XII. ANALYSIS OF COUNTRY QUESTIONNAIRES

Bhassorn Limanonda *

Introduction

As part of the preparation for the High-Level Meeting to Review the Implementation of the Programme of Action of the International Conference on Population and Development and the Bali Declaration on Population and Sustainable Development and to Make Recommendations for Further Action, questionnaires were distributed to the governments of all countries invited to participate in the Meeting.1 Governments were requested to complete the questionnaires and return them to ESCAP. Questionnaires were returned by 25 countries2 or areas.

The main areas covered in the questionnaires were as follows: (1) population and development strategies; (2) resource mobilization; (3) reproductive health; (4) gender equality; (5) adolescent reproductive health, and; (6) role of the non-government sector. The objectives of the analysis are: (a) to provide a broad overview of government concerns related to important aspects of population and development; (b) to document policy adjustments that have occurred in response to the Programme of Action; (c) to identify critical challenges for population policy and programme implementation, and; (d) to examine the resources available to plan and implement policies. Consistent with the objectives of the study, the results of the analysis are presented in aggregate form. An exception is the summary demographic data requested from each country (see table XII.1). These data may not agree with those published by ESCAP or other agencies. They are presented here to provide an indication of the range in demographic and health conditions that can be found for countries responding to the questionnaires and to indicate the types of data that are readily available to governments.

The variability in the social and demographic context of countries in the ESCAP region is clearly shown in table XII.1. For example, the total fertility rate varies from a low of 1.75 (Republic of Korea) to a high of 6.20 (Solomon Islands). The contraceptive prevalence rate is above 65 for 7 of the 20 countries that have available data, but is 30 per cent or below for 6 of the countries. The infant mortality rate exceeds 100 in the Lao People's Democratic Republic but is only 10 in the Republic of Korea. Within countries, there is also substantial disparity among males and females on those indicators where data are available. For all countries except the Philippines, levels of literacy of females are lower than for males, with the male rate of literacy for Pakistan being almost twice the female rate. Gender differences can also be seen in contraceptive use. Females are the primary users of contraceptives. With the exception of two countries (Indonesia and Sri Lanka), female rates of sterilization are much higher than those reported for males.

What is evident from table XII.1 is the wide range of information that most countries could not provide. While basic demographic data were available for all countries, many other indicators were only provided by a handful of countries. Many of the general social indicators were not available disaggregated by sex. For example, the child mortality rate was available separately for boys and girls for only five countries. Contraceptive data were available for most countries, but indicators relevant to a perspective that emphasizes reproductive heath were generally not provided. Only three countries reported the percentage of the service delivery points at the primary health care level providing the full range of reproductive health services either directly or indirectly through referrals. Only three countries reported incidence rates for reproductive tract infections (RTIs) and STDs for young adults. Five countries were able to provide an estimate of the number of induced abortions (illegal and legal) undertaken. It is clear that much needs to be done to ensure that basic indicators of reproductive health are available.

A. Population policy and planning

All but two countries reported that they had national social and economic development plans. Most plans are five-year development plans and all but one country incorporated population policies and programmes. Of the countries represented in the study, only Myanmar and Sri Lanka reported that they had no long-term sectoral plans.3 Of those countries with such plans, all stated that population issues were a component of the plans.

There is substantial agreement among the countries in the government's perceptions of the linkages between population and development. All but five countries stated that high fertility and population growth affect development adversely. Nineteen countries expressed the concern that high fertility was detrimental to the life of mothers and children. Sixteen reported that the government perceived population distribution and migration as key factors affecting development. It is noteworthy that only four countries expressed concern about low fertility and labour shortages affecting development, although the Republic of Korea did state that the government perceived that maintaining current levels of fertility was important in order to obtain an optimum age structure and labour force. Even though there is considerable diversity among countries in their demographic situations, the results show that governments see a clear link between high population growth and adverse effects on development.

Twenty-two of the 25 countries responded that improving reproductive heath services helped improve the health status of women and children and contributed to a reduction in fertility levels. Only Kazakhstan, Kyrgyzstan and the Republic of Korea provided different responses. Kazakhstan and the Republic of Korea stated that their governments viewed the linkage between improving reproductive health services in terms of only the improved health status of mothers and children. Kyrgyzstan felt that efforts should be directed towards promoting equality of men and women rather than focusing directly on reproductive health. In summary, there is broad agreement that improvements in reproductive health services would be a positive development for attaining population goals.

