Introduction

This year marks the end of the five-year implementation plan for the National Population Strategy, developed by the National Population Council in December 2014, and it also marks the end of the period allocated for the implementation of the National Strategy for Reproductive Health (2015-2020), which was issued by the National Population Council in January 2015. On the occasion of  World Contraception Day, this paper will offer an assessment of the implementation of some of the key points of both strategies.

The Egyptian Initiative for Personal Rights (EIPR) previously commented on the principles and mechanisms of implementing the two aforementioned strategies, and a number of experts shared their reservations regarding the focus of the first strategy on the birth control approach to limit the population increase, without securing women's reproductive rights  to make free and informed decisions regarding their bodies. And criticized the second strategy’s lack of quantitative data, targets and indicators for improving reproductive health services.  This paper focuses on the key aspects of family planning and reproductive health as a model for the deficiencies and failures revealed over the past five years.

• In particular, the paper reviews three problems surrounding the implementation of the two strategies, namely, first, the absence of data that feeds the indicators previously adopted in the two strategies that are indispensable for their evaluation, and their lack of availability in the few cases in which data are collected. And secondly, lack of commitment to evaluation and review which leads to the difficulty of social accountability.

• And finally, in the absence of a clear overall vision of how to implement reproductive health policies, as evidenced by the multiplicity of entities responsible for the issue, lack of coordination between them, and the instability of the regulatory frameworks that govern the work of the National Population Council. The paper concludes with a number of recommendations aimed at addressing the three problems and avoiding them in any future planning.

 Missing data

Both strategies, the National Population and Reproductive Health strategies, emphasize the necessity of collecting and extracting data for monitoring and evaluation, as access to information is among the fundamental rights of the individual necessary to obtain and access high-quality health care. In the National Reproductive Health Strategy, a set of reproductive health indicators were adopted:

• Maternal mortality ratio,

• The average age of first marriage,

• Percentage of women who received health care during pregnancy,

• Percentage of births attended by skilled health professionals,

• Percentage of women who received medical assistance from midwives during delivery, 

• Percentage of women who received medical assistance after childbirth,

• Percentage of coverage with tetanus vaccination,

• And percentage of C-section births 

The National Reproductive Health Strategy relied on the Demographic Health Survey (DHS) to be the source for compiling these indicators, however, the databases of this survey have not been updated since  2014.

The importance of the Demographic Health Survey is that it collects comparable data on fertility rates, patterns of contraceptive use, maternal and child health and nutrition, and the intersection of health with other aspects in general. The Demographic Health Survey provides information and databases that are not available elsewhere, which reinforces its critical importance. As for the reason for delaying the conduct of the Demographic Health Survey, one of the former officials in charge of the population file indicates security reservations on the part of the Egyptian official authorities regarding the request to access the primary survey dataset by the United States Agency for International Development (USAID)  (the main funder of the survey). Since then, the Demographic Health Survey has stalled and no alternative databases have been adopted that enable us to monitor and evaluate the quality of reproductive health services.

As for the evaluation indicators, the indicators adopted by the two strategies have varied, yet many experts and specialists consider the low birth rate monitored by the census of the Central Agency for Public Mobilization and Statistics - as the most important indicator of the improvement of reproductive health status in Egypt. And by extension, the low rate is celebrated as an achievement in itself. However, we agree with the opinion of a number of other experts that this indicator is not sufficient to measure the improvement of the reproductive health situation, especially with the failure to examine and research the causes of the decline, and whether family planning campaigns and birth control initiatives have effectively contributed to that decline. The Family Planning Sector and the National Population Council do not publish periodic reports, so all available information are shared through media statements from the Cabinet or the official spokesperson of the Ministry of Health and Population.

The previous examples indicate a severe insufficiency in the availability of data on family planning and reproductive health services in general, and a great difficulty in accessing data related to family planning programs and campaigns in Egypt, which impedes the analysis and evaluation of these efforts. The current source of information on patterns of contraceptive consumption is the internal reports and databases of the family planning sector, which are compiled by the Ministry of Health and Population through a “TA 8” form, provided by each clinic that provides family planning services, and the consumption is determined on the basis of the number of dispensed contraceptives. The health units send the gathered data on dispensed quantities (such as pills, IUDs and other contraceptives) to the National Population Council, in addition to the clinics supervised by of the Ministry of Social Solidarity through the "Two is enough" program, and the non-governmental and charity associations. The National Population Council receives reports of dispensed contraceptives from each governorate through the National Population Council local branches, totalling 27 branches across the country. This information is collected at several different levels until it reaches the Ministry of Health and Population, which uses it to calculate fertility rate, contraceptive prevalence rate, and type of method.

