Egypt s Population Policies And Organizational Framework 1

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1 Egypt s Population Policies And Organizational Framework 1 Hussein A. Sayed Professor of Statistics Faculty of Economics and Political Science Cairo University Introduction By mid-2011, Egypt population is estimated to be fluctuating between Million (CAPMAS, 2011) and 86.6 Million (IDSC, 2011 based on the findings of the PES for 2006 census), while estimated reported population by the UN/Population Division amounted to Million (2010 revision).annual population growth is currently around 2.0% and recent evidences showed the absence of any real changes in the level of population growth during the period The percentage population increase during the period was about 22.9 %, almost the same as what was achieved during the period amounting to about 22.4%. At the same time, the findings of successive Demographic and Health surveys indicated that the changes in the level of fertility are reflecting significant changes during past years. Fertility levels continuously dropped from 5.3 children per woman during the period 1979/1980, to 3.9 during the early nineties (1990/1991) and to about 3.6 children in 1993/1995. Fertility continued also to decline to reach 3.2 children per woman in the early years of the third millennium (2000/2003) and to about 3.0 children for the years 2005/2008. This showed that the highest level of decline in Egypt s fertility level was noticeable during the eighties (17%), the decline also continued during the nineties, although at a slower pace (14.6%) and a much slower pace of declining fertility of about 6.3% continued to prevail during the first years of the new millennium, confirming the noticeable stalling trend since Similar consistent trends are noticeable when considering the trends in the level of contraceptive utilization. The prevalence increased by about 4.2 percentage points during the stalling period (from 56.1% to 60.3%) with an annual average increase of about 0.53 during these years compared to about 1.6 percentage point increase during the period Contraceptive differentials are also observed by different background characteristics and for various regions, especially rural Upper Egypt that are consistent with the prevailing fertility levels for these groups/regions. A significant progress in contraceptive coverage was achieved during the period and the unmet need percentage declined from 20.1% to only 9.2% in 2008 and about 63% of those with unmet need were for stopping childbearing. Quality, 1 This paper was done under the project Policies to address fertility plateau in Egypt coordinated by the Social Research Center (SRC) of the American University in Cairo (AUC) and supported by the United Nations Population Fund (UNFPA), Cairo Office. 1

2 however, is questionable since half women, who drop out the use of contraception during the first year, attributed this to reasons related to quality of services. The stalling fertility level and the lack of evidences for further reductions is also combined with a clear stability in the stated ideal number of children per family around three, during last decades and was reported to be about 2.9 children according to the EDHS The data also indicated the early start of reproductive life (before 20 years of age) by a relatively high percentage of younger women reaching about 10%. Moreover, the three children norm is clear since 40% of women who have two children indicated their desire for a third one while data from the Observatory for Family Affaires (IDSC, 2009) showed that 40% of all recorded births are of order three or more. The current fertility levels and their trends are also associated with significant improvements in the overall health indicators (and the MDGs) that might lend support to the sustainability of the current norm, unless serious efforts are undertaken to change attitudes and culture. These improvements include: 1. Continuous declining infant mortality rate to be about 24.5 per 1000, for the period , and the same trend for child mortality rate to about 28.3 per 1000 during the five-year preceding the 2008 EDHS survey, 2. Reduced maternal mortality ratio to around 55 per 100 thousands births in 2008, 3. Higher percentage of mothers receiving any type of antenatal care during pregnancy reaching 73.6% and those who received regular care reached during the five-year preceding 2008, 4. Slightly more than 70% of births in the five-year period before the 2008 survey occurred in a health facility, 5. In 2008, about three quarter of all delivered births during the above mentioned period were assisted by a doctor, 6. Increasing expectation of life at birth to reach 70.2 and 74.8 years, in 2009, for males and females respectively. Overall, assessment of progress indicated that the specified goals for reproductive health as well as child survival are on the right track and some of the proxy indicators for fertility were also showing positive direction although only up to the early years of the millennium. This requires full understanding of both policy and organizational frameworks that are creating supportive environment for achieving national population goals. In turn, this would highlight possible policy, administrative and organizational challenges affecting the National Population and Family Planning Program and their implications for its performance and ability to achieve long-term national population goals, irrespective of the prevailing stalling levels of fertility and population growth. Population Policies and Strategies High-level population growth is the focus of official government intervention since the mid-sixties, irrespective of the development in the specification of the population 2