Most countries agreed on the key demographic factors that were felt to affect development (see figure XII.1). Of the 62 responses provided by the 25 countries, 18 (29 per cent of all responses) felt that age structure was a key demographic factor, while rural-urban migration and population distribution were also mentioned as constituting a key demographic factor by 18 countries. Fifteen countries cited high fertility and population growth.

Figure XII.1 Key demographic factors affecting development

However, given the demographic diversity among the countries in the study, it is not surprising that there are substantial differences in the priority that different countries attach to various issues related to population. In the survey, each country was requested to rank, in terms of priority, issues that need to be addressed immediately. Rankings were undertaken from 1 to 15, with the issue accorded the highest priority given a ranking of 1, and the issue accorded the least priority a ranking of 15. In table XII.2, several summary indicators of these rankings are displayed.

There is a clear division in rankings among the issues. Seven of the items have a mean ranking of between 5.48 and 6.76, and eight items have mean rankings of between 8.05 and 13.86. The seven items ranked most highly include issues that have been traditional focuses of family planning and health programmes, such as high infant and child mortality, and high maternal mortality, with the former having the highest overall mean ranking and the latter the second highest mean ranking. They also include items related to population distribution and rural-urban migration (ranked 5 and 7 respectively). Also included, however, are emerging issues such as socio-economic disparity (ranked fourth) and youth issues (the two issues related to youth are ranked 3 and 6).

The concern with adolescent and youth issues can be seen from the priority given to the "young population and increasing labour-force entrants" and to "adolescent issues" in the rankings. Although the former issue was ranked first by only two countries, eight other countries ranked it between 2 and 5, resulting in a mean ranking of 6. Adolescent issues were ranked as the first priority by three of the countries, and a further eight countries provided a ranking between 2 and 5. Based on the mean ranking, this issue was perceived as the third most important by governments. The concern over adolescents and youth can be understood within the context of the rapid social change occurring throughout the region. Many of these changes, especially that linked to globalization, have a major impact on the lives of adolescents and can lead to behaviour that is considered to be inappropriate.

Infant mortality, which was ranked first by only one country and in the top five by seven other countries, was ranked number 1 overall because it was assessed as being of at least moderate concern for almost all countries. Similarly, the issue that had the second highest rank, maternal mortality, was ranked in the top five by over half of the countries, although it was ranked as the first priority by only one country. The fourth most important issue, as measured by mean rankings, was socio-economic disparity. While not a traditional population issue, the increasing disparities in economic well-being that have characterized the development patterns of many countries in the region have an impact on population and are clearly a major concern of many governments.

High fertility did not receive a high priority ranking overall. However, fertility remains high in many countries of the region and these countries gave high priority to the issue of high fertility. Six of the countries ranked this as the main issue requiring immediate attention. But many other countries have already successfully lowered their fertility and therefore do not see high fertility as an issue of any priority. Because of the bimodal distribution of rankings for this item, the overall ranking of the issue of high fertility was only 8.

Other issues that were not ranked highly include gender disparity, family and household as an institution, son preference, population ageing, low fertility, and international migration. It is noteworthy that the first three issues are linked more closely to cultural norms and values than are issues ranked more highly. It appears that most governments place high priority for action on issues that are related to "events" rather than those that are related to the institutions of society. One issue that was not included in the list of alternatives was HIV/AIDS. Surprisingly, no country added this issue to their rankings, although several countries did specify and rank other issues not included on the list of alternatives.

Fourteen of the 25 countries included in the study reported that they had formally adopted a national population policy. Only 4 of these 14 countries indicated that the policy had been adopted prior to 1990. The nine countries that had not formally adopted a national population policy were Cambodia, the Democratic People's Republic of Korea, Fiji, Kazakhstan, Kyrgyzstan, the Lao People's Democratic Republic, Malaysia, Myanmar and Uzbekistan.4 The content of the policies varies widely among countries, but several include specific population growth and/or fertility targets (e.g. Islamic Republic of Iran, Mongolia, Nepal, Pakistan and Viet Nam). Many link population policy to support for the family. Several governments indicated that a major thrust of the national population policy was on improving the quality of life of the population (Republic of Korea) and promoting a balance between population and sustainable development (the Philippines).