There is also no accurate knowledge of women's consumption of contraceptive methods through the private sector, due to the gap in available data on consumption patterns in this sector. The Egyptian Pharmaceutical Trading company sends periodic reports to the National Population Council, but these reports do not reflect the reality as they provide information regarding the distribution of pills and not their consumption "off the shelf", meaning that it lists the units dispensed but not used. It is worth noting that the public sector covers approximately 57%, while the private sector covers 43% of contraceptive consumption, which of course magnifies the information gap. In addition, the information collected at the health unit level is not sufficient, it is concerned only with the rate of contraceptive use and adherence, which does not indicate the nature of consumption and on what basis women make their reproductive decisions. This represents another example of the need to conduct national surveys aimed at understanding the nature of contraceptive use among women, and analyzing the factors affecting their adherence and/or discontinuation of contraceptive methods and their satisfaction with reproductive health and family planning services.

Lack of follow-up and evaluation

Since the launch of the two strategies, no progress reports have been published to evaluate their implementation, as all official updates regarding them are limited to news and quantitative official statements that do not express the challenges and successes of implementation. In 2016, the United Nations Population Fund published the Population Situation Analysis and its data was based on the 2014 Demographic and Health Survey. One of the objectives of the analysis was to serve as a basis for monitoring the implementation of the National Population Strategy. The analysis showed that the goals adopted in the National Population Strategy were not achieved due to lack of resources, weak coordination, disruption of the institutional framework, centralization, and the absence of monitoring and evaluation. The analysis added that one of the factors that were overlooked in the National PopulationStrategy is the urgent need for more data and information to follow up on implementation.

In addition, the report flagged the oversight of monitoring and evaluation in the National Population Strategy and added that such shortfall explains previous failures in this matter. The report included several recommendations in this regard, including :

• Improving monitoring and evaluation tools, including indicators that will be used at the local level

• Improving unbiased and credible data collection 

• Linking monitoring and evaluation tools with accountability at the local and national levels

• Integrating monitoring and evaluation results into local and national decision-making, particularly with regard to resource allocation and priority setting

On the other hand, the lack of coordination between population policies and family planning stakeholders leads to weakening at the service level. Despite the National Population Council's mandate as a coordinating council that oversees population policies in general, the outcome was not always positive. The interconnectedness of population issues and family planning and reproductive health has led to the overlapping of many governmental and international agencies working to limit the population increase, and scattered efforts and resources due to poor coordination among them.

In the absence of follow-up and evaluation, the proposed budget of the National Population Council was rejected several times. The Committee for Social Solidarity, Family and Persons with Disabilities in the Parliament rejected the budget for the year 2020-2021, as the committee considered the allocated sums a waste of public money. The committee issued several recommendations, including granting the National Population Council powers that enable it to perform its function and to monitor and evaluate. These recommendations included: transferring the subordination of the National Population Council from the Ministry of Health and Population to become under the cabinet’s direct supervision, activating the role of the branches of the National Population Council in the 27 governorates to be headed by governors, and making use of the employees of the National Population Council and employing them for the benefit of the Egyptian state.

In light of what was discussed in the Egyptian Parliament regarding the poor performance of the National Population Council and the lack of clarity of the follow-up and evaluation mechanisms that were established in the National Population Strategy 2015-2030, six experts were hired last year by the council to evaluate the implementation of the strategy, the evaluation period took three months, and it was concluded that what had been implemented was less than 40% of what was planned. However, the Ministry of Health and Population at the time declined to publish the results of the evaluation to avoid the embarrassment the announcement of this result might cause.

Duplicating Strategies

Given the historical background of the establishment and development of the National Population Council, we can note the instability of the organizational and legal structure of the council, which is one of the reasons for confusion in population policies. In 1965, the Supreme Council for Family Planning was established, to be under the presidency of the Prime Minister. It was concerned with the following:

1) Develop a comprehensive planning for family planning programs in Egypt and setting a specific timeframe for implementation, follow-up and evaluation.

2) Study, encourage and coordinate population, medical, statistical, social and economic programs, and related scientific research related to family planning.

3) Coordinate between the various agencies that contribute to this program.

In 1972, the decision was amended to place the Council under the chairmanship of the Deputy Prime Minister. In 1985, the Council was reconstituted with changing its name to become the National Population Council, headed by the President. The law defined the council’s tasks, including preparing population policies that achieve the highest possible rate of economic and social development, and approving annual programs for population projects, such as:

The National Project for Family Planning. In 1996, the decision was amended to place the Council under the leadership of the Prime Minister, and in 2002, the decision was amended again to make the Council under the leadership of the Minister of Health and Population, and returned again in 2007, to go back under the leadership of the Prime Minister.  In 2009, it became The National Population Council and was  headed by the Minister of Family and Population Affairs. In 2011, the Supreme Council of the Armed Forces issued a decision to subordinate the National Population Council to the Minister of Health and Population. In 2015, all the functions of the Minister of Population, as mandated by Prime Minister Decree No. 745/2015, were transferred to the Minister of Health and Population. Now the National Population Council is headed by the Minister of Health and Population, and its membership includes the Deputy Minister of Health and Population, the Rapporteur of the National Population Council, and representatives of a number of ministries.

