X. ROLE OF CIVIL SOCIETY:
OPPORTUNITY AND CONSTRAINTS

Mahdi Nawi *

Introduction

At the International Conference on Population and Development, held at Cairo in 1994, governments unanimously endorsed the Programme of Action which, among other recommendations, called on governments and development agencies to "promote an effective partnership between all levels of government and the full range of non-governmental organizations and local community groups, in the discussion and decisions on the design, implementation, coordination, monitoring and evaluation of programmes relating to population, development and environment in accordance with the general policy framework of governments, taking duly into account the responsibilities and roles of the respective partners" (paragraph 15.7). Effectively, this means that the roles and contributions of non-governmental organizations (NGOs) and community-based organizations towards population and national development programmes have been recognized and deemed important. Consequently, their inputs should be considered in national policy formulation and other development efforts when population issues are discussed.

The Programme of Action has also set time-bound development goals, among which those especially relevant to population and reproductive health are the following:

Universal primary education to be achieved before the year 2015; countries that have achieved this goal before then are urged to extend education further to secondary and higher levels
Universal access to a full range of high- quality reproductive health services for all individuals at appropriate ages and the elimination of obstacles to the use of existing services by not later than the year 2015
Significant reductions of maternal mortality by the year 2015, involving a reduction to one half the 1990 levels by the year 2000, and an additional one half by the year 2015
These development goals have to a large extent been incorporated in the overall population and reproductive health programmes of most governments in the ESCAP region.

1. Population and reproductive health in the regional context

The Asian and Pacific region has a population of approximately 3.4 billion in over 50 countries and areas (ESCAP, 1996). It is a region of great diversity, not only in terms of its geographical spread but more importantly in terms of its diverse beliefs, cultures and religions. In addition, countries in the region are at various stages of political and economic development, so that there is no single method of comparison of results achieved in population and reproductive health programmes. The health conditions of the people have shown tremendous progress over the last 30 years. Access to health services (that is, being able to reach appropriate health services within an hour using local modes of transport) improved from 75 to 93 per cent between 1960 and 1993 (Asian Development Bank, no date). The ratio of doctors to population decreased from 1:11,000 in 1970 to 1:4,500 in 1990 (World Bank, 1993). In the area of population and reproductive health, regional aggregates also showed that TFR in the region decreased from 5.9 children in 1960 to 2.9 in 1995.

However, it should be noted that regional health indices do not truly reflect the health conditions of individual people of the various countries in the region. The regional population aggregates certainly do not indicate the health conditions of the poor, women and the marginalized people of each country. For example, in Pakistan the infant mortality rate decreased from 85 (1990) to 83 per thousand live births (1995), but the maternal mortality remains at 340 per 100,000 live births (ESCAP, 1996; Population Reference Bureau, 1997). Further, the poorest quintile have to travel 39 per cent further to reach a health facility than the average citizen (Asian Development Bank, no date).

A. Participation of civil society in policy formulation and programme planning and implementation in the region

"Civil society" as defined in the present paper includes NGOs, community-based organizations, the private sector, academic institutions, labour unions, religious and political groups etc. In the Asian and Pacific region, many of the countries are experiencing epidemiological transitions (shifts in the burden of disease from primarily communicable illnesses, such as diarrhoea and tuberculosis, to non-communicable illnesses related to changes in lifestyles, such as heart attacks, strokes and cancer). Some of the countries are also undergoing a demographic transition (increase in the proportion of older persons among the population because of reductions in fertility and increases in life expectancy due to improvements in health). There is also a trend towards urbanization, and more of the cities in the region will become megacities in the near future where population numbers and density are concerned. Several of the economies in the region are also in transition, for example, Cambodia, China, the Lao People's Democratic Republic, Mongolia, Myanmar and Viet Nam. These countries, which in the past had command economies, are undergoing economic restructuring towards open market economies. All these changes have an impact on the health and social welfare of the population in the region. However, regardless of their political ideologies and economic systems, the concept and spirit of community efforts and voluntarism prevail. There are both formal and informal civil organizations in all these countries, and their contribution has been recognized by governments for decades.

