)Improved mechanisms to ensure susta<strong>in</strong>ability of RHCS(policy dialogue, resource mobilization, communitybaseddistribution)Preparation of an essential drugs list.The status of implementation of <strong>the</strong>se recommendations isunclear at this po<strong>in</strong>t, but <strong>the</strong> 2005 report reviewed <strong>the</strong> statusof <strong>the</strong> recommendations of <strong>the</strong> 2003 RHCS assessment,some of which reappeared <strong>in</strong> 2005. Implementationappeared to be limited over <strong>the</strong> two-year period follow<strong>in</strong>g<strong>the</strong> 2003 review. Importantly, progress had been slow <strong>in</strong>establish<strong>in</strong>g an RHCS coord<strong>in</strong>at<strong>in</strong>g body. 16Adolescents, youth <strong>and</strong> olderpersonsAdolescents <strong>and</strong> youthThe teenage fertility rate <strong>in</strong> Papua New Gu<strong>in</strong>ea, at 65 per1,000, is at <strong>the</strong> high end of <strong>the</strong> range for <strong>Pacific</strong> countries<strong>and</strong> territories, provid<strong>in</strong>g some obvious outliers, such asMarshall Isl<strong>and</strong>s (127) <strong>and</strong> Nauru (78), are left out of <strong>the</strong>comparison. Essentially, Papua New Gu<strong>in</strong>ea, SolomonIsl<strong>and</strong>s <strong>and</strong> Vanuatu all have <strong>the</strong> same teenage fertilityrate. Teenage fertility patterns are largely determ<strong>in</strong>ed bycultural-behavioural conditions <strong>and</strong> are not closely relatedto overall fertility (Hayes <strong>and</strong> Robertson, 2010). Teenagefertility does not necessarily follow <strong>the</strong> overall TFRdownward if it is decl<strong>in</strong><strong>in</strong>g.Although very strong socio-cultural pressure can br<strong>in</strong>gteenage fertility down to significantly lower levels, as <strong>the</strong>special case of Tonga suggests, most <strong>Pacific</strong> cultures areei<strong>the</strong>r unwill<strong>in</strong>g or unable to practise <strong>the</strong> necessary degreeof social control of teenage girls (less so of boys) that Tonga371

is able to achieve. In Papua New Gu<strong>in</strong>ea <strong>and</strong> o<strong>the</strong>r <strong>Pacific</strong>cultures, teenage births generally occur outside marriage– even if marriage eventually occurs between mo<strong>the</strong>r <strong>and</strong>fa<strong>the</strong>r <strong>in</strong> <strong>the</strong> fullness of time. Here<strong>in</strong> lies <strong>the</strong> problem foradolescents <strong>in</strong> access<strong>in</strong>g family plann<strong>in</strong>g prior to becom<strong>in</strong>gparents. Although both <strong>the</strong> law <strong>and</strong> government policy <strong>in</strong>Papua New Gu<strong>in</strong>ea allows any person above <strong>the</strong> age of 16to obta<strong>in</strong> contraceptives from government cl<strong>in</strong>ics, or anyo<strong>the</strong>r source, <strong>the</strong> practice is ra<strong>the</strong>r different. Many healthworkers <strong>in</strong> family plann<strong>in</strong>g cl<strong>in</strong>ics regard <strong>the</strong>mselves asguardians of <strong>the</strong> moral order ra<strong>the</strong>r that a service provider.As Burdon et al. (2002) noted, “…most health workerswould not dream of giv<strong>in</strong>g any family plann<strong>in</strong>g methodsto anyone over <strong>the</strong> age of 16 who is unmarried” (p. 56).While this attitude may not be universal, it is probablyquite common.One of <strong>the</strong> limitations of <strong>the</strong> MCH approach to familyplann<strong>in</strong>g is that young unmarried people without childrenhave no access to <strong>the</strong> services. This was part of <strong>the</strong> rationalefor broaden<strong>in</strong>g <strong>the</strong> approach to family plann<strong>in</strong>g <strong>and</strong> plac<strong>in</strong>git with<strong>in</strong> a rights-based reproductive health strategy. Inpractice, this approach is still <strong>in</strong>sufficient for young people.Consequently, adolescents have to seek services fromNGOs, or STI cl<strong>in</strong>ics, community-based distributors, orprivate pharmacies. However, <strong>the</strong>se sources are difficult forrural youth to access as most NGOs operate <strong>in</strong> urban areasor at best <strong>in</strong> peri-urban villages. Similarly, peer educators<strong>and</strong> university-based cl<strong>in</strong>ics serv<strong>in</strong>g students are bydef<strong>in</strong>ition urban <strong>and</strong> not of much assistance to rural youth,who have to fall back on an aid post or a health centre,where <strong>the</strong>ir access to services depends on <strong>the</strong> attitude of<strong>the</strong> community health worker or aid post orderly. Wherea health centre is Church-operated, it would be difficultfor unmarried adolescents to access contraception, even ifsupplies are available.The recent <strong>in</strong>crease <strong>in</strong> <strong>the</strong> number of NGOs address<strong>in</strong>greproductive health needs <strong>in</strong> Port Moresby is of assistanceto youth <strong>and</strong> adolescents as <strong>the</strong>se organizations are notconcerned with uphold<strong>in</strong>g <strong>the</strong> moral order, as manygovernment staff seem to be. The expansion of <strong>the</strong> PapuaNew Gu<strong>in</strong>ea <strong>Family</strong> Health Association’s operationsbeyond its current three cl<strong>in</strong>ics would be of great assistance<strong>in</strong> improv<strong>in</strong>g access to family plann<strong>in</strong>g for young unmarriedpeople.Older personsOlder persons face barriers of a different type to thosefaced by adolescents. In this context, “older persons” refersto women who wish to stop childbear<strong>in</strong>g before <strong>the</strong>ywould naturally do so. Even <strong>in</strong> traditional times, womensought ways to cease childbear<strong>in</strong>g long before <strong>the</strong>y lost <strong>the</strong>biological capacity to conceive. It is important to recall thatunmet need for family plann<strong>in</strong>g <strong>in</strong> 2006 was 61.5 per centamong women aged 40-44 <strong>and</strong> 76.8 per cent among women45-49. These are <strong>the</strong> women who generally would like tostop childbear<strong>in</strong>g but may still be at risk of conceiv<strong>in</strong>g if<strong>the</strong>y are not us<strong>in</strong>g some form of family plann<strong>in</strong>g. Ruralwomen are particularly at risk of an unwanted pregnancy<strong>in</strong> older age.As Townsend (1984) po<strong>in</strong>ted out, tubal ligation is <strong>the</strong>ideal contraceptive method for rural women who have hadall <strong>the</strong> children <strong>the</strong>y wish to have had. When tubal ligationwas <strong>in</strong>troduced <strong>in</strong> <strong>the</strong> 1970s it was taken up rapidly byrural women. In <strong>the</strong> Goroka area <strong>the</strong> average age of womenseek<strong>in</strong>g tubal ligation <strong>in</strong> <strong>the</strong> 1970s was 34 years <strong>and</strong>average parity was 5.5 (Townsend, 1984). When healthcentres were function<strong>in</strong>g well (i.e., fully supplied withrunn<strong>in</strong>g water <strong>and</strong> ma<strong>in</strong>ta<strong>in</strong>ed <strong>in</strong> a hygienic condition)tubal ligation could be conducted <strong>the</strong>re. Increas<strong>in</strong>gly tuballigation is available only <strong>in</strong> a prov<strong>in</strong>cial hospital. For poor,rural women liv<strong>in</strong>g <strong>in</strong> remote areas, travel to a prov<strong>in</strong>cialhospital is very difficult due to <strong>the</strong> cost <strong>and</strong> difficulties oftransport.In health centres operated by <strong>the</strong> Catholic Church, tuballigation is <strong>in</strong> any case not available <strong>and</strong> this is also true <strong>in</strong>some health centres operated by <strong>the</strong> Anglican Church.However, vasectomy is an <strong>in</strong>creas<strong>in</strong>gly popular permanentmeans of stopp<strong>in</strong>g childbirth <strong>and</strong> tra<strong>in</strong><strong>in</strong>g <strong>in</strong> non-scalpelvasectomy is be<strong>in</strong>g provided across Papua New Gu<strong>in</strong>eawith UNFPA support.L<strong>in</strong>kages to o<strong>the</strong>r reproductivehealth issuesHIV <strong>and</strong> AIDSThe advent of <strong>the</strong> HIV epidemic <strong>in</strong> Papua New Gu<strong>in</strong>eahas had consequences for family plann<strong>in</strong>g <strong>in</strong> <strong>the</strong> sensethat <strong>the</strong>re is no shortage of condoms <strong>in</strong> <strong>the</strong> country, evenif specific service providers, particular rural aid posts orhealth centres, have <strong>in</strong>termittent or unreliable supply.Female condoms are also be<strong>in</strong>g distributed <strong>in</strong> <strong>in</strong>creas<strong>in</strong>gquantities, particularly by NGOs address<strong>in</strong>g <strong>the</strong> needs ofcommercial sex workers.Government policy is that condoms should be made freelyavailable to anyone who wants <strong>the</strong>m without hav<strong>in</strong>g toregister <strong>in</strong> a cl<strong>in</strong>ic. However, <strong>the</strong>re is evidence that healthworkers resist this policy. Despite <strong>the</strong> urgency of <strong>the</strong>HIV <strong>and</strong> AIDS crisis, some health workers cont<strong>in</strong>ue tobelieve that <strong>the</strong> free distribution of condoms encouragespromiscuity or prostitution.372

