More than numbers!

4 August 2020

Population and development have historically been intertwined. For decades, economic growth and family size have been viewed as two sides of a single equation. Population policies and strategies are typically statistic-heavy, number-focused documents until initiatives from feminists and women’s rights groups introduced human rights principles to these endeavors (Samir, 2020).

As Egypt’s population topped 100 million this year, the state is seeking to reduce the total fertility rate (TFR), which currently stands at 3.5. To this end, it has unfortunately reverted to the traditional strategy. This approach is characterized by top-down population policies that aim to persuade families to have fewer children, at times through coercive incentive schemes, and by implicitly denying women’s agency and autonomy. This stands in contrast to the people-centered agenda of the landmark International Conference on Population and Development (ICPD) Agenda in Cairo in 1994. Marking a global shift, the ICPD Program of Action defined reproductive rights as “the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children, and to have the information and the means to do so, and the right to attain the highest standards of sexual and reproductive health.” In designing and implementing its population policies, Egypt must center rights and justice, and ensure that women and families are encouraged and able to exercise their rights with full, free, and informed choices.

Population Policies and Control

Over the years, the Egyptian government has viewed the increasing population as a problem to be solved. In the effort to reduce the TFR, it often relies on coercive methods that fall short of participatory approaches. In 2018, for example, Egypt launched the “Two [children] are enough campaign, with the aim of reducing TFR to 2.4. Concurrently, the UNFPA, in partnership with the Ministry of Health and Population’s Family Planning Sector and the European Union, launched an ongoing campaign, “Your Right to Plan,” which offers family consultation and dispenses contraceptives (UNFPA, 2019a). While the two campaigns employ different discourses, they share a top-down approach. In the first campaign, the state imposes regulations on family size, while in the latter, international agencies unilaterally design a program to ostensibly guarantee women’s reproductive health rights. Despite their distinctly different tones, in both campaigns women are cast as recipients of awareness messaging, rather than as active decision makers.

In 2019, the Egyptian parliament discussed a family planning act to mitigate population increase (Enterprise, 2019). Relying heavily on social and economic incentives for parents of two children, the legislation implicitly targets Egyptian families of limited means. In practice, it would likely be poorer families who ‘choose’ to take advantage of the incentives, thereby ceding their rights to decide freely and parent on their own terms.

This example demonstrates the importance of real choice in population strategies—a term often invoked in policymaking but less commonly defined. In her analysis of contraceptive autonomy, Leigh Senderowicz (2020) identifies three types of choice in global family planning: 1) informed choice 2) full choice, and 3) free choice.

Equally problematic is the method used to gauge progress toward achieving health targets. Traditionally, family planning campaigns have implemented national policies and strategies through a set of action items (UNFPA, 2019b): door-to-door awareness, engaging community and religious leaders, state televised campaigns, training service providers and women community leaders, and primarily gauging achievements in numbers (Sayed, 2011). TFR and contraceptive uptake remain central to planning and evaluating progress to achieve family planning policies and goals. For instance, Egypt’s Family Planning 2020 profile states, “[Egypt] is committed to safeguarding the health of its women and girls and mitigating the rate of its population growth by expanding its contraceptive programs, and improving the quality of services to attract new users while expanding contraceptive method choice” (n.d.). Egypt’s Vision 2030 includes two health indicators relevant to population policies: the maternal mortality rate and a composite indicator including the percentage of pregnant women making follow-up visits and the percentage of married women of reproductive age using modern contraception and new family planning methods. But the vision includes no qualitative indicators and no operationalization of ‘quality of care’ beyond numeric indicators.

In 2017, the National Strategy for the Empowerment of Egyptian Women was issued to complement Egypt’s Vision 2030 and fulfill Egypt’s commitments under the UN sustainable development goals (SDGs). This strategy, however, is limited by its adherence to the conventional discourse of ‘women empowerment,’ instead of adopting a broader social-justice perspective to address the structural barriers to women’s autonomy (National Council for Women, 2017). While numeric goals to enhance the quality of service by improving family planning is key,[i] contraceptives are a means to uphold reproductive rights and not an end (Hardee et al., 2014). When contraceptive uptake is centered in population policies, it reads as population control.

Recently, researchers have been contesting guiding conceptual terms for family planning in policymaking. In this context, ‘unmet needs’ came under scrutiny. Used for decades as a point of departure to examine population and development interactions, ‘unmet needs’ implies that women’s desires to plan their lives are not addressed and their needs are unmet. In Egypt, the unmet need for family planning increased by 1% between 2008 and 2014 (Ministry of Health and Population, 2015).

