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<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
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Family Pla
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ForewordThe Asia <
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Part 1Part 1Asia <
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Ensuring that <str
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of methods for all, in</str
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and undertake <str
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Report on the Regi
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SESSION 1: Changin
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that improving <st
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at a hospital would be offered post
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Bounkoung Phichit, Deputy M
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medicines
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Thus, while knowledge of modern met
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Hon. Mr. Malakai Tabar, Chairman, P
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curricula. If the
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dialogue as well as regional <stron
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BackgroundGlobal development effort
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TableTable1EventNational policyYear
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A third observation is that reporte
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TableTable2Current Contraceptive Pr
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Figure(-1.2), Cook Island</
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FigureTableTable3Trends in<
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Nam. Nearly all economies i
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2008 2009% Bilateral % Multilateral
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family planning wi
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IntroductionFamily
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The advent of the
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FigureFigure1Oceania and</s
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next 25 years, however, TFR fluctua
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FigureFigureFigure2Total fertility
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family planning pr
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esponsible for the
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that estimates of CPR for earlier p
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Figuremarried at an older age compa
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As previously mentioned most <stron
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FigureFigure945Relationship between
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The concept of “unmet need” has
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TableTable8Percentage of th
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TableTable9Percentage of reasons fo
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family planning pr
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As far as the supp
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Socio-cultural challenges tofamily
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likely to use contraception than yo
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15 Tests of statistical significanc
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of the South <stro
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104
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Figurewill exceed the</stro
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in urban (67%) tha
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ased service delivery poin<
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Page 131 and 132: ConclusionThe Bangladesh Fa
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Page 158 and 159: TableTable11 Total fertility rate <
Page 160 and 161: End Note1The first camp was success
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Page 166 and 167: Figure1980s and ex
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Page 186 and 187: per cent of women reported us<stron
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Page 212 and 213: acceptable. From an NGO perspective
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the 1980s
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Policy Management.__________ (n.d.,
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218
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Population Activities (UNFPA) for a
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where family plannin</stron
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Thus an objective assessment of <st
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226
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Figureeconomic growth durin
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TableTable1TableTable2For spac<stro
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eflect a provider bias (e.g., <stro
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The Indonesian delegation was very
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than in ensur<stro
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in-country <strong
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(Ministry of Healt
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242
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244
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FigureTrends and p
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TableTable3Unmet need for contracep
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TableTable5TableTable6TableTable725
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TableTable8TableTable9Malaysia, abo
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previously mentioned is based on fo
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TableTable16births and</str
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FigureFigure3TRF54.5Scatter plots o
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ReferencesAng, Eng Suan (2007). Stu
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Demographic data sheet: population
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population size, with just 336,000
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NuptialityIn Myanmar nuptiality is
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FigureIn Myanmar, birth-spac<strong
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Scope of coverage and</stro
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FigureIn Myanmar, out of six select
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equirements. The Min</stron
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according to <stro
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Adolescent sexual and</stro
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FigureHIV/AIDS. An HIV-positive wom
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National Population PolicyMyanmar i
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Linkages with o<st
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TableTable4Achievements of Myanmar
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monitoring <strong
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Nay Pyi Taw, 26 October 2010.53 Sit
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292
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294
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TableTableA296
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dispense and adm<s
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(1) I am against a
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FigureFigureFigure3Use of modern co
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FigureFigure7Traditional method use
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Figureprojection, and</stro
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Figure 11 summarizes the</s
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correlating <stron
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Figurethe use of c
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FigureFigure15Sexual behaviour <str
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track the distribu
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Figureservices, which should <stron
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FigureFigureFigure18 Population <st
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National Statistics Office, <strong
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TableTable11326
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TableTable19Laws and</stron
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worker and hours w
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334
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336
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includin</
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TableTable1Contraceptive prevalence
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These results suggest that about 70
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2 The (period) TFR is the</
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346
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FigureThe existence of traditional
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Guinea case by <st
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The establishment of provin
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provide family plannin</str
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Figurelegal requirement nor a condi
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FigureTableTable5TableTable6Figure4
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modern method and
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married or in unio
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Figureolder. Both the</stro
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TableTable15The immediate past Nati
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out that the “ne
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Commodity securitySupply cha<strong
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is able to achieve. In Papua New Gu
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Qualitative assessments by a number
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increasin<
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service delivery poin</stro
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Population: Views from Men
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1545-1730Day 2: December 9Session 2
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Day 3, December 10Session 50830-100
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15Mr. Tong Sithen1
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54Ms. Shadiya IbrahimAssistant Repr
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93Mr. Melkie AntonProject OfficerUn
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131Dr. John P. SkibiakDirectorRepro
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International <str
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