Sexually transmitted <strong>in</strong>fectionsIncreas<strong>in</strong>g rates of o<strong>the</strong>r STIs is hav<strong>in</strong>g an impact on <strong>the</strong>provision of some forms of contraception, such as IUDs. Aconsiderable proportion of women seek<strong>in</strong>g IUDs from <strong>the</strong>Marie Stopes cl<strong>in</strong>ic <strong>in</strong> Port Moresby, for example, cannotbe fitted with an IUD because <strong>the</strong>y have an STI, whichhas to be treated before <strong>the</strong> cl<strong>in</strong>ic can fit <strong>the</strong> woman withan IUD. As an IUD alone provides no protection froman STI it is not suitable for women who are not <strong>in</strong> anexclusively monogamous relationship. At <strong>the</strong> same time, <strong>the</strong>expansion of NGO services has made it much more likelythat young people will seek advice <strong>and</strong> treatment as <strong>the</strong>services provided at NGO cl<strong>in</strong>ics are more likely to followa rights-based approach <strong>and</strong> ma<strong>in</strong>ta<strong>in</strong> confidentiality.Socio-cultural challenges tofamily plann<strong>in</strong>gDem<strong>and</strong> <strong>and</strong> supply of childrenIt is normally assumed that <strong>in</strong> traditional or underdevelopedsocieties, family size preferences are ei<strong>the</strong>r high or that<strong>in</strong>dividuals do not perceive <strong>the</strong> size of <strong>the</strong>ir family assometh<strong>in</strong>g that is with<strong>in</strong> <strong>the</strong>ir control. There is ampleevidence, however, that many traditional societies <strong>in</strong> <strong>the</strong><strong>Pacific</strong> did not aim at high fertility <strong>and</strong> took steps to limit<strong>the</strong> number of children, particularly <strong>in</strong> Melanesia, however<strong>in</strong>effective <strong>the</strong>se means may have been. 17 With <strong>in</strong>creas<strong>in</strong>g“modernization”, women <strong>in</strong> particular come to believe that<strong>the</strong>y can effectively limit <strong>the</strong>ir family size, at which po<strong>in</strong>tit becomes reasonable to ask how many children <strong>the</strong>ywould prefer to have. Agyei (1988) was probably <strong>the</strong> firstresearcher to put this question to a sample of Papua NewGu<strong>in</strong>ea women <strong>in</strong> <strong>the</strong> late 1970s, f<strong>in</strong>d<strong>in</strong>g that <strong>the</strong> majorityof women wanted at least six children. At that time TFRwas 5.4; thus “wanted” fertility appeared to be higher than“actual” fertility.Village-based research <strong>in</strong> a variety of sett<strong>in</strong>gs throughoutPapua New Gu<strong>in</strong>ea a decade later did not confirm thisf<strong>in</strong>d<strong>in</strong>g. McDowell summarized this research by conclud<strong>in</strong>gthat “four or five” children would be a sufficient number tomeet <strong>the</strong> genu<strong>in</strong>e needs of rural families (McDowell, 1988),with <strong>the</strong> implication that <strong>the</strong>re would be broad acceptanceof any population policy that was aimed at limit<strong>in</strong>g <strong>the</strong>average number of births to between four <strong>and</strong> five.TableTable16TableTable17373

Qualitative assessments by a number of researchers<strong>and</strong> <strong>in</strong>formed observers from <strong>the</strong> 1970s onwards havesuggested that most women <strong>in</strong> Papua New Gu<strong>in</strong>ea wouldprefer to have four children. However, <strong>the</strong> actual numberis less important than <strong>the</strong> balance of male <strong>and</strong> femalechildren. As Townsend (1984) notes, women need boysfor old-age support <strong>and</strong> girls <strong>in</strong> order to receive bridepricewhen <strong>the</strong>y marry (<strong>and</strong> child-price when <strong>the</strong>y havechildren). This observation highlights <strong>the</strong> cultural fact thatdecisions about <strong>the</strong> number of children that a woman willbear are not necessarily for her alone to make (or even forher <strong>and</strong> her husb<strong>and</strong> to make jo<strong>in</strong>tly) but belong to <strong>the</strong>social group. In fact, negotiations over bride-price may also<strong>in</strong>volve an agreement between <strong>the</strong> respective clans be<strong>in</strong>gl<strong>in</strong>ked by marriage regard<strong>in</strong>g <strong>the</strong> number of children ofeach sex that <strong>the</strong> woman would have.In traditional times, <strong>and</strong> <strong>in</strong> some areas probably up untiltoday, a married woman who aborted a child or committed<strong>in</strong>fanticide could be depriv<strong>in</strong>g her own k<strong>in</strong> group of <strong>the</strong>payments or gifts that <strong>the</strong> fa<strong>the</strong>r’s k<strong>in</strong> group is obligedto pay on <strong>the</strong> birth of a child, depend<strong>in</strong>g on how manychildren she already had. Abortion could be grounds fordivorce at which po<strong>in</strong>t <strong>the</strong> woman’s k<strong>in</strong> group would haveto repay all or part of <strong>the</strong> bride-price <strong>the</strong>y had receivedfrom <strong>the</strong> husb<strong>and</strong>’s k<strong>in</strong> (O’Coll<strong>in</strong>s, 1979). Thus, so longas such <strong>in</strong>stitutions as bride-price <strong>and</strong> child-price areculturally supported, a woman is not completely free tochoose <strong>the</strong> number of children she will have. Never<strong>the</strong>less,it is possible to negotiate such issues when marriage isbe<strong>in</strong>g arranged, <strong>and</strong> it is highly likely that nowadays malek<strong>in</strong> groups will be satisfied with fewer children as <strong>the</strong> valueof children’s labour decl<strong>in</strong>es <strong>and</strong> <strong>the</strong> cost of rais<strong>in</strong>g children<strong>in</strong>creases. 18The first reliable data on family size preferences <strong>in</strong> anationally representative sample was obta<strong>in</strong>ed from <strong>the</strong>1996 DHS. With a second DHS conducted <strong>in</strong> 2006 itis possible to measure changes <strong>in</strong> family size preferences.Table 16 shows ideal family size <strong>in</strong> 1996 <strong>and</strong> 2006 crossclassifiedby age. It is clear that <strong>the</strong> ideal number of childrenamong women has not changed significantly between1996 <strong>and</strong> 2006. (The small changes between <strong>the</strong> twosurveys <strong>in</strong> some age groups are unlikely to be statisticallysignificant.)The data suggest that women approach<strong>in</strong>g <strong>the</strong> end of<strong>the</strong>ir reproductive years (age 35-39) still wish to havefour children. However, when a comparison is madebetween <strong>the</strong> “wanted” TFR <strong>and</strong> <strong>the</strong> “actual” TFR <strong>in</strong> 1996<strong>and</strong> 2006, it is apparent that <strong>the</strong> gap between wanted <strong>and</strong>actual fertility is widen<strong>in</strong>g. This is evident from <strong>the</strong> data<strong>in</strong> Table 17, which shows that <strong>the</strong> gap between actual <strong>and</strong>wanted TFR has <strong>in</strong>creased from 0.9 to 1.4 between <strong>the</strong>two DHS. This widen<strong>in</strong>g gap implies that women are lessable to achieve <strong>the</strong>ir family size goals <strong>in</strong> 2006 than <strong>the</strong>ywere a decade earlier – yet ano<strong>the</strong>r <strong>in</strong>dication that familyplann<strong>in</strong>g services are not meet<strong>in</strong>g <strong>the</strong> needs of women.It is noteworthy that <strong>the</strong> gap between wanted <strong>and</strong> actualTFR is smallest <strong>in</strong> both years for women who have beeneducated to grade 7 <strong>and</strong> over; but <strong>the</strong> percentage <strong>in</strong>crease<strong>in</strong> <strong>the</strong> gap is <strong>the</strong> highest for educated women. In thisgroup, <strong>the</strong> difference between wanted TFR <strong>and</strong> actualTFR <strong>in</strong>creased by 100 per cent (from 0.5 to 1.0), whereas<strong>in</strong> o<strong>the</strong>r groups <strong>the</strong> <strong>in</strong>crease ranged from 66 per cent (forwomen with no education) to 33 per cent (for womeneducated to grade 6). The implication of <strong>the</strong>se figures isthat education is f<strong>in</strong>ally beg<strong>in</strong>n<strong>in</strong>g to have a clear impacton desired family size, someth<strong>in</strong>g that was not so evident<strong>in</strong> <strong>the</strong> past (Townsend, 1984).In sum, family size preferences should not present a socioculturalchallenge to family plann<strong>in</strong>g programmes <strong>in</strong> PapuaNew Gu<strong>in</strong>ea. It is not <strong>the</strong> case that women generally wanta large family <strong>and</strong> <strong>the</strong>refore that <strong>the</strong> dem<strong>and</strong> for familyplann<strong>in</strong>g needs to be generated before family plann<strong>in</strong>gwill be taken up. This may well have been <strong>the</strong> situation <strong>in</strong><strong>the</strong> 1970s, <strong>and</strong> possibly up to <strong>the</strong> early 1980s, but it is not<strong>the</strong> case today. Women want fewer children than <strong>the</strong>y arelikely to have given <strong>the</strong>ir current access to <strong>and</strong> utilizationof family plann<strong>in</strong>g services. This is evident from Figure 6,which is based on data from a special DHS (based on <strong>the</strong>1996 model) conducted <strong>in</strong> 2002/03 <strong>in</strong> <strong>the</strong> four prov<strong>in</strong>ces<strong>in</strong> which UNFPA has concentrated its activities s<strong>in</strong>ce1997.The figure shows that if this group of women were membersof <strong>the</strong> same cohort, <strong>the</strong>y would have reached <strong>the</strong>ir preferredor ideal family size (about 3.8 children) by age 35-39.However <strong>the</strong> mean number of children ever-born <strong>and</strong> <strong>the</strong>mean number of surviv<strong>in</strong>g children cont<strong>in</strong>ue to <strong>in</strong>creasebeyond that age, reach<strong>in</strong>g about 5.5 by age 40-44. This isnot, of course, a real cohort <strong>in</strong> <strong>the</strong> same sense that TFRis not calculated on <strong>the</strong> basis of a real cohort but ra<strong>the</strong>r asyn<strong>the</strong>tic cohort. Yet <strong>the</strong> data give an <strong>in</strong>dication that <strong>the</strong>“supply” of children exceeds <strong>the</strong> “dem<strong>and</strong>” for children evenwhen allow<strong>in</strong>g for <strong>the</strong> mortality of children. The motive tohave more births than needed <strong>in</strong> order to achieve a preferrednumber of children is significantly weakened as <strong>the</strong> <strong>in</strong>fantmortality rate decl<strong>in</strong>es, as it has been do<strong>in</strong>g <strong>in</strong> Papua NewGu<strong>in</strong>ea <strong>in</strong> recent decades. “Excess” births to compensatefor <strong>the</strong> mortality of children are no longer required <strong>in</strong> <strong>the</strong>Papua New Gu<strong>in</strong>ea context, although <strong>in</strong>dividual women<strong>in</strong> high-mortality areas may be <strong>in</strong> this situation.374

