Reproductive Health in Policy & Practice: Case Studies From Brazil, India, Morocco, and Uganda
Date: February 1, 1999
To assess how the Programme of Action, agreed upon at the 1994 International Conference on Population and Development (ICPD), is being implemented, senior researchers in Brazil, India, Morocco, and Uganda conducted country case studies. This report includes these case studies and also provides an analysis of how resources have been raised and allocated to support reproductive health programs.
The four case studies and this report have been made possible by grants from the Rockefeller Foundation and the David and Lucile Packard Foundation. This report is based on the original country studies as well as discussions held during meetings with the project’s researchers and international steering committee. The facts and analysis presented here are the responsibility of the authors, and do not necessarily reflect the views of all of the project participants, PRB, or the funding organizations.
The authors wish to thank the four research teams who devoted a great deal of effort to the case studies, the members of the international steering committee for contributing their time and useful advice, and the project’s funders for offering guidance and ideas throughout the process. Many of the project participants offered helpful comments on this report, for which we are grateful. Special thanks go to Elizabeth Ransom for her tireless assistance behind the scenes.
(2000) The fifth anniversary of the United Nations International Conference on Population and Development (ICPD) gives governments and nongovernmental organizations (NGOs) an opportunity to review progress toward the conference’s 20-year goals. The 180 nations that met in Cairo in 1994 agreed to a Programme of Action that outlined a new approach to population issues. The Cairo program enlarged the scope of earlier population policies and called on governments to take action in many areas to promote individual and social well-being. It also called for family planning services to be provided in the context of comprehensive reproductive health care.
To assess how the Cairo program is being implemented in diverse settings, senior researchers in Brazil, India, Morocco, and Uganda conducted case studies that document changes in reproductive health policies and services, as well as in the political and social environment in which initiatives are carried out. They also analyzed how resources have been raised and allocated to support reproductive health programs.
Has Cairo made a difference? In all four countries, the ICPD reaffirmed efforts that were already under way to provide family planning as part of a broader health approach. The Cairo process was, at times, a catalyst for action, for example, when nationally prescribed targets for specific family planning methods in India were eliminated and the Brazilian debate on abortion was advanced. Not surprisingly, progress on reproductive health and women’s status is uneven across and within countries, and none of the countries have addressed all of the Cairo goals.
The studies reveal major changes in the political, social, and economic environment in which reproductive health goals are pursued. In all of the countries studied, there is greater openness in political decisionmaking, a growth in NGO activity, and increasing visibility and influence of the women’s rights movement. All of these changes appear to reinforce the implementation of the Cairo agenda. There is also increasing decentralization of authority from national to local governments and some major reforms in the way that health systems operate. These trends may help or detract from efforts to make reproductive health services universally available; in either case, they need to be well understood for progress to continue.
Changes have also taken place at the service level. Attempts have been made to improve the quality of services (for example, by offering a wider array of contraceptive methods), to increase the integration of family planning and other health services, and to expand services to underserved groups. Still, much remains to be done. In spite of some encouraging beginnings — which are described in this report — more progress is needed in addressing the needs of adolescents, in expanding access to treatment for the consequences of unsafe abortion, and in providing services that address (even modestly) reproductive cancers, infertility, and AIDS. The interpersonal skills of health practitioners also need to be strengthened if women are to be fully informed of their choices and supported in making the decisions that best suit their needs. Such changes mean overcoming habits of a lifetime, including the effects of gender and social-class biases that practitioners and clients bring with them to the clinic.
Given that progress is inevitably uneven, observers may argue about its extent. It is easy point to areas of unfinished business, such as the need to move from policies and pilot projects to widespread practice, and the need to address socially divisive issues like adolescent sexuality and unsafe abortion. Further progress in all areas of implementation will require more resources and better use of existing resources, persistence in the face of overwhelming odds by all those who advocate change, and effective partnerships among governments, donors, researchers, and advocates. Ultimately, consumers themselves must become the driving force behind decisions on reproductive health policies and services.
At the International Conference on Population and Development (ICPD) held in Cairo in 1994, representatives of 180 countries reached a new consensus about how world population issues should be approached. They agreed that population policies should address social development beyond family planning, especially the advancement of women, and that family planning should be provided in the context of comprehensive reproductive health care. Such care includes family planning; safe pregnancy and delivery services; prevention and treatment of sexually transmitted infections (STIs); information and counseling on sexuality; and other women’s health services.