There has been an increase in the resources available for education, health and family planning during the 1990s. During this period, 20 countries reported an increase in allocations, one reported no change and four indicated a decline. However, most countries stated that there were resource constraints in obtaining allocations for these areas. Sixty per cent of the countries reported that worsening economic conditions was a constraint, 10 responded that a deficit in the current account constrained resource allocation, and four cited a shift in resources to production/private sector as constraining the allocation of resources. As many of the worsening economic conditions are of recent origin, it can be expected that resource allocations for social and population-related expenditure will meet an increasing challenge.

Both the Programme of Action and the Bali Declaration contained major changes in emphasis on how population is viewed in relationship to development. All but 4 of the 25 countries participating in the survey reported that national policy, plans and programmes were being modified in order to conform to the recommendations of the Programme of Action and the Bali Declaration. One of the countries (Indonesia) reported that modifications were not being made, as adjustments to conform to the Programme of Action and the Bali Declaration had already been undertaken. Another country, Cambodia, reported that other priority needs and a lack of human resources prevented the Government from making adjustments. The other two countries reporting no current adjustments were Kyrgyzstan and the Lao People's Democratic Republic. The types of actions being undertaken by the 18 governments adjusting their policies and plans are similar. The main changes are strengthening reproductive health programmes, integrating population issues into overall development planning and a greater focus on issues of gender equality. The steps taken to bring about these changes typically involved one or more of the following: setting up new ministries (including those focusing on population and those focusing on women) or other government bodies; adopting a population policy; integrating reproductive health services into other health services, and encouraging greater involvement of NGOs. Governments have made significant efforts to adjust their policies and programmes to conform to the recommendations of the Bali Declaration and the Programme of Action.

B. Gender equality

An important emphasis of the Bali Declaration, which came across more strongly in the Programme of Action, is the need to promote gender equality and empower women. The questionnaire responses indicate a clear consensus for the need to eliminate discrimination against women. Of the countries represented in the sample, only the Islamic Republic of Iran and Kazakhstan stated that they were not signatories to the Convention on the Elimination of All Forms of Discrimination against Women.5 However, both countries indicated that their governments were currently considering the Convention. Provisions to protect the rights of women are also common among all countries. For example, of seven areas listed on the questionnaire - education, employment, equal pay, inheritance, political participation, access to credit, and reproductive rights - only in the case of inheritance did more than one country (six countries) state that there were no provisions to protect the rights of women. Of the 23 countries that responded to the question, 22 reported that they had specific provisions protecting the reproductive rights of women. Eighteen of the countries had a national policy on women/gender issues; over half of these policies had been established in the 1990s. Of the seven countries without a national policy, one had a draft under consideration (Solomon Islands), and the other six were at various stages of developing policies (Bangladesh, Indonesia, Kazakhstan, Kyrgyzstan, the Lao People's Democratic Republic and Myanmar). At the level of international and national instruments and policies, all countries in the study reported that they gave substantial attention to gender issues.

Most countries recognized, however, that even with formal protection, gender-based discrimination existed. When asked to indicate the specific characteristics of gender-based discrimination based on a list of 10 characteristics, all except 6 of the 25 countries indicated at least one area of discrimination. One country that did not specify areas of discrimination provided the comment: "There is no discrimination as such. Above characteristics [referring to the 10 items specified in the question] are largely due to the inhibition of women themselves". Another country stated that there was no discrimination. The other three countries that did not identify any specific characteristic of discrimination did not elaborate. Those characteristics that were most frequently mentioned were: lower levels of employment and stereotyping in labour demand (15 countries); limited or no representation in the political process, senior-level policy-making etc. (12); limited role in decision-making at the family, community and national levels (11); lower education level and enrolment in schools (10); limited access to credit (8); and lower pay for the same work (6).