FigureFigure67Relationship between ideal number of children <strong>and</strong> children ever born <strong>and</strong> surviv<strong>in</strong>g, 2002Demographic <strong>and</strong> Health Survey of selected prov<strong>in</strong>ces654321015-19 20-24 25-29 30-34 35-39 40-44 45-49Mean No. Children ever Born Plus Current PregnancyMean No. of Liv<strong>in</strong>g ChildrenIdeal No. ChildrenSource: Azcuna (2007).Gender <strong>and</strong> family relationsThe figure shows that if this group of women were membersof <strong>the</strong> same cohort, <strong>the</strong>y would have reached <strong>the</strong>ir preferredor ideal family size (about 3.8 children) by age 35-39.However <strong>the</strong> mean number of children ever-born <strong>and</strong> <strong>the</strong>mean number of surviv<strong>in</strong>g children cont<strong>in</strong>ue to <strong>in</strong>creasebeyond that age, reach<strong>in</strong>g about 5.5 by age 40-44. This isnot, of course, a real cohort <strong>in</strong> <strong>the</strong> same sense that TFRis not calculated on <strong>the</strong> basis of a real cohort but ra<strong>the</strong>r asyn<strong>the</strong>tic cohort. Yet <strong>the</strong> data give an <strong>in</strong>dication that <strong>the</strong>“supply” of children exceeds <strong>the</strong> “dem<strong>and</strong>” for children evenwhen allow<strong>in</strong>g for <strong>the</strong> mortality of children. The motive tohave more births than needed <strong>in</strong> order to achieve a preferrednumber of children is significantly weakened as <strong>the</strong> <strong>in</strong>fantmortality rate decl<strong>in</strong>es, as it has been do<strong>in</strong>g <strong>in</strong> Papua NewGu<strong>in</strong>ea <strong>in</strong> recent decades. “Excess” births to compensatefor <strong>the</strong> mortality of children are no longer required <strong>in</strong> <strong>the</strong>Papua New Gu<strong>in</strong>ea context, although <strong>in</strong>dividual women<strong>in</strong> high-mortality areas may be <strong>in</strong> this situation.Gender <strong>and</strong> family relationsGender <strong>in</strong>equality makes a major contribution to maternalhealth problems <strong>in</strong> Papua New Gu<strong>in</strong>ea. Violence aga<strong>in</strong>stwomen is endemic <strong>and</strong> common; it <strong>in</strong>cludes sexual violence,rape <strong>and</strong> gang rape. Women <strong>and</strong> girls have unequal accessto health care. Boy children are more likely to receiveurgent health care than girl children. When life expectancyhas been calculated us<strong>in</strong>g data obta<strong>in</strong>ed on deaths amongadult women, male life expectancy has been shown to behigher than that for females. 19So far as family plann<strong>in</strong>g is concerned, <strong>the</strong> opposition ofhusb<strong>and</strong>’s is not among <strong>the</strong> ma<strong>in</strong> reasons that women givefor not us<strong>in</strong>g family plann<strong>in</strong>g; but it is generally understoodthat men have a major <strong>in</strong>fluence on a woman’s decision touse family plann<strong>in</strong>g <strong>and</strong> what k<strong>in</strong>d to use. Men certa<strong>in</strong>lywish to be more <strong>in</strong>volved <strong>in</strong> family plann<strong>in</strong>g matters than<strong>the</strong>y presently are <strong>and</strong> efforts to facilitate “men as partners”are certa<strong>in</strong>ly necessary. The success of <strong>the</strong> vasectomyprogramme pioneered <strong>in</strong> <strong>the</strong>Conclusions <strong>and</strong>recommendationsConclusionsThe fertility transitionFertility decl<strong>in</strong>e has occurred slowly <strong>in</strong> Papua NewGu<strong>in</strong>ea compared with o<strong>the</strong>r less developed countries<strong>and</strong> virtually came to a stop <strong>in</strong> <strong>the</strong> early 1990s. The mostlikely reason for this is that mortality was also decl<strong>in</strong><strong>in</strong>gslowly <strong>and</strong> this was <strong>in</strong> turn l<strong>in</strong>ked to a general slowdown<strong>in</strong> <strong>the</strong> pace of economic development. Decentralizationof health services, <strong>in</strong>clud<strong>in</strong>g family plann<strong>in</strong>g, may alsohave played a part <strong>in</strong> <strong>the</strong> slow fertility decl<strong>in</strong>e.Given current trends it is unlikely that TFR will reachreplacement level for at least ano<strong>the</strong>r 20 years, by whichtime <strong>the</strong> population will have reached 10 million <strong>and</strong>still be grow<strong>in</strong>g.Knowledge <strong>and</strong> use of family plann<strong>in</strong>g<strong>and</strong> unmet needKnowledge of modern family plann<strong>in</strong>g methods is375

<strong>in</strong>creas<strong>in</strong>g. In 2006, 81 per cent of married women knewof a modern method <strong>and</strong> 73 per cent knew a source of amodern method.Knowledge of a modern family plann<strong>in</strong>g method isgrow<strong>in</strong>g fastest among women with no education oronly primary education, <strong>and</strong> slowest among educatedwomen.Of women educated to grade 7 <strong>and</strong> higher, 94 per centknow a modern method compared with 70 per cent ofwomen with no education.Knowledge of contraception is grow<strong>in</strong>g fastest <strong>in</strong> urbanareas. Virtually 100 per cent of urban women who areaware of any method are aware of a modern method offamily plann<strong>in</strong>g.Use of modern contraception is grow<strong>in</strong>g at <strong>the</strong> very slowpace of 2.4 per cent per year <strong>in</strong> Papua New Gu<strong>in</strong>ea,reach<strong>in</strong>g only 24.4 per cent of currently married women<strong>in</strong> 2006. At this rate it will take about 32 years to reach50 per cent.The use of contraception is highest among womeneducated to grade 7 or higher.The proportion of women us<strong>in</strong>g “traditional” forms ofcontraception is ris<strong>in</strong>g <strong>in</strong> some regions of <strong>the</strong> country.Of all women <strong>in</strong> <strong>the</strong> Isl<strong>and</strong>s region who are us<strong>in</strong>g anyform of contraception, only 60 per cent are us<strong>in</strong>g amodern method. Although <strong>the</strong> proportion of all marriedwomen us<strong>in</strong>g modern contraception is ris<strong>in</strong>g, it is notris<strong>in</strong>g as a proportion of women us<strong>in</strong>g any method ofcontraception.The highest contraceptive prevalence rate is amongwomen who have had four or more children, followedby women educated to grade 7 <strong>and</strong> higher, followed bywomen aged between 35 <strong>and</strong> 44. Women aged 40-44are most likely to use a traditional method.The unmet need for family plann<strong>in</strong>g is 44 per cent ofcurrently married women, which is a small decreasefrom 46 per cent <strong>in</strong> 1996.The absolute number of women with an unmet needhas <strong>in</strong>creased to 632,000 <strong>in</strong> 2006, a 30 per cent <strong>in</strong>creases<strong>in</strong>ce 1996. This has occurred because <strong>the</strong> number ofwomen of childbear<strong>in</strong>g age has <strong>in</strong>creased substantiallyover <strong>the</strong> decade.The unmet need for family plann<strong>in</strong>g is highest amongwomen aged 40-49 <strong>and</strong> among women with noeducation.Only 36.5 per cent of <strong>the</strong> total dem<strong>and</strong> for familyplann<strong>in</strong>g (current users + unmet need) is satisfied.Older <strong>and</strong> uneducated women have <strong>the</strong> lowestpercentage of total dem<strong>and</strong> satisfied.The gap between desired or preferred family size(wanted TFR) <strong>and</strong> actual family size (actual TFR) iswiden<strong>in</strong>g.Very few women access contraception at mo<strong>the</strong>r<strong>and</strong> child cl<strong>in</strong>ics or from pharmacies <strong>and</strong> shops. Themost rapidly grow<strong>in</strong>g source of contraception is <strong>the</strong>Papua New Gu<strong>in</strong>ea <strong>Family</strong> Health Association (IPPFaffiliate). Access from hospitals <strong>and</strong> health centres isdecl<strong>in</strong><strong>in</strong>g, but access at aid posts is <strong>in</strong>creas<strong>in</strong>g.Barriers to <strong>the</strong> access <strong>and</strong> use of familyplann<strong>in</strong>g servicesThe general deterioration of rural (primary) healthservices, <strong>in</strong>clud<strong>in</strong>g: closure of aid posts, withdrawal ofdoctors, lack of ma<strong>in</strong>tenance <strong>and</strong> repair, lack of vehicles<strong>and</strong> fuel.Unwill<strong>in</strong>gness of some church-operated health centresto provide modern contraception.Imposition of consultation fees at <strong>the</strong> facility level.Low level of female education <strong>and</strong> high rates ofilliteracy.Lack of awareness <strong>and</strong> lack of access among less educatedwomen.Unreliable <strong>and</strong> <strong>in</strong>consistent supplies of contraceptivesaris<strong>in</strong>g from poor management.Negative attitudes of health staff towards poorerpatients.Reluctance of health staff to provide s<strong>in</strong>gle people withcontraception.Belief that contraception promotes promiscuity <strong>and</strong>prostitution.Religious prohibitions aga<strong>in</strong>st modern contraceptionon <strong>the</strong> part of health staff <strong>and</strong> with<strong>in</strong> <strong>the</strong> community.Fear of side effects or health concerns.Commodity securityRH commodity security is poor, ma<strong>in</strong>ly as a result ofpoor logistics management ra<strong>the</strong>r than <strong>the</strong> lack of fundsto purchase supplies.There is little coord<strong>in</strong>ation between agencies <strong>in</strong> termsof purchase of supplies.Status of previous recommendations to improve RHCSis not clear.Policies <strong>and</strong> strategiesPapua New Gu<strong>in</strong>ea has many policies, strategies <strong>and</strong>376

