Beware
of returning to population control
Rosalia Sciortino ; A health and social
development adviser, Author of Menuju Kesehatan Madani (Toward Civic Health,
Gadjah Mada University, 2007)
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JAKARTA
POST, 08 April 2014
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. ●
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