3 situation, the strategies and approaches adopted as well as the changes in the roles and responsibilities of various stakeholders. The reduction of fertility levels through expanding the utilization of contraceptives was at the centre of all interventions. This can be easily noted at various stages of the national population and family planning program. First Stage: Medical Approach: Although no population policy document was issued at the beginning of government intervention, in the mid-sixties, the national program adopted a fertility target aiming to reduce the CBR by about one per thousand annually and the formulated strategy centered on the following objectives: Reducing Natural increase from 2.54% in 1966 to about 2.1% by the end of 1970, resulting of a population size of about 33 million. Expanding coverage of service units to ensure fast increase of contraception utilization. Estimated number of users reached 400 thousand women in the first year and to increase to about 700 thousand and one million women in the following years to be able to reach the specified goal. According to this medical approach, increasing coverage is required to eventually respond to expected growing demand for FP which would enable the program to reach the specified targets. Promotion of services was the first priority at this stage. The outcomes, however, were affected by: MOH clinics were limited in coverage and providing FP services as an additional responsibility (overtime), under different supervision, Week availability of skilled human capacity in the area of FP and the limited number of trained physician and service providers. Lack of coordination among various stakeholders. Prevailing national political circumstances (the 1967 war) leading to changes in priorities and resulting in a stand still position for the process. This continued up to the end of this decade. A Ministerial Committee established in 1969, to assess the FP program and to propose future directions, recommended enhancing the program to aim toward reducing the CBR by one per 1000 annually, establish additional FP clinics to provide highly subsidized contraceptives. At the same time, the role of IEC programs was emphasized through establishing the Nile Centers and establishing a working group at the Ministry of Planning (MOP) to integrate population dimensions into development planning. The Second Stage: Developmental Approach The revitalization of the program took place in the early seventies which was reflected in reshaping the institutional framework and considering FP among the main responsibilities of the MOH. The main approach, however, was modified to consider population growth among other aspects of the situation. The main aim remains to 3

4 increase FP adoption to control fertility as well as population growth, but with due attention to factors affecting the demand. The Complete change towards developmental approach for the population and family planning program can be traced back to the mid-seventies, which coincides with the redefinition of the population problem. Official government position was clearly formulated in the two policy documents issued in 1973 (modified in 1975) and The first population policy document issued in 1973 and its attached population plan (for the period ) aim toward reducing the CBR by 10 thousand points during the specified period, although the demographic indicators for the period were in the other direction showing a rising birth rates and population natural increase. By 1975, the policy document was amended to include the various dimensions of Egypt s population problem, which were emphasized in the successive policy documents published in 1980 and These dimensions were: High-level annual population growth, Low-population characteristics that are not supportive to Egypt s position in a competitive world, Imbalanced population distribution and the utilization of only 4-5% of the overall country land. The policy documents, however, reflect the change in the adopted strategies to emphasize the importance of the developmental approach and the need to operationalizing the population and development interlinks to achieve the population goals, especially controlling population growth. It identified 9 factors that are necessary to be affected to expedite the reduction in population growth. These include, raising socioeconomic standards for families, education, and women work, and agriculture mechanization, rural industrialization, reducing Infant Mortality Rate (IMR), social security, IEC, and improving services including FP. For each of the areas specific objectives were identified to guide the work. At the early stage, the population and development project that covered most rural areas of Egypt represented the main strategy implemented by the National Population and Family Planning Board during the seventies and early eighties, to reach the specified goals in different areas. This included increasing the number of contraceptive users from about 543 thousands in 1972 to about 2502 thousands in 1982 (representing about 40% of married women in reproductive age). The evaluation of the project showed the absence of significant results at the macro level that might lead to higher levels of contraceptive utilization thus confirming the validity of the developmental approach to achieve the goals within the context of the socioeconomic interlinks. Following the reformulation of the Supreme Council for Population and FP, under the chairmanship of the Vice-President (1977), the policy directions focused on three areas: Support FP services within the context of relevant health and social activities, 4