implementation plans <strong>in</strong> health <strong>and</strong> several concernreproductive health <strong>and</strong> family plann<strong>in</strong>g.The ma<strong>in</strong> problem with <strong>the</strong>se plans is that, while<strong>the</strong>y are formulated by <strong>the</strong> national government, <strong>the</strong>irimplementation is <strong>the</strong> responsibility of prov<strong>in</strong>cial <strong>and</strong>district governments.Ano<strong>the</strong>r problem is that policies <strong>and</strong> plans set unrealistictargets <strong>and</strong> do not address <strong>the</strong> constra<strong>in</strong>ts block<strong>in</strong>g<strong>the</strong>ir achievement. Many plans are poorly formulated(confusion between ends <strong>and</strong> means) but even wellformulatedplans are not necessarily implemented.It is not helpful to characterize <strong>the</strong> dem<strong>and</strong> for familyplann<strong>in</strong>g <strong>in</strong> Papua New Gu<strong>in</strong>ea as “low”, as is suggested<strong>in</strong> <strong>the</strong> current draft National Sexual <strong>and</strong> ReproductiveHealth Policy. This perception needs to be corrected.Dem<strong>and</strong> for family plann<strong>in</strong>g <strong>in</strong> Papua New Gu<strong>in</strong>ea ishigh <strong>and</strong> only 37 per cent of current dem<strong>and</strong> is be<strong>in</strong>gmet.The review of family plann<strong>in</strong>g <strong>in</strong> 2002 states that<strong>the</strong> shift to a reproductive health approach hasdiluted <strong>the</strong> focus on family plann<strong>in</strong>g. In <strong>the</strong> NationalSexual <strong>and</strong> Reproductive Health Policy, it is statedthat concentration on family plann<strong>in</strong>g has dilutedreproductive health.Policies are not focused sufficiently on reproductiverights.The family plann<strong>in</strong>g policy is clear <strong>and</strong> <strong>the</strong> guidel<strong>in</strong>esfor service provision are good. However, it is possiblethat <strong>the</strong> policy is not widely distributed or well knownamong health staff.Some health staff do not follow <strong>the</strong> family plann<strong>in</strong>gpolicy on condom distribution, <strong>the</strong> legal right ofadolescents to be provided with contraception if <strong>the</strong>yare over 16 years of age, <strong>and</strong> <strong>the</strong> right of <strong>in</strong>dividuals toreceive contraception (<strong>in</strong>clud<strong>in</strong>g permanent methods)without <strong>the</strong> consent of a spouse.RecommendationsAddress <strong>the</strong> issue of <strong>the</strong> unwill<strong>in</strong>gness of some churchesto provide modern contraception, by:o Provid<strong>in</strong>g alternative government- or NGO-operatedhealth services <strong>in</strong> <strong>the</strong> catchment area of health servicesoperated by churches.o Promote community-based distribution <strong>and</strong> healthvolunteers <strong>in</strong> districts that are served only by churchhealth services.o Mobile family plann<strong>in</strong>g cl<strong>in</strong>ics.o Negotiate service agreements that permit churchhealth services to refer clients to alternative services.o Church health services need to be made aware ofhealth <strong>and</strong> family plann<strong>in</strong>g policies <strong>and</strong> guidel<strong>in</strong>es.Place <strong>in</strong>creased emphasis on aid posts as <strong>the</strong> primaryservice delivery po<strong>in</strong>t for contraception <strong>and</strong> familyplann<strong>in</strong>g, by:o More reliable distribution of commodities to aidposts (commodity security).o Produce a new, revised version of <strong>the</strong> family plann<strong>in</strong>gpolicy <strong>and</strong> service delivery technical guidel<strong>in</strong>es <strong>and</strong>distribute to all aid posts, health centres <strong>and</strong> cl<strong>in</strong>ics.o The <strong>in</strong>troduction to <strong>the</strong> guidel<strong>in</strong>es needs to be revised<strong>in</strong> order to put focus on reproductive rights, maternal<strong>and</strong> child health <strong>and</strong> not demographic issues.o Community health workers <strong>and</strong> o<strong>the</strong>r health staffneed to be tra<strong>in</strong>ed <strong>in</strong> order to emphasize <strong>the</strong> adoptionof appropriate attitudes towards clients, client rights<strong>and</strong> quality of care.Review all previous recommendations on how toimprove family plann<strong>in</strong>g, <strong>in</strong>clud<strong>in</strong>g <strong>the</strong> review offamily plann<strong>in</strong>g <strong>in</strong> Papua New Gu<strong>in</strong>ea by Burdon et al.(2002), <strong>the</strong> National Population Policy 2000-2010 <strong>and</strong><strong>the</strong> Report of <strong>the</strong> M<strong>in</strong>isterial Task Force on MaternalHealth (2009), <strong>and</strong> cross-check for consistency.Harmonize <strong>the</strong> recommendations <strong>and</strong> targets.Specifically review <strong>the</strong> recommendations of <strong>the</strong> Burdonet al. report <strong>and</strong> <strong>the</strong> Maternal Health Task Force on <strong>the</strong>management of <strong>the</strong> family plann<strong>in</strong>g programme.In particular, review <strong>the</strong> CPR <strong>and</strong> TFR targets <strong>in</strong> <strong>the</strong>Draft National Sexual <strong>and</strong> Reproductive Health Policy<strong>and</strong> <strong>the</strong> Maternal Health Task Force Report <strong>and</strong> adjust<strong>the</strong>m to realistic levels.Seek ways to elim<strong>in</strong>ate consultation fees for familyplann<strong>in</strong>g services imposed at facility level.Fur<strong>the</strong>r analysis of DHS data is needed, particularlyto fur<strong>the</strong>r assess <strong>the</strong> relationships between religion,contraceptive use <strong>and</strong> unmet need.Also recheck <strong>the</strong> DHS data on <strong>the</strong> low uptake of familyplann<strong>in</strong>g <strong>in</strong> <strong>the</strong> context of MCH cl<strong>in</strong>ics.Put stronger emphasis on reproductive rights <strong>in</strong>policy documents <strong>and</strong> materials used <strong>in</strong> <strong>the</strong> tra<strong>in</strong><strong>in</strong>gof health workers. Efforts should be made to educate<strong>the</strong> population at large about rights to family plann<strong>in</strong>gservices, regardless of who is manag<strong>in</strong>g <strong>the</strong> facility.Posters outl<strong>in</strong><strong>in</strong>g client rights should be displayed at all377