There were a wide range of activities being adopted by countries to overcome gender-based discrimination. Those included IEC efforts to change attitudes, setting quotas for the participation of women at various levels of the political system, targeting women for recruitment into high-level employment positions, and assisting women in continuing their education. In summary, most countries in the region were pursuing efforts to reduce gender-based forms of discrimination.

Thirteen countries stated that socio-cultural and/or religious factors reinforced gender-based discrimination. Those factors included beliefs such as son preference (cited by China, India and Viet Nam), caste (India), religion (Philippines and Vanuatu), and a variety of cultural beliefs, many of them common across many of the countries. Some of the beliefs cited were as follows: men should be leaders; women should concentrate on reproduction; women were best at household work etc. Sustained efforts needed to be made to change gender role beliefs that result in gender discrimination.

The central gender-based concern of the Programme of Action and the Bali Declaration is in terms of the relationship between gender and reproductive health. In a situation where there is gender-based discrimination, the reproductive health of the population, especially that of women, is likely to suffer. Most of the countries included in the analysis recognized that the issue of gender roles and gender relations affected the reproductive health of women. Of the eight specific issues detailed in the questionnaire, at least one country responded positively for each issue. In figure XII.2 the distribution of the number of countries responding for each issue is shown.

Figure XII.2 Frequency distribution of gender issues affecting the
reproductive health of women

The issue most frequently cited was the limited responsibility and participation of men in family planning. Twenty-one countries viewed that issue as affecting the reproductive health of women. Twelve of the countries also viewed the limited responsibility of men for the consequences of their sexuality as being injurious to the reproductive health of women. Related to the above two items is the issue that was cited second most frequently: "differential expectations of society that shape behavioural patterns of men and women". There was a clear consensus that more attention in reproductive health programmes should focus on men, particularly with regard to their sexual and family planning behaviour, in order to improve the reproductive health of women.

Institutional-based forms of gender discrimination, such as access to education, health care or food, and service delivery-based forms of discrimination, such as constraints on the use of family planning, and the attitudes and sex composition of service providers, were cited much less frequently than the items mentioned above that relate to gender roles. It appears that many countries perceive that attitudes towards gender roles and relations are now a greater constraint on improving the reproductive health of women than are issues of gender equity in access to basic services.

C. Reproductive health

The need to improve reproductive health services was central to many of the recommendations of the Programme of Action. Family planning services are considered a central component of reproductive health, with the emphasis of the Programme of Action being to focus family planning on meeting client needs. All of the countries that completed questionnaires stated that they had national family planning/birth-spacing programmes. Many of those programmes were long-standing, with 13 of the 25 having been established in 1970 or earlier. Only seven programmes had been established in the 1990s. Twenty countries reported that their family planning programme was fully integrated with health services and implemented by the Ministry of Health. Three others reported that their family planning programmes were separate but linked to health services at the primary health-care level, while one country reported that its family planning programme was separate from other health services.6

Overall, 22 countries reported that there had been follow-up activities in their countries to the Bali Declaration and/or the Programme of Action aimed at improving reproductive health. For 20 of those countries, that included the adoption of a national action plan. Eleven countries reported that as a result of action that had been undertaken to conform to the Programme of Action and the Bali Declaration, the family planning programme had been reoriented to provide comprehensive reproductive health/family planning services. Nine countries reported that family planning was already integrated with other health services. Two countries (Indonesia and the Republic of Korea) reported that no follow-up had been undertaken because elements of reproductive health/family planning services were already being provided. Kyrgyzstan reported no follow-up because of a lack of resources.

The results indicate that the Bali Declaration and the Programme of Action have had a significant effect on moving countries towards a more comprehensive reproductive health focus. However, there are major constraints on how far countries can move towards that goal. The main constraint is lack of human and material resources, with 19 countries citing this as a key constraint. Ten countries cited other priorities as a problem in moving towards a comprehensive reproductive health approach, while nine noted problems of integrating service delivery systems. Only three countries reported a lack of conviction and only three gave a reason related to cost-effectiveness. Based on the responses of the questionnaires, it appears that most countries had a strong desire to move to the type of comprehensive reproductive health programme that was recommended in the Programme of Action. However, lack of resources, competing priorities and problems of integrating various components of their health systems hampered their efforts. This indicates an urgent need for technical and other forms of assistance to overcome the barriers to desired changes.