Earlier UN conferences had looked at population from a broad, societal point of view, emphasizing problems such as rapid population growth and the slow pace of economic development in southern countries. Many governments supported family planning programs as a means to address these issues. By the time of the Cairo conference, there was growing concern that some policies and programs placed too much of an emphasis on reducing fertility and population growth and focused too narrowly on a single intervention: family planning programs. Critics maintained that these programs were insufficiently concerned with improving the lives of individuals, especially women.
The heart of the Cairo agenda is simple: Responding to the needs of individuals will help solve the aggregate problem of rapid population growth. Addressing a broad array of individual needs, however, is complicated in practice.
The Cairo Programme of Action contains a few hundred recommendations in the areas of health, development, and social welfare. Since the Cairo conference, governments and NGOs have faced the challenge of how to implement the new agenda on the ground. And few models exist in the developing world for providing comprehensive and complex services in resource-poor settings.
Nevertheless, in some countries, attempts have been made to integrate family planning with other services, to eliminate contraceptive “targets” as a means of measuring staff performance, to develop new reproductive health strategies, and to revise laws affecting women’s status and rights. In an effort to capture some of these experiences, the Population Reference Bureau (PRB) coordinated a project to conduct case studies in four countries — Brazil, India, Morocco, and Uganda. Specialists in each country carried out the studies, with advice from an international steering committee. (Project participants are listed in Appendix 1, below.)
Why these four countries? First, they were selected for their diversity — in terms of geographic region, level of development, health and social conditions, and culture. (Table 1 provides demographic and health information for each country.) Second, each was known to be implementing new policies and programs consistent with the Cairo agenda. The project organizers believed that policymakers elsewhere would be interested to learn from these experiments and their successes and failures that occurred along the way.
National Demographic and Health Indicators
|Total population in millions (mid-1998 estimate)||162.1||27.7||975.0||21.0|
|Total fertility rate
(births per woman)
|Percent of married women using contraception||77||59||41||15|
|Infant mortality rate
(per 1,000 live births)
|Number of females enrolled in secondary school per 100 males||134||75||65||59|
|Per capita GNP (US$, 1996–97)||4,400||1,300||380||300|
The case studies are selective in their approach. Among the central recommendations of the Cairo conference — and what distinguishes it most clearly from other UN conferences — are those related to reproductive health. Project organizers were especially keen to learn the extent to which the new spirit of meeting individual reproductive health needs was being translated into action on the ground. The case studies therefore focused on changes in reproductive health policies and services, and how resources have been raised and used to provide these services. In some instances, notable changes in the broader social and economic context — especially changes affecting women’s status — are also described. The researchers used a variety of methods to collect information, including reviews of existing data, interviews with policymakers and health care providers, and focus group discussions with users of reproductive health services.
While there are common threads among the case studies, they did not follow a single set of questions. Each study describes national trends in broad terms, then pursues issues of special interest in greater depth. In each case, researchers selected a small number of communities and health facilities in the country to illustrate specific successes and obstacles in implementation. The sample cases are not intended to represent the country as a whole.
Similarly, this synthesis report highlights lessons of special interest from the country studies, but does not provide a comprehensive summary. There is no substitute for reading the individual case studies, which are as rich and complex as the countries that they represent. (Case study summaries appear at the end of this report.) We hope that the case studies and the examples we have chosen to highlight here will be helpful to countries facing similar opportunities and challenges in other parts of the world.
Five years after the Cairo conference, policymakers, researchers, and advocates have an opportunity to review progress to date in meeting the conference’s goals and to identify remaining challenges. We must recognize, however, that progress on such a broad agenda is hard to quantify. And, even if it could be quantified, it would be hard to say which changes could be attributed directly to Cairo. A number of factors complicate our assessment.
First, the Cairo conference represents a process rather than a single event. Preparations for the conference took several years and involved discussions around the world. The thinking and emerging policies and programs in a number of countries influenced the international discussions that, in turn, influenced national events. In all four case-study countries, Cairo is credited with being a catalyst of national action but by no means the only or initial influence in the move towards reproductive health approaches. In particular, national developments and advocacy groups in both India and Brazil influenced the Cairo conference. One could say that Brazil and India influenced the conference as much as they were influenced by it.