service delivery po<strong>in</strong>ts.Encourage all prov<strong>in</strong>ces to appo<strong>in</strong>t a family plann<strong>in</strong>glogistics manager.Review <strong>the</strong> implementation of <strong>the</strong> recommendationsmade <strong>in</strong> <strong>the</strong> 2003 <strong>and</strong> 2005 RHCS assessments byUNFPA.Plan for a follow-up family plann<strong>in</strong>g assessment <strong>in</strong>2012 to review changes s<strong>in</strong>ce <strong>the</strong> last comprehensiveassessment by Burdon et al. <strong>in</strong> 2002.End Note1 For fur<strong>the</strong>r details, see IPPF.org/en/where/CN.htm. Accessed on8 October 2010.2 In Papua New Gu<strong>in</strong>ea, <strong>the</strong> lowest level of rural health-careprovision is <strong>the</strong> “aid post”, which usually services one or morerural villages or hamlets. The next step up <strong>the</strong> hierarchy of serviceprovision is <strong>the</strong> “health subcentre”, which serves a larger cluster ofvillages. A “health centre” is one step up from a health subcentre<strong>and</strong> services a district. In larger districts <strong>the</strong> health centre has beenupgraded to a district hospital. Reference to “health centre” <strong>in</strong> thisdocument refers to ei<strong>the</strong>r a health subcentre or a health centre, i.e.,step two or three up <strong>the</strong> hierarchy of services.3 O<strong>the</strong>r projections <strong>in</strong>dicate a population of 13.3 million by 2050(see SPC, 2010).4 The question of whe<strong>the</strong>r a focused family plann<strong>in</strong>g programmewas needed <strong>in</strong> Papua New Gu<strong>in</strong>ea was still be<strong>in</strong>g discussed 30years later (Burdon et al., 2002) but <strong>the</strong> justification had shifted tomaternal <strong>and</strong> <strong>in</strong>fant health.5 Personal communication with NGOs operat<strong>in</strong>g <strong>in</strong> Port Moresby.6 One nurse reported: “I even wrote a letter to <strong>the</strong> Bishop ask<strong>in</strong>gpermission to give FP to <strong>the</strong> high risk mo<strong>the</strong>rs who have had 5, 6or 7 children as <strong>the</strong>y are dy<strong>in</strong>g like flies up here—<strong>and</strong> <strong>the</strong>y told meno” (Burdon et al., 2002).7 The family plann<strong>in</strong>g review noted: “[M]ost health workers wouldnot dream of giv<strong>in</strong>g any family plann<strong>in</strong>g methods to anyone over<strong>the</strong> age of 16 who is unmarried. In fact, most family plann<strong>in</strong>gappears to be distributed only to women who already have a child(Burdon et al., 2002).8 The Population Reference Bureau (2008) reported Haiti’s CPR as24.8 for modern methods.9 The “ovulation” method is taught by family health workersassociated with <strong>the</strong> Catholic Church, but this is not a “traditional”method of birth control <strong>in</strong> Papua New Gu<strong>in</strong>ea, even though DHSclassifies it as such.10 Unmet need can also be calculated, <strong>and</strong> <strong>in</strong>creas<strong>in</strong>gly is, for allwomen of reproductive age regardless of <strong>the</strong>ir marital status. In thispaper only currently married women are <strong>in</strong>cluded <strong>in</strong> <strong>the</strong> numerator<strong>and</strong> denom<strong>in</strong>ator. If all women of reproductive age are <strong>in</strong>cluded,some method of exclud<strong>in</strong>g women who are not sexually active mustbe applied. O<strong>the</strong>rwise, unmet need will tend to be overstated.11 The method used was to calculate <strong>the</strong> proportion of women notus<strong>in</strong>g contraception who did not want to have ano<strong>the</strong>r child.Although this is not an unreasonable calculation, <strong>the</strong> st<strong>and</strong>ardformula uses all women of reproductive age as <strong>the</strong> denom<strong>in</strong>ator.The latter calculation gives a lower figure.12 The actual “dem<strong>and</strong>” for family plann<strong>in</strong>g <strong>in</strong> 2006 was 69.8 per cent.Only 36.8 per cent of dem<strong>and</strong> was satisfied.13 McRae (1982) po<strong>in</strong>ted out that <strong>the</strong> Papua New Gu<strong>in</strong>ea Crim<strong>in</strong>alCode allows a person to perform a surgical operation on a personthat is for his benefit, but a medical practitioner who performs asterilization know<strong>in</strong>g that <strong>the</strong> consent of <strong>the</strong> patient has not beenobta<strong>in</strong>ed will be considered guilty of assault <strong>and</strong> subject to civilaction by <strong>the</strong> patient. There is no law that requires <strong>the</strong> consent of aspouse before sterilization can be carried out, but until recently thiswas <strong>the</strong> general practice <strong>in</strong> Papua New Gu<strong>in</strong>ea. At least one NGOthat carries out tubal ligations <strong>in</strong> Papua New Gu<strong>in</strong>ea still requires<strong>the</strong> written consent of both <strong>the</strong> woman <strong>and</strong> her husb<strong>and</strong> if she ismarried. This practice is to protect <strong>the</strong> facility aga<strong>in</strong>st any risk oflaw suits or violence aga<strong>in</strong>st <strong>the</strong> facility or its staff. McRae fur<strong>the</strong>rnoted that any attempt to restrict access to contraception mayviolate <strong>the</strong> right to privacy guaranteed by <strong>the</strong> country’s constitution.It is unlikely that this right has been tested <strong>in</strong> <strong>the</strong> courts.14 Unfortunately <strong>the</strong> report misses an opportunity to expla<strong>in</strong> <strong>the</strong>possibility that <strong>the</strong> apparent doubl<strong>in</strong>g of <strong>the</strong> maternal mortalityratio between <strong>the</strong> last two DHS is a consequence of statisticalproblems ra<strong>the</strong>r than a real change.15 Midire et al. (2005) reported visit<strong>in</strong>g an aid post that had beenout of stock of condoms for four months, even though a plentifulsupply was available <strong>in</strong> <strong>the</strong> area medical stores. Baravilala (2006)reported that many health centres <strong>in</strong> prov<strong>in</strong>ces supported by aUNFPA project ran out of condoms with<strong>in</strong> two weeks of receiv<strong>in</strong>ga supply. Supply is clearly not dem<strong>and</strong>-driven.16 The National Sexual <strong>and</strong> Reproductive Health Policy (2009)does not refer to any of <strong>the</strong>se recommendations or <strong>the</strong> activitiesassociated with <strong>the</strong>m.17 Pirie (1971) noted that “Melanesian societies show a notablerestra<strong>in</strong>ed attitude toward fertility compared with Polynesian <strong>and</strong><strong>the</strong>re is every reason to believe that an effective means of limit<strong>in</strong>gfamily size would be welcomed”.18 The elim<strong>in</strong>ation of clan fight<strong>in</strong>g has reduced <strong>the</strong> <strong>in</strong>centive to havemany boys to <strong>in</strong>crease <strong>the</strong> strength of <strong>the</strong> clan.19 This was only possible <strong>in</strong> 1991 when DHS asked questionsdesigned to determ<strong>in</strong>e male <strong>and</strong> female mortality separately. 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Agenda0830-0900Day 1: December 8Open<strong>in</strong>g session0900 –10151015-1045Session 11045-13001300-1400Session 21400-15301530-1545RegistrationCURRENT SITUATION OF FAMILY PLANNING IN ASIA AND THEPACIFIC – SUCCESSES, CHANGING NEEDS AND CHALLENGESModerator: Mr. Najib Assifi, Deputy Director, UNFPA APROWelcome addres: Ms. Nobuko Horibe, Director, UNFPA APROBrief address: H.E. Mr. Jur<strong>in</strong> Laksanawisit, M<strong>in</strong>ister of Health,Royal Thai GovernmentKeynote Address: H.E. Mr. Gou Q<strong>in</strong>gm<strong>in</strong>g, Vice-M<strong>in</strong>ister, National Population<strong>and</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Commission of Ch<strong>in</strong>aRationale <strong>and</strong> objectivesof <strong>the</strong> consultation: Dr. Wasim Zaman, Executive Director, ICOMPGroup photo/coffee breakChang<strong>in</strong>g Context of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Objective: To review <strong>the</strong> current situation of fertility decl<strong>in</strong>e <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong> –Successes, chang<strong>in</strong>g needs <strong>and</strong> challengesModerator: Dr. Anrudh Ja<strong>in</strong>, Dist<strong>in</strong>guished Scholar, Population <strong>Council</strong>, USA1. <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Programmes <strong>in</strong> <strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong> <strong>and</strong> Achiev<strong>in</strong>g MDG5b:Prof. Amy Tsui, Director, The Bill <strong>and</strong> Mel<strong>in</strong>da Gates Institute of Population <strong>and</strong>Reproductive Health, Johns Hopk<strong>in</strong>s University2. Fertility <strong>and</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>in</strong> <strong>the</strong> <strong>Pacific</strong>:Dr. Geoffrey Hayes, Development Consultant, New Zeal<strong>and</strong>3. Address<strong>in</strong>g Universal Access to <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> through Reproductive HealthCommodity Security:Mr. Jagdish Upadhyay, Chief of Commodity Security Branch, UNFPADiscussionsLunchVoices from CountriesCountry Case Studies <strong>and</strong> Responses/Statement from Government CounterpartsObjective: To present situational analysis <strong>and</strong> identify priorities for action at <strong>the</strong> countrylevelModerator: Mr. Tomas Osias, Executive Director, Population Commission, <strong>the</strong> Philipp<strong>in</strong>esHigh fertilityAfghanistan: H.E. Dr. Nadera Hayat Burhani, Deputy M<strong>in</strong>ister, M<strong>in</strong>istry ofHealth, AfghanistanPakistan: Dr. Zeba Sathar, Country Director, Population <strong>Council</strong>, PakistanPapua New Gu<strong>in</strong>ea: Dr. Geoffrey Hayes, Development Consultant, New Zeal<strong>and</strong>Timor-Leste: Dr. Adrian Hayes, Research Associate, Australian Demographic <strong>and</strong>Social Research Institute, AustraliaDiscussionsCoffee break381

1545-1730Day 2: December 9Session 2(Cont’d fromDay 1)0830 - 09300930 - 11001100 - 11151115 - 1300Success <strong>and</strong> Stagnation of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> ProgrammeBangladesh: Dr. Barkat-e-Khuda, Professor of Economics <strong>and</strong> Chairman, Bureau ofEconomic Research, University of Dhaka, BangladeshIndonesia: Dr. Adrian Hayes, Research Associate, Australian Demographic <strong>and</strong> SocialResearch Institute, AustraliaIndia: Dr. Anrudh Ja<strong>in</strong>, Dist<strong>in</strong>guished Scholar, Population <strong>Council</strong>, USANepal: Mr. An<strong>and</strong> Tamang, Executive Director, Centre for Research on EnvironmentHealth <strong>and</strong> Population Activities, NepalDiscussionsVoices from CountriesCountry Case Studies <strong>and</strong> Responses/Statement from Government CounterpartsObjective: To present situational analysis <strong>and</strong> identify priorities for action at<strong>the</strong> country levelModerator: Mr. P.K. Pradhan, Additional Secretary <strong>and</strong>Mission Director of National Rural Health Mission, IndiaChallenges <strong>in</strong> Susta<strong>in</strong><strong>in</strong>g Universal Access to <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Sri Lanka: Dr. A.T.P.L. Abeykoon, Senior Fellow,Institute for Health Policy, Sri LankaMalaysia: Dr. Norliza Ahmad, Director, Human Reproduction Division,National Population <strong>and</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Board, MalaysiaThail<strong>and</strong>: Dr. Kittipong Saejeng, Director, Bureau of Reproductive Health,Department of Health, M<strong>in</strong>istry of Public Health, Thail<strong>and</strong>Iran: Dr. Mohammad Eslami, Head of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> Population Bureau,M<strong>in</strong>istry of Health <strong>and</strong> Medical Education, IranDiscussionsIssues <strong>in</strong> Countries with Medium FertilityPhilipp<strong>in</strong>es: Dr. Junice L. Demeterio-Melgar, Executive Director, Likhaan Center forWomen’s Health Inc., Philipp<strong>in</strong>esMaldives: Dr. Bhanu Bhakta Niraula, Country Director – Programme <strong>and</strong> Operations,Brita<strong>in</strong>: Nepal Medical Trust, NepalMyanmar: Dr. Hla Hla Aye, Consultant, Human Resources for Health, MyanmarDiscussionsCoffee breakIDENTIFICATION OF GAPS AND ISSUESStatements from CountriesModerator: Mr. Budihardja S<strong>in</strong>ggih, Director General, Public Health,M<strong>in</strong>istry of Health, IndonesiaBhutan: Dr. Sonam Gyamtsho, Gynaecologist, M<strong>in</strong>istry of HealthNepal: Hon. Ms. Ang Dawa Sherpa, Member of ParliamentCambodia: H.E. Ms. Lork Kheng, Member,National Assembly CommissionLao People’s DemocraticRepublic: H.E. Dr. Bounkoung Phichit, Deputy M<strong>in</strong>ister,M<strong>in</strong>istry of HealthViet Nam: H.E. Dr. Nguyen Ba Thuy, Vice-M<strong>in</strong>ister of Health,M<strong>in</strong>istry of HealthDiscussions382