In some countries of the ESCAP region, the concept of voluntarism and community effort has been so well developed that there are both local and international community organizations. Countries such as India, Indonesia, Malaysia, Pakistan, the Philippines and Thailand may have as many as hundreds of these NGOs. Whether international or local, these NGOs collaborate with each other in addressing common issues identified for joint action. In India, for example, a local NGO for family planning (the Family Planning Association of India) works with more than 300 other NGOs in the implementation of their programmes. In Thailand, two of the more well-known NGOs have expanded their programmes to cover international projects as well as networking with other NGOs.

Even in countries that have a command economy and a socialist/communist system of government, such as the Lao People's Democratic Republic, Mongolia and Viet Nam, where the concept of national NGOs is new, there are other national civil societies, and many of these are community-based. In the Lao People's Democratic Republic, for example, the Youth Union and the Women's Union have vast grassroots networks. In many of these countries, representative offices of international NGOs have been established to provide technical assistance and funding to population and reproductive health projects of national governments/agencies. Viet Nam has over 200 foreign NGOs working in the population and development field, but there are not more than 10 national NGOs working in population. Civil society has been involved in the implementation of the population and reproductive health programmes of the region in the past. Has the Programme of Action added impetus to the involvement of NGOs and community-based organizations in population and development?

1. Experience and observations of the role of civil society (opportunities and constraints) in regional development

The International Planned Parenthood Federation (IPPF) is the world's leading voluntary family health-care organization. Founded in 1952, IPPF today has a membership of over 150 family planning associations in countries worldwide. It enjoys category I status with the United Nations Economic and Social Council. As an international NGO, it believes that improving the sexual and reproductive health of people will help them to lead socially and economically productive lives and take greater control over their own destinies. Thus, IPPF endorses the Programme of Action especially concerning chapter 15. As an international NGO, IPPF has also taken active steps to promote greater partnerships with other international organizations and national governments in the implementation of the Programme of Action.

Prior to the Cairo Conference, IPPF had seen the need for NGOs to work in partnership with governments in the development of policy and the implementation of programmes on population and reproductive health. Thus, in countries where its member is the only NGO in the field of population and reproductive health, IPPF has encouraged and assisted the family planning association to play an advocacy and pioneering role in the provision of family planning and reproductive health information, education and clinic service delivery. In countries where there are national population policy and programmes which involve both government and civil society, IPPF has assisted its member to play a complementary and supplementary role in policies and programmes on population and reproductive health. All this was formalized in 1992 with the development of the IPPF Vision 2000 Strategic Plan, in which it was stated that IPPF and its member associations would "strive, in particular, to advance the family planning movement among the under-served by addressing, through information, advocacy and service, their growing unmet need and demand for sexual and reproductive health; and to work cooperatively in this endeavour with all interested governmental and non-governmental parties."

Following the conclusion of the Cairo Conference, IPPF urged its members to take a proactive role in the implementation of the Programme of Action. Member family planning associations were told that they should not be content to leave the implementation of the Programme of Action to governments. They should continue to be advocates with their national governments and other NGOs to ensure that the commitments of the Programme were transformed into reality. As an immediate follow-up, member associations in the region were encouraged to translate the Programme of Action and the IPPF Vision 2000 Strategic Plan into their own national languages and disseminate the documents widely to policy makers, the government and other NGOs, community-based organizations, the media and the public. Now translations of the IPPF document on Vision 2000 and the Programme of Action are available in Korean, Chinese, Vietnamese, Bahasa Indonesia and some languages of Pacific island countries.

Besides disseminating the IPPF Vision 2000 and Programme of Action, other member associations in the region such as India, Nepal and Pakistan held in-country meetings and seminars to advocate the implementation of the Programme of Action. The Family Planning Association of India, for example, brought together 770 representatives of government, international NGOs and national NGOs/commnity-based organizations and the media at workshops held in 29 of its branches throughout India to increase NGO-government partnership. The Association also played an active part in the formulation of the Government of India's National Population Policy. The Family Planning Association of Pakistan held a post-Cairo symposium in 1995, which was attended by 84 participants from government, NGOs and donor agencies. Recommendations from the symposium form the framework for activities by all key players in population and reproductive health in Pakistan. The Family Planning Association of Nepal endorsed a "Pregnancy Protection Bill 1996" which had been submitted to the Government for consideration. The bill advocates conditional abortion being permitted in Nepal. Such meetings have resulted in positive action plans being formulated to incorporate reproductive health programmes and policies in these countries.

