Realising the unfinished agenda of ICPD in Bangladesh

Mahfuz Anam, Editor & Publisher, The Daily Star

The 25th anniversary of the ICPD (International Conference on Population and Development) is a momentous occasion to assess what Bangladesh has done so far and what we need to do for the future regarding population issues. It seems that earlier, we were very intense on population-related issues and achieved remarkable success, but now we have become a bit more relaxed about it.

Population can be both a burden and an asset. A big population can do wonders, but there needs to be a balance between population numbers and the ecology that supports it. In Bangladesh, we are currently experiencing a population density problem. Quantitative assessments have shown that there is reason for genuine concern at the number of people we can healthily sustain. Qualitative evaluations have revealed our shortcomings in different key population-related issues such as skills, education, health services, human rights, youth unemployment, violence against women and labour wages. Hence, population issues should be placed at the core of our planning process. We need to look at population with all its challenges and prospects and move beyond focusing on how to control it.

Dr Asa Torkelsson, Country Representative, UNFPA Bangladesh

The ICPD meeting and Programme of Action taken in Cairo in 1994 brought a shift from viewing population in the sense of control to allow people to make their own reproductive choices. At that very moment, we identified the agenda and the ambitious plans needed in terms of maternal health, family planning, and addressing gender-based violence. This year we have the opportunity to see, worldwide, how well we have done against the goals we set, and what more needs to be done. I believe our upcoming ICPD+25 meeting in Nairobi will be an opportunity to re-energise global commitment towards the unfinished agenda and achieve Agenda 2.

ICPD's vision is well-reflected across the Sustainable Development Goals (SDGs) as an accelerator to leaving no one behind. We hope there will be several pre-conference meetings for the Nairobi Summit where world leaders and governments and other parties will meet to come up with new commitments for the remainder of the time. We have the high-level political forum (HLPF) in September to galvanise support for ICPD. The HLPF will meet under the auspices of the UN General Assembly at the level of heads of state and government to follow up and review progress in the implementation of the 2030 Agenda and the 17 SDGs. This will also mobilise further support for action to achieve them.

Dr. Mainul Islam, Chairperson and Project Director, Department of Population Sciences, University of Dhaka

In the last 25 years since the ICPD meeting, Bangladesh has made substantial progress in several key areas such as economic growth, poverty reduction, gender parity in primary school, under-five mortality reduction and gains in life expectancy at birth. In terms of Total Fertility Rate (TFR), the rate has decreased from 3.4 children per woman in 1994 to 2.3 children per woman in 2014. However, challenges persist due to some regional variations in TFR and the use of contraception.

Among the major challenges, child marriage is on the top, which is adversely affecting employment, education, decision-making and overall empowerment of women and girls. Early pregnancy and adolescent fertility rate is at 31 percent (BDHS, 2014), compared to 33 percent in 1994, which implies that we have not progressed much in this aspect. Unmet needs for family planning among women aged between 15 to 19 stand at 17 percent, which is quite high. Prevalence of partner violence in marriages is 80.2 percent compared to 87.2 percent in 2011, which does not imply a significant reduction. The percentage of skilled birth attendants has increased (42.1 percent in 2014), but maternal mortality  ratio is still high which need to be reduced from its current level of 176 (UNFPA SWOP) to 70 per 100,000 live births to meet the SDGs. Our demographic trends are more diverse with a large youth population and an increasingly ageing population. Youth unemployment rate (11 percent) for people aged 15-29 has doubled since 1994. Half of the Not in Education, Employment or Training (NEET) group consists of women.

Rapid urbanisation is happening in Bangladesh (35.9 percent in 2017). However, it is bringing adverse effects in terms of population mobility and displacement, which in turn are hampering health, housing and transport. Migrants, particularly women in urban areas, are facing numerous challenges in terms of sexual and reproductive health issues.We have good policies,but we need to consider whether these policies are connected with the SDGs and aligned with the ICPD framework.