Second, a series of UN conferences has had a cumulative effect on national and international polices related to health and social development. In addition to Cairo in 1994, these conferences include the 1993 UN Conference on Human Rights in Vienna; the 1995 World Summit on Social Development in Copenhagen; and the 1995 Fourth World Conference on Women in Beijing. A common element of these conferences has been the promotion of women’s rights, an issue that has moved to center stage in many countries.
Third, the process of implementation is complicated and does not always proceed in a straight line. National priorities are continually reexamined, and commitments made at international conferences are one of many demands on policymakers’ attention. Policy and program advocates might make advances in a particular area, only to have them reversed by another constituency emerging on the policy scene. Progress is also uneven within countries, given the varying economic and social conditions that exist in different regions and communities.
Finally, the diffusion of new ideas and new ways of doing things takes time. We found several examples in the case studies. For example, it is easier to write a new medical training curriculum than to change the attitudes of doctors toward their patients, and it is easier to provide services to married women than to reach out to unmarried women or adolescents. It is also easier to change laws addressing women’s status than to change the social conditions that give rise to women’s inequality.
Bearing these caveats in mind, we believe that important changes are under way. The remainder of the report documents some of these changes, as well as the factors that have helped or hindered progress.
The Broader Context
Major changes are taking place in much of the developing world that affect the context in which international population and health policies are conceived and implemented. Among the most important changes are: greater openness in political decisionmaking; decentralization of authority from national to local governments; the increasing political importance of women’s issues; and institutional and financial reforms in the health sector.
The Policymaking Process
Brazil, Morocco, India, and Uganda all demonstrate increased openness in political decisionmaking, decentralization of authority from national to local governments, and growth in the importance of NGOs, also known as “civil society.” In some ways, these changes complicate the decisionmaking process, but they make it more likely that citizens will affect and accept the decisions that are made and press for their implementation.
In Brazil, the case study authors note that “Since the 1980s, democratization has definitely lengthened the policy decisionmaking process. But it has also given voice to the advocacy community and allowed for debate of the reproductive health and rights agenda. The adoption of this agenda by other actors and voices would not have occurred without open political debate about its meanings.”
Similarly, the devolution of authority from central to local or regional governments entails both challenges and opportunities. Since the community participates more directly in setting priorities, developing programs, and allocating resources, decentralization should result in programs and policies that are more responsive to local needs. But responsibilities may be transferred before local governments have the capacity to manage them, and local communities may be slow to perceive or act on national-level priorities — for example, reducing the spread of HIV infections. As a result, progress on national objectives is bound to be uneven across states and localities. Still, the process of decentralization is unlikely to be reversed in the foreseeable future, and it poses an interesting challenge to UN conference organizers. National representatives engage in conference discussions and sign on to international agreements, yet local authorities are increasingly responsible for implementing these agreements. They may have quite different priorities.
Recently, NGOs have grown in number and influence in the policymaking process. In Morocco, 76 NGOs (one-third established since 1994) now work on issues related to women and development. In other countries, NGOs are credited with influencing the latest generation of national policies. Partnerships that broaden the base of support for new policies and programs are also increasing — for example, collaboration between government and NGOs and cooperation within the NGO sector among academics, advocates, and service organizations. And there is no question that national and international policy meetings have become livelier and more diverse in the 1990s with the growing presence of NGOs. At the same time, not all NGOs in developing countries are truly indigenous, grassroots organizations. Some are arms of government and some represent interests from abroad.
The Political Importance of Women
Thanks largely to the activities of women’s rights advocates, the situation of women has moved to the forefront of both national and international policy debates. Since the Cairo and Beijing conferences, there is greater discussion of gender issues, or the differences in men and women’s socially prescribed roles. Governments and donor agencies increasingly acknowledge the inferior legal, social, and economic positions of women and their detrimental effects on national development. As a result, many new policies and programs attempt to reduce gender inequalities.
