Health

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Sectoral and Social Drivers of Fertility

NAHLA ZEITOUN, AMR ELSHALAKANI, BRIDGET CRUMPTON, CORNELIA JESSE, AMIRA KAZEM, SOURAYA EL-ASSIOUTY, SEEMEEN SAADAT, AND SAMEH EL-SAHARTY

This chapter explores some of the distal and proximate determinants of fertility relevant for the Arab Republic of Egypt, specifically the sectoral and social drivers that influence fertility directly or indirectly, including health, with a focus on contraceptive prevalence, education (particularly for girls), female labor force participation, poverty and social protection, and gender. The chapter highlights the main challenges for Egypt within each sector, the steps that have been taken (or are being taken) to address these issues, and what gaps remain. The chapter also reviews the implications of policies related to women’s empowerment that can have a positive influence on women’s participation in decision-making on their reproductive health and fertility. And because fertility is one of the main drivers of population growth, how well these issues are addressed will have a lasting impact on Egypt’s demographic outcomes.

HEALTH

Child mortality is one of the distal determinants of fertility. As child mortality declines, fertility also declines. Between 1988 and 2008, Egypt’s child mortality rate declined from 108 to 33.4 child deaths per 1,000 live births, similar to the declining fertility trend during the same period. Between 2008 and 2014, these two rates were decoupled as child mortality continued its decline, reaching 27 child deaths in 2014, while the fertility rate increased (MOHP, El-Zanaty and Associates, and ICF International 2015).

Contraceptive prevalence is a proximate determinant of fertility. Egypt has made significant strides to improve contraceptive use through its First Five-Year Population Implementation Plan 2015–2020 (appendix A). The plan supported scaling up family planning (FP) services at the primary health care level in urban areas and reaching rural and remote areas, enhancing public awareness and behavior change, and improving the supply chain. FP services were made available in 5,109 of the 5,414 primary health care units (PHCUs) across the country. In addition, the Ministry of Health and Population (MOHP) opened and reactivated 32 FP and reproductive health clinics, including 19 in university hospitals, four in police hospitals, and nine in the Health Insurance Organization (HIO) hospitals and the Curative Care Organization (CCO). The MOHP expanded FP

services in remote and deprived areas through mobile clinics, serving more than 3.6 million women. The MOHP shared its updated quality standards guide with the nongovernmental organizations providing FP services and trained their service providers, including doctors and nurses.

The MOHP organized training courses for medical staff, pharmacists, and others in the FP supply chain. Rural female pioneers were trained to conduct home visits. Warehouse officials were also trained on the management of FP methods in terms of needs assessment, storage, and distribution according to the national standards. More recently, the government has launched an initiative with the support of the World Bank to cover the shortage of physicians by contracting with retired doctors (60–65), to provide FP services in selected governorates. The MOHP also held meetings and seminars in health units and public spaces— such as youth centers, government directorates, clubs, public libraries, schools, and universities, while the national Population Council (nPC) organized media seminars. In addition, the MOHP supported 16 million home visits by the female pioneers it trained.

Funds for purchasing FP methods were made available from the state budget and through the financial support of development partners—the United nations Population Fund and the World Bank—particularly for IUDs and subdermal capsules. Egypt aims to manufacture contraceptives, such as pills and injectables, locally through the Arab Company for Drugs Industries and Medical Appliances.

The MOHP has also helped to shape regulations to support women’s empowerment and improved reproductive health. Finally, 700 rural female pioneers were assigned with the support of the World Bank and the small and Micro Enterprises Authority to reduce the number of families targeted by every worker.

Current challenges

Despite these accomplishments, multiple challenges persist. First, the PHCUs that provide FP services are still insufficient, especially in rural and remote areas. second, PHCUs suffer from a shortage of physicians, especially female doctors. Although steps have been taken to address these gaps, they have yet to show results. Even though FP services were made available at 94.4 percent of the PHCUs, 1,250 units did not have a physician present, in effect reducing the actual availability of effective FP services to 70 percent. Further, the legal framework and administrative arrangements to allow task-sharing among trained health workers such as nurses to address the shortage in the provision of FP services in remote and hard to reach areas. Third, FP activities oscillated between being conducted independently or as part of the sexual and reproductive health care (sRH) services, and between being offered at mobile or fixed clinics. This lack of stability contributed to fragmented programs and “lost” messaging on FP. FP services also failed to engage men as partners in reducing high fertility. Fourth, inadequate systems of supply and monitoring resulted in stockouts of FP methods in MOHP outlets.

The lack of recent data on fertility and FP services, such as EDHss and service Provision Assessments, made it difficult to accurately assess demand and to plan services, and data are not systematically used for planning and policy making. Plans developed by the MOHP were often generic, overstretched, and missed the underlying trends of fertility increase among different populations and regions. Challenges also exist at the policy level. The governance structure of the population program was unstable and fragmented, and the changes in the status of the nPC and rapid leadership turnover weakened the oversight and coordination of the FP program.