Kiribati: H.E. Dr. Kautu Tenaua, M<strong>in</strong>ister of Health,M<strong>in</strong>istry of HealthSolomon Isl<strong>and</strong>s: Dr. August<strong>in</strong>e Gasivaka Melly, Medical Officer (MasterTra<strong>in</strong>er <strong>in</strong> <strong>the</strong> National Non-Scalpel Vasectomy Programme),M<strong>in</strong>istry of Health <strong>and</strong> Medical ServicesVanuatu: Mr. Mark Peter Bekonan, Director General,M<strong>in</strong>istry of Health Services1300 - 1400Session 31400 - 1530DiscussionsLunchObjective: Identification of ways to improve commodity security for reproductive health,<strong>in</strong>clud<strong>in</strong>g family plann<strong>in</strong>gReproductive Health Commodity SecurityModerator: Mr. Jagdish Upadhyay, Chief of Commodity Security Branch, UNFPA1. Global RHCS Movement: Mr. John Skibiak, Director,Reproductive Health Supplies Coalition2. Local Production ofContraceptives <strong>and</strong>RHCS Status <strong>in</strong> Ch<strong>in</strong>a:Ms. Hu Yun, Deputy Director,Ch<strong>in</strong>a Tra<strong>in</strong><strong>in</strong>g Centre for Reproductive Health <strong>and</strong><strong>Family</strong> Care, Ch<strong>in</strong>a3. Bangladesh: Dr. Dil Ruba, Director General,<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>, Bangladesh4. Lao PDR: Dr. Kaisone Chounramany,Director, MCH, M<strong>in</strong>istry of Health, Lao PDR1530 - 1600Session 41600 - 1700DiscussionsCoffee breakObjective: Address<strong>in</strong>g challenges to quality of care <strong>in</strong> family plann<strong>in</strong>g <strong>and</strong> focus<strong>in</strong>g on <strong>the</strong>needs of special groupsInequities <strong>in</strong> Access to <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Moderator: Mr. Shahzad Ahmad Malik, Chief (Population), <strong>Plann<strong>in</strong>g</strong> Commission,Pakistan1. Role of counsell<strong>in</strong>g <strong>in</strong> <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Services:Ms. N<strong>in</strong>uk Widyantoro, Chair, Women’s HealthFoundation, Indonesia2. Inequities <strong>in</strong> Access<strong>in</strong>g <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Services <strong>in</strong> <strong>the</strong> <strong>Asia</strong>-<strong>Pacific</strong> Region<strong>and</strong> its Implications: Ms. Sujatha Ram, Monitor<strong>in</strong>g <strong>and</strong> Evaluation ResidentAdvisor, Measure Evaluation, ICF Macro, Bangkok3. Inequities <strong>in</strong> Access to <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>in</strong> Indonesia:Mr. Kartono Muhammed,Women’s Health Foundation, IndonesiaDiscussions383

Day 3, December 10Session 50830-1000ADVOCACY AND ACTIONS FOR TAKING FORWARD COMMITMENTSTO INVESTING IN FAMILY PLANNINGObjective: To advocate for cont<strong>in</strong>ued <strong>and</strong> adequate <strong>in</strong>vestments <strong>in</strong> FPRound table: Parliamentarians <strong>and</strong> media expertsModerator: Mr. Najib M. Assifi, Deputy Director, UNFPA APROHon. Dr. Sumaryati Arjoso, Member of Parliament, IndonesiaHon. Congressman Mr. Rodolfo Biazon, Member of Parliament, Philipp<strong>in</strong>esHon. Mr. Malakai Tabar, Chairman, Parliamentarian Group on Population,Development <strong>and</strong> <strong>the</strong> MDGs, Papua New Gu<strong>in</strong>eaHon. Mr. Raymond Palat<strong>in</strong>o, Congressman, Philipp<strong>in</strong>e CongressMs. Huma Khawar, Journalist, PakistanMs. Maria Hart<strong>in</strong><strong>in</strong>gsih, Journalist, Indonesia1000 - 10151015-1145Coffee breakAccess of Young People to Contraceptive ServicesModerator: Dr. Nadera Hayat Burhani, Deputy M<strong>in</strong>ister, M<strong>in</strong>istry of Health, Afghanistan1. Unmet needs for contraception among adolescents:Dr. Nuriye Ortayli, <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> Adviser, UNFPA2. Access of young people to reproductive health services, <strong>in</strong>clud<strong>in</strong>g contraceptiveservices – Experiences from <strong>the</strong> region:Ms. Sono Aibe, Senior Advisor for Strategic Initiatives,Pathf<strong>in</strong>der <strong>International</strong>, USA3. Meet<strong>in</strong>g <strong>the</strong> sexual <strong>and</strong> reproductive health needs of youth – Insights fromIndia:Dr. Shireen Jejeeboy, Senior Associate, Population <strong>Council</strong>, IndiaPanel discussion with young people from selected countries:Bangladesh, India, Marshall Isl<strong>and</strong>s <strong>and</strong> Philipp<strong>in</strong>esDiscussionsSession 61145 - 12451245-14301430-1530Objective: To develop action plans/strategies for tak<strong>in</strong>g forward commitments to <strong>in</strong>vest<strong>in</strong>g<strong>in</strong> FP <strong>and</strong> reduc<strong>in</strong>g <strong>in</strong>equitiesGroup workModerator: Dr. Kautu Tenaua, M<strong>in</strong>ister of Health, KiribatiConsensus-build<strong>in</strong>g on action plan for tak<strong>in</strong>g forward commitments to <strong>in</strong>vest<strong>in</strong>g <strong>in</strong>family plann<strong>in</strong>gLunchModerator: Mr. Najib Assifi, Deputy Director, UNFPA APROPresentation of Plan of Action: Presenter – H.E. Dr. Kautu Tenaua, M<strong>in</strong>ister ofHealth, KiribatiTak<strong>in</strong>g Consensus Forward: Ms. Nobuko Horibe, Director, UNFPA APROClos<strong>in</strong>g remarks384

List of participantsNo.NameTitleOrganizationE-mail addressAfghanistan1H.E. Dr. Nadera HayatBurhaniDeputy M<strong>in</strong>isterM<strong>in</strong>istry of Public Healthmoph.ird@gmail.com2Dr. Habibullah AhmadzaiHead of <strong>International</strong>RelationsDepartment <strong>and</strong> NationalConsultant, HealthEconomy <strong>and</strong> F<strong>in</strong>anc<strong>in</strong>gDepartmentM<strong>in</strong>istry of Public Healthmoph.ird@gmail.com3Mr. Arie HoekmanRepresentativeUNFPAhoekman@unfpa.orgBangladesh4Ms. Meher AfrozeMember of Parliament5Mr. Abu TaherJo<strong>in</strong>t SecretaryM<strong>in</strong>istry of Health &<strong>Family</strong> Welfare(MOH & FW)6Ms. DilrubaDirector General, FPMOH & FW7Dr. Hash<strong>in</strong>a BegumAssistant RepresentativeUNFPAhash<strong>in</strong>a@unfpa.org8Ms. Syefa AhmedTeam Leader ofOpposition of <strong>the</strong> FPABYouth Parliament (YouthRepresentative)Bhutan9Dr. Sonam GyamtshoGynaecologistM<strong>in</strong>istry of Health(MoH)gyamtsho.sonam@yahoo.com10Hon. Tashi WangmoMember of Parliamenttashiwangmo2002@yahoo.com11Ms. Karma Tsher<strong>in</strong>gNational Programme Officer UNFPAtsher<strong>in</strong>g@unfpa.orgCambodia12H.E. Dr. Ricksy PenUnder-Secretary of StateMoHp_ricksy@yahoo.com13H.E. Ms. Lork KhengNational AssemblyCommission Memberlork.kheng@gmail.com14Ms. Sodany TongAssistant to NationalAssembly CommissionMember385

15Mr. Tong Si<strong>the</strong>n16Mr. Edmund AttridgeDevelopment ManagementAdviser, GovernanceSpecialistejattridge@yahoo.com17Ms. Sarah KnibbsRepresentativeUNFPAknibbs@unfpa.orgCh<strong>in</strong>a18H.E. Mr. Gou Q<strong>in</strong>gm<strong>in</strong>gVice-M<strong>in</strong>isterNational Population <strong>and</strong><strong>Family</strong> Commission ofCh<strong>in</strong>a19Mr. Hu HongtaoDirector General,Department of <strong>International</strong>CooperationNational Population <strong>and</strong><strong>Family</strong> Commission ofCh<strong>in</strong>ahthu@npfpc.gov.cn20Mr. Shi Yuanm<strong>in</strong>gDivision Director,Department of <strong>International</strong>CooperationNational Population <strong>and</strong><strong>Family</strong> Commission ofCh<strong>in</strong>aymshi@npfpc.gov.cn21Ms. Hu YunDeputy DirectorCh<strong>in</strong>a Tra<strong>in</strong><strong>in</strong>g Centre forReproductive Health <strong>and</strong><strong>Family</strong> Carehy@ctc-health.org22Ms. Mariam KhanDeputy RepresentativeUNFPAmkhan@unfpa.orgIndia23Mr. P.K. PradhanAdditional Secretary<strong>and</strong> Mission Director ofNRHM24Dr. Manohar AgnaniMission DirectorNational Rural HealthMission, Madhya Pradeshmanoharagnani@gmail.com25Dr. S.K. SikdarAssistant Commissioner,<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>M<strong>in</strong>istry of Health &<strong>Family</strong> Welfaresikdarsk@gmail.com26Ms. Suchitra RathProcess Evaluation Manager<strong>in</strong> "Ekjut"NGO, Jharkh<strong>and</strong> <strong>and</strong>Orissasuchitra.ekjut@gmail.com27Dr. Marc DerveeuwRepresentative, a.i.UNFPAderveeuw@unfpa.orgIndonesia28Dr. Sugiri Syarief, MPHChairpersonBKKBNsugiri@bkkbn.go.id29Dra. Kasmiyati, M.ScDeputy ChairpersonBKKBNkasmiyati_july@yahoo.com.co.id30Dr. BudihardjaDirector General, PublicHealthM<strong>in</strong>istry of Healthbuddy-s<strong>in</strong>ggih@yahoo.com31Dr. Dedy KuswendaChief of Sub-Directorate,Maternal <strong>and</strong> ComplicationPreventionM<strong>in</strong>istry of Healthp_kuswenda@yahoo.com32Mr. SyaifullahChairperson of FPSitubondo Districtkantorkbsit@yahoo.com33Dr. Kartono MuhamadBoard Member of Women’sHealth FoundationWomen HealthFoundationkmjp47@<strong>in</strong>dosat.net.id34Ms. Maria Hart<strong>in</strong><strong>in</strong>gsihJournalistKomas Dailymaria@kompas.co.id386