Session 1

Leaving no one behind: Key catalysts for Bangladesh to achieve SDGs

Dr Sathyanarayanan Doraiswamy, Chief, Reproductive Health, UNFPA Bangladesh and moderator of the session

Health is a critical indicator of sustainable development. Bangladesh has achieved significant gains in the last four decades, but still, a lot needs to be done, particularly on the issues of universal access to sexual reproductive health and rights.

SDG 3 makes specific reference to universal access to sexual and reproductive health and rights through at least three specific targets: reducing maternal mortality to 70 per 100,000 live births; universal access to sexual and reproductive health and rights with specific focus on family planning and reducing unmet needs of family planning; and linkages to universal health coverage and how financial protection is a critical piece in ensuring access to sexual reproductive health and rights.

We all know that health is both a means and an end for the SDGs. Hence, the achievement of the 16 other SDGs will help achieve SDG 3, which would, in turn, assist Bangladesh immensely in achieving the other SDGs.

Professor Dr. Barkat-E-Khuda, Dr Muzaffer Ahmad Chair Professor, Bangladesh Institute of Bank Management

In Bangladesh, we see sharp inequities in terms of access to healthcare depending on a person's location, wealth status, gender and education. Therefore, the issue of "leave no one behind" arises.

To ensure universal access to reproductive health and rights, we need to think outside the box. The one-size-fits-all approach will not work. Thankfully, the government and the ministry of health are awakening to the idea that we need to adopt a client-segmented and need-based reproductive health approach. Yet, I do not see much enforcement of the idea in the planning documents and much less implementation of it. 

The essence of ICPD and SDGs is to promote the quality of their lives. Therefore, you cannot have reproductive health as a standalone programme. It is connected with all the other aspects of life such as food safety, job creation, gender equality and environmental issues. We need a coordinated programme adopting a holistic approach.

Dr Hossain Zillur Rahman, Executive Chairman, PPRC

I think there is a serious issue of "mission confusion" regarding the population issue in Bangladesh among the policymakers and lawmakers. We are not sure whether the population is an asset or a burden. Originally, the idea behind family planning was that overpopulation could be a burden. However, since the shift to the idea of the population as an asset, family planning, at the institutional level, has not been getting appropriate budget and policy attention. I believe we cannot just depend on experts for solutions to this confusion. We need to hear the voices of the people at the grassroots. If we could end this mission confusion, it would be of great help for the formulation of the right policy regarding ICPD. 

Urban health is a core policy area where solutions must be found that would address the overarching goal of "leave no one behind" and, at the same time, look at health as the health of the environment. Right now, there is a "mission confusion" about who will look after the urban health sector. The Municipality Act 2009 has given the ministry of local government jurisdiction over urban health. Thus, the health ministry is, actually, not allowed to address the urban poor. There are no counterparts to community clinics, union health centres or Upazila health complexes in the urban context. The private health facilities have monetary issues, and therefore, everyone cannot afford it.

One may think that the idea of "leave no one behind" is only about ensuring access. However, it should be about leaving no one behind from quality services. The quality aspect must be highlighted in our development plans. Coverage, which  is not effective would not be of help to us. We do not have a proper understanding of the indicators for good quality. We should develop these indicators listening to the demands of people at the grassroots. 

Dr Nazrul Islam, Programme Director, Partners in Population and Development (PPD)

Different segments of the population have different needs. Do we have enough resources to cater to each segment according to their needs? Moreover, there are hard-to-reach areas such as Chittagong Hill Tracts and haor areas where it is really difficult to provide health services. Although the slums are within the city, we have not been able to reach these places and provide proper health facilities. To live up to the spirit of leaving no one behind, we have to reach the population in all areas. 

Asif Ibrahim, Director, BGMEA

The labour law has made it mandatory to provide childcare facilities, up to six years, for the garment workers. We do have healthcare facilities in most factories, but not all of them provide childcare services up to the age of six. Collaboration is needed between development partners and NGOs to provide these services.