5 Enhance socioeconomic development projects at the village level, Support IEC programs that can affect fertility levels and contribute to changing attitudes towards contraceptive utilization. The 1980 National Strategy for population and human resources emphasized once again the priority of the growth goal through aiming to reduce the CBR by 20 percentage points during the period In addition, the strategy aim at reducing population growth within the context of the national socio-economic development plan, promoting the preparation of a new map including the establishment of new settlements, re-building Egyptian villages and improving labor productivity through upgrading skills, training and creating relevant opportunities for work. However, the lack of clearly assigned roles and responsibilities for handling these various dimensions of the population problem was the main defect of this stage, especially since efforts to increase contraceptives that would lead to lower fertility level, is hanging on the successful manipulation of socioeconomic factors and these falls within the main responsibilities of various entities. Other critical observations include: High-level political support for FP was not clear, especially during the late seventies, in contradiction with the priority given to reducing population growth, Coordination role was more obvious but with no executive power, which was only limited to pilot projects. Further attention to establish a data base to provide relevant information for assessing progress in achieving national goals. The Third Stage: Effective Integrated Approach Expanded and effective debate about the population situation and interlinks to the economic position, took place in the mid-eighties and Culminated by holding the first National Population Conference in The discussion reaffirmed the specified dimensions of the population problem and emphasized their mutual interaction, in addition to their interlinks to various socioeconomic factors. The main principles of the 1986 policy stressed the "families freedom of choice in determining the number of children they want" and the responsibility of the program in assisting them to achieve their goals. It also included the freedom of migration, decentralization of population and FP program, promoting the role of voluntarism and civil society, enhancing human development and the adoption of voluntary positive incentivizes that lead to changing fertility behavior. Once again the policy indicated that high-level population growth is the result of higher fertility levels and accordingly a package of integrated interventions need to be adopted to slow down the prevailing levels of demographic indicators. These policy quantitative goals were specified in a separate document to allow flexibility for their modifications according to actual performance and their implementation was carried out under the umbrella of long-term plan including a number of successive strategies 5

6 issued in 1986 and The first segment was to cover the period up to 1991, while the second part covered the period (three successive five-year plans). The strategy document for the first period specified the planned interventions that included increasing coverage and the provision of quality FP services as well as upgrading other socioeconomic dimensions such child survival, social security without depending on children, basic education, empowerment of women, intensify illiteracy programs and expanding IEC campaigns to change attitudes as well as behavior. Moreover, the strategy specified goals for the other dimensions of the population problem, namely distribution and characteristics. The second Strategy document adopted a set of quantitative demographic goals for the period (with specified goals for the years 1997, 2002 and 2007) that would be achieved through nine national programs covering: 1. Family planning, 2. Information, education and communications, 3. Maternal and child care, 4. Youth, 5. Environment, 6. Upgrading education standards and levels as well as reducing illiteracy, 7. Increasing working level and productivity, 8. Women development, and 9. Population redistribution and land utilization. This stage watched highly intensified efforts that led to a significant progress toward approaching the specified population and FP goals that was faster in the early years of this stage then slowed down during last year s, up to the end of the century. This was documented by various assessments that indicated: Slightly decreasing population growth to reach 2.01% during the period compared to 2.1% during the previous period , Declining CBR to 26.3 per thousand population in 2002 instead of 40.9 per thousand in 1985, Reduced TFR from 4.9 children in 1984 to about 3.5 children in 2000, Increasing prevalence to 56.1% of women of reproductive age in 2000 compared to about 30.3% in 1984, Significant decline in the level of infant mortality from 97 per thousand live birth to only about 44 per thousand by the end of the nineties, Reducing illiteracy ration from 50% in the year 1986 to about 39% by 1996, 6

7 Increased percentage of land utilization and accordingly improving population distribution within the context of the developed new map for Egypt. The establishment of new settlements, expanding toward desert land in governorates and large-scale projects. In sum, assessment of progress during this period indicated that goals for fertility, contraceptives, mortality as well as maternal and child care were approaching achievement while those related to women, labor, youth, illiteracy, environment and population distribution require intensified efforts and resources for their achievements. High political support, especially at the top level, effective coordination among various stakeholders within the context of an integrated population strategy while promoting decentralization at the implementation level, as well as a strong leadership for the program, high-level institutional framework shown by a strong National Population Council, the establishment of the Ministry for Population and Family Planning and intensified IEC activities, were the main factors behind the progress achieved during these years. Holding the international conference on Population and Development in Cairo (1994) and its action plan emphasizing this comprehensive framework were also additional elements for strengthening population and FP activities in Egypt, and their expansion within the context of reproductive health approach. The Fourth Stage: Targeting/Health Orientation Approach In 1996 the recently established Ministry for population and family planning was abolished and the strong leadership role of NPC diminished while the overall responsibility for the national Population and FP program was transferred to the Ministry of Health and Population (MOHP), although the PM continue to chair NPC up to By the end of the millennium the MOHP embarked on a process to assess the validity of the latest population policy and its attached documents after around 15 years of implementation since The main purpose was to examine the various dimensions of the population problem, the specified goals and to assess the effectiveness of the adopted strategies for this period. The revision process was completed and a proposed policy document was drafted by April Its main contribution was adding another fourth dimension for the population problem concerned with the wide differentials between the prevailing demographic indicators for various regions and population groups. The document included 11 components covering all stakeholders concerned with population situation. To operationalizing such policy directions a National population Strategy was launched in November 2001, including for each of the 11 strategies the main objective, the specified sub-objectives as well as the responsibility for implementation. These strategies covered: Family planning and reproductive health; child health and survival; education and illiteracy; improving the status of women; adolescent and youth; support and family protection; IEC; Environment protection; Population redistribution; reducing demographic differentials and finally strengthen research and information. 7

