The Programme of Action adopted by the International Conference on Population and Development (ICPD) in Cairo in 1994 had the support of all Asia-Pacific countries, but in some cases it was a qualified support. The new paradigms it promoted had their sources elsewhere, and were in some important respects at odds with a declaration adopted by the Asia-Pacific countries only two years earlier (the Bali Declaration on Population and Sustainable Development adopted by the Asian Population Conference in 1992). The Programme of Action paid only limited attention to aggregate population-development relationships. Its paradigm of development emphasized broad social policy in addressing population issues and stressed sustainability, poverty alleviation, and promotion of human rights and women’s empowerment. The traditional family planning approach was replaced by a broader reproductive health approach. This approach was seen as having a substantial impact on fertility through both changing reproductive aspirations and better meeting those aspirations. But for many proponents of the new approach, the fertility impact was more of a side effect than the ‘main game’.

This paper will briefly assess post-Cairo re-thinking of population policies and programmatic approaches by governments in the Asia-Pacific region, and discuss challenges in implementing a reproductive health approach.

The Programme of Action’s intellectual break with prior emphases, though significant, was not actually as dramatic or sudden as it appeared to many observers. The emphasis on women’s empowerment, reproductive health and reproductive rights represented the culmination of a movement critical of traditional approaches to population policy, approaches which emphasized family planning programs as the key mechanism for achieving reductions in high rates of fertility while ignoring the welfare of women. The roots of this new approach had actually been growing for some time and can be traced in studies such as those by Rosenfield and Maine¹ (from a public health perspective) and by Germain, Dixon-Mueller, and Sen, Germain and Chen² (from a feminist perspective). And there had long been many insiders in the family planning movement who, while stressing the importance of lowering fertility rates, also stressed the benefits of family planning to women’s welfare and the need to respect women’s rights and dignity in the approaches taken in family planning programmes (for example, the Taylor-Berelson programme for integrating family planning with maternal and child health services).³

The ICPD Programme of Action’s shift in emphasis from the earlier Bali Declaration can readily be observed by reading the two documents. The Bali document showed a clear concern about the implications of aggregate population trends, noting in its preamble that ‘population issues remain among the most pressing challenges facing the region’. It urged that ‘all members and associate members of ESCAP [the Economic and Social Commission for Asia and the Pacific] make a firm political and financial commitment to incorporate population and environmental concerns fully in all national efforts to achieve sustainable development’, and that ‘all members and associate members of ESCAP establish a set of population targets in line with sustainable development goals, and initiate and implement policies and programmes to achieve those targets’. The targets were later spelled out:

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

There is a continuing strong belief in the Asian region that population-development relationships are very important. This belief underlines the continuing emphasis on family planning and fertility reduction in the largest countries of the region — China, India, Indonesia and Bangladesh, and an apparently increasing emphasis in Pakistan. While direct family welfare implications of contraceptive practice are stressed in these and other family planning programmes, there is little doubt that they, and other active programmes that have wound down because fertility has fallen to low levels (for example in the Republic of Korea, Thailand, Singapore) received their impetus from a belief that rapid population growth is a heavy drain on national development. And if the ‘national development’ goal was criticized as dealing with aggregate matters and lacking a focus on individual welfare, the response was that individual and family welfare is the ultimate goal of such development and cannot be raised very much without it.

The Bali approach, which was also reflected in the recommendations of the African Population Conference, came under attack from various sources in Cairo. The emphasis on aggregate demographic goals was anathema to many feminists, who argued that programs that are intended to act directly on fertility ‘are inherently coercive and abusive of women’s right to choose the number and timing of their children’.⁴ (Even the use of the term ‘women’s’ rather than ‘couple’s’ in this context reflected a hard-fought change from earlier World Population Conference documents).

It is important to note that the Bali Declaration did contain recommendations that are fully compatible with a reproductive health approach. For example, item 19 of the Bali Declaration states that:

reproductive health care should be improved considerably in the region. Policies and programmes should strive to incorporate the totality of reproductive health care and aim at reducing maternal morbidity and mortality, induced abortion, sterility, childlessness, sexually transmitted diseases (STDs) and spread of the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS).

Asian countries were not in the forefront of the feminist agenda so forcefully promoted in Cairo. Indeed, some of them would probably have been unwilling to agree to all the provisions of the Programme of Action had it not been for the ‘chapeau’ — the umbrella statement that explicitly recognizes the right of individual countries to autonomy in population policy:

The implementation of the recommendations contained in the Programme of Action is the sovereign right of each country, consistent with national laws and development priorities, with full respect for the various religious and ethical values and cultural backgrounds of its people, and in conformity with universally recognized human rights.