The nature of the RMG industry is such that it is really difficult to take time out from day-to-day production activities for training workers on sexual and reproductive health issues. Using modern communication technologies can be a solution in this regard. We are talking to various smartphone manufacturers to make low-cost smartphones available for the workers so that they can use e-wallet services. We can run awareness campaigns on sexual and reproductive health issues through these smartphone devices. We are also open to the idea of health insurance for the workers.

As RMG is the largest employer of women in Bangladesh, the ICPD programmes need to be redesigned in partnership with the sector.

Munia Zain Islam, Programme Manager, Telenor Health Bangladesh

There have been rapid technological advances in terms of mobile technology. Why are we not leveraging that in Bangladesh? People should be able to use their phones for issues like doctors' consultations and family planning. At Telenor Health, Tonic is being used by about 500,000 people for health consultations.

I believe Bangladesh is ready for a full-scale introduction of health insurance. Although there are some grey areas in the health insurance industry, ways to form partnerships between public and private sectors can be found. We need updated clinical services in a more non-traditional setting. Currently, telemedicine is an area where our technological advances are taking us.

Dr Shamsul Alam, Member (Senior  Secretary) General Economic Division, Ministry of Planning, Bangladesh

I do not see any confusion in the mission of the government regarding the population issue. Earlier our slogan was "two is enough, one is better". Now, it has changed to "two is enough, whether boy or girl". This implies that the government has not abandoned the idea of managing our population. Still, there is a genuine concern about the population density in Bangladesh. We are also concerned about other population-related issues such as unemployment, child marriage, adolescent sexual and reproductive health, maternal mortality, stunting and malnutrition. However, we really need to go a long way to achieve the SDGs.

The Eighth Five-Year Plan will be more action-oriented; we will have strategies and clear targets for every sector. We will have attainable macro unit targets.

We should particularly focus on ICPD recommendations. One of the recommendations is to adopt a target (related to coverage)-oriented approach to reach potential users with unmet need. Secondly, we should focus on increasing savings ratio to ensure education and job creation both in the formal and informal sectors. We will devise ways to increase our national savings as an investment is related to savings. The third recommendation is to provide adequate schooling along with improvement in quality service to reduce neonatal mortality. Improving the quality of education will be one of the top priorities in the Eight Five-Year Plan. The fourth recommendation of ICPD is policy formulation regarding shifting income from the agriculture sector to the service and industrial sector.

Shaheen Anam, Executive Director, Manusher Jonno Foundation (MJF)

Earlier there were huge campaigns regarding family planning which are somehow missing now. They need to be started again with the same intensity. However, only providing contraceptives and door-to-door services will not bring down the population. It has to be followed up by quality education, reproductive health services and, most importantly, the improved position of women in the family as well as a society where men and women are equal partners in decision-making about the size of the family. There is still a negative perception about women in our society. Security of girls is another major concern. These lead to child marriage and violence against women. We need to bring a huge shift in this attitude.

SDGs are all connected to each other. Everything hinges upon SDG 16, which talks about ensuring justice and strong institutions. Unless we make all the service-providing institutions accountable, strong and transparent, we will not be able to achieve SDGs.

Jin Anrong, International Programme Coordinator, PPD

We need to focus more on postpartum haemorrhage, which is a major cause of maternal mortality in Bangladesh. Media can play a big role in creating awareness about this critical issue.

Session 2

Inequalities in Bangladesh: Bridging gaps, mapping the way forward to achieve SDG 5 (Achieve gender equality and empower all women and girls)

Mahboob-E-Alam, National Programme Officer and Chief, Population Planning & Research (PPR), UNFPA, Bangladesh and moderator of the session

Our Honourable Prime Minister made a promise in the London Summit that rate of child marriage below the age of 15 will be brought down to zero and child marriage below the age of 18 will be reduced by one-third by 2021, and by 2041 there will be no child marriage. Despite efforts by UN organisations, development partners and NGOs along with the government, the rate of child marriage is still very high (59 percent). Over the last one decade, the figure has not changed much.