Policy in Action

In 2018, the Central Agency for Public Mobilization and Statistics (CAPMAS) ran a comparative study to highlight shortfalls and achievements of population policies in countries sharing socioeconomic similarities with Egypt. During the 1990s in Iran, for example, the national family planning program encouraged men to take part in family planning by promoting “male methods,” such as condoms, vasectomy, and withdrawal, with overall use reaching 36% (Roudi-Fahimi & El-Adawy, 2005); in contrast, only 0.1% of married couples in Egypt use male condoms with no data collected on vasectomy. Tunisia’s rights-based program includes providing reproductive and sexual education, engaging with civil society actors in conceptualizing and implementing population policies, and building a rigorous body of data that facilitates evidence-based interventions.

Recommendations

National and international population commitments measure success by increased contraceptive uptake, which implicitly perceives women as recipients rather than agents, excluding them from the process of policy-making and program design. For a people-centered population policy to become a reality, women should be predominantly involved in shaping reproductive health interventions. Interacting with women only for the purposes of implementation revives the traditional population and development approach. Moreover, social disparities must also be considered. Reproductive rights are largely accessible for the economically secure. In contrast, women and men “choosing” to have fewer children in order to be socially and economically empowered under incentivizing reproductive schemes are not making an informed, free, or full choice. To achieve this shift, the following should be taken into consideration:

Governance

  • Reinstate the midwifery program designed in 1997 (Ghanam & Sebae, 2018) to ensure accessibility, the decentralization of reproductive health services, and diversified options for women.
  • Incentivize health providers to spend more time in consultation with women and girls, to maintain the quality of service and ensure informed, free, and full reproductive choices.
  • To ensure women’s reproductive autonomy, a multi-sectoral response should be initiated to streamline gender-responsive policies, fostering environments in which women can overcome structural barriers.

Reproductive health ≠ family planning

  • To facilitate women’s contraceptive autonomy, acknowledge diverse methods to support women’s reproductive decisions. Traditional methods are equally as important as modern contraceptives.
  • Re-conceptualize comprehensive community interventions to address different challenges in women and girls’ life cycle. Reproductive health interventions should address malnutrition, sexual and reproductive misconceptions, economic barriers, illiteracy, and unpaid care work.
     

Impact

  • Fund qualitative research for effective planning and implementation that address service provision realities, women’s lived experiences, and sub-cultural attitudes toward reproductive health.
  • Regularly gather data and publish national demographic and health surveys to allow experts, stakeholders, and government bodies to draft effective policy recommendations.
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[i] Despite the great reliance on numerical benchmarks, the most recent Egypt Demographic and Health Survey (EDHS) was published in 2014 (EIPR, 2020). For decades, the EDHS has provided a window into households’ knowledge of and attitudes toward contraceptives.

Views and opinions expressed are those of the authors only and do not reflect the opinions of The American University in Cairo or Alternative Policy Solutions.

References

  • Central Agency for Public Mobilization and Statistics. (2018). Experiences and efforts in the population crisis.
  • Egyptian Initiative for Personal Rights. (2020). In facing COVID-19, do we remember the Demographic Health Survey?
  • Enterprise. (2019, December 23). House moves ahead with family planning act.
  • Family Planning 2020. (n.d.). Commitments.
  • Ghanam, A., & Sebae, A. (2018). Health and social justice in Egypt. Egyptian Initiative for Personal Rights.
  • Hardee, K., Kumar, J., Newman, K., Bakamjian, L., Harris, S., Rodríguez, M., & Brown, W. (2014). Voluntary, human rights-based family planning: A conceptual framework. Studies in Family Planning 45(1), 1–18.
  • International Conference on Population and Development. (1994). Programme of Action (paragraph 7.3).
  • Ministry of Health and Population, El-Zanaty and Associates, & ICF International. (2015). Egypt demographic and health survey 2014.
  • National Council for Women. (2017, March). National strategy for the empowerment of Egyptian women 2030.
  • Population Council. (2020, March). Two implementation models of workers' health education programs in Egypt: What works? What doesn't work?
  • Roudi-Fahimi, F., & El-Adawy, M. (2005). Men and family planning in Iran. The XXVth IUSSP International Population Conference. Tours.
  • Ross , L., & Solinger, R. (2017). Reproductive justice: An introduction. University of California Press.
  • Samir, M. (2020). Cairo 94: Desk review on reproductive rights in Egypt. Ikhtyar African Feminist Collective.
  • Sayed, H. A. (2011, December). Egypt’s population policies and organizational framework. Social Research Center, American University in Cairo.
  • Senderowicz, L. (2020). Contraceptive autonomy: Conceptions and measurement of a novel family planning indicator. Studies in Family Planning 51(2), 161–176.
  • United Nations Economic Commission for Africa. (2013). Addis Ababa declaration on population and development in Africa beyond 2014.
  • United Nations Population Fund. (2019a, January 10). ‘Give yourself a break’: A day at the mobile family planning clinic.
  • United Nations Population Fund. (2019b, January 16). EU support of Egypt’s national population strategy.
  • World Health Organization. (2018). Multisectoral and intersectoral action for improved health and well-being for all: Mapping of the WHO European region.

This article has been published via Alternative Policy Solutions website in  July 28, 2020