The Jakarta Post
On April 7-11, the 47th Commission on Population and Development meets in New York to assess the program of action agreed at the International Conference on Population and Development (ICPD) held 20 years ago in Cairo. The program promotes a radical shift toward right-based development with women's health at its center, away from population control.
A comprehensive reproductive health and rights agenda was formulated to address the diverse needs of women (and men) throughout their life cycle, including contraception, HIV prevention, elimination of violence against women and screening and treatment of cancers of the reproductive system. It was stressed that women had a fundamental right to decide on their reproduction and to make informed choices about when and what contraceptive to use, and no pressure or coercion could be used for population control purposes. With the rise of the AIDS epidemic, the agenda was expanded to include sexual health and rights, and a renewed call was made for the provision of an integrated package of sexual and reproductive health information and services.
Today, recent developments indicate reemerging neo-Malthusian concerns about population growth and its impacts on economic and environmental sustainability, and a heightened interest for family planning not necessarily linked to the broader sexual and reproductive health agenda. Most telling, a global initiative launched by foundations, foremost the Bill and Melinda Gates Foundation, governments and other stakeholders at the London Summit on Family Planning in 2012 focus solely on expanding access to family planning information, services and supplies for women and girls in poor countries by 2020.
The so-called FP2010 partnership clearly cites the ICPD words that it subscribes to 'voluntary family planning' and 'supports the rights of women and girls to decide, freely and for themselves, whether, when and how many children they want to have'. Yet closer scrutiny suggests that efforts providing women 'with contraceptives that meet their needs' are biased toward long-lasting and permanent methods (LAPMs) such as intrauterine devices (IUDs), implants and sterilization. Pills and condoms receive little attention either because they are assumed to be available or because of the long-held mistrust in women's capacity to use them effectively.
Indonesia illustrates this tension between comprehensive and right-oriented rhetoric and more narrow top-down practices. The national family planning program implemented during 1970-1998 has often been described as a success story for reducing fertility rates drastically from 5.6 to the current rate of 2.6 children born per woman, and establishing a small family size as a social norm.
However, it also attracted criticism for its stress on targets at the cost of quality of care and for the coercive methods employed to promote LAPMs (from social and financial incentives and disincentives to community pressure and outright abuse).
Since the ICPD and the fall of the Soeharto regime, calls for the National Population and Family Planning Board (BKKBN) to implement the Cairo consensus intensified, while challenges were decentralization and increased privatization in the provision of contraceptives. There is now renewed interest among government agencies and international donors to revitalize the national family planning program.
An economic rationale is provided for the targeted fertility rate of 2.1 as necessary for the country to reap the benefits of a young population without depleting its economic and environmental resources. As only 60 percent of married women use contraceptives and that 73 percent of them prefer hormonal injections and pills, it is argued there is a need 'to expand their choices' with endorsing 'preferable' LAPMs.
No need is felt to adhere to the recommended 'cafeteria approach' and have an open discussion of the pro and cons of each method to enable informed and safe choices. For instance, Indonesia had one of the world's largest implant programs and now that new implants are again being praised, still no comprehensive information of their side effects is provided, nor screening for exclusion conditions. There is neither public discussion on the extent of past problems with the insertion and timely removal of implants.
Integration with HIV services is not considered, sex education is not provided and condoms are ignored even for possibly-at-risk couples and in spite of the growing infection rates among married women.
To achieve contraceptive prevalence and mix for married couples a number of strategies are being applied. Participants in the national childbirth insurance (Jampersal) plan have been compelled to use IUDs after free-cost deliveries and this practice may continue under the new national health insurance (JKN) program.
Government-funded JKN coverage for poor families is limited to three children and incentives for health professionals are also being discussed to continue to motivate them to provide LAPMs. Targets and quota are set by provincial and district governments for family planning acceptors and use of LAPMs, and achievement prices given to mayors meeting or surpassing the target. Village-level organizations and especially their women's wing (PKK) are being activated to 'recruit acceptors' and family planning slogans are again painted on rural roofs and walls. Collaboration is sought with the Army in promoting family planning, and financial schemes are devised to offer access to credit for poor couples who assent to use LAPMs .
In this heightened enthusiasm for family planning and especially LAPMs, sexual and reproductive health seems to be left out. The operationalization of 'voluntary family planning' and 'informed choice' may also need close monitoring to ensure that Beyond ICPD 2014 family planning efforts finally empower women ' and do not fall back into the temptation of the past population control paradigms.
The writer is a health and social development adviser and author of Menuju Kesehatan Madani (Toward Civic Health, Gadjah Mada University, 2007).
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