8 1 The First Cycle The comprehensive strategy was implemented through a series of successive five-year plans; the first covered the period and elaborated various activities to be carried out within the framework of the different substrategies. Concerning FP and fertility indicators, the plan aim to reach the following goals by 2007: Increasing contraceptive to reach 63.1 % of women in reproductive age, Reducing unmet need to about 6 %. Increasing couple-years of protection to about 9.8 million women, Reducing fertility level to about 2.9 children per women. Moreover, the plan included specific indicators for other components that are being generally covered within the overall strategy. The sub-strategies, however, were mainly elaborating the overall mandate of various contributing stakeholders, based on the assumption that long-term effect would eventually lead to changing behavior and reduce fertility levels as needed, without focusing on the specified population aspects or indicating the path that would produce such impact. In addition, observations and comments about this five-year plan can be highlighted in the following: 1. The main goal focuses on population growth. It aims to reduce fertility to reach replacement level (2.1 Child per family) by 2017 and accordingly reducing population growth to about 1.2% annually, 2. The absence of a comprehensive set of quantitative goals within the context of the 11 sub-strategies that would lead, if achieved, to realizing the national population goals. However, a subsequent document presented the specified quantitative goals for various areas and included a total of 80 indicators. Specific plans for monitoring progress, however, were not elaborated, 3. Specified national objectives for the long term strategy were mainly guided by the population and development action plan as well as the millennium development goals they were globally endorsed in This was clearly shown for child health (infant and child mortality), maternal mortality, coverage for primary education and reducing gender gaps as well as expanding access to reproductive health services, 4. Generic formulation of the stated objectives without specifying neither the selected mechanisms for implementation nor elaborating the relevant plan, 5. Lack of any plans for monitoring progress as well as measuring the impact of the adopted strategies. Irrespective of such constraints, the performance of the first cycle of the long-term plan ( ) showed positive results for several sub-strategies. The assessment indicated that progress was significantly noticed for the indicators of 8

9 reproductive health, most indicators of FP, coverage for primary education and reducing the gender gap at this level. Low performance was also noticed in some critical areas such as: Eliminating/ reducing the level of unmet needs that reached about 9% according to EDHS Survey, Such level was much higher in Upper Egypt, especially rural areas (about 15%), Low progress in raising the couple-years of protection to the required levels, indicating the inability of the program to recruit new acceptors which might lead to slower increasing trend in contraceptive levels, Indicators concerning women status showed very slow progress in reducing illiteracy which was estimated to be about 34.6 % of women 10 years and over compared to only about 9.6 % for males. The progress in coverage of primary education was not matched by similar progress for higher education levels and the unemployment levels among women was almost 4 times the reported level for males around 2007 (24.6% compared to 6.8%), Limited progress in expanding land utilization where the area used increased to only about 8% in 2007 instead of 24.7% as planned. In sum, further assessment based on the findings of the EDHS 2008 indicated that progress was very limited in the areas of contraceptive utilization, fertility and accordingly population growth, especially in late period of this five-year plan which witnessed the beginning of the stalling trend since The Second Cycle Lessons learned from the implementation of the first five-year plan and its results emphasized the need for a different orientation in the formulation of the five-year plan. The rational adopted in the preparation of this plan include: 1. The main concern of the population program is to rationalize the level of population growth while at the same time taking into consideration the various dimensions of the population problem. This was clearly noticeable throughout previous strategies where population growth goals were always at the center of any formulated plan, 2. The other population problem dimensions (Characteristics, distribution and differentials) as well as the population and development interlinks, although important on their own, are also considered among the main strategies to change attitudes and behavior that would create supporting environment for adopting small family norm and accordingly initiate contraceptive utilization to reduce fertility, 3. Adopting an integration approach that combines reproductive health and family planning services while maintaining the highly needed privacy for FP clients, 4. The population problem should be considered at the national level and accordingly its handling is the responsibility of all partners/stakeholders, 9

