EXECUTIVE SUMMARY
The International Conference on Population and Development (ICPD) took place in Cairo in 1994 and 20 years on, it is timely to revisit the extent to which its internationally endorsed recommendations were implemented in the Arab countries.
Approach taken to review
This regional review by the Reproductive Health Working Group (RHWG), a regional network now over 25 years old, covers a selected group of Arab countries presenting a spectrum from high income countries such as Oman to low income countries such as Yemen. The range of countries reviewed includes two countries from Al Maghreb (the western sub-region also known as North Africa), namely Morocco and Tunisia; three countries from Al Mashreq (the eastern sub-region) namely Lebanon and Syria, and Egypt (although physically located in North Africa); Oman from the Gulf region, and Yemen from the Least Developed Countries of the region. We chose to focus on countries where we have active RHWG researchers who know the sexual and reproductive health and rights (SRHR) situation in these countries very well. We developed a common framework for the national reports following the guidelines prepared by Development Alternatives with Women for a New Era (DAWN). We then drafted an outline and agreed accordingly on sets of relevant indicators to track. We shared and commented on the national reports among ourselves and submitted these separately to DAWN at the end of July 2013. This report consolidates findings from the national reports and has been reviewed by the national reports’ authors as well as other members of the network. Appendix one to the report includes trends for a select number of indicators deemed relevant to this review for the years 1990, 2000 and 2010. Limitations to the approach taken are noted in the report.
Summary of findings
Access to Comprehensive and Integrated Sexual and Reproductive Health (SRH) Services
The review identifies that, in general, there has been significant progress in terms of providing more comprehensive SRH services to women. With a few exceptions such as low-income countries or those with difficult topographies like Yemen and Morocco, SRH services are generally available to many women and are physically accessible. However, barriers exist to access to comprehensive SRH services. High levels of inequities in access to services persist across socio-economic groups and across geographies (with urban areas being much more privileged than rural ones). Many key SRH issues such as infertility and reproductive morbidity remain neglected, at least by the public sector. Moreover, there is poor integration of services and continuity of care (poor post-natal care as a clear illustration of this). Some routine practices particularly related to maternal health are not based on the latest scientific evidence about recommended interventions (such as high and increasing C-section rates documented across most countries under review). The questionable quality of free health services in some contexts, the growing role of the private sector, the lack of integration of services, the proliferation of vertical health programs and fragile health systems (particularly in context of conflict) all pose a risk to the optimum provision of health care services for women in the Arab world. The relative lacks of attention to socio-cultural barriers that limit women’s access to available services, as well as the lack of emphasis on eliciting women’s perspectives about these services, have both been identified as major gaps both in terms of research and policies and programs.
Specific Sexual and Reproductive Health (SRH) Needs and Rights of Young people
There is strong evidence that the sexual and reproductive health needs of young people in the region are many and yet are not being fully addressed. Young people’s SRH needs should be seen in the context of demographic changes characterizing the region, such as a rapidly rising age at marriage, the decline in almost universal marriage and the youth bulge. There has been recent progress both in terms of generating information on young people (including those who are unmarried) and the development of youth policies, in some cases in a participatory fashion. However, the provision of services to young people has been limited to small-scale efforts, and often only caters to well-off economic groups. Moreover, young people have not been adequately surveyed or involved in the development of services and programs to meet their needs. In many countries, especially where the age at marriage remains low, the special needs of young married women having to undergo an often abrupt transition to marriage during their adolescence are not always considered. While many countries have initiated processes for developing youth policies that include SRH, there remains the need to better link policies and programs across sectors for the benefit of young people.
Sexual and Reproductive Rights
It is difficult to generalize across the review countries about the progress in this area. Outstanding examples of reform of personal status legislation exist, such as the major reform undertaken by Morocco documented in this review. There has also been significant legal reform in a number of countries around marriage (such as age at marriage), divorce and custody, and on conveying citizenship. Egypt has made significant progress on the issue of female genital mutilation/cutting, sparked in large part by the public debate stimulated by the ICPD in 1994. An issue on which there appears to have been little progress, however, is that of abortion that remains a highly sensitive and politicized issue in the region. In addition, the SRHR situation of foreign female domestic workers needs further investigation to offer them more protection than is presently the case.
Conclusions
There are many barriers to implementing the ICPD agenda which lie in the institutional, social and political context of the region. These need much more analysis than has been the case to date. The 20 years since the ICPD have certainly witnessed more willingness of governments in the region to address issues of SRH in terms of policies and programs. Often these governmental initiatives have been jointly led by United Nations bodies, non-governmental organizations (NGOs) and women’s organizations at a small-scale, and have then been taken up by governments with international donor support. The ICPD gave prominence and a public platform to the role of NGOs which was very important in countries with authoritarian political systems. Although NGOs which are active on SRH are fairly limited in the region, their particular strength lies in their advocacy for greater attention to these neglected issues and their ability to voice the perspectives of women. NGOs often face particular constraints in the political context of the region. Women’s organizations suffer from many of these same problems, but women’s movements are further constrained by on-going polarizations along religious, political and other lines. Women’s movements and organizations need to be strengthened in general, and particularly concerning their engagement with issues of SRHR. Much of the advocacy efforts of NGOs has been focused on specific issues and is highly dependent on donor funding.
As members of a research network, we also note that there needs to be better engagement in the region between research institutions, civil society organizations and governments.
Our general concern emanating from this review has been that there is a lack of deliberate effort to build the SRHR field as a whole and strengthening the role of institutions within the region whether from a research, advocacy or program perspective. Rather, the last 20 years has seen a fragmentation of the field into specific issues. The focus on the MDGs has been one element of this trend, as have been donor priorities. Work is needed to promote a broader concern and commitment to SRHR as an integral field in the post-2015 plan moving forward.
Finally, we have witnessed first-hand the devastating impact of conflicts in this region on the SRHR situation. This has most severely impacted the SRH needs and rights of populations due to conflict, and yet does not appear to be a central element of displaced response to humanitarian emergencies in the region. At the same time, the consequences of conflicts have also dominated policy priorities in general and diverted resources, thus affecting all national health systems and their ability to deliver SRHR services to all in diverse ways. This area needs much further research and given that the region has been characterized by periodic and intense conflicts, addressing its effects on SRH should be more central in the region in policies, services and educational programs.