In July 1996, in meeting the recommendations in the Programme of Action, UNFPA and IPPF signed a Memorandum of Understanding replacing a 1988 memorandum, in which certain key issues were agreed on:

To convene joint meetings for the purpose of information exchange, exploring the country programmes, discussing collabo- rative approaches to existing and potential donors, exchanging views on important policy matters related to the objectives of the two organizations with governments and other NGO partners, and to promote greater collaboration and coordination at the field level through annual meetings to discuss planned country programmes and other initiatives.
UNFPA and IPPF will explore the possibility of developing collaborative regional, interregional and global activities.
UNFPA will continue using IPPF and its member associations as executing or assisting agencies, as appropriate.
UNFPA and IPPF will make joint efforts to identify and inform decision makers in population and development in order to promote awareness of and commitment to population-related issues.
UNFPA will assist IPPF in meeting supply costs for selected IPPF-supported programmes, as well as collaborating closely with other agencies in the Global Contraceptives Supply and Logistics Management Initiatives.
Arising from this Memorandum of Understanding, IPPF and its member family planning associations (or partners) in selected countries in the Asian and Pacific region are involved in a European Commission (EC) and UNFPA special programme to strengthen reproductive health activities and services with the involvement of governmental organizations and NGOs to push forward the Programme of Action agenda. The countries involved in this EC/UNFPA Reproductive Health Initiative in Asia are Bangladesh, Cambodia, India, the Lao People's Democratic Republic, Nepal, Pakistan and Viet Nam. In addition, the IPPF member associations in the Democratic People's Republic of Korea and Mongolia, as well in the Pacific islands, are executing/implementing agencies in UNFPA programmes in these countries.

Steps are also being taken by both organizations to explore the possibility of obtaining a commitment from contraceptive suppliers to set up manufacturing plants in some of the developing countries in the region to supply cheaper contraceptives in order to meet regional demands.

2. South-South cooperation

The Cairo Conference also promoted increased South-South cooperation in the area of population and reproductive health programmes. Thailand is among those countries that are actively involved in South-South cooperation. Under this initiative, the Government has not only funded reproductive health projects which are implemented in neighbouring countries such as the Lao People's Democratic Republic, but it has also supported local Thai NGOs in the development and execution of the reproductive health and development project in the Lao People's Democratic Republic and Viet Nam. In addition, the Department of Technical and Economic Cooperation of Thailand and a Thai NGO jointly organized a workshop for reproductive health programme managers on IEC strategies and approaches with special reference to target groups under the South-South initiative. The workshop, sponsored by UNFPA, was altended by participants from Cambodia, China, Indonesia, the Lao People's Democratic Republic, Malaysia, Myanmar, the Philippines and Viet Nam.

What this initiative has done is to provide avenues for developing countries in the region to exchange experience and expertise for the promotion of population and reproductive health programmes for their people. It is also a demonstration of mutual self-help in the light of declining international resources and expanding unmet needs in the region.

3. NGO networks

As mentioned earlier, in every country in the region there are civil societies. In Viet Nam, for example, there are national NGOs and community-based organizations, such as the Viet Nam Family Planning Association, the Women's Union, the Viet Nam Fatherland Front, the Youth Union, the Peasants' Union, and academic institutions. All the community-based organizations (or "mass organizations", as they are called in Viet Nam) are members of the Viet Nam Fatherland Front, and through this umbrella organization, policies, management and programmes of the organizations can be coordinated. There are also various international NGOs, such as Pathfinder International, CARE International, Marie Stopes International Viet Nam, the Population Council, and DKT International, operating in Viet Nam in various development and health programmes. Pathfinder International, for example, has a collaborative project with International Project Assistance Services (IPAS), the Association for Voluntary Surgical Contraception (AVSC International), and the Ministry of Health assisting Viet Nam in improving the quality and range of family planning and other reproductive health services. Its training materials have been translated into Vietnamese and shared with other NGOs. The Population Council has conducted several studies relating to reproductive health and HIV/AIDS in Viet Nam, while Marie Stopes International is operating reproductive health and family planning clinics in selected provinces in the country. Each of these agencies has its areas of expertise and skills that could be tapped and transferred or shared with local civil societies or even between themselves. There is as yet no formal coordinating agency that could mobilize all civil societies in Viet Nam. The Government has empowered the People's Aid Coordination Committee to monitor the activities of all international NGOs operating in Viet Nam. This has the potential to become the mechanism for coordinating all activities of international NGOs. The danger is that in the process of trying to coordinate activities, procedures and rules might be developed that would be too restrictive and thus curb the innovative traits of NGOs. However, in the absence of any formal coordinating mechanism for international NGOs and national NGOs working in the field of population and reproductive health, UNFPA in Viet Nam initiated an informal forum among these organizations for the purpose of sharing experience on common issues. This informal discussion group has met regularly and has enabled the various NGOs to establish links and working relationships with each other.