10 their contribution should be clearly spelled out and the roles of the Government as well as public and private sectors need to be defined, 5. Cost-benefit assessment is demonstrated to emphasize potential returns & savings as a result of the national population and family planning program and their implications at the macro-level. The detailed budget for the plan was estimated and presented for approval, 6. Monitoring and evaluation is considered an integral part of the overall plan and the relevant indicators for measuring progress are identified at the initial stage, 7. The ultimate goal of the national population strategy for 2017 (replacement level fertility) is to be maintained and the specified goals for the interim year 2012 should be in accordance with such goal. These factors shaped the structure of the five-year plan that was launched in April The main goal was to reduce fertility to reach 2.4 children by 2012 in order to reach replacement level by Plan was built around four axes: First: Upgrading quality and coverage of RH/FP services within the framework of primary health care. The objective is to provide quality affordable RH/FP services to all people in need at the right time &place and to increase the prevalence to about 67.3% by 2012 through providing the service to about 8.6 million women. Moreover, the unmet need is to be reduced to about 6.6 % and early marriage is to be limited to 2.7% of woman in the age group years. Achieving the contraceptive and fertility goals for the years 2012 and 2017 require maintaining current users as well as recruiting a total of 300 thousands new acceptors annually, out of which half is to be provided by public health facilities while the balance is to be shouldered by the private and civil society, according to their share of the market, as indicated by the EDHS Second: Changing attitudes and behavior of Egyptian families to voluntary adopt the concept of small family size. The aim is to increase the percentage adopting the two-child norm to about 75% instead of the current level of 60%. Four strategies are to be implemented in that respect: 1. Strengthen the role of IEC to adopt small family size norm and to bridge the gap between knowledge and approval of FP from the one hand and using contraceptives on the other hand, 2. Emphasize the role of religious leaders and reformulate the religious messages, 3. Target youth, from both sex, to change their reproductive behavior, 4. Target geographic areas with high fertility level. The specified indicators for this axis include reducing fertility level for the age group15-19 years and increasing prevalence to about 36.4% for women of the same age group. 10

11 Third: Strengthen linkages between population goals and comprehensive sustainable development. The work is to concentrate on upgrading the health status of the family and support protection programs that lead to better characteristics, education and illiteracy programs as well as increasing coverage, especially for females, improving women status and population redistribution. Fourth: Effective monitoring and evaluation system that allow periodic assessment of various indicators. Areas to be covered include upgrading population information systems; high-level coordination mechanisms and data collection for all stakeholders and efficient analysis and evaluation of data to assess progress. A total of 28 indicators were identified as key measures to assess periodic progress. The implementation of this well coordinated and detailed plan was highly supported by the second National Population Conference held in 2008 and the political support at both central and governorate levels, especially after reformulating the National Population Council to be chaired by the Prime Minister and included a limited number of key Ministers as well as establishing the technical Executive Committee as a middle layer to translate high-level decisions into relevant strategies and plans for implementation. Full implementation of the first years of the plan was seriously hampered by the lack of financial resources that were actually approved by NPC (chaired by the PM). This resulted in continuing work as usual by all stakeholders. A rapid assessment of performance for the first two years showed that only about 45% of expected new acceptors for FP was reached and accordingly the number was increased to about 420 thousands new acceptors annually, if the goal of achieving replacement level by 2017 is maintained. This was too ambitious especially with the continuous decline in the contribution of the civil society and the absence of a clear assessment of the private sector s role. Following the establishment of the Ministry for Family and Population in 2009, efforts to intensify population and FP activities were elaborated in Proposed activities focused on targeting some groups that are approving FP but not able to find neither mere service (unmet need group) or quality service (drop-out group). The door-to-door plan was developed to be targeting women with unmet need in about 800 villages in Upper Egypt, as a first step, to be later expanded to other regions after assessing performance. The process started by creating bench-mark data about these villages and no evidences are available to assess its performance during the period preceding the 25 January revolution. The Current Stage: Human Development After the 25 th January revolution, the responsibility about the population problem was shifted back to the MOHP and although the FP sector continued its level of work, the prevailing circumstances dictated a different set of priorities and the new leadership of the National Program did not have sufficient time to be involved since five Ministers of Health and Population shouldered the responsibility during this period, and only recently a First Under-Secretary for Family and Population was appointed. Moreover, overall assessment of Egypt s population situation was debatable and some key influential figures were refusing 11