Quantitative targets have played an important role in the family planning programmes of many countries in the ESCAP region. Eighteen countries responded that their programmes had been based on targets that were to be realized by service delivery providers.7 The Programme of Action strongly recommended that targets not be considered as a component of family planning programmes; however, only 4 of these 18 countries, China, Fiji, India and Malaysia, reported discontinuing targets. India reported that the introduction of a "target-free approach to family planning" was a key change in modifications it had made to conform to the recommendation of the Programme of Action. The continued use of targets among many of the countries in the region requires further investigation about the reasons for which targets are used.

Of the 10 countries that indicated that their family planning programmes did not currently use targets, 8 responded that there were constraints in responding to client needs. From the responses, two sets of constraints can be clearly identified: (a) lack of access to adolescents and unmarried youth (six of the eight countries reported this as a constraint and six reported the focus only on married women as a constraint); and (b) lack of skills and staff (five countries) and lack of information about client needs (five countries). The first set of constraints indicates the need to try to integrate family planning efforts into reproductive health services that are available for all groups of the population. The second set of constraints identifies the need for basic research on client needs, and for technical assistance for upgrading staff skills.

Although no data are available on the quality of services provided, the responses indicate that most of the countries provide some of the basic components of a "quality of care" package of family planning services. For example, 16 countries stated that their family planning workers were trained to provide counselling, with 9 others reporting that their workers were partly trained. Eight countries reported that there were adequate mechanisms in place for follow-up of acceptors, while 13 said that the mechanisms in place were of a limited scale, and 4 stated that mechanisms were available but depended on client initiative. Twenty-two of the countries reported that family planning and safe-motherhood workers also provided guidance and referral for the treatment of reproductive tract infections, STDs and HIV/AIDS. The other three countries reported that they had plans to provide those services.

D. Adolescent reproductive health

The increasing number of adolescents and youth in the population, and the increased length of time in which the young spend in adolescent roles, have made adolescents and youth a major target group for social policy. According to the results of the survey, universal primary education was a policy in all countries except the Lao People's Democratic Republic. All except three countries also had policies or goals related to secondary education. With the exception of Cambodia, the Islamic Republic of Iran, Solomon Islands and Uzbekistan, all countries reported policies related to age at marriage, while 17 had measures to address child labour, and 20 had policies related to child nutrition. Of some concern is that only 14 countries reported that they had policies related to child prostitution and 9 countries had no policies or goals related to family life/sex education. The results indicate that there is still substantial room for policy development that will improve the quality of life of children and adolescents.

The Programme of Action identified ARH as an important issue to be addressed in reproductive health programmes. Seventeen of the countries had initiated national-level consultations on ARH. For most of those countries, the consultations had resulted in the establishment of committees to study the issues further and/or draft action plans on reproductive health. Of the eight countries that had not held national consultations, the main reason had been a lack of understanding/research in the issue of reproductive health. This reason was cited by six of the eight countries. Other reasons cited included lack of political will (3) and fear of parental objections (4). There is a clear need to undertake research and advocacy on issues of reproductive health in order to establish a context in which policies can be discussed.

Most countries (21), had policies on ARH, or related policies that affected it. In 18 of the countries, those policies, in all or part, were contained in health policies. In 11 countries, all or part of the policies were found in the national population policy. Of the four countries without policies related to adolescent reproductive health, the most frequently cited constraint for developing policies in that area was the lack of information and research on adolescent needs and sexuality. This issue was mentioned by all four of the countries. Even basic information on effective channels to reach adolescents and youth was not available. Thirteen of the 25 countries reported that the lack of such information was an obstacle in their efforts to provide information and services.

A national action plan or strategy designed to meet the reproductive health needs of adolescents had been adopted by 15 of the countries. Most countries with a plan or strategy had adopted their plans in 1993 or later. Of those countries that had no action plan or strategy, three were currently considering a plan. Of those countries not currently considering a strategy, cultural sensitivity and lack of information on how best to provide services were the reasons provided for their lack of consideration of an ARH strategy.

