| SAPLER Population Trust | |
| Splendidly Alive People Within Limited Environmental Resources | |
Part IX: South African Policies
This section covers the documents of the RDP, the ANC Health Plan, The Women's Project and the WHO Report on Reproductive Services. I have also included in this section a page from the Cairo report, because much of the current thinking in SA uses this report as a stepping-off point.
However, there is only one sentence in the report which makes sense to SAPLER and that is the one which says, "The unmet need for family planning must be met. "It is difficult to see how the rest of the Cairo document can be translated into practical plans.
President Nelson Mandela Endores Statement on Population Stabilisation
President Nelson Mandela, along with other heads of Governments of the Non-aligned Nations, endorsed a Statement on Population Stabilisation prepared by the Global Committee of Parliamentarians on Population and Development.
This Statement urged national leaders to take an active personal role in promoting effective population policies and programmes which should emphasize improving the political, economic and social status of women; achieving the active participation of women in formulating policies and programmes and expanding basic education for girls and women. Attention should be given to setting realistic goals and timetables and developing appropriate economic and social policies.
The Statement calls for enhancing the integrity of the individual and the quality of life for all on the basis of the belief that all nations should participate in setting goals and programmes for population stabilisation. Measures for this purpose should be voluntary and should maintain individual human rights and beliefs.
South African in Force at the Cairo Conference
The International Conference on Population and Development (ICPD) was the largest United Nations Conference ever held. The Conference was attended by 182 countries and addressed by 249 speakers. A total of 10 757 delegates participated in the Conference. This included an official South African delegation of 14 members, which the Minister for Welfare and Population Development headed.
Running concurrently with the Conference, a forum of non-governmental organisations (NG0s) was held which was attended by NGO representatives from around the world. They shared ideas and experiences on population and development programmes which reach many people at grassroots level. 57 NGO representatives from South Africa also attended this massive event.
Other distinguished South Africans also attended other events prior to and during the ICPD. Most prominent among these was the Deputy President of the Senate, Mr Govan Mbeki, who attended a meeting of the Inter-Parliamentary Union in Cairo, Egypt on 7 September 1994. A message was prepared by the Union, as its contribution to the ICPD.
Four South African Parliamentarians participated in the International Conference of Parliamentarians on Population and Development (ICPPD), held under the auspices of the Global Committee for Parliamentarians, from 3-4 September 1994. This Conference culminated in the adoption of a Cairo Declaration on Population and Development which was presented to the plenary meeting of the ICPD.
Despite their involvement in the different activities, the South Africans took time off to get to know one another. A gala evening was hosted by the South African Embassy in Cairo in honour of Minister Abe Williams, Minister for Welfare and Population Development. The entertainment for the evening was provided by the Drakensberg Boys Choir who entertained the South Africans to traditional South African songs.
The RDP is all about the redressing of past wrongs, the levelling of the playing fields and the elimination of poverty. Yet none of this can be achieved unless South Africa (and her neighbours) reach Zero Population Growth. The paragraph on population (2.2.8) reads as follows:
The issue of population growth must be put into perspective. The present population policy, which asserts that overpopulation is the cause of poverty ignores the role of apartheid in creating poverty, and also implies that the population growth rate is escalating (which is untrue).
It is true, however, that a relatively high population growth rate exacerbates the basic needs backlogs our society faces. Raising the standard of living of the entire society, through successful implementation of the RDP, is essential over the longer term if we are to achieve a lower population growth rate.
In particular, the impact of any programme on the population growth rate must be considered. A population committee should be located within the national RDP implementing structure. Policies on international migration must be reassessed bearing in mind the long 1 term interests of all the people of the sub-continent.
1. SAPLER does not ignore the role of apartheid in creating poverty.
2. The population growth rate is slowly coming down. But an estimated one million South Africans are added to our population every year.
As Paul Ehrlich says: "The vast majority of people has been added to the ranks of the poor, not the rich."
3. A lower population growth rate has been achieved in many developing countries before living standards have been raised. There is nothing better than to have every development programme in the country accompanied by a well-organized family planning motivation, support and service structure.
4. The concept of a "population committee" within the RDP is an excellent idea.
However, it is my experience of attending meetings and conferences on this issue over the past 4 years that absolutely nothing is achieved by simply having people on committees who talk about population.
What we would suggest, whether within or outside the RDP, is four full-time people who devote their entire working lives to the issues surrounding population and effective family planning.
a) A director. This person would ensure that sufficient funds go into this area.
b) A person who makes certain that all family planning services are adequately staffed and are working well.
c) A nompilo organizer. This person makes use of the widespread wish and need for family planning information and help in the rural areas.
d) A youth director. This person would organize the energies of young people in educating and encouraging each other towards a full understanding of sexual responsibility.
The ANC Health Plan (May 1994)
Page 34. "Population Policy and Health"
The South African population is growing rapidly in spite of the decline in urban fertility rates in recent years. The annual growth rate is 2,5% (1990) with the African population showing the highest growth rate. This must be seen in the context of gross maldistribution and underutilisation of the country's resources.