12 the need to rationalize population growth and assuming that potential increase is actually enhancing Egypt s human capacity and wealth. At the same time, NPC is claiming a new vision that covers all aspects of comprehensive development planning. This would put NPC at the beginning of a new stage adopting different mechanisms that are consistent with the realities. According to NPC, the success of the National population and family planning program, during the last 30 years in reducing fertility, did not reflect on population size (approaching 80 millions) The new vision of NPC is to consider the population problem as one of the important issues of Human Development, since population is its real wealth and their production and innovation represent its effective soft power. In that respect, NPC is not to focus only on controlling population growth rates, which we all aims for, but to adopt a different package of intervention that include: Upgrading health and reproductive services while working at the same time on improving population characteristics that would contribute to reducing the level of poverty, illiteracy and unemployment problems, Enhancing women opportunities, Narrowing social differential between the population, Record slum areas problems and enhance activities to coordinate efforts for their treatment, Understanding the nature of the difficulties facing new cities in order to reach a balance toward optimum population redistribution, Support all developmental efforts to optimize progress and prosperity and to cope with development challenges, Collaborate with all concerned organs in the country to integrate population dimension within the context of all sustainable development programs and to ensure their effectiveness as well as their monitoring and evaluation to adopt correction measures, if needed. The operationalization of such vision is to be carried out through signing a set of Collaboration Protocols with various stakeholders concerned with population and development whether Governmental or not. Examples are those signed with Misr Al-Kheir to create a data base for the poorest 1030 villages in Upper Egypt and with the Fund for Developing Slum Areas. The National program for empowering Egyptian families is another intervention aiming to ensure full commitment of the country and the civil society toward allowing all family members to enjoy the rights guaranteed by the Constitution and the Law without any discrimination. This will improve the quality of life for the family at all economic, social, political and cultural levels. This new vision, however, is presenting another definition of the population problem that assigns priority to population characteristics and empowering the family while concerns about the level of population growth, which was the focus of all previous policies and strategies, is pushed to the side. The right to adopt 12

13 contraceptives in order to voluntary specify the desired number of children for the family (reducing fertility level) is being totally absent and the reference to FP is currently considered sensitive which might affect the country s achievement in that respect. Moreover, it can be noted that: The comprehensive nature of the population problem should be reflected in the formulation of this new vision to elaborate how this complex problem would be handled. An integrated population plan is the main responsibility of NPC, in collaboration with other stakeholders, The concept of human development is significantly important for various countries but their strategies are actually focusing on one aspect of the population situation (characteristics) without providing mechanisms about how this will affect other dimensions of the population problem, The expected outcomes of adopting such new vision is not anticipated to demonstrate how it will contribute to the handling of the population problem, Since 1975 the population policies & strategies and their subsequent documents, the population and development interlinks were considered the most likely acceptable approach to cope with the population situation. This almost covered all the pillars specified in the new vision although within the context of a comprehensive strategy. The main difference, however, is to push the growth dimension side way. Lack of monitoring and evaluation plans to assess progress in achieving what would be considered among specified national goals. Organizational Framework Efforts to have a governmental body responsible for handling the population situation can be traced back to the fifties when the Committee for Population Matters was established to assess the population situation and provide recommendation for the government. Such directions, however, were terminated and the committee was dissolved when the government decided to pull out completely from any involvement with the population situation. The first government organizational framework was established in 1965 as the Supreme Council for Family Planning. The Council was chaired by the Prime Minister and included as members all Ministers concerned with population. The technical Secretariat Executive Board for Family Planning was entrusted with managing the national family planning program with clear mandate aiming to reduce natural increase rate from 25.4 per thousand in 1966 to about 21 per thousand by 1970 resulting in a total population of about 33 millions by that date. The program was independently carried out although fully dependent on the Ministry of Health facilities and those of NGOs. The national program was later affected by the 1967 war and its subsequent circumstances that led to a complete stop of the activities up to 1969, when a Ministerial Committee was established to assess major activities and recommend future directions. The Supreme Council and its Secretariat were reactivated after introducing some basic changes: 13

14 Establishing an Executive Committee for the Supreme Council to be chaired by the Minister of Health, FP services were introduced within all Ministry of Health facilities that worked according to special time table in the afternoon, Allocating government financial resources (one million pound) for the Supreme Council activities, Establishing the Nile Center for Information within the context of the General Agency for Information, Creating a working group, within the Ministry of Planning to integrate population dimension within development planning. The goal for the national program was to reduce the CBR by one per thousand annually to reach the level of 30 per thousand in During the period the organizational framework for the population problem changed several times to reflect either changes in mandate, chairmanship and membership or administrative level within the hierarchy of the country. The Highlevel population council was reformulated 11 times as follows: 1) The supreme council for FP, 1965, chaired by the Prime Minster, 2) The Supreme council for family planning, 1972, chaired by the deputy prime minister, 3) The supreme council for family planning and population, 1974, chaired by the deputy prime minister, 4) The supreme council for family planning and population, 1977, chaired by the vice-president, 5) The national population Council, 1985, chaired by the President until endorsing the National Population Policy, 6) The national population council, 1986, chaired by the Prime Minister, 7) The national population council, 1996, chaired by the Prime Minister, 8) The national population council, 2002, chaired by the Minister for health and population, 9) The national population council, 2007, chaired by the Prime Minister, 10) The national population council, 2009, chaired by the Minister for family and population, 11) The national population council, 2011, chaired by the Minister for health and population. The main responsibilities for such high-level council are to approve proposed policies, develop comprehensive integrated population plans, in collaboration with all stakeholders, coordination as well as monitoring and evaluation. At certain time the 14

15 functions were expanded to have executing power for pilot experimental projects such as the population and development project, while at other points its role was narrowed to mainly research and data collection. The Council has local branches in all governorates to support customized population activities at local level and ensure decentralization of population plan implementation. The performance of this high-council is affected by many factors that determine its role in connection with other stakeholders. Among these are the level of political support, the priority given the population situation, ability to mobilize resources as well as the leadership personality and background. At the same time, in two occasions a special Cabinet Minister was appointed to shoulder the responsibility of the population situation. The first, the Minister for population and family affaires was nominated during the period , during which the International Conference on Population and Development was held in Cairo in 1994 (ICPD). Besides, it contributed to creating supportive environment for the national program. The second occasion took place in 2009 where a Minister for Family and Population was appointed and assigned the responsibility for chairing the NPC. However, its role and responsibility was largely debated and the Prime Minister continued to chair the meetings of the Council with the presence of the Executive Committee. This long list of organizational structure clearly indicates the lack of stability, the absence of continuous political support and a clear vision about both the population problem and the institutional framework required for its successful handling and establishing effective working relationship with various stakeholders. It also reflects the periodic seasonality that characterized the official political government position toward the population problem. Strategic planning, defining roles and responsibilities of all stakeholders, coordination between various programs to ensure their integration, the ability to assess the contribution of various programs in reaching national goals as well as periodic monitoring and evaluation should be spelled out within the mandate of such organs to ensure its effectiveness. Challenges and Future Directions The previous discussion about the policies and the organizational framework pinpointed several challenges that clearly affect the country s ability to achieve its national population goals within the current political environment. Building consensus around the Population Problem The various dimensions of the population problem were almost stable since 1975 with the built in assumption that rationalizing population growth is the ultimate goal that will be affecting and at the same time affected by the development of the other population dimensions. This clearly requires adopting a comprehensive strategy, with clearly assigned roles and responsibilities. Moreover, it is important to note: Population policy should be one of the components of a comprehensive development policy and not a replacement. Both should be harmonized and their implications (outputs) need to be mutually taken into consideration. 15

16 The specified goals for the population policy should be mainly linked to various demographic processes although strategies for their implementation can be cross-cutting with other sectoral activities. This would again emphasize the importance of having full partnership among all stakeholders in the community. Population would continue to grow for a longer period but the main question is the size of such expected increase. Population Growth Fertility is the main factor determining the level of population growth since the role of permanent migration is ineffective. Accordingly, the focus of various population strategies was to work on changing culture and reproductive behavior to adopt small family size norm without having a clear definition of its size. The strategy , however, referred to the norm of two children per family through adopting the replacement level goal by This was also clearly spelled out in the latest population and FP strategy Significant progress has been achieved during past years and the level of fertility declined from about 7 children per woman in the sixties to about 3 children around The pace of decline was slower in recent periods and reached a stalling level after The same trend was also noticeable for the level of contraceptive utilization since the prevalence fluctuated around 60 % of woman in reproductive ages in 2008 with no recent evidence about any change of direction. The prevailing norm for the desired number of children around 3 is also supported by the fact that the ideal number of children for both ever- and currently-married women was about 2.9 children in 2008 and is almost stable for the last 25 years. As noticed population projections are showing a large scale differences depending on the adopted base population (2006 census returns or those corrected using the results of the 2006 PES) as well as the highly risky estimates of Egyptians abroad fluctuating between 6 to 10 millions. However, for the sake of clarifying the point the UN/Population Division projection (the 2010 revision) is to be used. If fertility continues at its current level of 3 children, Egypt population would reach 89 million by 2015 and continue to grow to about 105 and 150 million by the years 2025 and 2050 respectively, as can be seen from Table One providing UN projection according to different variants. The table shows that population size continues to increase with different levels according to expected fertility. By 2025, the differences in population size would be around 4.2 million when considering constant fertility compared to the potential medium variant and these differences increases to about 26.1 million by The trend indicated that the population would continue to increase under both the constant fertility and the high variant assumptions while it will start to decline around 2055 and 2075 under the low and medium variant assumptions. Replacement level fertility would be only reached around according to medium variant assumption. Different projections, especially those adopting the corrected 2006 census (based on the PES findings) would produce higher population estimated for different years. These findings, however, need to be widely debated within the community to establish consensus about the goals that are to be adopted. 16