The majority of countries stated that information and services on ARH were available to unmarried adolescents and youth through a variety of channels8 (see table XII.3). Government health/family planning programmes, NGOs and school family life education programmes were all sources of information about ARH. Although the number of countries citing access to such services for unmarried adolescents and youth was slightly below the number claiming access to information on ARH, NGOs were cited more frequently than government health/family planning for access to services, while the reverse occurred for access to information. The four responses in the "other" category for access to services included three (Malaysia, Myanmar and Viet Nam), that specified the private sector as a source of services.

Even though information and services on ARH were reported to be available in most countries, all reported that there were numerous constraints on providing information and services (see figure XII.3). The most frequently mentioned constraint was parental/community attitudes. In 17 of the 21 countries where information and/or services were available, this was mentioned as a major constraint. The cultural sensitivity of ARH was also mentioned as a constraint by 12 countries, and 8 mentioned religion. The major service-related constraint was inadequate service outlets. The results indicate that the main constraints on providing information and services on the subject derived from values and attitudes rather than programme factors.

Figure XII.3 Frequency distribution of esponses to constraints on access to information and services relating to adolescent reproductive health

However, a number of countries responded that the focus of existing reproductive health programmes was unsuitable for adolescents and youth. Seventeen countries mentioned that in the existing programme there were constraints on reaching the youth and adolescent population. One response related to this problem was the need to differentiate youth and adolescents by age and sex in order to develop suitable programmes for each subgroup of adolescents. A constraint of existing programmes that was mentioned by 10 countries was the focus only on married women. If comprehensive ARH activities are to be integrated into existing reproductive health programmes, there is an obvious need to expand the population covered to include the unmarried. Nine countries mentioned the unsuitability of existing service outlets for servicing the needs of youth, and seven reported a lack of contraceptive methods that might be suitable for youth. It appears that many reproductive health programmes will need to modify their service delivery strategies in order to serve adolescents and youth adeqately.

The obstacles posed by attitudes can also be seen from responses to a question relating to the general attitude to the introduction of family life education in schools. Five countries stated that teachers generally had unfavourable attitudes towards the introduction of family life education, seven said that parents generally had unfavourable attitudes, and six reported that community leaders generally had unfavourable attitudes. Religious leaders were the most frequently cited as having an unfavourable attitude (10 countries). All except one country reported that peers had favourable attitudes towards the introduction of family life education in schools. Peers and the media were most frequently reported as the most effective ways of providing adolescents with information on ARH.

The legal framework of a country can hinder or facilitate the access of adolescents to reproductive health services. For example, 11 of the 25 countries reported that services and information (other than abortion) were available only to married women of reproductive age. Furthermore, in 13 countries abortion was illegal except under special circumstances. Only in nine countries was abortion legal, and in one country it was illegal but the law was not enforced.9 Only five countries reported that post-abortion services in cases of complications were not easily available. These results indicate that in some cases legal changes may be necessary to remove obstacles to the provision of reproductive health services to adolescents.

E. Role of civil society

The important role that civil society can play in population programmes is recognized in the Programme of Action and the Bali Declaration. The presence of NGOs and community-based organizations (CBOs) is widespread throughout the 25 countries represented in this study. Only the Lao People's Democratic Republic reported that there were no NGOs/CBOs offering information on reproductive health/family planning in its country. The reason indicated for this situation was that "government policies do not allow or favour the provision of information and services offered through NGO outlets". The same reason was provided by the Lao People's Democratic Republic for why NGOs/CBOs were not providing reproductive health/family planning services. The only other country (Uzbekistan) that indicated that NGOs/CBOs were not providing such services noted that NGOs were about to start offering those services. Twenty-four countries reported that NGOs were encouraged to participate in the policy dialogue on population and reproductive health issues. There are three main mechanisms for this participation - participation in workshops/seminars, informal consultations with government, and membership of committees that formulate policy. Each of these mechanisms was mentioned with approximately equal frequency, with some countries indicating that more than one mechanism was employed. The few countries which indicated that NGOs/CBOs were members of government-organized policy committees suggested that more effort might be needed to promote such membership.