International population trends recognise that development strategies which improve the quality of life of the population contribute significantly to the decline in fertility. T
he development of population programmes to maximize the capacity for individuals to fully develop their potential for social stability and economic growth is required. Improvement in women's legal, educational and employment status will help to reduce the rates of infant mortality, maternal mortality and morbidity, and teenage pregnancy.
Contraception is a necessary but not sufficient factor in promoting fertility decline. Moreover, contraception should not be provided independently of broader reproductive health care within a comprehensive primary health care system.
The population policy should promote reproductive freedom of choice and women's right to control their bodies. It should also recognise the human rights of individuals and couples freely and responsibly to decide the number and spacing of their children, and to have the information, education and means to do so.
The increasing numbers of the South African population, the shifting geographical distribution and the patterns of internal and international migration, all call for clear economic and social policies to help achieve a balanced development process which will redress some of the inequalities caused by apartheid.
SAPLER'S COMMENTS: These paragraphs are deeply disturbing in that they are based on vague ideological statements rather than on reality.
Good family planning strategies and other forms of human development can work synergistically, but to minimize the family planning side of it is to ensure failure.
A draft report was brought out in September 1994 called, "Assessment of Reproductive Health Services in South Africa, focusing on Family Planning 1994" by the Reproductive Health Task Force, SA Ministry of Health, WHO-HRP, Geneva.
The Reproductive Health Task Force Members consisted of a team of 13 people headed by Dr Helen Rees. The assessment team consisted of 8 people headed by Dr Helen Rees.
A report of this kind was not possible in the time they were given, so any criticism must be related to this fact. The team went round SA for 3 weeks in July and the report was brought out in September.
My main criticism of this report is that it recommends "everything" without saying how this "everything" can be achieved.
The report states in its conclusion that there must be "Transformation of Family Planning Services into Comprehensive Reproductive Health Services and their development as a key element of Primary Health Care services."
The "objectively verifiable indicator" of this will be "By 1999 all PHC services will deliver quality comprehensive reproductive health services."
All the way through this report there is the objective observation that vertical fp services work better than comprehensive PHC. Yet at the same time the ideological statement keeps being made that fp must be integrated into PHC.
The limits of our resources do now have to be acknowledged. If we are to reach everyone and improve everyone's health then we have to find workable ways of doing this. ,
The report comments extensively on the complaints and problems of nurses. But most of this stems from their not having clear enough roles and their roles being constantly changed for ideological reasons.
In contrast with all this we have the Bekimpilo Trust. This trust only does preventive health, with minor first aid. The morale of the nurses at this trust is very high indeed. Bekimpilo has never had to advertise for nurses and has files of nurses who want to work there.
Yet these nurses get paid less than their Durban counterparts. They thrive because they know exactly what they are doing and do not try to do "everything".
Women's Health Conference News (Oct.1994 - Women's Health Project)
Page 14. "Draft: Policy on Fertility Regulation (Contraception)"
This proposal is the result of research and discussion by a number of people who work in the field. It's open for discussion and redrafting by South African women. Your contributions are welcome.
Background In the last few years, the women's health lobby and the HIV/AIDS pandemic has resulted in a change of the health focus. Instead of considering mother and child health and family planning programmes in isolation, this area has been expanded into sexual and reproductive health.
This incorporates the needs of both adolescents and men, who have traditionally been left out of family planning programmes. The concept also incorporates the need for safe, legal abortion services while understanding that we are striving for services that reduce the need for abortions. The old term of family planning has been replaced by a new definition of 'fertility regulation'.
SAPLER's comment: Please don't change this term yet again. With every new ideological fashion this word changes. "Family Planning" was changed into "Planned Parenthood". Why? I've never met anyone who understood this change.
"Family Planning" is well understood and accepted throughout the world, Africa and South Africa. At the Cairo Conference other African countries all used "family planning". A Zimbabwean planner said to me: "Oh we also changed the word after Independence - but how we've gone back to it."
A fellow delegate at Cairo from Planned Parenthood of Cape Town said to me: We never say 'planned parenthood' any more. We say 'sexual reproductive rights'. All this is simply confusing. Even a single mother with a baby is a 'family'.
In making recommendations for a policy on fertility regulation, it is important to understand the present status of SA family planning services. In 1974 the State introduced a national network of free family planning services.
This, like all SA health services, was characterised by fragmentation between black and white services, between the public and the private sector and between SA services and those of the 'homeland' authorities.
Consequently, services in the urban, historically white areas, were good, while services to the poorer, black areas, including the informal settlement areas and the rural areas, were often inadequate.
In 1991 the State started.to integrate fp services into primary health care services. At present about half the family planning services are provided in this way. State fp services are provided by nurses, with the back-up of a few doctors.