17 Table (1) Egypt s Population Projection by Different variants (In thousands) YEAR Medium Variant High Variant High Variant Constant fertility Variant Source: UN/ Population Division, 2011 Family Planning Program Family planning stood at the centre point of all efforts to control population growth. This is clearly documented since in the official government recognition of the population problem in 1962 (the national Charter). This was sustained throughout various periods although adopted strategies became widely comprehensive and included all aspects of the population problem. The program widely benefitted from the increasing support of donor agencies, especially USAID and UNFPA, to expand coverage within the context of an integrated approach, upgrade the quality of services and ensure contraceptive security to guarantee the provision of quality affordable contraceptives when need at the right time and place. This was shown by the outcomes where prevalence doubled between 1980 and 1995 (percent of currently married women years increased from 24.2% to 47.9%). It also continued to increase to reach 56.1% in 2000, 59.2% in 2005 and in 2008 stood at around 60.3%, showing once again a stalling trend since 2003 as was reflected on fertility, irrespective of efforts to expand the program through introducing mobile services and increasing the number of female service providers. Working on the demand side continues to change norms and attitudes with moderate success that was reflected in the declining level of unmet needs. The estimated Family Planning Program Effort Index (FPPEI) that was carried out in 1999 and 2009 did not show significant improvement during the period under study as given in Table Two. 17

18 Table (2) Family Planning Program Effort Index for Egypt and some selected countries in 1999 and 2009 FPPEI Country Total Policy Services Evaluation Method availability 1999 Egypt Tunisia Malaysia Bangladesh Egypt Malaysia Bangladesh Sources: Ross, J. and Stover, J. (2001). The Family Planning Program Effort Index: 1999 Cycle, International FP Perspectives, 27(3); Ross, J. and Smith, E., USAID/ Health Policy Initiative (2010). The FP Effort Index: 1999, 2004 and This independent evaluation is based on collecting information from expert observers who provide their assessment of the details of the program according to the specified scales from 1 to 10. Responses for each country are converted to scores for 30 indicators within the 4 components of the overall index. Table (2) showed that Egypt s program effort index slightly improved during the 10- year period from 57 to about 61 (4 percentage points increase in 10 years). Both policy and evaluation components are the one that indicated noticeable improvements while method availability showed a slight increase and services did not show any progress during the period. Comparison with successful countries in 1999, such as Tunisia, Malaysia and Bangladesh indicated that they are ahead in Egypt, not only at the overall effort index but also in almost all the components, especially services and evaluation. The results for 2009 are putting Egypt in a better position compared to Bangladesh and reflect a relatively better improvement in comparison with Malaysia but who is falling behind in that respect. In sum, although the FP component is crucial for the overall population program, evidences are showing that further efforts are needed to strengthen and sustain program improvements. Financial and human resources would be instrumental in that respect. 18

19 The Unmet Need Challenge The level of unmet need significantly declined according to the findings of the EDHS (2008). It reached 9.2% for overall Egypt out of which around the third are desiring to space the next birth and the balance wants to limit their births. Wider differentials by geographic regions are noticeable. The highest level shown in rural Upper Egypt (15.4%) compared to only about 5.9 % in urban governorates and 7.4 % in Lower Egypt. Its value also varies by governorates as can be seen from the following table. Table (3) Unmet Need for Family Planning by Governorates (2008) Governorate % Unmet Need Governorate % Unmet Need Cairo 5.72 Giza 7.4 Alex 6.5 Beni-Suef 13.5 Port-Said 7.32 Fayoum Suez 4.69 Menia Damietta 8.0 Assuit 14.8 Dakahlia 10.3 Souhag Sharkia 7.74 Qena Kalyoubia 5.31 Luxor Kafr Elsheikh 8.42 Aswan 9.59 Gharbia 7.31 Red Sea 8.97 Menoufia 6.32 New Valley 5.88 Beheira 6.93 Matrouh 8.33 Ismaelea 7.63 North Sinai Total Egypt 9.25 South Sinai To explore the possibility of reaching replacement level if unmet need was eliminated, a set of possible scenarios were examined based on the desire for limiting or spacing: First Scenario: Increasing prevalence through reducing unmet needs for limiting only. The percentage reduction in the percentage of unmet needs is translated to an increase in the prevalence according to the following assumptions: Prevalence < 40%, annual increase would be about 2.54% Prevalence between %, annual increase would be about 1.9% Prevalence >50%, annual increase would be about 1.27%. Second scenario: in addition to reducing unmet need for limiting, this scenario also includes those with unmet need for spacing if they have their last birth since more than two years. Increase in prevalence would be dependent on the level of prevalence, as previously indicated, to be 3.0%, 2.2% and 1.5% respectively. 19