35Ms. N<strong>in</strong>uk WidyantoroBoard Member of Women’sHealth FoundationYayasan Kesehatann<strong>in</strong>ukw@hotmail.com36Hon. Sumaryati ArjosoMember of ParliamentPerempuan Women'sHealth Foundationaarjoso@yahoo.com37Mr. Jose FerrarisRepresentativeUNFPAferraris@unfpa.org38Mr. SamidjoProgramme Officer onAdvocacyUNFPAUNFPAsamidjo@unfpa.org39Dr. Melania HidayatNational ProgrammeOfficer, RHMoHhidayat@unfpa.orgIran40Dr. Mohammad EsmaielMotlaghDirector General ofPopulation & <strong>Family</strong> HealthDepartmentMoHmotlagh@health.gov.ir41Dr. Mohammad EslamiHead of <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>UnitUNFPAmeslami@mohme.gov.ir42Dr. Mehmet Hulki UzUNFPA RepresentativeM<strong>in</strong>istry of Healthuz@unfpa.orgLao PDR43H.E. Dr. BounkoungPhichitDeputy M<strong>in</strong>isterM<strong>in</strong>istry of Health44Dr. Somchit AkkhavongDeputy of Hygiene <strong>and</strong>Prevention DepartmentM<strong>in</strong>istry of Healthsrilayrack@yahoo.com45Dr. Kaisone ChounramanyDirector, Mo<strong>the</strong>r <strong>and</strong> ChildHealth CentreM<strong>in</strong>istry of Healthkaisonetic@hotmail.com46Dr. BouphanyPhayouphornCoord<strong>in</strong>ator of UNPFA atM<strong>in</strong>istry of Healthphayouphornbouphany@yahoo.com47Ms. Mieko YabutaRepresentativeUNFPAyabuta@unfpa.orgMalaysia48Ms. Noor Azl<strong>in</strong>Muhammad SapriNational Population <strong>and</strong><strong>Family</strong> DevelopmentBoardazl<strong>in</strong>@lppkn.gov.my49Dr. Shong Chi M<strong>in</strong>Volunteer DoctorFRHAM Cl<strong>in</strong>iccmshong2004@yahoo.com50Mr. Azlan b<strong>in</strong> AzizNational Population <strong>and</strong><strong>Family</strong> DevelopmentBoard51Ms. Suraya b<strong>in</strong>ti GhazaliNational Population <strong>and</strong><strong>Family</strong> DevelopmentBoardMaldives52Dr. Ibrahim YasirDirector General of HealthServiceM<strong>in</strong>istry of Health <strong>and</strong><strong>Family</strong>yasir@health.gov.mv53Dr. Ahmed JamsheedMohamedDirector, Centre forCommunity Health <strong>and</strong>Disease ControlM<strong>in</strong>istry of Health <strong>and</strong><strong>Family</strong>jamsheed@health.gov.mv387

54Ms. Shadiya IbrahimAssistant RepresentativeUNFPAibrahim@unfpa.orgMyanmar55Dr. Kyee My<strong>in</strong>tDeputy Director (MedicalCare), Department ofHealthMoHdrkyee@gmail.com56Dr. The<strong>in</strong> The<strong>in</strong> HtayDeputy Director (PublicHealth), Department ofHealthMoHthtay@mptmail.net.mm57Dr. Nyo Nyo M<strong>in</strong>Deputy Country DirectorPopulation Services<strong>International</strong>nnm<strong>in</strong>n@psimyanmar.org58Dr. Mya Yee MonProject OfficerMarie Stopes <strong>International</strong>myayeem@gmail.comNepal59Dr. Naresh Pratap K.C.Director, <strong>Family</strong> HealthDivision, Department ofHealth ServicesM<strong>in</strong>istry of Health <strong>and</strong>Populationnpkc@hotmail.com60Hon. Ms. Ang DawaSherpaMember of Parliament61Mr. Murari MahatUnder-Secretary, ParliamentSecretariatPakistan62Mr. Shahzad AhmadMalikChief (Population),<strong>Plann<strong>in</strong>g</strong> Commission63Mr. Yu YuDeputy RepresentativeUNFPAyu@unfpa.orgPhilipp<strong>in</strong>es64Dr. Paulyn UbialAssistant SecretaryDepartment of Health(DOH)paulyn_u@yahoo.com65Ms. Lady LisondraAssistant Youth Coord<strong>in</strong>ator<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Organization ofPhilipp<strong>in</strong>eslisondralady@yahoo.com66Hon. Congressman Mr.Rodolfo BiazonParliamentarianPhilipp<strong>in</strong>esmongpalat<strong>in</strong>o@gmail.com67Hon. Congressman, Mr.Raymond Palat<strong>in</strong>oParliamentarianPhilipp<strong>in</strong>es68Ms. Rena DonaAssistant RepresentativeUNFPAdona@unfpa.orgTimor-Leste69H.E. Dr. Nelson Mart<strong>in</strong>sM<strong>in</strong>ister of HealthM<strong>in</strong>istry of Health70Mr. Jose MagnoNational Director,Community HealthM<strong>in</strong>istry of Health71Dr. Julia XimenesMedical OfficerSame Referral Hospital,MoH72Hon. Virgilio Marcal,M.D.ParliamentarianNational Parliament ofTimor-Leste388

73Mr. Jose Bernardo74Mr. Pornchai SuchittaUNFPA RepresentativeUNFPAsuchitta@unfpa.orgVietnam75H.E. Dr. Nguyen Ba ThuyVice-M<strong>in</strong>ister of HealthM<strong>in</strong>istry of Healthd<strong>in</strong>hhuyduong63@yahoo.com.uk76Dr. Tran Hoa MaiDeputy Director GeneralGeneral Office ofPopulation <strong>and</strong> <strong>Family</strong><strong>Plann<strong>in</strong>g</strong>tranhoamai@yahoo.com77Mr. D<strong>in</strong>h Huy DuongDeputy Director, PersonnelDepartmentGeneral Office ofPopulation <strong>and</strong> <strong>Family</strong><strong>Plann<strong>in</strong>g</strong>d<strong>in</strong>hhuyduong63@yahoo.com.uk78Hon. Ms. Tran Thi HangMember of ParliamentParliamentarianvothidela89@gmail.com79Hon. Ms. Vo Thi DeMember of ParliamentParliamentarian80Mr. Dat Van DuongNational Programme Officer UNFPAdat@unfpa.orgThail<strong>and</strong>81H.E. Mr. Jur<strong>in</strong>LaksanawisitM<strong>in</strong>ister of HealthM<strong>in</strong>istry of HealthFax 662-591-202182H.E. Mr. Kasit PiromiyaM<strong>in</strong>ister of Foreign AffairsM<strong>in</strong>istry of Foreign Affairs83Mr. PraweenPayapvipapongVice-President, UrbanHealth <strong>and</strong> ResourceDevelopment BureauPopulation <strong>and</strong>Community DevelopmentAssociation (PDA)84Ms. Rose KoendersRegional Coord<strong>in</strong>ator<strong>Asia</strong> <strong>Pacific</strong> Alliancer.koenders@asiapacificalliance.org85Ms. Meanne LlanzaOfficer<strong>Asia</strong> <strong>Pacific</strong> Alliancemaeanne@asiapacificalliance.org86Dr. Kittipong SaejengDirector of RH BureauMOPHjeng4ever@hotmail.com87Dr. Taweesap SiraprapasiriProgramme OfficerAssistant RepresentativeUNFPA Country Office,Thail<strong>and</strong>siraprapasiri@unfpa.org88Ms. Wassana Im-emPublic Health TechnicalUNFPA Country Office,Thail<strong>and</strong>im-em@unfpa.org89Ms. Siriman WilairetOfficerDepartment of Health(DOH)sirwila@gmail.com90Mrs. Paradee CharsmonPublic Health TechnicalOfficerSame Referral Hospital,MoHparadee11@gmail.com91Ms. Lalita IntaseanYouth Advisory Panel(YAP) – YAP memberThail<strong>and</strong> (Batch 1)<strong>in</strong>tasean.l@gmail.comPACIFICPapua New Gu<strong>in</strong>ea92Hon. Mr. Malakai TabarChairmanParliamentarian Group onPopulation, Development<strong>and</strong> <strong>the</strong> MDGs389