There are signs of real change in the status of women — at least on paper. Uganda’s new Constitution guarantees the political participation of women by reserving 30 percent of all electoral seats for them. The government has also adopted several other new policies: The National Gender Policy aims to take into account gender in all aspects of development; the Land Act provides a new mechanism for women to own land; and the Universal Primary Education policy reserves one-half of all school enrollments for girls. Similarly, recent legislation in India reserves one-third of the seats on local governing bodies for women, and Brazil has established a quota reserving 30 percent of seats for women on national and local parliamentary bodies. It will take time, however, for communities to adapt to these changes, and a number of social barriers stand in the way of their effective implementation.
Reforms in the Health Sector
Equally dramatic changes are taking place in the organization and financing of national health systems. Reform is often a condition of receiving funds from international financial institutions, such as the World Bank, and is also prompted by the increased need for economic austerity. As in the case of political decentralization, health sector reform may assist or detract from progress in meeting reproductive health goals.
On the positive side, reforms often aim to channel public subsidies toward the neediest citizens and emphasize the provision of low-cost primary health care services over expensive, high-tech interventions. Also, in most settings, health reform requires managers to consider more integrated approaches to service delivery than in the past. Such reforms are generally consistent with the Cairo agenda. On the other hand, in striving to allocate overall health resources more effectively, planners weigh the various components of reproductive health care (family planning, prevention of sexually transmitted diseases, and maternity care) against a host of other health needs (combating malaria, tuberculosis and childhood diseases, and dealing with problems related to smoking, drug abuse, and injuries). Some elements of reproductive health may receive priority attention in government budgets if needs appear urgent and affect a large proportion of the population; other elements may not. Those who hope to influence resource allocation for reproductive health need to understand and participate in debates on health financing, including priority setting.
The Women’s Movement in Morocco
Despite a constitutional guarantee of equal political and legal rights, Moroccan women suffer great disadvantages. They are much more likely than men to be illiterate (90 percent versus 60 percent in rural areas and 50 percent versus 25 percent in urban areas); far less likely to participate in the labor force (one-third of women versus 80 percent of men); and have fewer rights than men in relation to marriage, divorce, and inheritance. These disadvantages are codified in the personal status laws and reinforced by social custom.
Recently, important legal and policy changes have taken place. The government established a special ministry to deal with issues related to childhood and the family. NGOs focusing on women’s issues and advancement, including microcredit schemes for poor women, have proliferated. The personal status laws have been revised, and steps have been taken to try to combat illiteracy and reduce domestic violence. The changes in the personal status laws mandate that marriage may be concluded only with the wife’s full consent, that polygamy may be practiced only with the knowledge of the first and subsequent wives, and create legal restrictions on the husband’s right to unilaterally divorce his wife. Advocates for women criticize these reforms on the grounds they do not go far enough, and it is likely that the changes have not yet affected women’s daily lives, especially in rural and isolated areas.
Policies in Support of Reproductive Health
While they are but one element in program implementation, national policies provide important impetus and guidance to local initiatives. The case studies analyze the evolution of national reproductive health policies over the last five years. In all four countries, governments have drafted and debated an impressive array of new legislation and strategy documents.
The Indian case study provides the most dramatic example of a major national policy shift — the removal of centrally mandated targets from the national family planning program. Several factors contributed to this change. The government recognized that India’s family planning program had stalled in terms of lowering the birth rate. The focus on sterilization ignored the birth-spacing needs of younger women, and the target system contributed to false reporting of contraceptive use. At the same time, women’s groups and NGOs were increasingly voicing concerns about the poor quality of services and their heavy reliance on sterilization as the main method of contraception. The international donor community also strongly supported a rethinking of the government’s policy. Soon after the Cairo conference, health officials in India experimented with the removal of method-specific targets and, in 1996, the government abolished the use of nationally prescribed targets for acceptors of different family planning methods throughout the country.
In Brazil, a flurry of policy debates preceded and followed the Cairo conference, the most heated of which concerned abortion (see Box 2, below). In Morocco, changes in policies affecting women’s status have marked the most significant departures from the past (see Box 1). In Uganda, in addition to the changes noted on the preceding page, new population and adolescent policies have been drafted since 1994.