Lack of progress in the development of institutional frameworks that provide NGOs and CBOs with the opportunities to participate in reproductive health/family planning programmes can be seen in responses to a question about specific steps taken to promote NGO/CBO participation in reproductive health/family planning. Although 23 of the 24 countries responding to the question reported that they had taken steps to promote participation, only six cited setting up institutional mechanisms for participation. In contrast, 19 mentioned an increase in support for NGOs, 19 countries cited greater involvement of NGOs in project development, and 15 reported greater involvement in implementation. Although NGOs are being increasingly encouraged to be involved in reproductive health/family planning programmes, in most countries they still appear to have little formal role in policy formulation.

Seventeen of the countries had specific goals related to the involvement of NGOs/CBOs in reproductive health/family planning programmes. Of those countries that indicated what the specific goals were, the most frequent response was that goals were for NGOs/CBOs to supplement the activities of the government in providing services. Some countries reported more specific aims, for example, to reduce child and maternal mortality, assist in STD/HIV prevention, to work with youth and adolescents etc. Most of the countries that had goals for NGOs/CBOs also had guidelines for their operations. Of the 19 countries reporting guidelines, 17 said that they were favourable and only one reported restrictive guidelines.10

Twenty-two of the countries reported that national population policies/programmes clearly envisaged the roles and responsibilities of NGOs/CBOs in the programme aspects of population and reproductive health/family planning, and 20 stated that the roles were clearly envisaged in policy areas. The implementation of the roles and responsibilities of NGOs/CBOs in these areas is achieved through a variety of means. For example, 21 countries responded that implementation was achieved through funding NGO programmes, with 18 citing funding from the government and 16 citing funding from donors (13 countries indicated that the funding came from both sources, while responses from three countries indicated only government funding and from three others only donor funding). Eighteen countries also stated that implementation was achieved by specifying areas or activities that NGOs/CBOs were encouraged and supported to undertake.

Fifteen of the 25 countries reported that there were constraints/obstacles to promoting NGO/CBO involvement in population and reproductive health/family planning issues. The most frequently cited constraint was the dependence on resources from government and donors with no initiative to mobilize resources from the community (see figure XII.4). This point was mentioned by 7 of the 15 countries. Five countries mentioned the lack of support for NGO operations, while five also cited that NGOs were new and untested. Three countries reported that a constraint was that the NGOs only operated around and in urban areas. Significantly, the constraints did not include misgivings about NGO operations and goals. The pattern of responses suggested that most of the constraints arose from the recent acceptance of NGOs in many of the countries, with the result that they were not yet fully supported and their potential advantages not yet fully recognized.

Figure XII.4 Frequency distribution of responses to constraints/obstacles to NGO involvement

Even though it appears that many countries are still adjusting to the role of NGOs, most have a favourable perception of their activities. Twenty-three of the countries felt that NGOs supplemented and complemented government efforts, while 15 responded that NGO activities on sensitive issues helped mobilize public opinion. Only four responded affirmatively to the statement that "some are committed to the cause while others are not".

Most countries judged the level of involvement of NGOs/CBOs in reproductive health/family planning to be limited (see figure XII.5). Only 25 per cent of the countries (6 of 24 countries) indicated a significant role for NGOs, 21 per cent evaluated their role as insignificant, while the remaining 54 per cent judged their role to be limited.11

Figure XII.5 Percentage distribution of perception of the role of NGOs in the reproductive health/family planning programme

F. Conclusion

The analysis of country responses to questions on their population policies and programmes is useful in highlighting some of the major population challenges. Governments continue to see a clear link between high population growth and adverse affects on development. However, there is also a consensus that a shift towards a reproductive health orientation would be a positive development for attaining population goals.

Although governments have made significant efforts to adjust their policies and programmes to conform to the recommendations of the Programme of Action and the Bali Declaration, it is clear that there are many obstacles to this process of adjustment. The constraints include lack of understanding, resources and information; resistance of groups within society to change; and cultural barriers to change.

The responses to the questionnaires clearly show that the constraints on implementation of the Programme of Action are not restricted to areas of reproductive health. Several countries expressed problems of lack of information and research on key development issues contained within the Programme of Action, for example, the relationship between population, environment and sustainable development, and issues of population distribution.