93Mr. Melkie AntonProject OfficerUniversity of PNGmelkie.anton@gmail.com94Dr. Gilbert HiawaliyerAssistant RepresentativeUNFPAhiawalyer@unfpa.org.Republic of Kiribati95H.E. Dr. Kautu TenauaM<strong>in</strong>ister of HealthM<strong>in</strong>istry of Healthktbwenawa@gmail.comRepublic of <strong>the</strong> MarshallIsl<strong>and</strong>s96Ms. Tata KallesYouth Coord<strong>in</strong>atorYouth to Youth <strong>in</strong> Healthlil_tatakalles19@yahoo.comRepublic of Vanuatu97Mr. Mark Peter BekonanDirector GeneralM<strong>in</strong>istry of HealthServicesmbebe@vanuatu.gov.vu98Ms. Apisai TokonNational ReproductiveHealth/FP Coord<strong>in</strong>atorM<strong>in</strong>istry of HealthServicesatokon@vanuatu.gov.vuSolomon Isl<strong>and</strong>s99Ms. Judith SekeSupervis<strong>in</strong>g Director <strong>and</strong>National ReproductiveHealth ProgrammeManagerM<strong>in</strong>istry of Health <strong>and</strong>Medical Servicesjseke@moh.gov.sb100Dr. August<strong>in</strong>e GasivakaMellyMedical Officer (MasterTra<strong>in</strong>er <strong>in</strong> <strong>the</strong> NationalNon-Scalpel VasectomyProgramme)M<strong>in</strong>istry of Health <strong>and</strong>Medical Servicesgasivaka@gmail.comDonors <strong>and</strong> DevelopmentPartners101Dr. Sadia ChowdhuryCoord<strong>in</strong>ator, Reproductive<strong>and</strong> Child HealthProgrammesWorld Bankschowdhury@worldbank.org102Ms. Michelle SullivanFirst Secretary, RegionalProgrammesAusAID, AustralianEmbassy, Thail<strong>and</strong>michelle.sullivan@dfat.gov.au103Ms. Kelly VuanivonoWomen <strong>and</strong> Children'sHealthAusAID, Canberrakelly.vuanivono@dfat.gov.au104Dr. Kate FraserHealth Unit, HumanDevelopment Section,<strong>Pacific</strong> DivisionAusAID, Canberrakate.fraser@ausaid.gov.au105106Ms. Salli DavidsonDr. Aye Aye Thw<strong>in</strong>Senior Health AdviserDirector, Office of PublicHealthNZAID, Well<strong>in</strong>gtonUSAID, Bangkoksalli.davidson@nzaid.govt.nzaathw<strong>in</strong>@usaid.gov107Dr. Anna Kl<strong>in</strong>ken WhelanRegional Director<strong>International</strong> PlannedParenthood Federationawhelan@ippfeseaor.org108Ms. Teresa O'ShannassyRegional RepresentativeMacro <strong>International</strong> Inc.,Thail<strong>and</strong>teressa.oshannassy@macro<strong>in</strong>ternational.com109Ms. Sujata RamMeasure EvaluationICF Macro, Thail<strong>and</strong>sram@icfi.com110Ms. Johanna WicksSenior Manager, Policy <strong>and</strong>PartnershipsMarie Stopes<strong>International</strong>, Australiajohanna.wicks@mariestopes.org.au390

111Ms. Elizabeth SimeMarie Stopes <strong>International</strong>,Australia Regional Director,<strong>Asia</strong>-<strong>Pacific</strong>Marie Stopes<strong>International</strong>, Australializ.sime@mariestopes.org.au112Mr. Shiv KhareExecutive DirectorAPFFD, Thail<strong>and</strong>afppd@afppd.org113Mr. Nyo M<strong>in</strong> KoProgramme AssociateAPFFD, Thail<strong>and</strong>afppd@afppd.org114Ms. Sono AibeSenior Adviser for StrategicInterventionsPathf<strong>in</strong>der Fundsaibe@pathf<strong>in</strong>d.org115Ms. Anupama Rao S<strong>in</strong>ghRegional DirectorUNICEF Regional Office,Bangkokaraos<strong>in</strong>gh@unicef116Ms. Geeta SethiUNAIDS RegionalSupport Team for <strong>Asia</strong><strong>and</strong> <strong>the</strong> <strong>Pacific</strong>, Bangkok117Mr. Harry S. JooseeryExecutive DirectorPartners <strong>in</strong> Population <strong>and</strong>Developmenthjooseery@ppdsec.orgResource Persons118Dr. Adrian C. HayesResearch AssociateAustralian NationalUniversityadrian_hayes84@yahoo.com119Dr. Geoffrey HayesDevelopment Consultant;Executive DirectorMaturori Ltd.geoffreyhayes@hotmail.com120Dr. Bhanu Bhakta NiraulaCountry Director –Programme <strong>and</strong> OperationsBritian-Nepal MedicalTrustBritian-Nepal MedicalTrust121Dr. An<strong>and</strong> TamangFounder Chairperson <strong>and</strong>DirectorCentre for Research onEnvironmental Health<strong>and</strong> Population Activities(CREHPA)an<strong>and</strong>@crepha.wl<strong>in</strong>k.com.np122Dr. Zeba SatharCountry DirectorPopulation <strong>Council</strong>zsathar@popcouncil.org123Dr. Barkat-e-KhudaProfessor of Economics<strong>and</strong> Chairman, Bureau ofEconomic ResearchUniversity of Dhaka,Bangladeshbarkatek@yahoo.com124Dr. Junice L. Demeterio-MelgarExecutive DirectorLikhaan Center forWomen's Health Inc.junice@likhaan.org125Dr. Hla Hla AyeConsultant, HumanResources for Health7117 West, Hood Avenue,Chicago, IL, USAcmawia@gmail.com126Dr. Anrudh Ja<strong>in</strong>Dist<strong>in</strong>guished ScholarPopulation <strong>Council</strong>aja<strong>in</strong>@popcouncil.org127Prof. Amy TsuiDirectorThe Bill & Mel<strong>in</strong>da GatesInstitute of Population &Reproductive Healthatsui@jhsph.edu128Dr. Anthony AbeykoonSenior FellowInstitute for Health Policyatpla@hotmail.com129Dr. Norliza AhmadDirector of HumanReproductionNational Population <strong>and</strong><strong>Family</strong> DevelopmentBoardnorliza@lppkn.gov.my130Ms. Genet MengistuPopulation DepartmentHeadM<strong>in</strong>istry of F<strong>in</strong>ance <strong>and</strong>Economic Developmentgenetfmb@yahoo.com391

131Dr. John P. SkibiakDirectorReproductive HealthSupplies Coalitionjskibiak@rhsupplies.org132Dr. Shireen JejeebhoySenior AssociatePopulation <strong>Council</strong>sjejeebhoy@popcouncil.org133Ms. Huma KhawarJournalistPakistanhuma@yahoo.com134Dr. Mehtab S. KarimDist<strong>in</strong>guished Senior Fellow& Affiliated ProfessorGeorge Mason University,Arl<strong>in</strong>gton, VA, USAmkarim2gmu.edu135Mr. Tomas OsiasExecutive DirectorCommission onPopulation, Philipp<strong>in</strong>esosias@popcom.gov.ph136Mr. M<strong>in</strong>ar PimpleRegional Director<strong>Asia</strong> <strong>and</strong> <strong>the</strong> <strong>Pacific</strong>Regional OfficeMillennium Campaignm<strong>in</strong>ar.pimple@undp.orgUNFPA Headquarters,New York137Mr. Jagdish UpadhyayChief, Commodity BranchUNFPA, New Yorkupadhyah@unfpa.org138Dr. Nuriye OrtayliTechnical AdviserSRH Branch, UNFPANew Yorkortayli@unfpa.org139Dr. Howard FriedmanTechnical SpecialistSRH Branch, UNFPANew Yorkfriedman@unfpa.orgUNFPA <strong>Pacific</strong>Subregional Office (SRO)140Dr. Annette S. RobertsonDeputy Director <strong>and</strong>Deputy RepresentativeUNFPArobertson@unfpa.orgUNFPA <strong>Asia</strong> <strong>and</strong> <strong>the</strong><strong>Pacific</strong> Regional Office(APRO)141Ms. Nobuko HoribeRegional DirectorUNFPA APROhoribe@unfpa.org142Mr. Najib AssifiDeputy Regional DirectorUNFPA APROassifi@unfpa.org143Ms. Eriko HibiRegional ProgrammeCoord<strong>in</strong>atorUNFPA APROhibi@unfpa.org144Dr. Saramma ThomasMathaiRegional Team Coord<strong>in</strong>ator<strong>and</strong> Adviser, MaternalHealthUNFPA APROmathai@unfpa.org145Ms. Ana Maria LealProgramme SpecialistUNFPA APROleal@unfpa.orgRapporteurs146Ms. Maria HoltsbergConsultant147Ms. Duangurai HemarakProgramme AssociateUNFPA APROsukvichai@unfpa.orgSecretariat148Ms. Suchitra ThamromdiProgramme AssistantUNFPA APROsuchitra@unfpa.org149Ms. Thanida VorauraiProgramme AssistantUNFPA APROvoraurai@unfpa.org392

150Ms. Claire JohnsonHealth Research <strong>and</strong>Liaison OfficerUNFPA APROcjohnson@unfpa.org151Mr. Caspar PeekProgramme AdvisorUNFPA APROpeek@unfpa.org152Mr. Richard ColumbiaMonitor<strong>in</strong>g <strong>and</strong> EvaluationAdvisorUNFPA APROrcolumbia@unfpa.org153Ms. Rizv<strong>in</strong>a DealwisProgramme OfficerUNFPA APROdealwis@unfpa.org<strong>International</strong> <strong>Council</strong>on Management ofPopulation (ICOMP)154Dr. Wasim ZamanExecutive DirectorICOMPzaman@icomp.org.my155Dr. Jun NaravalSenior Programme OfficerICOMPjunnaraval@icomp.org.my156Ms. Neera ShresthaProgramme OfficerICOMPshrestha@icomp.org.my157Mr. Hairud<strong>in</strong> Masn<strong>in</strong>Programme OfficerICOMPhairud<strong>in</strong>@icomp.org.my158Ms. Lim Hwei MianProgramme OfficerICOMPhweimian@icomp.org.my159Ms. Chong Pik LaiSenior SecretaryICOMPjoseph<strong>in</strong>e@icomp.org.my160Ms. Chitra Chan WaiPengAccounts <strong>and</strong>Adm<strong>in</strong>istrationICOMPchitra@icomp.org.my393

<strong>International</strong> <strong>Council</strong> on Management of Population ProgrammesNo 534, Jalan Lima, Taman Ampang Utama, 68000 Ampang, Selangor, MALAYSIATel: +603-4257 3234 • Fax: +603-4256 0029E-mail: icomp@icomp.org.mywww.icomp.org.my 394