In spite of the existence of the National Population Strategy 2015-2030, the Ministry of Health and Population launched in 2017 what it called the "Disciplined PopulationStrategy", which had not been distinguished from the National Population Strategy launched two years earlier.  Such duplication increases confusion over an issue of this size that requires huge human, financial and technical resources, and without explanation of the reason for its launch. It also  reflects the ambiguity of the population policy goals and its simultaneous amendments with the change in the ministerial and  leadership of the National Population Council,  and makes it difficult to define responsibilities and accountability. Over the past eight years, the position of the official rapporteur of the National Population Council has been occupied by eight individuals. This is in addition to the fact that the nature of the population issue and its close link to reproductive health and the multidimensional nature of both require more comprehensive interventions than the competence of a particular ministry. For example, it was planned to implement family planning awareness services in the National Strategy for Combating Violence against Women (2015-2020), and although this strategy emphasized what was laid down in the National Population Strategy, it did not clarify the link with the National Strategy for Reproductive Health. Here, the importance of the role of coordination of the National Population Council becomes clear by uniting efforts aimed at improving reproductive health services and ensuring that resources are not wasted on recurrent and incomplete projects and programs.

The scattering of strategies, initiatives, community interventions and indicators without collecting, publishing, and analyzing data periodically, prevents an actual measurement of the quality of services provided to people, and their potential improvement. It also reduces a very complex social, economic and cultural reality and distorts our understanding as to what is the impact of all those interventions on the autonomy and efficacy of individual choices for reproductive health. The Population Situation Analysis showed that most of the indicators related to fertility and reproductive health are derived from surveys conducted with sample sizes and time spaces that do not allow calculating the indicators at the level of small administrative units.

One of the recommendations contained in the Demographic Situation Analysis Report is to build an observatory of population data and indicators, confirming that there is currently no way to collect data and indicators and organize them in useful ways for planning, following up and evaluating the strategy, or presenting them to researchers and stakeholders. The UNFPA report also indicated that there are information gaps and the need to use new methodologies to fill these gaps.

Conclusion and recommendations

Family planning services are essential to promoting the well-being and autonomy of women and their families, and ensuring quality of care in contraceptive services is critical to achieving the highest standard of health. The three most important problems regarding the reality of reproductive and sexual health services in Egypt are summarized as follows:

• An almost complete absence of official information and data, and the monopoly of government institutions and agencies on information, while not disclosing them, bearing in mind that the last Demographic Health Survey dates back to 2014, which hinders monitoring and evaluation efforts, as well as accountability and responsibility

• The lack of stable and sustainable evaluation, review and accountability mechanisms

• The large number of amendments and changes in the organizational rules that govern the work of the National Population Council, as was previously explained, and the multiplicity of government bodies addressing this matter, reflecting the absence of a clear vision and policy, and the complexity of liability and accountability procedures   

In order to ensure the quality of services and to ensure the availability and accessibility of reproductive and sexual health services, we recommend the following:

• Tightening independent oversight of the implementation of national strategies related to the health and well-being of people, with an approach that ensures the declaration and provision of data for all sectors, and its collection and publication on a regular basis. It is insufficient to limit it to the statements of the Cabinet and the official statements about the numbers of training workshops and pictures of field visits, as they are not representative of the efficiency of services and awareness messaging and do not allow for accountability and an understanding of the demographic challenges.

• Starting a wide public discussion, with independent experts and concerned civil society organizations, about the current legal frame of the National Population Council, and how to amend it in order to activate its coordination role for which it was established, which is developing population policies that achieve the highest possible rate of economic and social development, and coordination and supervision of governmental bodies and institutions and ministries in implementing housing programs and projects.

• Adherence to national strategies in light of ministerial and structural adjustments to preserve the resources allocated for their design and implementation, and to avoid wasting financial resources and human efforts by changing representatives of the Ministry of Health and Population and the succession of rapporteurs of the National Population Council.

• In addition to focusing on fertility rates and birth rates, it is also important to focus on the efficiency and quality of the medical service provided, its comprehensiveness and availability, and investing in the infrastructure to cover all parts of the country geographically. In addition to the importance of allocating fair salaries to health service providers, to achieve the greatest possible benefit from reproductive health and family planning services and to ensure the quality of services and the provision of competent staff.

• Finally, the framework for community participation in family planning, reproductive and sexual health policies must be expanded by independent experts and researchers in reproductive and sexual rights and health and more generally in population policies, from outside government bodies and agencies, and by engaging civil society more broadly in the development of policies, and also for its role in oversight.