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

Countries of the Asia-Pacific region are characterized by an extraordinary diversity in population size, levels and trends in fertility and mortality, levels and rates of economic development, patterns of internal and international migration, and differences in approaches to development planning. This implies a diversity of issues and of appropriate policy recommendations. Fertility rates have sunk very low in countries and areas such as the Republic of Korea and Hong Kong, whereas they have remained very high in Afghanistan and fallen little in Pakistan and Nepal (see Table 1). Differences in female ages at marriage, however, appear to be lessening, with encouraging increases in South Asian countries,⁵ and age differences between spouses are also tending to narrow in countries where they were previously very wide. These trends reflect important effects of education and other influences on gender relations. They raise many important policy issues stemming from increasing intervals between attainment of puberty and marriage, and from the increasing autonomy of young people during those intervals.

One implication of wide differences in fertility and mortality (especially of fertility) is that the ageing of the population, though increasing throughout the ESCAP region, is proceeding much more rapidly in some regions and countries than in others. The proportion of aged in the population will remain lower in South and Southwest Asia and also in Southeast Asia than elsewhere in the region. Although all Asia-Pacific countries need to be taking steps to prepare for an ageing population, the nature and timing of these steps may differ.

For many countries, the issue of whether family planning programs should have a fertility reduction target has no further relevance. Countries with below-replacement fertility — and there are now a considerable number of them in the region — are normally interested in forestalling further fertility decline rather than in promoting it. In such countries, an approach to the provision of family planning services that stresses reproductive health should raise no concerns at all. There are many other countries where fertility is sinking towards replacement levels and, although population momentum ensures considerable further increase in their populations, there is no longer a feeling of urgency about reducing fertility rates. In such countries, the reproductive health approach should also prove non-controversial. But there are other countries where fertility remains high and governments have adjudged that rapid population growth is hindering development efforts. It is in such countries that planners may need to be convinced that an emphasis on reproductive health rather than fertility reduction per se will nevertheless have desired effects on fertility.

The recent economic crisis confronting a number of countries of East and South-East Asia provides a current context of greater pessimism than prevailed at the time of the Cairo conference. Resources will be scarce and this will make it hard to fund new initiatives in implementing population programmes. On the positive side, the countries worst affected by the economic crisis — Republic of Korea, Thailand, and Indonesia — have all succeeded in lowering fertility — to replacement level or below in Korea and Thailand. Their situation would be much worse had it not been for these reductions, which have muted the increase in the number of young people entering the labour market at present, as well as facilitating the rise in educational levels of those now entering the workforce. For example, if Thailand’s fertility rate had not fallen from the levels prevailing in the late 1960s, the number of young people reaching the workforce ages would have been rising by about three per cent every year at present. Instead, it is actually decreasing by about half a per cent each year, and entry into the labour force is delayed by the progressively longer time spent by the average young person in continuing their education. Nevertheless, layoffs will occur and unemployment rates will rise sharply.

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

The increased emphasis on empowerment of women and on reproductive health in the ICPD Programme of Action included attention to adolescent reproductive health, something that was entirely missing from the Bali document. This was a serious omission, given the lengthening periods of sexual maturity before marriage and evidence of increasing levels of premarital sexual activity in many countries of the region. The Cairo emphasis therefore represents a real step forward in bringing the needs of adolescents fully into the spotlight and forcing planners to take a realistic approach to issues of life and death importance to many young people. The same goes for the Programme of Action’s treatment of the problem of unsafe abortion, a serious issue for a reproductive health programme, and one which again raises the issue of the reproductive health of adolescents, since many abortions result from the sexual activity of unmarried youth.

The ICPD Programme of Action’s human rights approach, emphasizing gender relations, reproductive rights and reproductive health and poverty alleviation, can make a major contribution to the welfare of women and families. A little more ‘gender balance’ in its discussion of rights and responsibilities would have been desirable, however. ‘How can one make men more responsible for their own fertility if one denies them rights in reproductive decision-making, which is what ICPD’s female autonomy and empowerment model in effect implies?’⁶ The pervasive emphasis on women’s empowerment also leads to myopia with respect to barriers to improved welfare of the poor, of both sexes. Thus instead of targeting the striking inequity in access to education by socio-economic status, the Programme chooses to stress inequitable access by gender, a much lesser problem, albeit still very important in South Asia.⁷ The same anomaly occurs with relation to the gender difference in child mortality, which is seen as ‘much more crucial than the high level of child mortality, male and female, in poor societies across the world’.⁸

The strongest criticisms of past approaches have been aimed at those programs that translate the overall goals for fertility reduction, through some formula or other, down to the provincial, district and local level, to provide targets for recruitment of acceptors by family planning workers. Such targets are rightly criticized, not only on the grounds that they can lead to human rights abuses, but also on the grounds that they reflect a false assumption of the primacy of family planning programmes in reducing fertility, and divert attention from the complex range of policies that can be expected to act on fertility.