In other countries, such as Bangladesh, India and Nepal, the family planning associations have taken the initiative to mobilize NGOs to form networks with the aim of avoiding duplication in programmes, resource-sharing and the promotion of family planning and maternal and child health activities. The Family Planning Association of India was able to involve 3,778 NGOs in the promotion of family planning and MCH through its NGO Consultancy Cell and NGO Network. It established the Indian Network of NGOs for Population, Development and Environment in 1992. There are currently 2,000 NGOs in this Network. The Family Planning Association of Nepal also formed the Non-governmental Organization Coordination Council to avoid programme duplication and to ensure programme sustainability. The Family Planning Association of Bangladesh has networked with the Grameen Bank - one of the largest and most successful community-based organizations involved in the empowerment of women through providing credit to women - in the promotion of reproductive health service through the Bank's beneficiaries.

These examples show that in every country civil society is a substantial force that can be mobilized to assist in advocating policies and programmes that are in line with the Programme of Action. The issue is who should take the initiative to mobilize this force.

4. Legal provisions/instruments that hinder/support the participation of civil society in population and development programmes

Although in some countries that previously had command economies, such as Mongolia and Viet Nam, there are no legal provisions to hinder the participation of civil society in population and development programmes, the concept of NGOs, for example, is new and not fully understood by the government or the people. Thus the development and participation of NGOs in development programmes in these countries are slow.

On the other hand, in China, the Constitution stipulates the right of citizens to form associations. In March 1997, the Central Government of China issued a directive calling on local governments to support the NGO role and programmes of the China Family Planning Association. As at the end of 1997, 20 of the 31 provinces in China had given their written commitment to support the NGO role and programmes in population and reproductive health. In January 1997, the National Poverty Alleviation Programme of the State Council in China issued a directive calling on all local governments to collaborate with the local branch of the Association to develop and implement family planning and poverty alleviation integrated projects. The Yuanling County of Hunan Province, heeding the call, donated 3 million yuan to the Association to develop and implement income-generating projects at the village level.

In the Republic of Korea, the Maternal and Child Health Law provides the support needed for reproductive health programmes and activities. This has enabled the Planned Parenthood Federation of Korea to obtain government support for its reproductive health programmes. Most of its funds for programmes are given by the Government.

B. Population and reproductive health challenges for the region : opportunities and constraints

The Cairo Conference has had an immediate impact in the form of commitment from European countries to contribute money towards meeting its goals. This resulted in the EC/UNFPA Reproductive Health Initiative in Asia, mentioned earlier, with specific objectives towards strengthening the involvement of national NGOs and civil society in the reproductive health activities of the countries concerned. It also resulted in more South-South cooperation being initiated and supported by governments of the South, as in the case of Thailand.

In the development of the Reproductive Health Initiative in Viet Nam, interesting in-country developments among organizations and agencies that are involved in population and reproductive health in that country have been highlighted. Most important is that there is an informal mechanism that provides opportunities for dialogue and exchange of experience among these agencies. Through this mechanism, more is known about programme coverage in the country, the types of training activities and information and education materials that are available in Viet Nam and the sharing of technical expertise among the various organizations.

These have provided NGOs and community-based organizations that have the capability, but not the resources (financial), to share their expertise and skills in the area of population and reproductive health with other such organizations of collaborating countries in improving their programmes. Such efforts are currently fragmented throughout the region. They should be monitored and encouraged in countries that lack such initiatives. The crucial issue is that of funding, and in this area international organizations such as UNFPA, IPPF, Pathfinder International, Save the Children Fund, and regional development agencies like ESCAP, the Asian Development Bank and the ASEAN Secretariat, can play a role in mobilizing international and regional development assistance funds to enable civil societies in countries of the region to be more coordinated in their work in the area of population and reproductive health.