In 2017, Bangladesh ranked 47th out of 144 countries in the Global Gender Gap index. According to BBS, 72 percent of married women have reported  having experienced physical violence. According to the findings of research studies of UN Women, ILO, other development institutions and BRAC University, women in Bangladesh are facing violence both at home and outside. Despite achieving significant progress in the development indicators, Bangladesh continues to rank high in gender-based violence, and we need to figure it out what needs to be done to reduce it.

Dr Mohammad Mainul Islam

If we cannot prevent child marriage, Bangladesh will not be able to achieve half of its development goals. Our study shows that there are multiple factors behind the high prevalence of child marriage in Bangladesh. One important factor is a social perception of a child at the grassroots level. In rural areas, the majority of the people think that when a girl crosses 13 or 14 years of age she is no longer a child and she should be married off. Lack of security is another major reason behind child marriage. There are other factors like poverty, climate change, religious views, lack of educational facilities that are contributing to the prevalence of child marriage in the country. Lack of proper implementation of the Child Marriage Restraint Act is a big concern. Since the enforcement of the Act, we have not seen any study on its impact on child marriage.

Dr Hossain Zillur Rahman

Comprehensive Sexuality Education needs to be made mandatory for both boys and girls. Adolescent pregnancy is a bigger concern than child marriage because it causes health damages to both the mother and the child. The two issues should be dealt with separately.

Dr Barkat-E-Khuda

Child marriage is not uniform across the country. It is higher in Chattogram and Sylhet regions.I  do not think that child marriage and adolescent pregnancy can be dealt with separately. Once a young girl gets married, the automatic pressure of bearing a child comes along.

Asif Ibrahim

The laws regarding violence against women are there, but proper implementation of the laws is lacking, and this is where we must improve.

Shaheen Anam

The new law on child marriage has some loopholes. It allows the marriage of girls below age 16 under certain circumstances. However, it is an achievement that the new law has made child marriage a criminal offence, and there is punishment for violating the law. We also need to discuss whether consummation of marriage means that the marriage is not annulled even if the bride is a child. It is very difficult to implement the law where the major stakeholders like family, religious leaders, union parishad representatives are not part of the prevention process. Creating a social movement is very important to bring an end to child marriage.

The rate of conviction for rape is only 2 percent in Bangladesh, denoting is a prevailing culture of impunity on the issue of violence against women.

It took almost three decades to get the domestic violence prevention act. It is almost impossible to implement it. There are so many complicated issues regarding this law.

We need to recognise the unpaid care work of women. We also need to talk about the influence of drugs and pornography. These are the two huge reasons behind violence against women in the country.

Shamsul Alam

Strong academia, civil society and the media can make the government bring change on any issue. Therefore, all should play their respective roles. Only then will we be able to achieve our development goals.

Dr Nazrul Islam

As long as the ICPD agenda remains unfulfilled, achieving the SDGs by 2030 will be really difficult. Therefore, the 25th anniversary of ICPD will be used to harness momentum to advance the implementation of the ICPD agenda. It is expected that the global community will commit to the three zeroes: zero preventable maternal deaths, zero unmet family planning needs and zero violence.

Recommendations

♦ Put in necessary efforts to integrate a comprehensive package of sexual reproductive health and rights into the national policies and programmes.

♦ Take up initiatives to recruit an increased number of midwives, skilled birth attendants, nurses and doctors so that no woman gives birth without medical help.

♦ Ensure accessible and affordable safe, modern contraceptives for all, including urban slum dwellers and young people.

♦ Take necessary legal and policy measures to end child marriage, end sexual and gender-based violence and end all forms of discrimination against all women and girls.

♦ Take necessary initiatives so that old and young people with disabilities, ethnic minorities, indigenous people feel valued and  contribute to society.

♦ Generate better quality and disaggregated data to improve the overall data management system in the country.

♦ Increase domestic funding for basic social services for achieving ICPD and SDGs.

♦ Take up necessary initiatives to strengthen South-South cooperation to increase global evidence-based advocacy, exchange of knowledge and expertise, capacity building, technical cooperation for reproductive health, commodity and security.