Since Cairo, even the most ardent family planning programmes have learned either to eschew such targets, to downplay them or call them something else. But general targets for fertility reduction, such as those adopted in Bali, can still have a useful role to play in countries where fertility remains high, by keeping the need for slower population growth in the public eye. A key contribution of the ICPD was to re-emphasize that a wide range of social and economic policies can be expected to act on fertility, albeit with results that nobody pretends can be converted into precise forecasts of fertility trends. This point had already been emphasized in the implementation strategies and recommendations for action adopted by the Senior Officials Meeting held in Bangkok in 1994 to discuss implementation strategy for the Bali Declaration.⁹ It was also emphasized in the background paper for that meeting.¹⁰ One implication is that it is impossible to specify in isolation just what kind of family planning programme inputs will have particular impacts on fertility, because it all depends on the broader policy and programmatic context in which family planning programs are embedded.

Much post-Cairo discussion has focussed on the demographic implications of the reproductive health approach. Will a well-implemented reproductive health programme lower fertility as much as traditional approaches would have? The view that by diluting family planning resources, impacts on fertility will weaken has a plausible ring to it, because reproductive health approaches require more investment in health services not directly related to family planning. But others argue that the uptake of family planning would be higher, and contraceptive dropout and failure rates lower, if services were planned with community involvement, and oriented towards client needs, offering their clients real choices and paying more attention to their total circumstances.¹¹

Supposing that reproductive health programs could enable women to have only the number of children they desired, the effect on total fertility rates would more than exceed the governments’ targets for fertility reduction in 13 out of 17 countries where governments had quantitative targets for the reduction of fertility.¹² On a world scale, depending on whether a more conservative or liberal definition of unmet need was used, meeting this unmet need would bring developing country fertility below that of the UN medium projection or even approach the low projection.

How realistic is it, though, to argue that the reproductive health approach could lead to a complete meeting of unmet need? Sinding et al. recognize that this cannot quickly be achieved. Even to meet the conservative estimate of 17 per cent of unmet need in the developing world, excluding China, would mean raising contraceptive prevalence from about 42 per cent to 59 per cent. To achieve such an increase within seven years would be impossible, if historic experience is any guide, because of the limited human and material infrastructure for reproductive health programmes in many countries. But the increase could almost be achieved in ten years. A focus on unmet need, they argue, cannot guarantee either the early satisfaction of all need or a rapid reduction in fertility, but nor can demographic targets. Both approaches require a continued expansion of service outreach toward the under-served, as well as continued efforts to improve contraceptive technology and raise programmatic standards. The difference in the two approaches is in their assumptions and in their approaches to the public.

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

The goal of performance monitoring and evaluation is to ensure that the design and implementation of essential packages of reproductive health services provide value for money. Selection of appropriate indicators, the levels of the system at which they should be applied and the frequency of measurement, are essential parts of the design of an evaluation strategy. In India, efforts to introduce a target free approach have met with considerable skepticism and confusion on the part of many officials and workers, who ask whether ‘target free’ also means ‘responsibility free’.¹³ Similar issues have arisen in China and Indonesia. There is obviously a need to maintain clear program objectives and assessment procedures that can monitor worker performance without driving workers to inappropriate approaches. A reproductive health approach requires new assessment procedures, stressing different factors from those traditionally used to measure the productivity of family planning programmes and of individual workers. Accountability measures are needed of how well client needs are met, including client satisfaction and unmet need. Considerable work has already been done along these lines.¹⁴

Reproductive health is often understood as adding service components to existing programmes. But it actually requires institutional structures that promote a holistic perspective and a weaving together of services through gender-sensitive quality care.¹⁵ A wide range of practical issues must be faced in moving ahead with a reproductive health approach in countries whose health services are severely lacking in facilities and personnel. To give just one example, countries must decide whether paramedical staff can prescribe antibiotics to treat some reproductive tract infections (RTIs) and sexually transmitted diseases (STDs). ‘Some NGOs [non-government organizations] and government programs have demonstrated that it is possible to deliver a wide range of RH [reproductive health] services utilizing paramedical staff.’¹⁶

The content of a basic package of reproductive health services, including prevention of unwanted pregnancy, safe pregnancy and delivery, prevention and management of RTIs and STDs, as well as interventions to prevent harmful practices and promote positive ones, has been identified. But the key issue is how to deliver such a package in specific country settings, by involving all major stakeholders.¹⁷ The capacity of facilities at various levels to deliver the package needs to be assessed, as well as the skills of providers, the adequacy of support, procurement and logistics systems, and management capacity.