Some of the obstacles to change are institution-based. For example, many of the national population policies, the main instruments for defining population policy, were established during the 1970s, or even earlier. These instruments may not be able to fully accommodate the new initiatives contained in the Programme of Action and the Bali Declaration. Some countries recognize this as an obstacle to adjusting their policies and programmes to conform to the above documents and are in the process of reviewing their population policies.

The analysis of the responses collected in the questionnaires suggests a number of areas requiring attention:

Basic indicators of reproductive health and other priority issues emerging from the Cairo Conference need to be developed and collected on a regular basis
There is an urgent need for technical and other forms of assistance to overcome the barrier of lack of trained staff in many reproductive health/family planning programmes
Reasons for continued use of targets in family planning programmes in many of the countries in the region require further investigation
There is a need to integrate family planning efforts into reproductive health services and make them available for all groups of the population
Basic research on the needs of clients of reproductive health/family planning programmes is required
Efforts are required to change beliefs about gender roles that result in gender discrimination
Greater attention in reproductive health programmes should be focused on men, particularly with regard to their sexual and family planning behaviour, in order to improve the reproductive health of women
Research and advocacy on issues of adolescent reproductive health are required in order to establish a context in which policies can be discussed
If comprehensive adolescent reproductive health activities are to be integrated into existing reproductive health programmes, there is an obvious need to expand the population covered to include the unmarried
Many reproductive health programmes will need to modify their service delivery strategies in order to serve adolescents and youth adequately
Promotion of membership of NGOs/CBOs on national committees that formulate population and health policy is required
Continued efforts need to be made to fully support NGOs and to undertake advocacy activities to make governments aware of the potential advantages of NGO involvement in population programmes
Not all of the above issues are relevant for each country. However, among the countries that submitted questionnaires there is sufficient commonality of responses to suggest that many of the objectives of population policy, and many of the constraints on achieving those objectives, are broadly similar across countries. Therefore, the measures to be undertaken to address the constraints and meet emerging challenges can be developed within a regional framework, taking into account the specific characteristics of each country.

End Notes

* Associate Professor, Institute of Population Studies, Chulalongkorn University, Bangkok.

1 Questionnaires were sent to the relevant ministry or agency in each country. The responses in the questionnaires may not fully reflect the official position of governments and, especially for attitudinal items, the data may reflect the attitudes and beliefs of those completing the questionnaire rather than a general attitude existing among government officials. Evaluation of the responses of the questionnaires indicates a wide range of quality. For some questions, low quality could be judged by inconsistencies in responses, while for other questions there were obvious factual inaccuracies. Poor-quality responses may have resulted from a misunderstanding of some questions and/or failure to elicit a wide range of views and opinions from relevant ministries when completing the questionnaires. However, it should be noted that even when the analysis was restricted to those questionnaires that were of obvious high quality, the general conclusions that were drawn from the analysis do not change significantly.

2 For two countries, two questionnaires were submitted. For each of these countries, one questionnaire was chosen as the primary source, with the other providing supplementary information.

3 Data were not avaible for the Democratic People's Republic of Korea.

4 No information for this question was available for two countries.

5 Data were not available for two countries (the Republic of Korea and Solomon Islands).

6 Data were not available for one country.

7 The countries that reporting ithat targets had not been part of their family planning programme were Indonesia, Kyrgyzstan, Myanmar, Papua New Guinea, the Philippines and Sri Lanka. Data were not available for Nepal.

8 The question did not specify the types of information or services that were made available through the different sources, or the ease of access to the different channels. Given the responses to the questions it also seems that there may have been some misunderstanding of what adolescent reproductive health means in the context of the Programme of Action. By stressing that the reproductive rights of adolescents should include "reproductive health education, information and care and greatly reduce the number of adolescent pregnancies", the Programme of Action clearly incorporates issues of family planning, irrespective of marital status of adolescents, into adolescent reproductive health. Information from other sources indicates that most countries in the region provide no access, or very limited access, to reproductive health services for unmarried adolescents.

9 Two countries did not respond to this question.

10 One country that reported guidelines did not indicate whelther the guidelines were favourable or restrictive.

11 Data were not available for one country.