The EC/UNFPA Reproductive Health Initiative not only gave national NGOs an opportunity to expand their programmes, but also provided national NGOs with the opportunity to work in partnerships with international NGOs, thus gaining training and technical experience from their partners in the development and implementation of their programmes. The area that is addressed by the Initiative, namely, adolescent sexual and reproductive health, is sensitive. The culture and religion of the peoples in the region have made the subject of sex education taboo in quite a number of the countries in the region. With the spread of the HIV/AIDS epidemic, it has become increasingly necessary for adolescent sexual and reproductive health information, education and clinic services to be provided to youth for AIDS prevention. Civil societies in most of the countries in the region have played a leading role in advocating and providing adolescent sexual and reproductive health information and education and other AIDS prevention programmes. In Thailand, for example, the Red Cross Society of Thailand is actively promoting HIV/AIDS prevention programmes for the marginalized groups, such as sex workers and hill tribes. The Indonesian Planned Parenthood Association has also established a model for sexual and reproductive health promotion in the country through its Lentera Youth Project. In a predominantly Muslim society, this project not only provides sexual and reproductive health information and services to youth in the city of Yogyakarta, but also has out-reach activities and support for marginalized groups such as female sex workers, transvestites and gay males. In Malaysia, through the initiative of the Federation of Family Planning Associations, IPPF has supported a study of reproductive health of adolescents conducted by the National Population and Family Development Board of Malaysia. The study aims to assist the Government in the formulation of an explicit policy and comprehensive programme for the promotion and maintenance of optimal reproductive health of Malaysian adolescents.

The issue of abortion is still a sensitive one in the region. However, civil societies such as the National Family Planning Association of Nepal and the Indonesian Planned Parenthood Association have taken steps to advocate the eradication of unsafe abortion. In the case of Nepal, the Association has advocated the Pregnancy Protection Bill 1996 and in the case of the Indonesian Association, seminars on abortion were held in 1996 and 1997 to discuss the issue.

Thus, while it has often been stated that culture and religion are constraints faced in meeting some of the reproductive health needs in the region, it has been demonstrated that civil society can be effective in reaching vulnerable groups such as youth, sex workers, and people with high HIV/AIDS risk behaviour, as well as in work on sensitive issues. It is therefore important that governments and international development organizations recognize these strengths of civil society in more tangible ways. Support could be in the form of involving them in policy formulation as in India, or having policies that state the government's support of the role and work of NGOs, as in the case of China; or providing them with funds for innovative initiatives for vulnerable groups or which touch on sensitive issues.

"Doing more with less" must be the strategy for the future of population and reproductive health programmes in the region. This is due to the declining international support for development for countries in the region, mainly because many of those countries have made significant progress in their economic development as compared with those in other regions, such as Africa and Eastern Europe, and to increasing unmet needs worldwide. In addition, the recent economic downturn experienced by countries in Asia not only affected the countries concerned, but its economic impact is also felt by trading partners of these countries worldwide. The full impact of the economic crisis in the region is yet to come. Thus, it is anticipated that funds for development assistance will not increase in real terms in the foreseeable future. One strategy for stretching resources is to mobilize civil societies to form networks for information and resource-sharing, and for coordination to avoid duplication. International organizations such as UNFPA, the International Committee on the Management of Population Programmes (ICOMP), the Japan Organization for International Cooperation in Family Planning (JOICFP) and IPPF can work together to initiate such activities in countries in the region. Many of the civil societies lack the human and financial resources to implement comprehensive reproductive health programmes on a large scale. The geography of many of the countries in the region also makes extensive coverage by an NGO difficult. Thus it is essential that networks be formed to create impact and efficiency in programme implementation.

To ensure programme sustainability in the long term, international NGOs should work in partnership with national civil societies. This will enable the transfer of technology and skills to take place between the international and local NGOs so that programmes can be taken over by national organizations when international funding comes to an end.

What IPPF in the region has learned from its own initiatives to push forward the Programme of Action is that governments which committed themselves to it are receptive to initiatives on implementation. However, national civil societies in the field of population and reproductive health should be proactive, and not wait for an invitation to participate in the implementation of the Programme of Action in their countries.

End Notes

* Regional Director a.i., International Planned Parenthood Federation, East and South East Asia and Oceania Region.

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