The reproductive health approach is consistent with — and perhaps requires — the greater involvement of the community in the program. But community participation is frequently observed more in rhetoric than in reality, and top-down government programmes normally have great difficulty in opening themselves to effective community participation.¹⁸ The focus of reproductive health programmes on meeting a broader range of needs by providing services with immediate and tangible benefits should make community participation more feasible. However, it would still require the sensitization of community leadership to the importance of reproductive health programmes, and ideally an increased role for NGOs.

The reproductive health approach implies massive retraining needs, to upgrade the skills and reorient the attitudes of workers at all levels of health and family planning programmes. Physicians, midwives and laboratory and medical technicians will need their clinical, technical and interpersonal skills upgraded. Training needs in other areas promoted by the ICPD Programme of Action should also not be ignored. Monitoring and explanation of demographic trends, policy analysis and a range of social-science-based research needs will be impossible to meet in many countries without attention to the training of demographers. There will be a particular need for those able to link demography with economic, sociological, anthropological and other approaches to understanding human behaviour.

Clearly, demographic surveys of the traditional kind do not go far towards answering many of the questions demanding answers if reproductive health programs are to be soundly knowledge based. For example, traditional demographic surveys do not survey the young and unmarried, nor do they investigate abortion. They do not analyze effectively the social context of decision making, whether in the family, the community or within government agencies. They do not investigate sexuality, the power relationships between men and women, or between children and their parents, or the negotiation of fertility decisions. A range of research methods will be required if such research issues are to be effectively addressed.

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

The population community since Cairo has been faced by a major shortfall in funds from donor agencies — both multilateral and bilateral — and the difficulty of generating sufficient domestic funds to enable the full Programme of Action to be carried out. The Programme of Action estimated that on a global scale $17 billion would be needed in 2000, of which $10.2 billion would be needed for family planning, $5.0 billion for the additional reproductive health component, a further $1.3 billion for STD/HIV/AIDS programmes and $500 million for research, data, and policy analysis. It was estimated that, overall, about one third of these costs would need to be covered from external sources — about $5.7 billion in 2000. These funds have not been forthcoming, for a variety of reasons, including ‘aid fatigue’ in western countries. Whether additionally, donors have been less interested in contributing to the Cairo programme because of a perceived downplaying of the urgency of fertility reduction is hard to assess. But ESCAP countries are clearly being forced to rely more on domestic sources than the Cairo document envisaged. The impact of the funding shortfall will unfortunately be severest in high fertility countries, which also tend to be the poorer countries of the region. The shortfall will also pose grave difficulties for a number of East and Southeast Asian countries in their current climate of financial crisis and recession.

In this context, the need for effective utilization of all available financial resources is crucial. To provide high quality reproductive health services is expensive: for example, estimates of the cost of reproductive tract infection case management under various assumptions of infection loads and utilization scenarios in India are formidable.¹⁹ Many of the shortcomings currently observed in reproductive health services result from infrastructure deficiencies that will be expensive to redress. Financial shortfalls will therefore militate against the achievement of goals. To sound an optimistic note, however, it is also clear that in reorienting health and family planning services to a reproductive health approach, much can be done without any additional expenditure of funds, because what is crucial is often reorganization of services and reorientation of attitudes on the part of service providers. Faundes²⁰ argues, based on Latin American experience, that underutilization of facilities and improper use of human resources could be redressed by improvements in management, logistics and supervision; that the extra workload required by longer time spent with clients initially will reduce subsequent workloads because of better understanding and less need for follow-up care; and that adding family planning services to primary health care centres could quickly increase access to family planning services. Most of these arguments are probably true in many Asia-Pacific countries as well.

The Cairo agenda has taken population policy into new paths, promoting a wide range of policies that should generate conditions conducive to smaller family size. Will fertility rates fall as rapidly as they would have done under a more family planning-centred approach? This is hard to say. The earlier emphasis on family planning programs gave a spurious impression of the power of such programs to reduce fertility, and failed to identify the downside of coercive programs that did impact forcefully on fertility. The worry over the new approach, however, is that it may fail to provide adequate family planning services because of dilution of scarce resources available for family planning. This worry could be allayed by stronger government commitment — including the commitment of resources — to broader reproductive health goals. Health spending has arguably long been skimped in budgets of most countries, and a more comprehensive understanding of the benefits of improved health should result in greater budgetary commitment. This will need to be allied with flexibility and imagination in adapting programs to the new approaches.

A well implemented reproductive health approach, allied with serious emphasis on the human development strategies highlighted in the ICPD Programme of Action, would have good prospects of achieving as much impact on fertility as a traditional family planning approach. The challenge is to implement an effective reproductive health approach in the tight budgetary circumstances prevailing, and in the face of continuing confusion about what an effective reproductive health program requires. If successful, the benefits would be great: meeting the need for continuing fertility reduction in ways that respect the rights of individuals and couples and that emphasize broad human development in the society.