Brazil and India offer insights into the time and process necessary for policies to be diffused and adopted throughout an entire country. In Brazil, it has taken over 10 years for health reform to move from the level of national policy to real change on the ground. Key ingredients of progress observed after 1995 have been the persistence of the advocacy community and the strengthening of local health systems. In India, where national policy changes were debated very little before they were decreed, evidence from communities indicates that it may be some time before the changes are widely understood and adopted in practice. Local health care providers are just beginning to understand what the policy changes mean and how new procedures might work. The contrast between Brazil and India suggests that wider policy debate leads to wider acceptance of policy changes.
Not surprisingly, case study interviews reveal that a relatively small number of government officials and NGO representatives are fully conversant with the Cairo recommendations. In general, the responsibility for implementing reproductive health programs has been primarily with health officials whose mandate has expanded from maternal and child health programs, including family planning, to include reproductive health more broadly. Other ministries, such as those concerned with population, women’s affairs, or youth, have contributed to policy development. But they have generally been in weaker positions than the ministries of health to initiate and define new policies.
The Cairo Programme of Action has provided policymakers at all levels with language and concepts to help them promote the new reproductive health agenda. In Ceará, Brazil, the director of the women’s health program observed: “We have constantly used Cairo language in our dialogues with health managers, health agencies, and health professionals. Cairo language has been a critical political instrument.”
Cairo has also produced greater high-level political awareness of and support for reproductive health; a donor community willing to support new initiatives; and increased national debate and NGO activity. Where health ministries have taken advantage of these opportunities, concrete changes can be seen.
The Abortion Debate in Brazil
In Brazil, the adoption of the Cairo agenda did not represent a major policy shift, as the country had adopted a comprehensive reproductive health program a decade earlier. The conference served, however, to amplify the Brazilian debate on abortion and expand access to abortion services. The Programme of Action called for the provision of safe abortion services where legal and for compassionate care for the complications arising from unsafe abortion, whether legal or not.
Reproductive health and rights advocates in Brazil had worked since 1985 to ensure access to abortion services in the two cases permitted by law: when a woman’s health was at risk or she had been raped. Doctors were reluctant to provide the procedures, both because of a lack of information about the legal provisions and because of their own personal convictions. In the early 1990s, a legislative provision was submitted to the Brazilian Congress, calling on the public health system to make abortion universally available in these narrowly defined, but legal, circumstances. In 1995, in the aftermath of the Cairo and Beijing conferences, a new “right-to-life” provision was presented to Congress. A special committee debated and rejected the provision, sparking a heated public debate on abortion. In 1997, a congressional committee approved access to legal abortion, prompting both conservative reactions and a national mail-in campaign to lawmakers on the part of reproductive rights advocates.
On the one hand, the debate has led to harsh confrontations between reproductive rights advocates and conservative religious coalitions. On the other hand, open debate has increased understanding among health managers and professionals of the need for and meaning of legal abortion services. As one health manager in Recife said, “We have used the [Cairo] argument: abortion is a public health problem, when it is legal it must be safe, and incomplete abortion must be subject to adequate and compassionate care.” Since 1994, the public health system has expanded support for legal abortion services from two to 12 locations and has made improvements in the quality of postabortion care.
Improvements in Reproductive Health Services
The Cairo Programme of Action defined reproductive health in a comprehensive fashion for the first time in an international policy document. The definition states that “reproductive health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity….”
It goes on to state that reproductive health care should enhance individual rights, including “the right to decide freely and responsibly” the number and spacing of one’s children, and the right to a “satisfying and safe sex life.”
Operationally, reproductive health care encompasses many elements, including family planning information and services, prenatal care, safe delivery and postnatal care, prevention and treatment of infertility, abortion (where not against the law), care for complications of unsafe abortion, prevention and treatment of STIs, including HIV/AIDS, elimination of harmful practices such as female genital mutilation, and other women’s health services such as diagnosis and treatment for breast and cervical cancers. The Programme of Action calls on all countries to provide these services through the primary health care system by 2015.
An agenda of such ambitious proportions cannot be implemented overnight, especially in poor countries. All the case study countries have made significant strides toward the Cairo goals, but none has been able to address all of its elements. “We could not take Cairo wholesale, even if we wanted to,” said a program manager in Uganda, “until the systems are ready and people are in place to handle the workload.” The comprehensive definition has been used mainly