The private sector, through gp's, gynaecologists and pharmacists, also provides contraceptives. Information about fp services is provided by health advisers, a category of workers which used to be called fp advisers and have now been reclassified as primary health care educators.
Although many health worker's involved with fp strive to provide quality services, SA research has shown that there are many problems in the services rendered. Rural services are provided by mobile facilities which make examinations difficult. In some cases the numbers of patients seen make it impossible for adequate information or examination to take place.
Nurses are rushed, and clients frequently complain of poor staff attitudes. The staff themselves often feel under-trained for the job that they are expected to do, unsupported by their management structures and poorly rewarded. All these factors contribute to the overall quality of care in health service provision being low.
Contraceptive use in SA must be considered against this background of over-stretched services and low staff morale. Within the black community, only half the women who need contraception are presently able to access services.
Those who cannot access services include rural women, women in informal settlements and adolescents, all of whom are the most vulnerable when the risks of childbirth are considered.
One measure of the quality of care in fp services is the range of methods available to women using those services. In a good service all methods would be available and this would be reflected in the pattern of contraceptive use.
In SA there is a problem with the range of methods being made available to women. In many rural areas and informal settlements over 80% of women are using injectables.
Nearly all teenagers are put on to injectables. In some areas there are no facilities for women to be sterilised. Male sterilisation is not publicised and the service is not provided.
Barrier methods of contraception which include condoms and diaphragms are not being promoted as a method of contraception, despite the fact that they offer women some protection against sexually transmitted diseases and HIV infection. Facilities for the fitting of IUCDs are not available in the majority of outlying clinics.
Other unknown methods of contraception which are not widely available in SA include emergency contraception and menstrual regulation. EC is taken within 72 hours of unprotected intercourse and acts by preventing pregnancy from occurring.
Menstrual regulation can be safely performed by a trained health care provider in the first two weeks after a missed period. Both methods act as a back-up to contraceptive services, and can be used to prevent unwanted pregnancies.
Central Tenets of the Fertility Regulation Policy
* that fertility regulation replaces the older concept of family planning, and is seen as integral to sexual and reproductive health.
* that fertility regulation is essential to a woman's right to control her own fertility.
* that fertility regulation services are based on preexisting knowledge provided to the community by sexuality and gender education services.
* that fertility regulation programmes include contraceptive advice and delivery, and sexual and psychosocial counselling.
* that contraceptive prescribing is only done on the basis of informed choice.
* that contraceptive delivery programmes strive to provide quality of care at all times. Quality of care includes high standards in the following areas: choice of methods, information given to clients, technical competence, interpersonal relations, mechanisms to encourage continuity, and an appropriate constellation of services.
* that contraceptive delivery services are not restricted to married women but include the following: unmarried, divorced, elderly and adolescents of both sexes.
Policy Recommendations
* that the present services should be expanded to become comprehensive reproductive health services. These include contraceptive delivery and counselling, STD treatment and counselling, infertility prevention and treatment, safe abortion management and referral, and cervical cancer screening.
* that contraceptive delivery services should be accessible to all who require to use them. Accessibility includes physical access, times of opening and positive non-judgmental staff attitudes.
* that alternative methods of delivery of contraceptive services be developed with the community, with the aim of making contraceptives more easily available while still ensuring that the necessary information and medical supervision occurs.
that the physical environment of contraceptive delivery services respects the privacy and dignity of the clients using them, and facilitates counselling and physical examination.
* that the necessary equipment is available for contraceptive delivery services and for the relevant physical examination and screening of clients.
* that appropriate services are provided for adolescents, the aim of which is to allow them to maintain and enjoy good sexual health.
* that staff involved in the provision of contraception should be adequately trained and supported to provide services based on the principles of quality of care.
* that sexuality and gender education should be introduced into schools and be made available to non-school going youth.
* that contraceptive provision is made only on the basis of informed choice by the user.
* that a range of contraceptive methods, including barrier methods and sterilisation, should be made available to all clients using the services.
* that all contraceptive users who are at risk of contracting STDs or AIDS should be encouraged to use condoms in addition to their chosen method.
* that emergency contraception should be available in all appropriate health delivery outlets. To accomplish this there should be health worker training and community education about the method.
* that there should be an expansion of sterilisation services for both men and women. To achieve this, general practitioners should be trained and employed as sessional workers by the state, and state services should be made available to provide this service.
SAPLER's comments: This is a luxury request. When you try to provide "everything" and resources are limited, the first thing to go is "quality of service". It is better to provide one contraceptive to absolutely everyone who would like it than to offer the full range of services to a few people.
Reprodutive Health (From the final Cairo document)
Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity in all matters relating to the reproductive system and to its functions and processes.
Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have tile capability to reproduce and the freedom to decide if, when and how often to do so.
Implicit in this last condition are the right of men and women to be informed arid to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health care services that will enable, women to' go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.
In line with the above definition of reproductive health, reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being through preventing and solving reproductive health problems.
It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases.